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.

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.