Concussion Diagnosis & Management

Immediate management

The aim of immediate management is to stabilize the head-injured player. Basic aspects of first aid involving cervical spine protection followed by airway, breathing and circulation evaluation take priority. Any player who has lost consciousness should be treated as a neck as well as a head injury and should be removed from the field with head and cervical spine immobilized. Following this assessment, the team physician should decide whether the injured player is able to continue playing or is concussed and not fit to continue the game

Any player suspected of being concussed should be removed from the game immediately.

At the field a simple neuropsychological (brain function) test can be administered. Maddock’s are 5 simple adaptable questions that assess recent memory and are sensitive in discriminating concussed and non-concussed players. The standard approach of asking orientation item questions (time, place and person) has been shown to be unreliable, as this component of cognitive function may be preserved in concussion.

Other simple tests such as three-item recall or digit span to determine whether post-traumatic amnesia has resolved could be used. It should be emphasized that the concussed player must be medically assessed as soon as possible following injury. If a physiotherapist, fitness trainer or non-medical person suspects a concussion is present, the player should be referred to a doctor as soon as possible.

saru-sidebarThe South African Rugby Football Union guidelines state; ‘if in doubt sit then out’ a useful adage to follow, but more importantly advises concussed athletes not to return to the field of play on that day. Lovell et al. have shown that the athlete with concussions demonstrated impaired cognitive function for approximately 5 days, further validating the decision to not allow a player to return to the field of play.

Modified Maddock’s Questions:

  • What venue are we at?
  • Which half is it?
  • Who scored last?
  • Which team did we play last week?
  • Did we win last week?

Early management


Magnetic Resonance Image (MRI) scan

The main aim of this assessment is to determine if there are urgent indications for referral to hospital. Best performed in a quiet medical room, this assessment involves a thorough history and neurological examination, noting any symptoms of concussion and their severity and excluding potential catastrophic signs of intracranial injury. Following this, the team physician must decide if there is any indication to perform special neuroimaging (brain scan) investigations.

If the player has been unconscious for any period of time, it is recommended that either a Computed Tomographic (CT) or Magnetic Resonance Image (MRI) scan be performed. If there are no indications for these investigations and the concussed player is discharged home, he/she should be in the care of a responsible adult who is in possession of a head injury evaluation form – (see Patient Advice).

Late (follow-up) management

The aim is to determine whether the player has fully recovered from concussion and is able to return to play. This is best performed by combining a clinical assessment (See: Sports Physician Assessment) with neuropsychological testing as an objective and scientifically valid means of assessing recovery. This is essential as post-concussion recovery rates vary between individuals.

Picture-002The return-to-play decision must be individualized for that particular player. Some players may take days and others may take weeks to recover. Individual factors associated with each concussion injury are different and emerging evidence has hinted that genetic factors may be involved in both the response to head injury and recovery rates. There are dangers associated with universal mandatory exclusion criteria. It may be tempting to assume that a player has completely recovered from concussion as soon as the arbitrary time period (this in itself varies from a few days to several weeks!) has passed and that a medical assessment is not necessary, when in fact brain function is still abnormal.

A detailed clinical symptom assessment of the concussed athlete is imperative. The symptoms can be clearly evident as the patient may freely volunteer this information or the clinician may have to ask specific questions to both the athlete and gather collateral information from close family contacts in order to determine subtle mood or behavioral changes. A recent study has shown that post-concussion headache in high school athletes lasting longer than one week was associated with poor neurocognitive test scores, more other symptoms of concussion (anterograde amnesia) and may be a very important clinical marker of return to play. The clinician would certainly not allow athletes who are still demonstrating any symptoms of concussion to return to sport.

Finally, it is also appropriate to consider how the athlete should be managed out of the sporting environment. Mental stresses such as concentrating in the classroom, studying, using mobile phones and facing a computer monitor, may also result in a recurrence or exacerbation of symptoms and a prolonged post concussion syndrome. The concept of cognitive rest for at least a period of several days after injury is gaining increasing acceptance.

Neuropsychological testing

A neuropsychological test is designed to assess the ability of the brain to process information (cognitive function). Traditional “paper and pencil” tests, such as the Digit Symbol Substitution Test, have been replaced by computerised neuropsychological tests. ‘Paper and pencil’ tests may not be sensitive enough to detect abnormal cognitive function in concussed athletes. Computer tests are quick and easy to administer, show minimal learning effects and more importantly, are able to detect very subtle changes in cognitive function by measuring response variability, a feature not found with the “paper and pencil” tests.

School rubgy players being tested

Computerised tests are cost effective and easily accessible to a large number of players. A doctor can administer the test, as the aim of the test is to determine whether cognitive dysfunction is present and not the reason for abnormal function.

It is recommended that a neuropsychologist is consulted if cognitive function is severe and cognitive function recovery is prolonged. Examples of computerized tests include CogState Sport (CogState Ltd. Australia) and ImPACT (ImPACT Applications: University of Pittsburgh Medical Center). The South African Rugby Football Union utilizes the CogState Sport neuropsychological test, developed by leading concussion neuroscientists in Australia and peer-reviewed in the medical literature, as an objective measure of cognitive function following head injury.

This test is able to measure performance variability, a key measure in concussion diagnosis. The test can be administered by team physicians and performed as part of a pre-season evaluation forming a baseline neuropsychological assessment. The baseline test ensures reliable comparative data, will aid in the detection of subtle cognitive impairment, eliminates the need to compare to ‘normative data’ and assists with accurate clinical decision-making. The baseline data also ensure that baseline performance is not adversely affected by disease, drugs, practice effects and malingering. A report detailing the players’ response speed, accuracy and consistency is generated. The computerized cognitive test can be repeated following a head injury and compared to the athletes own baseline computerized test to determine whether cognitive function has deviated from baseline.

Return to sport

A structured and supervised concussion rehabilitation protocol is conducive to optimal injury recovery and safe return to play. Any return to play decision must be preceded by both clinical and cognitive recovery, simply because cognitive recovery often lags behind complete resolution of post-concussion symptoms. Following this, a graded rehabilitation program is commenced. The end point is a return to match competition. Return to play following concussion follows a stepwise process:

1. No activity and complete rest until the player is asymptomatic.
2. Neuropsychological test parameters return to baseline pre-season values.
3. Exercise rehabilitation program:

a. Light aerobic exercise (walking and stationary cycling)
b. Sport specific training (running drills, ball handling skills)
c. Non-contact drills
d. Full-contact practice
e. Game play

Read more about our Concussion Management Protocols.

The player can proceed in a stepwise progression to the level above provided he/she is asymptomatic. If any post-concussion symptoms develop, the player should drop back to the previous asymptomatic level. A minimum of 24 hours should elapse before progressing to the next step but this may be longer in severe or recurrent cases. World Rugby regulations state that all international players who adhere to the above protocol can return to play before the compulsory 3 week rest period has been completed. However all age group rugby players who are concussed have to rest from all rugby matches and practices for the required 3 week rest period.


The ideal management of concussion in sport has been an enigma for some time. The guidelines proposed by the world’s leading experts at international consensus conferences, most recently in Zurich 2012 (to be revised in Berlin, October 2016. See Research: International Consensus) and the South African Rugby Management Guidelines on Concussion (See Research: International Consensus), provide the team physician with a structured approach to concussion and the necessary tools to make sound judgment decisions regarding return to play. In professional sport, team physicians are not immune to litigation and this approach may afford some degree of medicolegal protection.