What is the recommended evaluation and treatment approach for a patient with a concussion, considering their age, medical history, and severity of symptoms?

Concussion Evaluation

Immediate Sideline/Field Assessment

Remove the patient from activity immediately when concussion is suspected and do not allow return to play on the same day, regardless of symptom resolution. 1, 2

Critical Initial Steps

• Monitor vital signs and level of consciousness every 5 minutes from the time of injury until the patient's condition improves or they are transferred for further care 1, 2, 3
• Activate EMS immediately if any of the following red flags are present: loss of consciousness, worsening headache, repeated vomiting, altered mental status, seizures, visual changes, skull deformities, or swelling 1, 2
• Assess for cervical spine injury before proceeding with concussion evaluation, as these injuries share common mechanisms 1

Structured Sideline Evaluation Components

Perform a systematic assessment using the following tools 1, 2:

• Standardized symptom checklist documenting: headache, dizziness, nausea, balance problems, confusion, memory issues, visual disturbances, tinnitus, feeling "stunned" or "dazed" 1
• Brief cognitive testing using the Standardized Assessment of Concussion (SAC) evaluating orientation, immediate/delayed memory, and concentration—standard orientation questions alone are unreliable 1, 2
• Balance Error Scoring System (BESS) to objectively assess postural stability 1, 2
• Neurological examination including cranial nerves, gait assessment, and coordination testing 1, 2

Document Specific Injury Details

Record the following information 1, 3:

• Mechanism of injury (direct head impact vs. indirect force transmission to head)
• Presence and duration of loss of consciousness (occurs in <10% of concussions but indicates potentially more serious injury) 3
• Retrograde amnesia (memory loss for events before injury) and anterograde amnesia (inability to form new memories after injury)—these are more predictive of severity than loss of consciousness alone 1, 3
• Time of injury and serial documentation of all signs/symptoms

Clinical Office Evaluation

Comprehensive Assessment Domains

Evaluate for five concussion subtypes within the first 3 days following injury 1, 2:

1. Cognitive: Concentration problems, mental fogginess, slowed processing
2. Vestibular: Dizziness, balance problems, nausea with movement
3. Ocular-motor: Blurred vision, difficulty focusing, eye strain
4. Headache/migraine: Severity, location, triggers, associated photophobia/phonophobia
5. Anxiety/mood: Emotional lability, irritability, anxiety, depression

Additionally assess for sleep disturbance (difficulty falling asleep, excessive sleepiness, altered sleep-wake cycle) 1, 2

Cervical Spine Evaluation

Because cervical strain and concussion share injury mechanisms, assess for 1:

• Cervical tenderness on midline palpation and paraspinal/suboccipital muscle palpation
• Cervical range of motion limitations and pain with movement
• Upper extremity weakness or radicular symptoms
• Occipital pain with palpation or head movement

Imaging Decisions

CT imaging is indicated for 2, 3:

• Any loss of consciousness
• Persistent or worsening symptoms despite normal examination
• Focal neurological deficits
• Severe mechanism of injury
• Suspected skull fracture or intracranial hemorrhage

Routine imaging is NOT indicated for uncomplicated concussion with normal examination and improving symptoms 2

Initial Management

First 24-48 Hours: Complete Rest

Prescribe complete physical AND cognitive rest for the first 24-48 hours 2:

• Physical rest: No sports, exercise, or strenuous physical activity
• Cognitive rest: Limit screen time, reading, homework, video games, texting
• Academic accommodations: Reduced workload, extended time for assignments, frequent breaks 2

Symptom Management

• Acetaminophen only for headache—avoid NSAIDs initially and never prescribe medications to mask symptoms for return-to-activity purposes 2
• Antiemetics for persistent nausea/vomiting 3
• Avoid complete sensory deprivation—some light activity and stimulation is appropriate after initial 24-48 hours 1

Home Monitoring Instructions

Provide written instructions to return immediately for 2, 3:

• Severe or worsening headache
• Repeated vomiting
• Seizures
• Increasing confusion or inability to wake
• Weakness, numbness, or slurred speech
• Focal neurological deficits

Return-to-Activity Protocol

Prerequisites for Starting Protocol

Begin return-to-activity ONLY when the patient is completely asymptomatic at rest 1, 2

Before starting, confirm 1, 2:

• Symptom-free at rest using standardized checklist
• Normal cognitive function compared to baseline (if available)
• Normal postural stability on BESS testing

Stepwise Progression (Minimum 24 Hours Per Step)

Each step requires a minimum of 24 hours; if symptoms recur at any step, return to the previous symptom-free step 2:

1. Complete rest: Physical and cognitive rest until asymptomatic
2. Light aerobic exercise: Walking, stationary cycling at <70% maximum heart rate, no resistance training
3. Sport-specific training: Running drills, skating drills, no head impact activities
4. Non-contact training drills: Progression to more complex training, may begin progressive resistance training
5. Full contact practice: Normal training activities with medical clearance
6. Return to game play: Normal competition

Special Population Considerations

Young athletes (<18 years) require more conservative management 1, 2:

• Longer recovery periods expected (adolescent recovery takes longer than adults)
• Stricter return-to-play guidelines due to risk of catastrophic second-impact syndrome
• Lower threshold for specialist referral

Athletes with concussion history require heightened caution 1, 2:

• More conservative timeline for return-to-activity
• Increased risk of subsequent injuries, slowed recovery, and prolonged cognitive dysfunction
• Consider baseline testing for future comparison

Alternative Timeline Without Standardized Testing

If standardized assessment tools are not available, use a 7-day symptom-free waiting period before return-to-play 2

Persistent Symptoms (>3 Weeks)

Referral Indications

Refer to specialists when symptoms persist beyond 3 weeks 1, 2:

• Sports medicine physician
• Neurologist or neurosurgeon
• Vestibular therapist
• Neuropsychologist
• Physical therapist trained in concussion management

Targeted Interventions by Subtype

Implement subtype-specific treatments 1, 2:

• Vestibular symptoms: Vestibular rehabilitation therapy
• Cervical symptoms: Manual therapy, cervical strengthening
• Headache/migraine: Targeted pharmacotherapy, trigger avoidance
• Cognitive symptoms: Cognitive rehabilitation, academic accommodations
• Anxiety/mood: Psychological counseling, consider pharmacotherapy

Graded aerobic exercise is recommended for adolescents with acute concussion and may accelerate recovery 1

Critical Pitfalls to Avoid

• Never use the term "ding" to describe concussion—this diminishes the seriousness of the injury 1
• Never allow same-day return to play regardless of symptom resolution 1, 2
• Never rely on loss of consciousness alone to determine severity—amnesia and symptom burden are more predictive 1
• Never use medications to mask symptoms for return-to-activity purposes 2
• Never advance through return-to-play protocol if any symptoms recur 2
• Never use a single assessment tool to determine recovery—combine symptom assessment, cognitive testing, and balance evaluation 1, 4