Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Concussion and return-to-activity advice
Musculoskeletal medicine and orthopaedics · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Suspected concussion with deterioration
Concussion symptoms overlap with intracranial bleeding; increasing drowsiness, repeated vomiting, seizure, focal deficit, severe worsening headache or behavioural change is not routine recovery.
Action: Stop activity, return to ABCDE with cervical protection, assess GCS, pupils and glucose, arrange emergency evaluation and NICE-indicated CT, and do not allow the label concussion to delay escalation for a structural brain injury.
Overview
Recognise concussion after direct or transmitted force, exclude dangerous structural injury, provide practical early recovery advice, and guide graded return to learning, work, driving and sport.
Concussion is a traumatic brain injury diagnosed clinically from symptoms and signs after direct head or body force. It may cause headache, pressure, nausea, dizziness, visual sensitivity, slowed thinking, memory gap, irritability, anxiety, sleep change or imbalance. Loss of consciousness occurs in only a minority. The first task is not to prove concussion but to exclude immediate threats, cervical injury and CT-indicated structural brain injury using mechanism, GCS, neurological examination and NICE criteria.
At the scene or pitch, recognise and remove. Stop play immediately if concussion is suspected and do not return the person the same day. Check ABC, cervical pain, GCS, pupils and red flags. A sideline tool can structure recognition but cannot clear a player. Arrange appropriate healthcare assessment and emergency transport for deterioration. Record the event and notify parents, carers, school, employer and other clubs so restrictions follow the person across settings.
Practice
Two practice questions
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Musculoskeletal medicine and orthopaedicsOriginal SBA
Same-day sport decision
A footballer is briefly confused after a collision, then reports feeling normal ten minutes later and wants to resume the match. What is the safest action?
Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Early advice balances protection and activity. For the first twenty-four to forty-eight hours, encourage sleep and relative rest: ordinary quiet activity is acceptable if it causes no more than mild, brief symptom increase, while intense exercise, alcohol and safety-critical tasks are avoided. Reduce screen, reading and noisy environments when they clearly aggravate symptoms. Prolonged total rest, isolation or waking a stable patient repeatedly without clinical reason can impair sleep and recovery.
After the initial interval, begin a graded return to daily life. Add light walking or stationary cycling, then more demanding cognitive and physical work while symptoms remain mild and settle promptly. Education and employment adjustments can include shorter days, rest breaks, reduced screen brightness, delayed tests, quiet space, reduced driving and lighter duties. Progress is individual rather than based on pressure from a fixture, examination or staffing need.
Sport follows successful return to ordinary function. The UK grassroots principle is recognise, remove and return gradually. Build from symptom-limited daily activity to light aerobic exercise, sport-specific non-contact work, more complex non-contact training, contact practice only after appropriate clinical clearance, and competition last. Each governing body may impose a longer minimum. Any meaningful recurrence means stop, recover and return to the previous tolerated stage rather than pushing through.
Driving and work require task-specific judgement. Headache alone does not define safety; slowed processing, poor concentration, diplopia, dizziness, fatigue and sleep disturbance impair hazard response. Advise no driving until symptoms no longer compromise control and the person meets DVLA and occupational requirements relevant to their licence or job. Machinery, heights, lone work, armed roles and professional sport may need formal occupational or specialist clearance.
Persistent symptoms need phenotype-based care rather than a generic label. Reassess for missed structural or cervical injury, medication overuse, migraine, vestibular or ocular dysfunction, sleep disorder, mood symptoms and autonomic exercise intolerance. Symptoms lasting more than four weeks warrant healthcare review and often multidisciplinary rehabilitation. Discuss urgent mental-health help for suicidal thinking. Repeated injuries require a specialist risk conversation about longer restriction or retirement from exposure.
Key points
Suspect concussion after direct or indirect force when headache, dizziness, confusion, amnesia, imbalance, visual disturbance, nausea, emotional change or sleep symptoms appear; loss of consciousness is not required.
First exclude airway, cervical-spine and intracranial emergencies and apply NICE CT criteria; concussion is a clinical diagnosis and routine CT is often normal.
Remove a suspected player immediately and do not allow same-day return to training or competition, regardless of rapid symptom improvement.
Arrange assessment by an appropriate healthcare professional, give a responsible adult warning signs and avoid leaving the person unsupervised during the early risk period.
Use relative physical and cognitive rest for the first 24–48 hours, with sleep as needed and reduced screen, reading and work only to the extent that these substantially worsen symptoms.
Then increase ordinary daily and aerobic activity gradually below a marked symptom threshold; prolonged strict dark-room rest can delay functional recovery.
Return to education or work with temporary adjustments before unrestricted contact sport; progress stepwise and move back a stage if symptoms significantly recur.
