Concussion and return to learn or play — formative SAQs

SAQ 1 (10 marks) — The dazed fourteen-year-old rugby player

Stem: A fourteen-year-old boy is helped off the rugby field after a tackle. He is dazed and slow to rise, complains of a headache and a feeling of being foggy, and is nauseated. He did not lose consciousness. On examination he is alert and orientated, his pupils are equal and reactive, his cervical spine is non-tender, and his neurological examination is normal. Outline your assessment, the acute management, and the graduated pathway. [1] [2]

Model answer

Assessment and the red-flag screen (3 marks). This is a sport-related concussion. The diagnosis is clinical, and I run the red-flag screen first to separate the concussion from the evolving intracranial injury. The deterioration of consciousness, the drowsiness, the repeated vomiting, the severe headache, the seizure, the focal deficit, and the unequal pupil are the red flags that send a child to the emergency department. This boy is alert, orientated, and neurologically intact with a non-tender cervical spine, so the screen is negative and the pathway is the graduated recovery. I use the SCAT6 because he is fourteen, which frames the symptom, cognitive, and balance components against the baseline. [8] [2]

Acute management (3 marks). The boy is removed from play and not returned the same day, because a second impact in the vulnerable window risks the catastrophic second impact syndrome. I advise twenty-four to forty-eight hours of relative rest with reduced physical and cognitive load, followed by early symptom-limited activity, and I explicitly reject the prolonged strict rest or cocoon therapy that the older practice taught, because it increases the isolation, the deconditioning, and the persistent symptoms. I give the family a clear safety-net for the red flags that would bring them back to the emergency department. [12] [5]

The graduated pathway (4 marks). The boy returns to learn before he returns to sport. The return-to-learn ladder moves through the light activity, the schoolwork at home, the part-time school, and the full school with accommodations such as the shorter days, the extra time, the reduced screen time, and the breaks, tapered as the symptoms ease. Only then does he begin the six-stage return to sport: the symptom-limited activity, the light aerobic, the sport-specific drill, the non-contact training, the full-contact practice after the medical clearance, and the return to play. Each stage is held for at least twenty-four hours, and he drops back a stage if the symptoms worsen. [4] [1]

SAQ 2 (10 marks) — The adolescent with persistent symptoms at four weeks

Stem: A sixteen-year-old netballer is reviewed one month after a concussion. She still has daily headaches, poor concentration, fatigue, and irritability, and her school grades have slipped. Her initial symptom burden was high, she has a history of migraine, and she has been resting at home for much of the month. Outline your assessment, the factors that frame the prognosis, and your management. [6] [5]

Model answer

Assessment and the diagnosis (3 marks). This girl has persistent post-concussive symptoms, defined as the symptoms that persist or worsen beyond the expected four-week recovery window. Most children recover within four weeks, so the persistence at the one-month mark redirects the management from the straightforward graduated recovery to the structured multidisciplinary plan. The decline in her school performance reflects the cognitive load of the classroom exceeding the recovering brain, and I re-run the red-flag screen to exclude the rare missed intracranial injury or the post-traumatic seizure that an atypical course would prompt me to image. [6] [5]

The factors that frame the prognosis (3 marks). Her risk factors for the prolonged recovery are several. The high initial symptom burden is the strongest predictor of persistence, the adolescent and the female sex recover more slowly, the migraine history adds to the risk, and the prolonged rest at home for much of the month has itself contributed to the deconditioning, the isolation, and the persistent symptoms. I name these factors aloud because they frame the multidisciplinary plan and the expectation. [5] [6]

Management (4 marks). I shift from the rest to the structured multidisciplinary plan. I end the prolonged strict rest and begin the early sub-symptom-threshold aerobic exercise, because the evidence shows that the adolescents who adhere to the aerobic prescription recover faster. I arrange the targeted therapies: the headache management, the vestibular or the cervicogenic physiotherapy for the dizziness, and the psychology for the mood and the anxiety. I liaise with the school for the staged return to learn with the accommodations, and I refer to the multidisciplinary concussion service with the neurology, the neuropsychology, and the physiotherapy. [4] [5]