Concussions in Sports
Abstract & Commentary
Synopsis: The AOSSM Concussion Workshop Group presents evaluation and return-to-play criteria.
Source: Wojtys EM, et al. Current concepts. Concussion in sports. Am J Sports Med 1999;27(5):676-687.
This "current concepts" article, which is a special report of the findings of a concussion workshop sponsored by the American Orthopaedic Society for Sports Medicine (AOSSM), is an excellent review of the pathophysiology, diagnosis, management, and return-to-play guidelines following a concussion in an athlete. Dr. Hovda, in his section on the neurobiology of concussions, emphasizes how little we really know about the short- and long-term effects of concussions on brain cells. A concussion, or cerebral contusion, is followed by a reduction in cerebral blood flow. In the immediate post-concussion period (approximately 3 days), brain cells that are not irreversibly destroyed may exist in a "vulnerable state," most likely secondary to metabolic dysfunction. This period of enhanced vulnerability is characterized by an increase in the demand for glucose but at the same time a decrease in cerebral blood flow.
This decrease in cerebral blood flow is thought to be due to increased vasoconstriction caused by endothelial accumulation of CA++.
Wojtys and colleagues remind us that the initial on-field evaluation of a concussed athlete is similar to that for any acutely injured athlete, i.e., first assess the athlete’s airway, breathing, and circulation. Also, all head-injured athletes must be assumed to have had a concurrent neck injury until ruled out through a thorough physical examination. Art Boland’s explanation of the steps for evaluation of the concussed athlete on the field and on the bench is excellent.
Wojtys et al stress the need for a reliable, easily administered neurophysiologic evaluation for concussed athletes and end the article with recommendations for return to play following a head injury.
Comment by Letha Y. Griffin, MD, PhD
Recently, there has been a fair amount of debate as to what constitutes reasonable criteria for return to play following a head injury. Several concussion-rating systems have appeared in the literature, including those of Cantu, the Colorado Medical Society, and the American Academy of Neurology.
The AOSSM-sponsored concussion workshop arrived at several conclusions regarding return-to-play issues:
1. If the signs and symptoms of concussion clear within 15 minutes or less, both at rest and with exertion, and the athlete has a normal neurologic exam and had no loss of consciousness, the athlete can return to competition that day.
2. A loss of consciousness precludes return to play that day.
3. Persistence of symptoms longer than 15 minutes, or delayed onset of symptoms, should prevent return to play that day and the athlete should be closely monitored. Symptoms indicative of a head injury are headache, dizziness, memory loss, slowness in response to questions, difficulty concentrating, and physical sluggishness.
4. Any deterioration in physical or mental status warrants emergency transportation for further evaluation.
5. Athletes with prolonged symptoms may return to play after five to seven days of rest, although this time frame varies and should be individualized. Repeated examinations as activity is resumed should be performed to determine if stress triggers symptoms.
6. A physician should evaluate every athlete with a concussion.
This article is an excellent overview of an important topic that all of us covering sports events should be familiar with.
Symptoms associated with concussions include:
a. headache and vertigo.
b. slowness in responding and difficulty concentrating.
c. confusion and memory loss.
d. nausea and physical sluggishness.
e. All of the above
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