Concussion Management for Nurses & Physicians in the
Health Care Setting
Source: *The following information is obtained through the CDC Foundation developed through a grant sponsored by the NFL.
Sports Concussion is defined as a complex pathophysiological process affecting the brain,
induced by traumatic biomechanical forces. It occurs by a direct or indirect hit. It is not a
structural injury, it is a functional injury. The magnitude of force dictates damage. A
concussion will not typically show abnormality on standard structural neuroimaging
evaluations.
Overview and Introduction for Physicians and Clinicians:
Concussion symptoms may appear mild, but this injury can lead to significant, life-long
impairment affecting an individual’s ability to function physically, cognitively, and
psychologically. Appropriate diagnosis, management, referral, and education are critical for
helping young athletes with concussion achieve optimal recovery and to reduce or avoid
significant and further injury.
 Pathophysiology of Concussions
 Diagnosing a Concussion
 Management of Concussions
For many of us the first chance to assess the athlete will not be on the side-lines, but in an
office or ED.
Your examination should include a:
o Physical Examination
o Cognitive
o Neurology
o Balance
Any signs of deteriorating neurological function – any suspicion of neurological deterioration or
persistent focal neurological deficit should prompt emergency evaluation. You may also choose
neuroimaging such as CT or MRI to rule out an intracranial bleed or other structural pathology.
While there is practice variation and no level one evidence on when to perform cranial
radiological exams in this population, head CT scans are commonly performed when
intracranial injury is suspected based on the:
o
o
o
neurological exam,
mechanism of injury or
symptom assessment.
An MRI is considered to help in the evaluation of athletes:
o With persistent signs or symptoms after the initial acute period or
o Following recovery if the athlete has known risk factors for prolonged recovery
The need to admit an athlete for hospitalization following a concussion, may not always be
clear. Your experience and judgment are key to this decision. Common indications that may
prompt decision for admission may include:
o Signs of intracranial injury that require monitoring and repeat neurological
exams
o The athlete has a fluctuating or deteriorating neurological, cognitive or symptom
evaluation
o The safety of the athlete is better served by careful neurological evaluation than
by home observation
o Unclear if the athlete can be adequately observed for deteriorating neurological
function if sent home or unsupervised.
If no signs of deteriorating neurological function or other indicators for
emergency evaluation are present, you should assess:
Three Diagnostic Areas:
 Characteristics of injury
 Symptom Type and Severity
 Risk Factors that can lead to a protracted period of recovery
CHARACTERISTICS OF INJURY:
1. Ask how it happened – different biomechanics may result in varied symptoms. It is
helpful to understand the type of force and the location where the force was received.
You want to know what happened; how they were hit, how they went down, the
directionality, so that you can determine where in the brain they might be having
symptoms.
2. Document type and location of force – however, a relatively minor force can also lead to
significant symptoms. These athletes may have increased vulnerability to concussion or
may have other physical or psychological factors that are exacerbating symptoms
-Rotational Force is also a factor. Studies show the magnitude of rational force can
cause a concussion and increase its severity. Among them Angular -Acceleration may
increase the risk of concussion from 25% - 80%
3. Loss of consciousness – if so, attempt to determine how long – traumatically induced
loss of consciousness indicates a concussion, however, remember that only a small
percentage of people with a sports-related concussion lose consciousness. In sportsrelated concussions, a loss of consciousness occurs approximately 10% of the time. It is
a marker for severity, but it is not the only marker of a severe concussion.
4. Areas of Concern – find out about any seizures, symptoms or any concerning signs
happening after the injury.
SYMPTOM TYPE AND SEVERITY
1. Record Symptoms – note the severity of:
 Somatic
 Cognitive
 Affective
 Sleep symptoms
A checklist of symptoms can help.
2. Focus on Changes – symptoms might changes (headache) from usual symptom
presentation (might be present prior to injury)
3. Exertion – symptoms will worsen or re-emerge with exertion if not recovered;
frequent exertion may prolong symptoms
RISK FACTORS
Risk factors that may complicate the recovery process:
1. Concussion History – For previous concussions, assess the:
 Number
 Severity
 Time of occurrence
 When possible find the mechanism of concussions and
 Duration of symptoms
 May be cumulative - The effects of multiple concussions may be cumulative
especially with little time between injuries.
2. Personal and Family History of Conditions that may result in protracted recovery
from concussions.
Personal or Family History of:
 Migraines
 Depression
 Mood Disorders
 Anxiety
 Or other developmental such as Learning Disabilities and Attention
Deficit/Hyperactivity Disorder
3. Signs of Deteriorating Neurological Function
Tell the athlete and guardian what to expect and what to watch for and which signs
and symptoms need immediate medical attention
4. Discuss Management and Expected Recovery
Provide take home messages:
 Avoid physical exertion and activities that put the athlete at risk for
additional concussions
 Avoid cognitive exertion that exacerbate symptoms until being cleared by
trained clinician
 Look out for worsening symptoms
 Discuss management and expected recovery
Inform parents/guardians that some symptoms may not be noticed until a few days after
the initial injury.
MANAGEMENT OF CONCUSSIONS
Good news is that most athletes with a concussion recovery quickly and fully. The speed of
their recovery, however, may depend on appropriate management of their injury.
1. MONITORING CONCUSSIONS
Your Concussion Management plan should :
 Monitor physical activities
 Monitor cognitive activities
 Consider concussion history
 Be individualized to the athlete
It most cases you can monitor the athlete where you work, as an athlete with a concussion
often recovers within 7-14 days. However, if you work in an ED the athlete should be
referred for care by a health care professional that is trained in concussion management.
The athlete should gradually return to play when they are fully recovered.
Discharge from an ED SHOULD NOT indicate:
 Return to play the same day
 Nor should a future return to play date be given during an ED visit.
