How to identify and manage sports related concussions in primary careBMJ 2023; 382 doi: https://doi.org/10.1136/bmj-2022-073161 (Published 18 September 2023) Cite this as: BMJ 2023;382:e073161
- Michael McLarnon, foundation year 1 doctor1,
- Neil Heron, clinical lecturer, NIHR clinical lecturer23
- 1Belfast Health and Social Care Trust, Belfast, Northern Ireland
- 2Centre for Public Health, Queen’s University Belfast, Belfast
- 3School of Medicine, Keele University, Newcastle-under-Lyme, UK
- Correspondence to N Heron
What you need to know
Concussion rehabilitation should last at least 20 days for non-elite sport participants, with a dedicated relative rest period of 24-48 hours and then phased return to work, education, and finally, sport
No return to competitive sport should occur before day 21 following concussion in non-elite athletes
Recovery from concussion varies, but for most people, symptoms will resolve within two weeks. If symptoms have not settled within four weeks, refer patients to a concussion specialist, eg, a consultant in sport and exercise medicine or a neurologist with a specialist interest
A 20 year old female amateur footballer comes to your GP practice following a head collision on the pitch two days ago. She felt unsteady at the time of the collision, has had a headache since, and is finding it difficult to concentrate.
Sports related concussion (SRC) is defined as “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.”123 It is typically caused by a direct blow to the head, face, neck, or elsewhere on the body, with force transmitted to the head. It generally causes rapid onset transient neurological dysfunction, including presenting with headache or difficulty concentrating (however, this may be delayed in some cases) and is not associated with structural injury to the brain or pathology on neuro-imaging. One study in Canada reported an average annual incidence of one concussion per 87 residents.4
SRC is relevant to primary care because head injuries and potential SRC are common presentations from events such as rugby tackles or falling off a bicycle or horse. Patients are often advised to see their GP for concussion symptoms, and recent UK Concussion Guidelines for Non-Elite (Grassroots) Sport recommend that anyone who still has symptoms after 28 days should seek medical advice from their GP.5 Additionally, all concussion diagnoses should be made within 24 hours of the injury by on-site healthcare practitioners (or NHS 111) and therefore patients may be referred to GPs via these routes.5 Correct identification of SRC is integral to management and preventing re-injury. This article covers a generalised framework to diagnose SRC in amateur athletes, management as a non-specialist, and when to refer onwards.
Carry out a full history and focused assessment to confirm or rule out SRC. Neuro-imaging is usually not necessary. Symptoms may or may not involve loss of consciousness (only occurring in approximately 10% of cases) with a sequential return to baseline thereafter,1 and most patients recover within four weeks. Assess whether the patient has any of the common concussion symptoms outlined in table 1. One cohort pilot study of Australian footballers noted that 40% of athletes reported headaches after the injury event.7 Persistent headache following injury can be difficult for GPs to recognise in a single consultation; encouraging patients to re-attend if their headache does not settle, with safeguarding advice, aids concussion diagnosis.
Using a concussion assessment tool
If SRC is suspected, consider further assessment using a concussion assessment tool. Although no valid, office based primary care tool exists for concussion assessment, potential tools to consider include the Sports Concussion Assessment Tool 6 (SCAT 6), vestibular ocular motor screening, neuropsychological testing, or the Balance Error Scoring System.89
SCAT 6 is widely used, free to access online, and standardised. The tool is intended to be used in conjunction with clinical assessment to make a diagnosis of concussion, and offers a framework for non-specialists to work through when encountering a patient with potential SRC. It can be applied to individuals aged 13 or older (a separate Child SCAT 6 is available for children aged 8-12),810 and is designed for use by medical professionals as soon as possible after the injury and up until 72 hours following the suspected concussive event.8 Current research is looking to develop appropriate concussion assessment tools that can be used outside this window post injury. For example, the Sport Concussion Office Assessment Tool 6 (SCOAT6)11 has been developed for office assessment of concussion between three and 30 days post injury, but was designed for use by concussion specialists and is not suitable for GPs because of the time taken to complete (typically 45-60 minutes). Use of SCAT 6 does not require prior training or experience, and the process takes about 10 minutes to complete.8 Performance of SCAT 6 generally improves with patient age, and utility increases from adolescence to adulthood.8
SCAT 6 consists of five domains (box 1), with the sixth step being diagnosis. It should be performed with the patient in a resting state, in an environment free of distraction. Scores across each domain should be reviewed and compared with baseline values (if available)—the greater the number of symptoms present and the higher these symptoms are scored predicts a more prolonged recovery from the concussion.7 If a clinician strongly suspects SRC, they may overrule a non-indicative SCAT 6.
