The physical exam of the head may show lacerations, bruises, or other signs of impact from the injury. However, it is important to note that the site of injury to the head does not reflect any damage referred to the brain. As noted previously, coup-contrecoup and rotational forces are far more important than the site of the external impact. The neurologic examination is usually normal except very early nystagmus or other extraocular movement deficits, pupillary changes, mild ataxia or dysmetria observed on cerebellar testing, and anosmia (it is helpful to include CN I given its sensitivity to TBI from orbital frontal abrasions from the cribriform plate). It is recommended to spend more time than usual on the cerebellar part of the exam, including tests of upper extremity coordination (finger-to-nose as well as finger-nose-finger), lower extremity coordination (heel-to-shin), and gait (normal, tandem, heel walking, toe walking). A useful and sensitive adjunct to the cerebellar examination is the Balance Examination Scoring System (BESS; [14]). This exam is part of the SCAT-3 [2] and many other PCS tools and is quick and easy to administer. There are three lower extremity stances utilized: feet together, tandem stance, and (for older children) standing only on the nondominant leg. Detailed instructions are given in the SCAT-3 form that is available for download from the CDC.

Counseling the child and parent on the natural course of concussion is obviously important. The intense media attention given to concussion has produced a near-hysteria among some parents and schools, and you may be asked if the concussion sustained will leave the child at risk for two of the buzzwords frequently occurring in the popular press: second impact syndrome and chronic traumatic encephalopathy.

This is a difficult decision for a pediatrician to make. Most importantly, the child must never return to any sport or active play on the same day as a suspected concussion. The first few days after a concussion, the child may have a wide range of symptoms of varying severity. There is no hard and fast rule about when to recommend that a child stay out from school. Instead, these recommendations should be individualized to the specific child’s symptoms, severity, and school circumstances. It was once thought that children (and adults) should avoid all activities involving sustained concentration, such as schoolwork, for a period of time after the injury. However, more recently experts have suggested that a child who is mildly to moderately symptomatic return to school, but with instructions to report to the school nurse and/or return home if class work exacerbates any symptoms. Prolonged absences from school should be avoided unless the signs and symptoms of the concussion are especially severe, given that the child can be stressed by later having to catch up with missed exams or projects. Additionally, some concentration in school (or at home) can be beneficial, much like patients who have back pain benefit more from mild exercise or activity than from going on bed rest. The schools may be overly conservative and want the child held out, but they should be informed in writing of what your opinions are and what you recommend. Accommodations may be offered to assist the child in returning to school, such as shortened school days, fewer classes, rest breaks, reduced workload, and extended time for tests.

Determining when the child may return to sports is also difficult; most guidelines were researched and developed for professional athletes first and then adapted for children. Professional sports such as football (NFL) and hockey (NHL) have very well-researched and reasonable guidelines for return to practice and play, generally following the recommendations of the 4th International Conference on Concussion in Sport and those listed on the CDC’s website. These organizations recommend that the athlete begin an escalating program of exercise after the patient is symptom-free or has symptoms equivalent to baseline and has neuropsychological testing that is normal or equivalent to baseline. ImPACT testing, the BESS, and re-administration of the Child-SCAT3 can be helpful in tracking recovery of cognitive and motor functioning. However, be aware that an athlete may have intentionally produced poor ImPACT scores at baseline in anticipation of retesting after a concussion to be able to return to play faster or hurried through the battery without sufficient effort at baseline.

A typical exercise program would include riding a stationery bicycle up to a heart rate of 120 and then 160 bpm on 1 day, weight or strengthening exercise on a second day, noncontact practice on a third day, and finally practice with contact or equivalent intensity on subsequent days. If at any time the exercise produces any symptoms, the program should back down to the previous step (as long as that does not cause symptoms). Take steps to ensure that coaches, PE teachers, and athletic trainers are informed of this graduated approach.

Recommendations for activities at home or away from school should be similar. Video games, TV, and computers do not necessarily have to be avoided and, like classroom work, may be of some benefit as long as the concussion signs and symptoms are not severe. Again, titrating the activities to the child’s reaction is the best plan of action. For both home and school, gradually increasing the amount of time spent in activities requiring sustained concentration helps speed recovery and curtails the tendency of some children to become chronic patients. Also be cognizant of secondary gain. Some children may enjoy the attention they receive while at home, and prolong their symptoms (consciously or subconsciously) to avoid school, chores at home, etc. and enjoy being told to rest while at home.

There is no medication that will facilitate the recovery from a concussion. Instead, the signs and symptoms that occur following a concussion can be treated individually. Headache is the most common complaint that is amenable to medication. However, any medication should be avoided or minimized in the first 24–48 h to assure that a possible hemorrhage is not developing that could be masked by analgesics. It is common to have headaches persist throughout the recovery period. Clinicians differ in their views on treating continuing headaches, with some encouraging their patients to avoid analgesics. However, a number of neurologists have been prescribing amitriptyline, an older tricyclic antidepressant, for posttraumatic headaches with reported success. Although there have been no controlled studies on this drug, anecdotal reports suggest that it can be beneficial. If the child has a history of migraines or if the posttraumatic headaches resemble idiopathic migraines, medication used in treating classic migraine could be considered until the headaches subside.

Patients may be referred for consultation by a neuropsychologist if assistance is needed in determining an appropriate return to play and especially return to school timeline. Evaluation should be performed by a neuropsychologist familiar with sports-related concussion. The American Academy of Clinical Neuropsychologists (AACN) provides a directory of board-certified clinicians which may be helpful in identifying a qualified consulting neuropsychologist (http://​www.​theaacn.​org).