Refer to a Concussion Specialist if:
 Symptoms have not gone away after 10-14 days
 The symptoms worsen
 The patient has a history of multiple concussions or risk factors for prolonged
recovery
During the acute phase you may also consider further testing. Neuroimaging can rule out
intracranial bleed, skull fracture, or other more severe brain injuries.
Neuropsychological testing may help confirm self-reported symptoms and track recovery.
Neuropsychological tests assess brain behavior relationships including:
 Memory
 Concentration
 Information processing
 Executive functioning
 Reaction time
Neuropsychological testing is not, however, a stand-alone tool to diagnose, manage or make
return-to-play decisions.
2. RETURNING TO SCHOOL
Concussions don’t only effect youth on the field. They effect youth in the classroom. Your plan
needs to be individualized for each patient and cover managing cognitive exertion and
returning to school as well.
Cognitive Rest:
Avoiding mentally exerting activities that aggravate symptoms
This may include:
 Working on a computer
 Watching television
 Using a cell phone
 Reading
 Playing video games
 Text messaging
Advise parents and guardians that school nurses, teachers and administrators can help make
accommodations. They can also keep an eye out for symptoms.
Return to School Signs:
 Increased problems concentrating
 Increased problems remembering new information
 Longer time required to complete tasks
 Increased symptoms (i.e., headache, fatigue) when working
 Greater irritability
 Poorer academic performance
Your return to school plan may include:
Return to School Supports
 Time off from school
 Shortened day
 Shortened classes (i.e., rest breaks during classes)
 Rest breaks during the day
 Allowances for extended time to complete coursework
 Reduced work load
 Untimed tests
 No significant classroom or standardized testing until symptoms subside
Tolerance for cognitive activity increases as the student recovers. They rate may vary from one
student to another.
3. RETURNING TO SPORTS
Athletes are anxious to return to sports, but returning to play is not the athlete’s or coach’s
decision. It is the clinicians. The complication is the spectrum of severity.
The Return to Play is an individualized process that should consider:
 Pre-existing conditions
 Age of the athlete – the younger the athlete, the more conservative the treatment.
There are 5 gradual steps to Return an Athlete to Play
Five-Step Process
 These progressive steps should take place over days, weeks, or months
 Monitor symptoms and cognitive function carefully over each increase of exertion
Five Step Progression
 Team approach – and by a health professional that has worked with the athlete and
knows the athlete’s physical abilities and endurance
 Determine daily progress- By gauging the athlete’s performance on each individual step
you will be able to determine how to progress the athlete on a given day
 Progress with your clearance – the athlete should undergo the 6-step progression only
under your clearance
In some cases you may be able to work on one step in a given day while in other cases it may
take several days to work through a given step; it may take several weeks or months to work
through the entire progression.
RECOMMENDED GRADUATED RETURN TO PLAY PROTOCOL
The athlete needs to have completed physical and cognitive Rest and not be experiencing
concussion symptoms for at least 24 hours or longer. Athletes should only progress to the next
level of exertion if they are not experiencing symptoms at the current level.
REST – No physical or cognitive activity as long as there are symptoms of concussion
STEP 1– Light aerobic exercise (e.g., stationary bicycle)
Goal: Only to increase an athlete’s heart rate.
Time: 5-10 minutes
Activity: Exercise bike, walking or slight jogging
No weight-lifting , jumping or hard running
STEP 2– Moderate exercise; sport specific training (e.g., skating, running)
Goal: Limited body and head movement.
Time: Reduced from typical routine
Activity: Moderate jogging, brief running, moderate intensity stationery biking, and
moderate intensity weight-lifting
STEP 3- Non-contact Exercise (e.g., incudes lateral movements)
Goal: More intense but non-contact.
Time: Close to typical routine
Activity: Running, high intensity stationery biking, regular intensity weight- lifting
routine, and non-contact sports-specific drills
This Stage may add some cognitive component to practice in addition to the aerobic and
movement components introduced in Steps 1 and 2.
STEP 4- Practice (e.g., full contact controlled training)
Goal: Reintegrate into full contact practice
STEP 5- Play
Goal: Return to competition
When any symptoms return, stop these activities because the athlete is pushing too hard. Only
after additional rest, and again, when the athlete is once again not experiencing symptoms for a
minimum of 24 hours should you can start again at the previous level - prior to the level where
the athlete experienced symptoms.
During the Return to Play Progression be prepared for athletes to offer resistance, as they may
feel frustrated, sad or even angry that they have to sit out. It is important to acknowledge their
feelings and be honest about the risks and explain:
o Play with a concussion can not only hurt them, but also their team
o Taking time to rest will actually help them get back to play more quickly
4. MANAGING PERISISTENT SYMPTOM CONCUSSION
Not everyone will recover quickly. Some athletes will have symptoms for weeks and if they
have Post-Concussive Syndrome their symptoms may last for weeks, months or longer.
Post-Concussive Syndrome
Post-Concussive Syndrome is when patients are experiencing symptoms from several weeks to
months post-injury. While rare after only one concussion it is believed to occur in
approximately 5%-8% of individuals with a history of multiple concussions.
For young athletes with persistent symptoms, referral to a Specialist is recommended. You may
want to consider a discussion with the student-athletes’ school district and parents the
recommendation of a 504 plan. A 504 plan is implemented when students have a disability,
temporary or permanent, that affects their academic performance. Services and
accommodations for students may include:
 Environmental
 Curriculum
 Methodological
 Organizational
 Behavioral
 Presentation Strategies
In addition to Post-Concussion Syndrome, suffering a second blow to the head while recovering
from an initial concussion can have catastrophic consequences as in the case of "Second Impact
Syndrome," which has led to approximately 30-40 deaths over the past decade.