Domains of the SCAT 6 tool (off the field assessment)
Patient background—Collect information on the patient’s sport, team (or school), age, previous concussion injuries, previous neuropsychiatric conditions, and time/date of current injury.
Symptom evaluation—Patients complete a self-administered symptom form consisting of 22 symptoms similar to those presented in table 1.
Cognitive screen—Assess orientation (time, person, place), immediate memory (repeating back 10 word lists and doing this three times), and concentration (repeat back digits in reverse order, months in reverse order).
Coordination and balance screen. Modified Balance Error Scoring System (mBESS). —Double and single leg stances as well as tandem gait are measured over 20 seconds for each trial. Tandem gait is now also measured along a 3 m line created by a 38 mm sports tape and the athlete is asked to walk heel-to-toe down the line and then turn 180 degrees and repeat this process in the reverse direction. The time to undertake the tandem gait is measured and three trials are undertaken.
Delayed recall—Five minutes following the immediate recall, the patient should be asked how many of the 10 words they remember from those that were read out loud earlier (in any order), and this is scored.
Decision then made (concussed or not) from the above testing.
Perform a formal neurological examination, including assessment of balance. Clinicians can cover these domains by performing a motor/sensory neurological examination, including cranial nerves and cerebellar examination. Diagnosis is made based on history, examination, and, if used, SCAT 6 score or other appropriate concussion assessment tool. If any red flags are present, refer to hospital immediately (box 2), in keeping with the National Institute for Health and Care Excellence (NICE) guidelines for managing head injuries.12
Red flags—immediate hospital referral (NICE guideline recommendations)12
Glasgow coma scale score of less than 15 on initial assessment
Loss of consciousness because of the injury
Focal neurological deficit since the injury
Suspicion of a complex skull fracture or penetrating head injury since the injury
Severe neck pain5
Amnesia for events before or after the injury (it will not be possible to assess amnesia in children who are pre-verbal and is unlikely to be possible in children under 5)
Persistent headache since the injury
Vomiting episodes since the injury (use clinical judgment about the cause of vomiting in children under 12 and about the need for referral)
Seizure since the injury
Previous brain surgery
High energy head injury
History of bleeding or clotting disorders
Current treatment with anticoagulants and antiplatelets (except aspirin monotherapy)
Current drug or alcohol intoxication
Safeguarding concerns (for example, possible non-accidental injury or a vulnerable person is affected)
Continuing concern by the professional about the diagnosis.
What should I do after confirming a SRC diagnosis?
Management strategies are multifactorial, and need to be tailored to the patient’s sport, the risk of re-injury, their non-sporting commitments (such as work or studies), and the severity and duration of their symptoms. Routine neuro-imaging is generally not necessary to diagnose concussion; instead follow the NICE head injury guidance for imaging.12 The Concussion in Sport Group states that evidence for the use of pharmacotherapy in concussion management is limited, and the possibility of masking ongoing symptoms needs to be considered before return to play.113 Simple analgesia such as oral non-steroidal anti-inflammatory drugs or paracetamol may be considered in the acute post-concussion phase for management of headache.13141516 However, their use beyond the first few days should be minimised to avoid medication overuse headache.1317
Below, we outline a framework from initial head injury event to eventual rehabilitation. Practical advice for patients is outlined in box 3.
What should you advise your patient?
Anyone with a concussion or suspected concussion should not:
Be left alone in the first 24-48 hours
Consume alcohol until they are free of symptoms
Drive a motor vehicle or operate heavy machinery until symptom free. Commercial drivers, eg, HGV, should be reviewed by a healthcare practitioner before returning to driving activities.
Describe to the patient what to expect during the recovery process—it is acceptable to allow patients to return to school or work activities, and subsequently school or work part time (eg, half days or with scheduled breaks), even if symptoms are still present, as long as these activities do not exacerbate symptoms more than “mildly.”5
Headaches can persist for several months after a concussion and often resemble migraine headaches. If the headache is not increased by mental or physical activity, it need not preclude an individual from returning to school, work, and physical activity.5
Provide information such as the Headway leaflet (https://www.headway.org.uk/media/8508/hw-booklet-mild-head-injury-2020-web.pdf) and the UK Concussion Guidelines for non-elite (Grassroots) Sport (http://sramedia.s3.amazonaws.com/media/documents/9ced1e1a-5d3b-4871-9209-bff4b2575b46.pdf)5
Active rest is undertaking sub-threshold aerobic exercise treatment. Examples of active rest include short bouts (eg, 10 minutes) of gentle walking on the flat, or gently spinning the legs on a stationary bicycle, and these activities should not more than mildly exacerbate concussion symptoms.
