Diagnosing and Treating Concussion

Many concussions are diagnosed in the emergency room after a fall or accident, or after an incident on an athletic playing field. Others are diagnosed later, when a person who’s suffered a head injury seeks medical care for the symptoms. (See Symptoms of a Concussion.) Coaches, athletic trainers and parents of athletes should also be trained to look for signs of concussion, so that they can make an immediate sideline assessment. (Download a PDF of a wallet card that can be used at athletic events to help evaluate players for concussion.)

Anyone taken to an emergency room with a head injury will be given basic neurological tests, and may have neuroimaging tests such as an MRI scan or CT scan. A concussion does not cause structural injury to the brain, so these scans are used primarily to rule out a more serious injury, especially bleeding inside the skull.  If the scans show visible injury, the diagnosis is usually “mild traumatic brain injury” (TBI). If the scans show no visible injury, the patient will be evaluated for concussion.

Since there’s no simple test for diagnosing a concussion, the process takes several steps:

• Interview to document the extent of any retrograde amnesia (loss of memory of the events immediately before the injury), loss of consciousness, or post-traumatic amnesia (loss of memory of events after the injury).  Post-traumatic amnesia is the best indicator of a patient’s prognosis after a concussion, so this step is extremely important.
• Determination of the range and severity of post-concussion symptoms on the field. There are several standardized scales, the most common of which is the SCAT-2 (Sideline Concussion Assessment Tool). This scale inquires about symptoms, attention, and memory; asks about recent events in the game; and checks balance and coordination.  
• Examination for any neurologic signs or symptoms:  Tests of strength, sensation, reflexes, coordination, cranial nerve functions, mental status, and other neurologic functions to determine any serious injury to the brain.

If the diagnosis is concussion, the patient is usually sent home with instructions to stay awake for several hours (or have someone wake them up to be sure they can be roused) and watch for signs of bleeding in the brain (primarily lethargy or a decline in mental status).

In the days following a concussion the patient should see a concussion expert.  That concussion expert could be a physician specializing in brain disorders (a neurosurgeon or neurologist) or a neuropsychologist specializing in assessing brain disorders through tests of mental functions such as attention, concentration, and memory.  Often a physician specializing in concussion works with a neuropsychologist as part of a team approach, ensuring a comprehensive evaluation and diagnosis.   

Treatment Options
There is no specific treatment for concussion other than rest — both physical and mental. This includes refraining from exercise, sports or other physical activities, and often refraining from reading, watching TV, or using a computer, all of which can worsen symptoms such as headache, visual disturbances, sensitivity to light and sound, and concentration problems. Strenuous mental tasks that require intense concentration (homework, difficult tasks at work) may also worsen symptoms. Patients are advised to avoid any activity that could cause further head injury, including riding a bicycle, roller skating, even riding a roller coaster.

The patient’s return to work, school, or athletics is sometimes recommended to be gradual, starting with half-days if possible. Many schools offer injured students neuropsychological consultations that can help identify possible residual problems and make recommendations for gradual return to school. Similar consultations for adults can help guide a safe return to full-time work.

Athletes should follow the CDC guidelines for returning to play, and coaches and parents should work together to be sure young athletes adhere to the schedule. Some coaches and most athletic trainers are certified in concussion management, but many are not. Patients and parents should rely on sound medical advice from a concussion expert — either a physician or a neuropsychologist with experience assessing concussion — to ensure a safe return to play.

The signs and symptoms of uncomplicated concussion usually run their course in one to two weeks, and it is very rare to have symptoms that last longer than a month.