Concussion and Contusion Management

Pathophysiology and Definition

• Concussion represents a functional disturbance rather than structural injury to the brain, with no abnormality visible on standard structural neuroimaging studies 1, 2
• Concussion results from biomechanical forces transmitted to the head causing a neurometabolic cascade that increases local energy demand in the presence of decreased cerebral blood flow and mitochondrial dysfunction 1, 2
• Concussion is defined as traumatically induced transient disturbance of brain function with Glasgow Coma Scale scores of 13-15, with or without loss of consciousness for less than 30 minutes 1, 3
• Symptoms of concussion typically resolve spontaneously following a sequential course, though 15-20% develop persistent symptoms beyond 2 weeks 1, 2

Diagnostic Approach

• Standard structural neuroimaging will be normal by definition in concussion 1, 2
• Contusion requires neuroimaging (CT or MRI) for diagnosis and monitoring 4
• Clinical examination must identify red flags warranting immediate imaging in contusion: repeated vomiting, worsening headache, focal neurologic deficits, altered mental status, seizures 4, 5

Acute Management

• Implement moderate physical and cognitive rest for 24-48 hours to allow initial recovery during the acute neurometabolic cascade in concussion 6, 5, 4
• Avoid strict prolonged rest exceeding 3 days as this can worsen outcomes and be detrimental to recovery in concussion 6, 5
• Remove immediately from play—"When in doubt, sit them out!" in concussion 5
• Acetaminophen may be used for symptom management in concussion, avoiding NSAIDs/aspirin due to theoretical bleeding risk 4
• Implement "cognitive rest" including temporary reduction in school workload, avoidance of video games, computer use, television, and loud music in concussion 4
• Contusion requires hospitalization for neurological monitoring in most cases 4
• Serial neurological examinations to detect deterioration in contusion 4
• Repeat imaging as clinically indicated to assess for expansion in contusion 4

Return to Activity Protocol

• After initial 24-48 hour rest period, begin gradual progressive return following a specific stepwise protocol in concussion 5, 4
• The return to activity protocol for concussion includes: light aerobic exercise, sport-specific exercise, non-contact training drills, full-contact practice, and return to competition 5
• Each step requires a minimum of 24 hours before progression in concussion 5, 4
• If symptoms recur, return to the previous asymptomatic level and rest 24 hours before attempting progression again in concussion 5, 4
• Supervised, non-contact aerobic exercise below symptom threshold is particularly beneficial for adolescents with acute concussion 6, 4
• Allow return to full activity only when the individual has returned to premorbid performance, remains symptom-free at rest, and shows no symptom recurrence with increasing physical exertion in concussion 6, 5, 4
• No standardized return to activity protocol exists for contusion as management is individualized based on injury severity, location, and complications 4
• Requires neurosurgical clearance before any return to physical activity in contusion 5
• May require months of complete rest from contact activities in contusion 4
• Neuropsychological testing typically required before clearance in contusion 4
• Many patients with significant contusions may be permanently disqualified from contact sports 2
• Return decisions must account for structural brain damage and risk of catastrophic reinjury in contusion 4

Management of Persistent Symptoms

• Implement multidisciplinary management for symptoms persisting beyond 10 days in concussion 5
• Treatment options include sub-symptom threshold aerobic exercise, cervical physical therapy, vestibular rehabilitation, vision therapy, cognitive behavioral therapy, and pharmacological management in concussion 4
• Graded physical exercise, vestibular rehabilitation, and manual therapy for neck pain when present in concussion 4
• Referral to specialist in traumatic brain injury if symptoms persist beyond 3 weeks in concussion 4
• Persistent symptoms in contusion may reflect ongoing structural pathology requiring repeat imaging 4
• Multidisciplinary rehabilitation similar to moderate-severe TBI protocols in contusion 4
• May require formal neuropsychological rehabilitation programs in contusion 4
• Long-term neurosurgical follow-up to monitor for late complications (post-traumatic epilepsy, hydrocephalus) in contusion 2

Critical Pitfalls to Avoid

• Never allow same-day return to play after diagnosed concussion 7, 5, 4
• Do not return to play while taking medications for concussion symptoms as this indicates incomplete recovery 7, 5, 4
• Avoid high-intensity physical activity during recovery as this is detrimental in concussion 6, 4
• Do not rely solely on patient-reported symptoms without objective assessment in concussion 5
• Be more conservative with younger athletes (<18 years) due to potential catastrophic effects on the maturing brain in concussion 4
• Never discharge without appropriate imaging to rule out structural injury in contusion 4
• Do not assume clinical improvement means radiographic stability—repeat imaging is often necessary in contusion 4
• Never clear for contact sports without neurosurgical consultation in contusion 4
• Recognize that contusion patients are at higher risk for post-traumatic epilepsy and require counseling 2

Concussion Management Guidelines

Evidence Against Meclizine Use

• Vestibular suppressants like antihistamines (including meclizine) and benzodiazepines should not be routinely used to treat concussion or its symptoms, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery, based on observational studies showing no benefit as definitive primary treatment 8
• The American Academy of Pediatrics and other major organizations do not include meclizine in their recommended treatment algorithms for concussion, indicating no established role in concussion management protocols 8
• No evidence supports meclizine as effective treatment for concussion-related symptoms, while these medications may show symptom resolution over time in some studies, this occurs within the timeframe of spontaneous recovery that would happen regardless of medication use, according to the American Academy of Otolaryngology-Head and Neck Surgery 8
• Meclizine may interfere with central compensation mechanisms that are critical for recovery from vestibular dysfunction, as stated by the American Academy of Otolaryngology-Head and Neck Surgery, which is particularly problematic since concussion involves a neurometabolic cascade requiring proper neural recovery processes 8
• Vestibular suppressants can decrease diagnostic sensitivity during clinical examination maneuvers, potentially masking important clinical findings, as noted by the American Academy of Otolaryngology-Head and Neck Surgery 8

Appropriate Concussion Management

Active Recovery Phase

• Graded physical exercise below symptom threshold is recommended as a primary intervention, according to JAMA network open 9, 10
• Vestibular rehabilitation should be used specifically for persistent vestibular dysfunction, not vestibular suppressant medications, as recommended by JAMA network open 9, 11
• Multidisciplinary treatment approaches including psychological treatment, manual therapy for neck pain, and oculomotor vision therapy are recommended for persistent symptoms, according to JAMA network open 9, 10

Context: When Meclizine IS Appropriate

• Meclizine is appropriate for benign paroxysmal positional vertigo (BPPV) and other peripheral vestibular disorders unrelated to concussion, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 8