No driving, cycling on roads, machinery, heights or other safety-critical activity while attention, vision, balance, reaction time or medication makes performance unsafe.
Aetiology
01
Direct head impact
Collision, fall, ball, tackle or assault transfers linear and rotational force to brain tissue even without visible scalp injury or loss of consciousness.
02
Indirect force
A blow to the body can accelerate the head and produce concussion without direct contact, particularly in contact sport and road trauma.
03
Repeat injury
A second concussion before recovery can prolong symptoms and may expose the person to catastrophic or cumulative harm, making removal and staged return essential.
Pathophysiology
1
Transient network dysfunction
Mechanical strain alters neuronal membranes and connectivity, producing cognitive, vestibular, visual, emotional and sleep symptoms despite normal routine structural imaging.
2
Metabolic mismatch
Increased ionic and energy demand occurs while cerebral blood flow and metabolic reserve are altered, explaining vulnerability to exertion early in recovery.
3
Autonomic and vestibular effects
Disrupted autonomic control, eye movements and balance pathways contribute to exercise intolerance, dizziness, motion sensitivity and headache.
4
Recovery variability
Most improve progressively, but migraine tendency, prior concussion, mental-health needs, sleep disruption and excessive early load can prolong recovery.
Clinical features and red flags
Cognitive features
Confusion, slowed responses, amnesia, difficulty concentrating, repeated questions and feeling foggy can occur without loss of consciousness.
Physical features
Headache, nausea, dizziness, imbalance, visual disturbance, light or noise sensitivity and fatigue commonly fluctuate with cognitive and physical load.
Behavioural and sleep change
Irritability, anxiety, low mood, emotional lability, sleeping more or less and difficulty falling asleep may emerge hours after injury.
Emergency progression
Increasing drowsiness, focal weakness, seizure, repeated vomiting, severe escalating headache, unequal pupils or CSF leak requires emergency structural-injury assessment.
Exercise intolerance
A disproportionate symptom rise during light aerobic activity may reflect incomplete recovery and helps guide a sub-threshold rehabilitation plan.
Persistent phenotype
Dominant migraine, neck, vestibular, ocular, mood or sleep features after several weeks can direct specialist therapy rather than continued generic rest.
Red flags requiring action
Falling consciousness, seizure, weakness, unequal pupils, repeated vomiting, worsening severe headache, neck pain or clear fluid from nose or ear requires emergency reassessment rather than home concussion management.
Any suspected sports concussion means immediate removal with no same-day return, even if symptoms settle quickly or the player passes a brief sideline screen.
Investigations
01First-line clinical assessmentFirst stepFirst line
Why
Diagnose suspected concussion and identify emergency features.
Interpretation and limitations
Use history, GCS, pupils, neurological, balance, cervical and symptom assessment; no single brief screen, blood test or normal CT rules concussion in or out.
02CT head when NICE criteria are met
Why
Exclude acute haemorrhage, fracture and mass effect.
Interpretation and limitations
CT is selected by structural risk, not by symptom burden alone; a normal scan is expected in many concussions and does not authorise immediate sport return.
03Cervical-spine assessment
Why
Identify fracture, instability or cervicogenic symptoms accompanying the head injury.
Interpretation and limitations
Apply NICE clearance and imaging criteria before attributing neck pain, dizziness or limb sensory change solely to concussion.
04Standardised symptom and function review
Why
Track recovery across cognition, balance, vision, mood and sleep.
Interpretation and limitations
Use the same instrument serially when practical, but interpret change with baseline, effort and daily function rather than a pass-fail clearance score.
05
Differential diagnosis
01
Intracranial haemorrhage
Progressive headache, vomiting, focal deficit, GCS decline, seizure or NICE risk factors require CT because concussion cannot exclude structural bleeding.
02
Cervical or vestibular injury
Neck pain, movement-provoked dizziness and balance difficulty may arise from cervical strain, peripheral vestibular damage or both and need targeted assessment.
03
Migraine
Headache, photophobia, nausea and aura can resemble concussion, but temporal relation to trauma and change from the person's usual pattern guide interpretation.
04
Psychological response
Acute stress, anxiety, low mood and sleep loss can amplify symptoms; these are treated seriously rather than used to dismiss possible brain injury.
Management
01ImmediateRecognise, remove and assessFirst stepA person develops possible concussion after direct or transmitted head force.+
1Stop sport or hazardous activity immediately, assess ABC and cervical spine, record GCS, pupils, symptoms, amnesia and observed behaviour.
2Arrange emergency transfer for red flags or NICE CT indications and do not let a concussion screen delay treatment.
3Do not permit same-day return and arrange assessment by an appropriate healthcare professional, with a responsible adult supervising early recovery.