Ensure that patients and their families are aware of red flag symptoms and advise them to go to the emergency department immediately if any develop, or to contact their GP if they feel their other symptoms are worsening.
Advise the patient that if they engage in bouts of intense physical activity during the active rest period this may temporarily exacerbate their symptoms, potentially prolonging their recovery.18
Patients should not return to competitive sport before 21 days from injury.5
Anyone with symptoms after 28 days should seek advice from their GP.5
Removal from play—If concussion is suspected, immediately remove the patient from the field of play. This is to reduce the risk of injury to the player and their team mates and to avoid the potentially lethal consequence of second impact syndrome,19 when an individual has not fully recovered from an initial concussive injury before enduring a second concussive event, which leads to potentially lethal brain swelling. This approach is consistent with the “If in doubt, sit them out” policy developed by the Scottish Sports Concussion Guidance,20 the UK Concussion Guidelines for Non-Elite (Grassroots) Sport,5 and the Lystedt Law, which applies in certain US states.21
Active rest—This is a subjective term but may be considered any state that does not induce cognitive or physical strain in the patient. It may evolve with symptom resolution. Prescribing initial active rest is the primary form of management with concussion protocols.118
Active rest can ease discomfort and mitigate post-concussion symptoms. Risk of re-injury is greatest during the first week following concussion, based on a systematic review that cited 79% of repeat concussions occurring within seven to 10 days in one large randomised controlled trial.18 Therefore:
Advise relative physical rest in the first 24-48 hours, after which the patient can begin slowly re-introducing low level activity (eg, walking).18
Advise avoidance of vigorous exercise and sport throughout the active rest period.
Prescribe cognitive rest (ie, avoiding intensive studying or strenuous mental work) for one to two days.22 Evidence is unclear, but based on one narrative review of seven studies, the patient should be counselled specifically to avoid high cognitive activity (defined as more than one hour of combined homework, videogames, or online activity, or unrestricted activity) in the first few days following the SRC.22
The 2023 UK Concussion Guidelines advise that people may walk, read, and do some easy daily activities, provided that concussion symptoms are no more than mildly increased. They advise keeping phone or computer screen time to the absolute minimum.5
Inquire about the patient’s mood: a 2019 systematic review and meta-analysis identified increased risk of depression and suicide (relative risk 2.03, P<0.01) following SRC.23
Return to school/work—A randomised comparative effectiveness trial of 200 high school students suggests that school or college level patients should return to academic studies as soon as symptoms resolve and in line with returning to physical exercise.24 Based on expert opinion and narrative literature reviews, accommodations should be made on an individual level to rehabilitate patients in the classroom or workplace,2225 such as a reduced length of working day,26 with most people able to get back to full school or work activities by day 10 post concussion.27 A “return to learn” protocol has been described in the recent UK Concussion Guidelines for Non-Elite (Grassroots) Sport.5
Where possible, the patient can slowly return to normal activities (school or work) as long as these no more than mildly increase symptoms.20
If work or study more than mildly exacerbates symptoms, the patient should return to the level that they were able to manage, for a period of at least 24 hours, before then trying to increase their work or school activities.
Return to play—a graded return to play or sport protocol is typically indicated. An example of a protocol is presented in table 2 and applied to the footballer in our case study. The protocol was synthesised from the 2023 Concussion in Sport Group consensus statement and reflects the stages of graduated return to activity that the consensus statement1 and the 2023 UK Concussion Guidelines advocate.5
Patients can outline a personal plan for each of the steps of recovery presented in the protocol, guided by their doctor, who can alternatively signpost them to a sport and exercise medicine service, where available, for further advice. Discuss examples of activity that can be undertaken at each level and encourage patients to also discuss this with their training coach.18 This return-to-play protocol should not start until the patient:
Has completed their initial minimum relative rest period as indicated by relevant sporting guidelines
Has returned to normal education and/or work activities
Is not using any medications that may mask concussion symptoms, eg, analgesia for headaches or sleeping tablets.5
The 2023 UK Concussion Guidelines recommend only returning to training activities involving head impacts or risk of head injury once the person has not experienced symptoms at rest for 14 days.5
The principles of management apply regardless of the patient’s level of sport participation (amateur to professional).1 Most patients are back to full learning and sporting activities at around day 10 and 20, respectively.27 The patient cannot compete in any other competitive sports until they have completed the stages of the return-to-sport guidelines in the sport in which they were concussed. Key points include:
Tailor protocols to the individual and match to their progress and sport
Start training activities in the chosen sport once the patient is not experiencing symptoms from their recent concussion at rest5
Stages 1-2 can be defined as light exercise, 3 and 4 as non-contact sports-specific exercise, and steps 5-6 return to normal practice.
