Recognising Concussion and What to Do on the Day

A head knock with any of the features below is not a concussion assessment problem. It is a potential neurosurgical or spinal emergency, and it needs an ambulance or an emergency department, not a clinic appointment and not a wait-and-see.

Anyone with a suspected concussion is removed from play or training immediately and does not return that day. This is not a judgement call to be revisited after a few minutes on the bench — under both the AFL community guidelines and the Rugby Australia procedure, no coach, parent or official can override a removal, and there is no same-day return at community level.

The AFL's May 2026 update made a point that is easy to get wrong: symptoms that settle quickly do not rule out concussion. A player who says they are fine five minutes later is still a player with a suspected concussion, and the guidance now sets out clearer expectations for monitoring over the following 24 hours.

The reason for the strictness is the risk of a second impact while the brain is still recovering, and the fact that most of the damage from returning too early is done in the days immediately after the injury.

There does not have to be a loss of consciousness. Most concussions occur without one. What you are looking for is any change from how that person normally is — in how they move, how they answer, how they look, or what they report.

Signs someone else can observe include lying motionless, slow to get up, unsteadiness or loss of balance, a blank or vacant look, a facial injury after head trauma, disorientation, or an inability to answer simple questions about where they are and what the score is. Symptoms the person reports include headache, pressure in the head, dizziness, nausea, blurred vision, sensitivity to light or noise, feeling slowed down or in a fog, difficulty concentrating, and being unusually emotional or irritable.

Symptoms can be delayed. Someone who seems fine at the ground and deteriorates over the evening is a common pattern, which is why the 24-hour period after the injury matters and why the person should not be left alone with nobody aware of what has happened.

The ANZ Concussion Guidelines endorse three standardised tools: the Concussion Recognition Tool, for anyone at the ground with no medical training; the Sport Concussion Assessment Tool (SCAT6) for adults; and the Child SCAT6 for children. The AFL's May 2026 update strengthened its position on these — SCAT6 and Child SCAT6 assessment is now expected rather than merely permitted.

It is worth being clear about what these tools do. They structure an assessment so nothing is missed and so the same things are checked each time. They do not diagnose concussion on their own and a normal score does not exclude it. The diagnosis remains clinical.

The guidelines also point to validated rules for the neck, because a head injury and a cervical spine injury arrive together often enough that the neck must be actively cleared rather than assumed: NEXUS and the Canadian C-Spine Rule in adults, and the PECARN rule in children.

Imaging in concussion is not looking for the concussion. It is looking for the things that are not concussion — bleeding, a fracture, a lesion needing neurosurgical attention. A normal CT does not mean nothing happened; it means nothing surgical happened.

The ANZ guidelines direct clinicians to validated decision rules rather than scanning on anxiety: the PECARN rule in children, which weighs features such as a Glasgow Coma Scale below 15 or altered mental status, abnormal neurological examination, severe mechanism, post-traumatic seizure, a palpable skull fracture, loss of consciousness of five seconds or more, and a parent's report that the child is not acting normally. In adults the Canadian CT Head Rule applies, weighing a GCS below 15 at two hours, suspected open or depressed skull fracture, any sign of a base-of-skull fracture, two or more episodes of vomiting, and age 65 or over.

On timing, CT is the appropriate investigation for excluding a neurosurgically significant lesion in the acute phase — within 48 hours — and is not the appropriate investigation after that. Routine repeat CT is not warranted, even in people at higher risk of a bleed progressing.

Two groups warrant a lower threshold: anyone on an anticoagulant or antiplatelet, particularly over the age of 60, and people with a neurodevelopmental disability, in whom neurological deterioration is harder to detect against their baseline.

Advice has moved a long way from the old instruction to sit in a dark room. The ANZ guidelines recommend relative rest, not strict rest, and specifically advise against complete rest and isolation. Most ordinary daily activities can continue. Reduced screen use in the first 48 hours is reasonable; a blanket ban is not supported.

Alcohol and recreational drugs should be avoided while symptoms persist. For pain, paracetamol or ibuprofen are acceptable in the first two weeks — after that, keeping to fewer than three doses a week or fifteen a month avoids medication-overuse headache, which is a common and entirely avoidable reason a recovery stalls. Ibuprofen and other anti-inflammatories are not appropriate for anyone on an anticoagulant or with a bleeding disorder.

Sleep does not need to be interrupted. There is no need to wake someone hourly through the night — that advice has been superseded, and disrupted sleep makes recovery harder rather than safer.

Anyone discharged from an emergency department after a concussion should be advised to follow up with their usual doctor within one to two weeks, and that follow-up is where the return-to-learn and return-to-sport plan should be set.