What is the recommended follow-up examination and treatment plan for a patient with a concussion?

Concussion Follow-Up Examination and Management

All patients with concussion require serial clinical monitoring with structured symptom assessment, cognitive testing, and balance evaluation, followed by a graduated return-to-activity protocol that begins only after complete symptom resolution at rest. 1

Initial Follow-Up Assessment (First 24-48 Hours)

Remove the patient from all physical and cognitive activities immediately and prescribe complete rest for the first 24-48 hours. 1 During this period:

• Monitor every 5 minutes initially until the patient's condition stabilizes or clears completely 1
• Assess for red flag symptoms requiring emergency evaluation: severe or worsening headache, repeated vomiting, seizures, increasing confusion, weakness/numbness, slurred speech, or inability to wake 1
• Document serial assessments using a standardized symptom checklist to track severity and progression 1
• Avoid all medications except acetaminophen; never prescribe medications to mask symptoms 1

Structured Follow-Up Evaluation Components

Each follow-up visit should include:

• Symptom checklist assessment using graded scales to objectively track symptom severity over time 1, 2
• Cognitive testing including orientation, immediate and delayed memory, new learning, and concentration (Standardized Assessment of Concussion is validated for this purpose) 1
• Balance Error Scoring System (BESS) to assess postural stability 1
• Neurological examination including gait and coordination assessment 1
• Evaluation for five concussion subtypes: cognitive, vestibular, ocular, headache/migraine, and anxiety/mood disturbances 1

Timing of Follow-Up Visits

• First 72 hours: Close monitoring for delayed deterioration, as 18% of patients who deteriorate do so between days 2-7 3
• Weekly assessments until symptom resolution for uncomplicated cases 1
• More frequent monitoring if symptoms persist or worsen 1

Cognitive Rest and Academic Accommodations

Students require cognitive rest and academic accommodations during recovery, including 1, 2:

• Reduced workload
• Extended time for tests
• Frequent breaks
• Delayed return to full academic schedule until symptoms resolve

Return-to-Activity Protocol

Begin the graduated protocol only after the patient is completely asymptomatic at rest. 1 The stepwise progression includes:

1. Complete rest (24-48 hours minimum) 1
2. Light aerobic exercise (walking, stationary cycling at <70% max heart rate) 1
3. Sport-specific training (running drills, no head impact) 1
4. Non-contact training drills (more complex training activities) 1
5. Full contact practice (normal training activities) 1
6. Return to game play (unrestricted participation) 1

Each step requires a minimum of 24 hours. 1 If symptoms recur at any step, return to the previous asymptomatic level and rest for 24 hours before attempting progression again. 1

Critical caveat: No return to play is permitted on the day of injury under any circumstances, regardless of symptom resolution. 1, 2

Special Populations Requiring Conservative Management

Young athletes (<18 years) and those with concussion history require stricter management due to:

• Prolonged recovery times in youth 1
• Risk of catastrophic second-impact syndrome in adolescents 1
• Increased risk of subsequent injuries and slowed recovery with prior concussions 1

For these populations, consider extending each step of the return-to-activity protocol beyond the minimum 24 hours. 1

Management of Persistent Symptoms (>3 Weeks)

For symptoms persisting beyond 3 weeks, implement a multidisciplinary approach with specialist referral. 1 Targeted interventions based on subtype include:

• Vestibular symptoms: Vestibular rehabilitation therapy 1
• Headache/migraine: Manual therapy and targeted pharmacotherapy 1
• Exercise intolerance: Graded physical exercise programs 1
• Cognitive symptoms: Neuropsychological evaluation and cognitive rehabilitation 1
• Mood/anxiety: Mental health specialist referral 1

The evidence for predicting prolonged post-concussive syndrome is limited, with studies showing variable methodology and definitions. 4 However, patients with neuropsychological deficits, acute pain, or postural instability at initial ED assessment are statistically more likely to have continued symptoms at 3 months. 4

Imaging Considerations

Routine imaging is not indicated for uncomplicated concussion with normal examination. 1 However, CT head without contrast is indicated if:

• Delayed onset of symptoms (dizziness, nausea, vomiting) appears days after injury 3
• Neurological examination deteriorates 4
• Severe or worsening headache develops 1
• Any red flag symptoms emerge 1

MRI should be considered if CT is negative but symptoms persist or worsen, as MRI has superior sensitivity for detecting subtle traumatic brain injuries. 3

Return-to-Play Medical Clearance

Return to play requires medical clearance from a licensed healthcare provider trained in concussion management. 1, 2 The decision should integrate:

• Complete symptom resolution at rest and with exertion 1
• Normal cognitive testing compared to baseline (if available) 1
• Normal balance testing 1
• Successful completion of graduated return-to-activity protocol 1
• Input from athletic trainers, physicians, and any specialists involved 1

Common Pitfalls to Avoid

• Never allow same-day return to play, even if symptoms resolve quickly 1, 2
• Do not use standardized assessment tools without proper training in their administration and interpretation 1
• Avoid prescribing medications to mask symptoms for return-to-activity purposes 1
• Do not skip the observation period even with normal imaging, particularly in patients with vomiting or delayed presentation 5
• Never discharge based solely on normal imaging; clinical assessment remains paramount 4