Concussion Diagnosis & Management

What is a concussion?

A concussion is a traumatic brain injury (TBI) that occurs when there is a blow to the head or force to the body that moves the head rapidly.  This results in changes in how the brain functions.  You do not need to lose consciousness to have suffered a concussion.

Signs and Symptoms of Concussion

Individuals can experience a concussion on the sport field, at home, at their place of work, or almost anywhere.  It is important to look out for the signs and the symptoms of concussion after a fall or any contact to the head.

Signs (observable by other people):

• Loss of consciousness
• Inability to recall events before or after the injury
• Impaired balance/moves clumsily
• Appears confused/dazed
• Slow to answer questions
• Mood or personality changes

Symptoms (reported by the patient):

• Headaches or “pressure” feeling in the head
• Nausea or vomiting
• Dizziness or feeling off balance
• Blurred or double vision/other visual changes
• Ringing in the ears or changes in hearing
• Sensitivity to light or sound
• Feeling mentally slowed, foggy/cloudy, confused
• Memory problems
• Fatigue

What to do if a concussion is suspected?

Fortunately, not all contact to the head causes a concussion but all head injuries should be taken seriously.  If a concussion is suspected, the individual should be removed from any activity that may cause an additional injury (e.g., remove an athlete from the game or practice).  It can be difficult to determine if someone has a concussion immediately after an incident, but it is important to err on the side of caution.  When in doubt, sit them out. 

The individual should be evaluated by a medical professional trained in the assessment of concussion.  Symptoms may not emerge immediately so the onset of symptoms should be closely monitored.  The injured person should be immediately brought to his or her physician or the emergency department if there are indications of a more serious injury (see below).  

When is it important to immediately visit a doctor or the emergency department?

If there is:

• Loss of consciousness
• One pupil noticeably larger than the other
• Worsening severe headache
• Slurred speech
• Any evidence of seizure activity
• Repeated vomiting
• Severe drowsiness, cannot be awakened
• Increased confusion or irritability
• Significant personality changes
• Weakness or numbness in the arms or legs

What should be done after a concussion is diagnosed?

It is important for an individual who has suffered a concussion to avoid any activity that risks additional injury.  We know that there is a period after a concussion during which the brain is more vulnerable to contact. Athletes should be kept out of practice or game play and adults are removed from work or recreational activity that may result in further injury.

In the first 24-48 hours after a concussion, it is recommended that concussed patients reduce their physical and cognitive stimulation if this activity increases their symptoms.  The evidence does not support the recommendation for “complete cognitive rest” or complete removal from activity.  There is no more resting in dark rooms!  Instead, current evidence demonstrates that early sub-threshold activity (ie., activity that doesn’t significantly increase symptoms) is beneficial after this initial rest period.  However, a healthcare provider trained in the management of concussion should work closely with the patient to design an appropriate return to activity plan. 

Those diagnosed with a concussion should follow all recommendations of their healthcare provider regarding medication use, workplace or school accommodations, proper sleep schedule and return to activity.  They should speak up if their symptoms are persisting. 

When do patients typically feel better?

Most people will recover from a concussion in one to three weeks (although it can be longer in children) but a portion of individuals will have symptoms that persist beyond this typical recovery period.  At that time, it is particularly important to have a thorough evaluation by a concussion specialist to determine the possible factors contributing to those symptoms. 

There are a number of evidence-based treatments that can effectively treat persistent concussion symptoms. These include:

• Physical therapy for the neck/pain management
• Vestibular therapy
• Ocular-motor/vision therapy
• Exertional therapy and return-to-play progression
• Individual psychotherapy to address anxiety or depression related to the injury
• Neuropsychological evaluation of persistent cognitive complaints
• Medication management