New Recommendations for Management of Sports- Related Concussion Injury
Abstract & Commentary
Source: Kelly J. MMWR Morb Mortal Wkly Rep 1997;46:224-227; also reported in JAMA 1997;277:1190-1191.
In recent years, disease surveillance has improved for injuries, including traumatic brain injury (TBI). Previously undetected by public health officials, the number of sports-related TBIs in the United States is now estimated at 300,000 each year, most of which are of mild-to-moderate severity. These mild-to-moderate "concussion" injuries, defined as a temporary and self-limited alteration in neurologic status following trauma to the head, have been lightly regarded in the past. There is now good evidence that mild brain injury occurring repeatedly, even over months to years, can result in cumulative cognitive and neurologic deficits. Furthermore, the first occurrence of a concussion increases the risk of subsequent TBI, and repeated brain injury within short periods of time (i.e., hours to days) may lead to severe brain injury and death.
Kelly has reported the problem of "second impact syndrome" in Morbidity and Mortality Weekly Report. This syndrome is the occurrence of severe or fatal TBI as a result of repeated blows to the head, occurring most often in young adult or adolescent males engaged in contact sports. It is characterized by the occurrence of a concussion injury, followed by a second injury from a blow to the head within hours, leading to permanent, severe brain injury.
The true incidence of second impact syndrome is not known, but concussion among athletes is ubiquitous. Because of the widespread nature of this problem, and the youthful, robust nature of the victims of these injuries, a national solution is advocated. The American Academy of Neurology has issued recommendations for individuals who assess athletes with concussions to help categorize the injuries and determine whether the athlete should continue to engage in the sporting activity. The recommendations are summarized in the table.
Table
American Academy of Neurology Recommendations for Assessment and Management of Concussions in Athletes
When concussion occurs, remove the individual from sport activity and examine neurologic and mental status every five minutes.
Grade 1: Transient confusion, no LOC*, duration of AMS* less than 15 minutes
Management: 1) May return to sport that day if asymptomatic within 15 minutes
2) If second Grade 1 concussion occurs that day, remove from sport until asymptomatic for one week
Grade 2: Transient confusion, no LOC, duration of AMS 15 minutes or greater
Management:1) Extensive diagnostic evaluation if any symptoms worsen or persist for more than one week
2) Remove from sport until asymptomatic for one week.
3) If Grade 2 concussion occurs following a Grade 1 on same day, remove from sport until asymptomatic for two weeks
Grade 3: Brief LOC (seconds) or prolonged LOC (minutes or longer)
Management: 1) If LOC present on first exam or patient is awake with persistent AMS following an LOC, transport to nearest appropriate ED for full evaluation
2) If LOC is brief, remove from sport until asymptomatic for one week; if prolonged, remove from sport until asymptomatic for two weeks
3) If second Grade 3 concussion, remove from sport for one month
4) If any intracranial pathology is evident on CT or MRI, remove from sport for season and discourage future participation in contact sports
* LOC = loss of consciousness; AMS = altered mental status
COMMENT BY JEFFREY W. RUNGE, MD
Emergency physicians evaluate and treat the entire spectrum of brain injury, from life-threatening severe brain injuries to children who fall off the bed. Management is relatively straightforward for patients with severe brain injury or those who present to the ED with persistent neurologic changes. Such patients receive appropriate neuro-imaging and consultation or transfer for definitive care. But those patients who present with a history of LOC or AMS who appear normal at the time of presentation present a particular challenge. Even if we could all agree on who needs a CT scan following an episode of AMS, how soon can a patient return to normal activity with a negative scan? What if their normal activity subjects them to further head trauma, as in contact sports?
Until now, physicians have had little guidance from the medical literature on the safety of returning a patient to normal activity after a minor brain injury that may place him or her at risk for yet another minor brain injury. This is frequently the dilemma in the evaluation of athletes who are motivated to return to sports; without rational guidelines, physicians may be hesitant to resist the desire of coaches, players, or parents to "get back in the game." Fortunately, these recommendations from the American Academy of Neurology provide guidance to whomever is charged with the safety and health of athletes, be it coaches, trainers, or physicians. Those physicians who serve as de facto sports medicine doctors for their chosen sporting events should teach these recommendations to trainers and coaches, particularly the grading of concussion, so that the vocabulary can be standardized. Teaching proper evaluation should also draw attention to the potential harm this injury can cause, instead of hearing "he just got his bell rung."
Recurrent concussion is an injury that is virtually completely preventable by application of the "three E’s" of injury control: Education of parents, coaches, trainers, and physicians about recurrent concussion; Engineering of sports equipment to prevent brain injury when contact does occur; and Enforcement of guidelines about cessation of contact sports when indicated. Even though both recurrent concussion and its sequelae are common and widespread, the problem has existed below the radar screen of public health surveillance until recently. The fact that the true incidence of second impact syndrome and of behavioral or cognitive problems from recurrent brain injury is not known suggests the need for widespread public education on this issue. Methods for reporting these injuries must be developed in order to determine the extent of the problem. The good news is that the National Center for Injury Prevention and Control at the CDC is committed to the study of traumatic brain injury, which will serve to elucidate the nature and scope of the problem. For now, these recommendations serve as a useful starting point for future recommendations that will be based on more sound epidemiologic and neuropathologic data when available. In the meantime, emergency physicians have a useful tool to address a long-standing problem.
The immediate bottom line for emergency physicians is that these recommendations will most certainly be interpreted as the current standard of care for managing sports-related concussions. Whether or not the recommendations are appropriate or are thought to be too conservative or too liberal, they will serve to standardize the method by which young athletes are returned to sports activities.
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