Concussion

Symptoms cluster into four domains (SCAT6 / Amsterdam 2023): somatic (headache, neck pain, nausea, dizziness, balance / visual disturbance, photo / phonophobia), cognitive (slowed thinking, brain fog, amnesia, 'in a daze'), emotional (irritability, lability, low mood, anxiety), and sleep. Onset may be delayed up to 24-48 hours.

Pitchside:

Remove from play at the first suspicion ('if in doubt, sit them out'). Cervical spine first. Confirmed concussion = no same-day return in any age group, any sport. SCAT6 if trained.

ED / clinic:

GCS, pupils, focal neurology, cervical spine examination. Vestibular and oculomotor screen (VOMS) where trained. Apply NICE NG232 imaging criteria.

Red flags - do-not-miss:

Extradural haematoma (lucid interval then deterioration; classically temporal impact in a young patient), acute subdural (high-energy or coagulopathic), cervical spine injury, cervical cord neuropraxia, depressed skull fracture, post-traumatic seizure, second impact syndrome.

Concussion is a clinical diagnosis. Imaging excludes structural injury rather than confirms concussion.

NICE NG232 - CT head within 1 hour, any of: GCS <13 at any time, GCS <15 at 2 hours, suspected open / depressed / basal skull fracture, post-traumatic seizure, focal deficit, 2+ vomits in adults (3+ in children).

NICE NG232 - CT head within 8 hours: LOC or amnesia plus age 65+, coagulopathy, dangerous mechanism (pedestrian / cyclist struck by motor vehicle, occupant ejected, fall >1 m or >5 stairs), or retrograde amnesia >30 minutes pre-impact.

Anticoagulation: consider CT within 8 hours for adults on anticoagulation or non-aspirin antiplatelets, even without other red flags.

Children under 16: separate NICE paediatric criteria with a 4-hour observation pathway. Do not transpose adult thresholds.

Cervical spine: CT C-spine within 1 hour if suspicion plus high-risk factors.

SCAT6 sideline; SCOAT6 office assessment tool.

Pitchside:

Remove from play at first suspicion - 'if in doubt, sit them out'. Cervical spine precautions. ABCDE if reduced GCS or signs of structural injury. Confirmed concussion: no same-day return, in any age group, in any sport.

First 24-48 hours - paradigm shift (Amsterdam 2023):

Strict prolonged rest worsens outcomes. Active recommendation: relative rest plus early sub-symptom-threshold aerobic exercise (light walking, stationary cycling). Limit cognitive load (screens, demanding work) for the first 24-48 hours. No driving for at least 24 hours and no driving while symptomatic. Avoid alcohol and opioids; paracetamol for headache; avoid NSAIDs in the first 24-48 hours unless intracranial bleeding has been excluded.

Return to learn / work BEFORE return to sport. Most tolerate a full school / work day within 1-2 weeks.

GRAS pathway (six stages, minimum 24 hours per stage, symptom-limited):

• •Stage 1 - symptom-limited daily activities (return to learn / work)

• •Stage 2 - light aerobic exercise (sub-threshold)

• •Stage 3 - sport-specific exercise (no head impact)

• •Stage 4 - non-contact training drills

• •Stage 5 - full contact / unrestricted training

• •Stage 6 - return to competition

UK grassroots minimum stand-down (April 2023, updated November 2024):

• •Stage 5 not before day 15, and only after at least 14 days symptom-free at rest

• •Stage 6 not before day 21

• •Routine medical clearance is not required at grassroots if progress is normal; elite, professional, school, and many sport-specific protocols are stricter

• •Mild brief symptom exacerbation can be acceptable; more than mild or prolonged worsening, or new symptoms, means step back to the previously tolerated level

Persistent symptoms (beyond 4 weeks, all age groups - Amsterdam 2023 harmonised):

Multimodal rehabilitation. Sub-symptom-threshold aerobic exertion (Buffalo treadmill protocol) has the strongest evidence. Add vestibular, cervical, cognitive, and mental-health input as indicated. SCOAT6 for office assessment.

Discharge (NICE NG232): verbal and written advice, responsible adult for 24 hours, safety-netting for delayed deterioration (worsening headache, repeated vomiting, drowsiness, confusion, seizure, weakness, slurred speech, visual disturbance), GP letter within 48 hours.

Recovery is not uniform, and several factors that predict slower recovery are worth identifying early, because they change how closely an athlete is followed rather than how the acute injury is managed. The most consistently supported predictor is the initial symptom burden, with a higher number and severity of symptoms in the first days predicting a longer course. A recent or recurrent concussion history may influence prognosis, particularly where recovery has been lengthening or symptoms have persisted, though it is not a uniformly reliable independent predictor. Pre-existing migraine, anxiety or depression may modify recovery, while the evidence for attention deficit hyperactivity disorder and learning difficulties is mixed. Age-related findings vary with setting and outcome definition, and some datasets report longer symptom duration in female athletes, though neither should determine prognosis in isolation. Prominent dizziness, vestibular or oculomotor symptoms at presentation, and any coexisting cervical spine injury, are each associated with a longer course.

