Concussion is defined as a trauma-induced alteration in mental status that may or may not involve loss of consciousness. Concussion is a common consequence of trauma to the head in contact sports and can also result from collisions or falls in all types of athletic activity. Confusion and amnesia are the hallmarks of concussion. These may occur immediately after the injury or several minutes later and may lead to the development of memory dysfunction. Common features include confusion, inability to focus, disorientation, slurred speech, lack of coordination, and memory deficits. Players may also experience headache, dizziness, fatigability, irritability, and sleep disturbances.

One of the most difficult decisions for the team physician is determining when an athlete can return to competition after an injury. In 1997, a Quality Standards Subcommittee of the American Academy of Neurology published sports concussion guidelines to prevent catastrophic outcome and cumulative neurobehavioral conflicts from repeated concussions. Neurologists, neurosurgeons, sports medicine physicians, physiatrists, neuropsychologists, athletic trainers, and players reached a consensus to balance maintaining a competitive edge in a sport and ensuring participant safety. A Grading Scale was established (1-3) as such:

Grade I concussion: Transient confusion (inattention, poor concentration) without loss of consciousness; symptoms resolving in less than 15 minutes

Grade 2 concussion: transient confusion without loss of consciousness with symptoms lasting more than 15 minutes

Grade 3 concussion: any loss of consciousness

Based on literature review and expert consensus, the following recommendations were made for return-to-play following a concussion:

Grade 1: remove from contest and examine immediately and at 5 minute intervals for mental status abnormalities. May return if post-concussive symptoms clear within 15 minutes. A second grade 1 concussion in the same contest eliminates the player from competition for that day. Return to play only if asymptomatic for 1 week.

Grade 2: remove from contest; no return to play that day. A physician should perform a neurological examination to clear the athlete for return to play after 1 full asymptomatic week. If headaches of other symptoms persist for more than a week, CT or MRI scanning is recommended. A second grade 2 concussion means at least two weeks of symptom-free rest before return to play.

Grade 3: athlete should be brought to the nearest ER and a thorough neurological examination performed, including appropriate neuroimaging procedures where indicated. Hospital admission is signs of pathology detected; otherwise, the patient is sent home and neurological status assessed daily until all symptoms have stabilized or resolved. For any symptoms that worsen or persist longer than a week, CT or MR[ scanning should be performed.

For a brief (seconds) grade 3 concussion, the athlete should be withheld from play for 1 week. For prolonged (minutes) grade 3 concussion, the athlete should be withheld from play for 2 weeks. Following a second grade 3 concussion, the athlete should be withheld from play for at least 1 asymptomatic month. Any abnormality on CT or MRI should result in termination of the season for the athlete.

More information may be found in: Practice Parameter: The management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee. Neurology 1997; 48: 581-585.

Lisa Hu, M.D.