Full contact training cannot begin before the patient has been symptom free at rest for 14 days.5
The earliest a patient can return to competitive sport following a concussion is day 21.5
If symptoms more than mildly worsen during the rehabilitation process, the patient should return to the previous stage that they could tolerate and then slowly build up their activities again.
When should I refer to a concussion specialist?
Refer to a concussion expert, usually a consultant in sports and exercise medicine and their multidisciplinary team, if symptoms persist beyond 28 days.5 This occurs in roughly one fifth of cases and is commonly known as “post-concussion syndrome.”2528 Initial concussion management should be started by the GP.
Risk factors for post-concussion syndrome are presented in box 4.2229 The short and long term consequences of concussion are detailed in box 5. Chronic traumatic encephalopathy (CTE) is a spectrum of disease concerning progressive neurodegenerative changes, and definitive diagnosis is histological or made post mortem. However, suspected CTE is often diagnosed via symptom clusters following recurrent mild traumatic brain injury (ie, concussion).3031 CTE presents clinically with symptoms such as cognitive impairment and depression later in life.13233 The patient should be made aware (and reassured) that CTE and associated symptoms tend to occur as a result of repetitive trauma, and not from a single concussive event. A systematic review on concussions in amateur athletes did not find an association between concussions and future risk of mental health issues and neurodegenerative disorders,34 but the authors recognise the need for further studies in this area, with improved control of confounding factors in the study population.
Risk factors for post-concussion syndrome
≤18 years old when experiencing a concussion
History of previous concussion(s)
More than one concussion in the past 12 months
Unusual presentations, eg, predominantly balance symptoms
Children with a history of attention deficit/hyperactivity disorder and/or mental health problems, particularly anxiety
Potential consequences of concussion injuries
Short term (weeks to months)
Development of post-concussion syndrome requiring longer rehabilitation
Increased risk of re-injury in short term (greatest in the first seven days)
Poorer academic performance30
Long term (years)
Chronic traumatic encephalopathy (incidence unknown)
Cognitive impairment and depression
What should you do to reduce the risk of sports related concussions?
Educate the patient and sporting teams on concussion prevention and correct management. Rules of the sport in question should be stringently adhered to, to reduce risk. Concussion prevention programmes should be encouraged among teams and this can include neck strengthening exercises.1335 Although no clear evidence supports the role of mouthguards in preventing concussion in contact sports, evidence from one meta-analysis indicates that they may be protective, with findings suggesting a 19% reduction in concussion risk when combining data from the basketball, ice hockey, and rugby, although this was not statistically significant.3536 It is reasonable to advise players to consider using mouthguards within a multi-component prevention programme.136
Protective headgear reduces the risk of other head injuries, but has not been shown to reduce incidence of concussion.36 Beyond this, rapid concussion identification and adherence to the “return to play” protocol will help to minimise risks.
Education into practice
Ideally, SRC would be identified at the pitch side (“if in doubt, sit them out”). How might you consider a medical education outreach programme with local schools and sports clubs, or a prevention programme?
If you work in primary or emergency care, how often is a concussion assessment tool applied when treating patients for potential SRC (ie, “head injury” patients)? Could this be audited in your unit?
How this article was created
This article was created by reviewing the SCAT 6 guidelines, UK sporting and government organisation guidelines, the 2022 Concussion in Sport Group consensus statement and earlier consensus meetings, as well as research on the management of concussions (based on Level I evidence were available) based on a literature search of the topic “management of sports-related concussion”, with input from general practice and sports and exercise medicine, including one physician with a strong research interest in SRC. The literature search included the following databases: Medline ALL, Embase, Scopus, and Web of Science. Additionally, studies were accessed via references from included papers and searching Google Scholar. A fictitious scenario was created to frame a GP consultation.
Patient involvement: patients were not directly involved in the creation of this article.
Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: none.
Contributorship and guarantor: NH conceived the initial vignette. NH conceived of the project and both MM and NH drafted the initial manuscript. Both MM and NH were responsible for manuscript revisions. Both authors approve the manuscript for publication and agree to be accountable for all aspects of the work. NH is responsible for the overall manuscript content as guarantor. All authors adhere to the authorship guidelines as outlined by the ICJME (2018).
Provenance and peer review: commissioned; externally peer reviewed.