Current Concepts in Concussion: Initial Evaluation and Management


Mild traumatic brain injury, also known as concussion, is common in adults and youth and is a major health concern. Concussion is caused by direct or indirect external trauma to the head resulting in shear stress to brain tissue from rotational or angular forces. Concussion can affect a variety of clinical domains: physical, cognitive, and emotional or behavioral. Signs and symptoms are nonspecific; therefore, a temporal relationship between an appropriate mechanism of injury and symptom onset must be determined. Headache is the most common symptom. Initial evaluation involves eliminating concern for cervical spine injury and more serious traumatic brain injury before diagnosis is established. Tools to aid diagnosis and monitor recovery include symptom checklists, neuropsychological tests, postural stability tests, and sideline assessment tools. If concussion is suspected in an athlete, the athlete should not return to play until medically cleared. Brief cognitive and physical rest are key components of initial management. Initial management also involves patient education and reassurance and symptom management. Individuals recover from concussion differently; therefore, rigid guidelines have been abandoned in favor of an individualized approach. As symptoms resolve, patients may gradually return to activity as tolerated. Those with risk factors, such as more severe symptoms immediately after injury, may require longer recovery periods. There is limited research in the younger population; however, given concern for potential consequences of injury to the developing brain, a more conservative approach to management is warranted.

Mild traumatic brain injury, also known as concussion, accounts for 80% to 90% of traumatic brain injuries and is recognized as a major national health concern.17 Whereas 2.8 million traumatic brain injuries were reported in 2013,8 estimates suggest up to 3.8 million occur annually.4,7,9 Concussion diagnosis and management can be challenging, complicated by the lack of a universal definition.2,6,10 No single objective measure or combination of measures for diagnosis and no definitive evidence-based treatments exist. Return-to-activity and return-to-play decisions are limited by a shortage of prospective data.6 Physicians must rely on expert guidelines and available assessment tools with clinical judgment for diagnosis and treatment.2,5,6

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Clinical recommendationEvidence ratingReferences

Athletes should not return to play until symptoms of concussion are completely resolved and they are cleared by a health care professional.


2, 46, 13, 33

Imaging should be used only to eliminate concerns of more significant injuries and not for evaluation of uncomplicated concussion.


2, 47, 10, 12, 13

Early patient education and reassurance are a cornerstone of concussion management.


5, 10, 12

Initial management of concussion includes brief cognitive and physical rest. The degree and duration of rest are not well defined, but most guidelines recommend at least 24 to 48 hours.


2, 5, 6, 12, 27, 28

No medications are available specifically for concussion. Treatment focuses on symptom management with the same medications used in patients without a concussion.


6, 7, 10, 12

An individualized approach to the gradual return to activity after concussion is favored over rigid guidelines, and most algorithms allow for patients to progress at various rates.


2, 5, 6, 10, 1213

After an initial brief rest period, individuals with concussion should be encouraged to gradually return to normal daily routines, such as school, work, and leisure activities, as tolerated.


6, 10, 12, 14, 3033

A more conservative approach, including waiting longer for return to activity/return to play and more frequent follow-up, is recommended for children and adolescents with concussions.


4, 5, 7, 13, 28

Children and adolescents should not return to play in sport until they have successfully tolerated returning to school.


5, 6

Protective gear should be worn to prevent overall head and dental injuries, but this has not been clearly shown to reduce the incidence of concussion in most sports.



A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to


Clinical recommendationEvidence ratingReferences

Athletes should not return to play until symptoms of concussion are completely resolved and they are cleared by a health care professional.


2, 46, 13, 33

Imaging should be used only to eliminate concerns of more significant injuries and not for evaluation of uncomplicated concussion.


2, 47, 10, 12, 13

Early patient e

The Authors

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KEITH A. SCORZA, MD, MBA, is the medical director of Robinson Heath Clinic, Womack Army Medical Center, Ft. Bragg, N.C....

WESLEY COLE, PhD, is a neuropsychologist and research director at the Intrepid Spirit, Womack Army Medical Center.

Address correspondence to Keith A. Scorza, MD, Womack Army Medical Center, 2817 Reilly Rd., Fort Bragg, NC 28310 (e-mail: Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


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