A critical distinction applies to the modifiable factors, and it is easy to get backwards. Continuing to play immediately after the injury, delayed removal from play and delayed access to appropriate care are associated with a longer course. Early symptom-limited physical activity is not: current consensus recommends relative rest for only the first 24 to 48 hours, light activity such as walking within that window as tolerated, and prescribed sub-symptom threshold aerobic exercise from around days two to ten, with a mild symptom increase of up to two points on a ten-point scale acceptable provided it settles within an hour. Strict rest until symptom-free is unnecessary and may itself delay recovery. What remains restricted is contact and any activity carrying a risk of a further head impact, until the appropriate stage of the return pathway. The presence of several modifying factors should therefore prompt earlier follow-up, targeted vestibular, cervical or psychological assessment, school or work support and earlier specialist referral, rather than more rest.

Phase 1 (24-48 hours) - relative rest plus early light aerobic exercise:

• •Limit cognitive load (screens, study, demanding work)

• •Light walking or stationary cycling at sub-symptom threshold is actively encouraged (Amsterdam 2023)

• •Symptom diary

Phase 2 (days 2 to 7-14) - return to learn / work:

• •Gradual return to school / work with rest breaks as needed

• •Continue Stage 2 GRAS aerobic exercise

Phase 3 (after symptom resolution and minimum stand-down) - graduated return to sport:

• •Stages 3 to 6 of GRAS, minimum 24 hours per stage

• •Honour grassroots minimum stand-down (Stage 5 not before day 15, Stage 6 not before day 21)

Phase 4 (persistent symptoms beyond 4 weeks) - multimodal rehabilitation:

• •Sub-symptom-threshold aerobic exertion (strongest evidence)

• •Vestibular and oculomotor rehabilitation if indicated

• •Cervical rehabilitation if neck pain or movement-provoked headache

• •Cognitive and mental-health support

• •Specialist concussion / sport medicine clinic input; SCOAT6 office assessment tool

Driving: none for at least 24 hours; none while symptomatic. Commercial (Group 2) drivers and significant injuries may need DVLA / occupational health review.

• •NICE NG232: Head injury (May 2023, replaces CG176) - UK assessment and early management: CT head criteria (1-hour and 8-hour), paediatric pathways, cervical spine, anticoagulation, discharge and safety-netting requirements.

• •UK Concussion Guidelines for Non-Elite / Grassroots Sport (April 2023, updated November 2024) - 'If in doubt, sit them out.' GRAS six-stage pathway with minimum stand-down: Stage 5 not before day 15, Stage 6 not before day 21.

• •Amsterdam Consensus Statement on Concussion in Sport (BJSM 2023) - Paradigm shift to early sub-symptom-threshold aerobic exercise within 24-48 hours; harmonised the 'persistent symptoms = beyond 4 weeks' definition across all age groups.

• •SCAT6 (BJSM 2023) - Sideline / acute structured assessment tool. SCOAT6 - subacute / office follow-up tool, designed for clinic assessment beyond the acute window.

• •Buffalo treadmill protocol / sub-symptom aerobic exertion - The strongest single evidence-based intervention for persistent symptoms; outperforms passive rest.

• •Sport-specific protocols (RFU HEADCASE, FA, World Rugby) - Age-graded return-to-play; elite and school-age pathways are stricter than grassroots and require sport-specific medical clearance.

• •'If in doubt, sit them out' (UK Concussion Guidelines, April 2023, updated November 2024). Confirmed concussion: no same-day return, any age, any sport.

• •NICE NG232 1-hour CT: GCS <13, GCS <15 at 2 hours, open / depressed / basal skull fracture, post-traumatic seizure, focal deficit, 2+ vomits adults (3+ children).

• •NICE 'dangerous mechanism' = pedestrian / cyclist struck by motor vehicle, occupant ejected, or fall >1 m or >5 stairs. Boxing, rugby, sports falls NOT included.

• •Grassroots GRAS: Stage 5 not before day 15 (after 14 days symptom-free at rest); Stage 6 not before day 21. Routine medical clearance not required at grassroots if progressing normally.

• •First 24-48 hours = relative rest PLUS early sub-symptom-threshold aerobic exercise (Amsterdam 2023 paradigm shift); strict prolonged rest worsens outcomes.

• •Persistent symptoms = beyond 4 weeks in all age groups (Amsterdam 2023 harmonised). Multimodal rehab; sub-symptom aerobic exertion has the strongest evidence.