Once it has been determined that a concussion has been sustained, a decision must be made as to whether the athlete can return home or should be considered for overnight observation or admission to the hospital. For more severe injuries, the athlete should be evaluated by the team physician or emergency department physician if the team physician is not available. If the athlete is allowed to return home or to the dormitory room, the athletic trainer should counsel a friend, teammate, or parent to closely monitor the athlete. Traditionally, part of these instructions included a recommendation to wake up the athlete every 3 to 4 hours during the night to evaluate changes in symptoms and rule out the possibility of an intracranial bleed, such as a subdural hematoma. This recommendation has raised some debate about unnecessary wake-ups that disrupt the athlete's sleep pattern and may increase symptoms the next day due to the combined effects of the injury and sleep deprivation. It is further suggested that the concussed athlete have a teammate or friend stay during the night and that the athlete not be left alone. No documented evidence suggests what severity of injury requires this treatment. However, a good rule to use is if the athlete experienced LOC, had prolonged periods of amnesia, or is still experiencing significant symptoms, he or she should be awakened during the night.1 Both oral and written instructions should be given to both the athlete and caregiver regarding waking.1,56 The use of written and oral instructions increases the compliance to 55% for purposeful waking in the middle of the night. In the treatment of concussion, complete bed rest was ineffective in decreasing postconcussion signs and symptoms.57 The athlete should avoid activities that may increase symptoms (e.g., staying up late studying, physical education class) and should resume normal activities of daily living, such as attending class or driving, once symptoms begin to resolve or decrease in severity. As previously discussed, a graded test of exertion should be used to determine the athlete's ability to safely return to full activity.1
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