7 “if in doubt, sit them out” minimum of 14 days from when symptoms cease before returning to full contact/collision activities (after medical clearance). > > The long-term consequences of concussion, and especially multiple concussions, are not yet clearly understood. > > If in doubt, sit them out. See diagrams 3 and 4 for non-medical assessment of concussion (on and off field) on pages 10–11. Key Points for medical practitioners > > Concussion can be very difficult to detect. The symptoms and signs can be varied, non-specific and subtle. > > Athletes with suspected concussion should be removed from sport and assessed by a medical practitioner. > > When assessing acute concussions, a standard primary survey and cervical spine precautions should be used. > > Concussion is an evolving condition. Athletes suspected of, or diagnosed with concussion require close monitoring and repeated assessment. > > The diagnosis of concussion should be based on a clinical history and examination that includes a range of domains including mechanism of injury, symptoms and signs, cognitive functioning and neurology including balance assessment. > > The SCAT5 is the internationally recommended concussion assessment tool and covers the abovementioned domains. It can be freely downloaded at bjsm.bmj.com/content/bjsports/ early/2017/04/26/bjsports-2017-097506SCAT5.full.pdf. This should not be used in isolation but as part of the overall clinical assessment. > > Computerised neurocognitive testing can be undertaken as part of the assessment but should not be used in isolation. > > Children and adolescents take longer to recover from concussion. A more conservative approach should be taken with those aged 18 or younger. The graduated return to sport protocol should be extended such that the child does not receive medical clearance to return to contact/collision activities in less than 14 days from resolution of symptoms. > > Blood tests are not indicated for uncomplicated concussion. Medical imaging is not indicated unless there is suspicion of more serious head or brain injury. > > Standard head-injury advice should be given to all athletes suffering concussion and to their carers. > > Once the diagnosis of concussion has been made, immediate management is physical and cognitive rest. This includes time off school or work and deliberate rest from cognitive activity for 24 – 48 hours. After this period, the patient can return to moderate intensity physical activity as long as such activity does not cause a significant and sustained deterioration in symptoms. Concussive symptoms usually resolve in 10 – 14 days. Once the symptoms have resolved the patient can proceed with a graduated return to sport protocol. > > Some sports have their own guidelines or recommendations around the management of concussion in sport which should also be considered. > > If in doubt, sit them out. There is currently no strong evidence clearly linking sport-related concussion with chronic traumatic encephalopathy (CTE). The evidence purporting to show a link between sport-related concussion and CTE consists of case reports, case series and retrospective analyses. The reliance on retired athletes nominating to posthumously undergo autopsy for this research generates significant bias in the samples examined. Confounding factors such as alcohol abuse, drug abuse, genetic predisposition and psychiatric illness have not been controlled for adequately. Further well designed prospective studies are needed to better understand the possible relationship. See diagrams 5 and 6 for medical assessment of concussion (on and off field) on pages 12–13.