CBL: Concussion

Learning Objectives

• Recognize that concussion is a clinical diagnosis (imaging is normal in uncomplicated cases).
• Describe early management with brief relative rest (24–48 hours) followed by a graded return to cognitive and physical activity.
• Apply the principle that symptoms should resolve at rest and with exertion before full return to play; earlier return increases risk of prolonged symptoms.

Vignette

A 19-year-old soccer player collides with another player. No loss of consciousness, but she reports brief amnesia. Removed from play and asked to rest. The next day she develops diffuse, aching headache worse with exertion, decreased appetite with nausea and dizziness, poor concentration when studying, and irritability. Persistent symptoms prompt clinic evaluation.

PMH: Seasonal allergies; prior tonsillectomy. Meds: Loratadine seasonally. Allergies: None. FH: No headaches. SH: College junior; alcohol ≤2 drinks/month, none in last 2 weeks; nonsmoker. ROS: No fever, travel, sick contacts, bowel/bladder issues, rash, arthralgias, visual disturbance, cough, or chest pain.

Examination

T 98.7°F, HR 68, BP 112/66. Well-appearing athlete in warmups. Cardiovascular exam normal. Pupils and fundi normal; no photophobia. Cognition, orientation, and fund of knowledge normal. EOMI without nystagmus; hearing and facial sensation normal; facial expression symmetric. Head impulse (thrust) normal. Full strength and normal tone; DTRs normal; plantar responses flexor. Sensation intact to pinprick. Finger–nose–finger and heel–knee–shin intact; no tremor. Tandem gait and Romberg normal.

Localization & Neuroanatomy

Concussion (mild traumatic brain injury) reflects transient dysfunction of distributed neural networks from rotational/acceleration forces. It does not require a focal exam or imaging abnormality, and routine CT/MRI are typically normal in uncomplicated cases.

Diagnosis

Clinical diagnosis is supported by a compatible mechanism (head collision) plus new symptoms (headache, cognitive difficulty, irritability, nausea/dizziness) with a nonfocal neurologic exam. Differential includes migraine, intracranial hemorrhage/hematoma, and (rarely) neoplasm. In mild injury with improving course and normal exam, routine neuroimaging is not required. Imaging (often CT acutely) is indicated with red flags: worsening or severe headache, repeated vomiting, prolonged or recurrent loss of consciousness, focal deficits, seizure, anticoagulant use, dangerous mechanism, or signs of skull fracture.

Sideline and clinic tools (e.g., symptom checklists, standardized assessments) assist recognition; they do not replace clinical judgment. Concussion should not be diagnosed by CT/MRI—their role is to exclude more serious injury.

Treatment

• Early management: Relative rest for 24–48 hours (limit strenuous physical and cognitively heavy tasks), then gradual, stepwise increase in cognitive and physical activity as tolerated without symptom worsening. No same-day return to play.
• Return to learn & play: Resume academics with accommodations as needed; progress through a supervised, multi-step exertional ladder. Advance only if asymptomatic at the current stage at rest and with exertion.
• Headache management: Prefer acetaminophen in the first 24 hours; consider NSAIDs after intracranial bleeding is excluded and beyond the immediate post-injury period. For prolonged post-traumatic headache, consider standard neuropathic/migraine-directed options per clinician guidance.
• Counseling & prevention: Avoid alcohol and high-risk activities during recovery. Recurrent concussions warrant counseling about cumulative risk and sport/role modifications.

Return-to-Learn & Return-to-Play Ladders

Teaching Points

• Concussion is a clinical diagnosis; CT/MRI are normal unless there is a different injury.
• Use brief relative rest then a graded return to cognitive/physical activity—no same-day return to play.
• Escalate evaluation with red flags (worsening headache, vomiting, focal deficits, seizure, anticoagulants, skull fracture signs, dangerous mechanism).
• Symptoms should be resolved at rest and with exertion before full contact or high-risk activity.

References

1. Module adapted from provided teaching text on concussion, updated to reflect modern return-to-learn/return-to-play principles and red-flag imaging indications.