4Provide written and verbal warning signs and ensure school, work and other sporting settings know the restriction.
02RecoveryResume daily life graduallyEmergency structural injury has been excluded and symptoms are stable or improving.+
Complications
01
Persistent symptoms
Headache, fatigue, slowed thinking, dizziness, sensory sensitivity and poor sleep beyond expected recovery can impair school, employment and relationships.
02
Repeat concussion
Returning before recovery increases exposure to another injury while judgement, reaction time and balance remain impaired.
03
Mood and sleep disorder
Irritability, anxiety, depression and insomnia can emerge or worsen after concussion and require direct risk assessment and treatment.
04
Educational or occupational failure
Unmodified cognitive, visual and physical demands can exacerbate symptoms, increase absence and delay a sustainable return to normal roles.
Monitoring and follow-up
Use a daily symptom and function trajectory rather than expecting linear recovery; brief mild fluctuation with increased activity can occur.
Confirm return to school or work, driving safety and each sport stage rather than recording only headache severity.
Ask directly about sleep, anxiety, depression, irritability and suicidal thinking, with urgent mental-health escalation when risk is present.
Review analgesic frequency because frequent use can contribute to medication-overuse headache and obscure the recovery pattern.
For repeat concussion, retain dates, mechanisms, recovery durations and prior imaging to support a specialist exposure-risk decision.
Special situations
No loss of consciousness needed
Concussion can present with headache, memory, balance or behavioural change while consciousness remains continuous.
A scan answers another question
CT looks for acute structural injury; it does not measure the functional network disturbance responsible for concussion.
Relative rest has an endpoint
After the initial short interval, carefully dosed activity usually supports recovery better than prolonged isolation and inactivity.
Return spans several lives
Education, work, driving and sport each carry different cognitive and safety demands and need explicit staged advice.
Persistent symptoms are treatable
Migraine, vestibular, cervical, sleep and mood patterns can receive targeted therapy instead of repeated reassurance alone.
Common pitfalls
01
Allowing same-day return because symptoms settled or the player passed a brief screen.
02
Calling a normal CT evidence that concussion is absent or recovery is complete.
03
Prescribing prolonged strict dark-room rest without a graded reactivation plan.
04
Returning to contact sport before ordinary education or work is tolerated.
05
Giving generic advice without addressing driving, machinery, heights and responsible supervision.
06
Ignoring mood and sleep symptoms or repeating reassurance when recovery exceeds four weeks.
Symptoms lasting more than 4 weeks, worsening after initial improvement, repeated concussion, major mood change or inability to resume education or work warrants clinician-led multidisciplinary review.
Vestibular and ocular assessment
Why
Characterise persistent dizziness, visual intolerance and motion sensitivity.
Interpretation and limitations
Specialist eye-movement, convergence and vestibular testing can identify treatable deficits; severe or focal neurological findings still require medical imaging review.
06MRI or specialist testing
Why
Investigate atypical, focal or prolonged symptoms selectively.
Interpretation and limitations
Routine MRI, biomarkers and formal neuropsychology are not required for uncomplicated recovery; use them when a specific clinical question will alter care.
1
Use relative rest and sleep during the first twenty-four to forty-eight hours, limiting only activities that substantially aggravate symptoms.
2Add light routine and aerobic activity below a marked symptom threshold, then increase cognitive and physical demands in small steps.
3Use temporary education or work adjustments and progress toward full ordinary function before unrestricted contact training.
4Stop and step back if symptoms significantly recur, and seek reassessment for new neurological signs or a worsening overall trajectory.
03EscalationTreat prolonged recoveryEscalationSymptoms persist beyond 4 weeks, worsen, or prevent a sustainable return to normal roles.+
1Reassess the original injury, medication use, cervical spine, headache phenotype, vestibular and visual systems, sleep and mental health.
2Refer to an appropriate concussion, neurological, vestibular, rehabilitation or paediatric service according to the dominant impairment.
3Create a paced activity and role plan with school, occupational health or employer, avoiding both forced exertion and indefinite complete withdrawal.
4Discuss repeat-injury exposure and specialist clearance, especially after multiple concussions, prolonged symptoms or high-risk competition.
Key medicines and prescribing safety1 treatment · regimens, roles and cautions+
Treats headache without the cognitive and balance effects of opioids or sedating antiemetics, supporting a clearer functional assessment.
Paracetamol for acute headache
Take 1 g orally when required up to four times in 24 hours, leaving at least 4 hours between doses; reduce the maximum in adults under 50 kg or with frailty, malnutrition, chronic alcohol excess or hepatic risk.
Count all paracetamol-containing products, avoid overdose and seek reassessment rather than repeatedly masking a worsening headache or new neurological feature.