Concussion Guidelines

ATTENTION PARENTS AND ATHLETES!

CONCUSSION EVALUATION FORM FOR COACHES - This form is for use by coaches to assess the athlete for a concussion.

SCAT CARD: SPORT CONCUSSION ASSESSMENT TOOL - This card is for use by medical personnel to assess the athlete for a concussion.

Girls Are Often Neglected Victims of Concussions - N.Y. Times, October 2, 2007

"According to the Centers for Disease Control and Prevention, 20 percent of the brain injuries that occur yearly in the U.S. can be attributred to athletics. That is more than 300,000 concussions! High school, college and amateur athletes receive most of these injuries, because thee are so many more of these players than there are pros." 1 There are an estimated 62,800 concussions annually among high school students nationwide. 2 Data from the NCAA Injury Surveillance System for the perior 1994-1996 estimated that more than 1500 concussions occur annually in college football. 3

"'This is a major public health issue that's been geven short shrift,' says Michael W. Collins of the Henry Ford Hospital in Detroit. 'It's underrecognized, underdiagnosed and misdiagnosed. It's happening with alarming frequency at the high school, college, and professional levels." 1

"A single blow to the head can cause a whole range of symptoms, from problems with balance and coordination to impaired decision making, failing memory and personality changes. Unless the injury is severe, patients generally recover with time. But most athletes return to games or practices far to soon. A second blow before a consussion is fully healed has a far greater chance of imposing more serious, long-lasting harm." 1

393 college football players were studied and about one in three had suffered a concussion and one in five had suffered two or more. Those who had suffered two or more were significantly more likely to report continuing problems with headaches, sleep and concentration, and they scored significantly worse on tests of the ability to learn words, to think quickly and to handle complex tasks. 2

Players who had learning disorders fared even worse if they had two or more concussions, suggesting that the disorders make the brain especially vulnerable to jarring head injuries. 2

Another study in JAMA reported that amateur soccer players scored lower on tests of memory and planning than other amateur athletes did, and that repeated blows to the head may be the culprit. 2

WHAT IS A CONCUSSION?

"The definition of concussion is a post-traumatic impairment of neural status. While the loss of consciousness and amnesia may have been viewed as the primary components of this injury and have formed the basis for most grading scales, some of the mild concussions, the so called 'bell-rung' or 'ding,' with no resulting loss of consciousness or post-traumatic amnesia, may go unrecognized by coaches, athletic trainers, fellow players or team physicians." 3

The brain sits inside a bony encasement called the skull. A collision, abrupt stop or whiplash motion can cause the brain to slam up against the inside of the skull like a pinball. Most of the time the brain tissue itself is not damaged (except in the worst cases), but a devastating cascade of chemical reactions is unleashed. 1

This slamming of the brain causes the brain cells (neurons) to fire off sending the brain into a panic almost like a brief seizure. This sinister wave of extreme electrical activity spreads across the brain telling the neurons to keep firing. This excess firing clogs the mitochondria (energy producing part of the neuron) and prevents it from doing its job. This is a big problem because the neurons are attempting to regain a normal state so that they can fire again and this scramble consumes a lot of energy. So just when more energy is needed, the mitochondria cannot produce it. 1

To compound the problem, the brain's blood vessels constrict, preventing the blood from carrying glucose ("fuel")and thereby causing an energy crisis. This can kill brain cells and result in permanent brain damage. 1

To make matters even worse, extra sodium enters the neurons causing them to swell and push against the skull. If the swelling is severe, the brain can crush itself against the skull causing more cell to die. 1

These chemical reactions peak rapidly, but it takes a long time to settle the brain back to normal. Once the brain can meet the high energy demand and does return to normal it goes into a state of metabolic depression, i.e. exhaustion. The more severe the concussion, the longer this chemical cascade can continue. 1 "If a second concussion interrupts the brain's quest for equilibrium...a new cascade starts on top of the first one. The resulting damage is not just additive but multiplicative." 1

DANGEROUS SPORTS

The threat of concussion varies from sport to sport, but a 1999 study tracked varsity athletes from 235 Iowa high schools. The authors found football accounted for the most brain injuries, followed by wrestling, soccer and basketball. For all the sports except volleyball, the rate of concussion was up to 14 times greater during games than practice. Athletes "who sustained more than one concussion tended to get their second in the same season as the first, rather than later - perhaps because of the impairment from the first concussion." 1

CONCUSSION RECOGNITION AND MANAGEMENT

A concussion may or may not involve loss of consciousness. The following is a list of symptoms of concussion: 3

Headache	Irritability
Confusion/Disorientation	Hyperexcitability
Tinnitus (Ringing in the ears)	Loss of consciousness
Dizziness	Unsteadyness
Amnesia Post-traumatic Retrograde	Concentration Difficulty

Other symptoms can include confusion, lack of awareness, slurred speech and nausea.

SCAT CARD: SPORT CONCUSSION ASSESSMENT TOOL - This card is for use by coaches and doctors to assess the athlete for a concussion.

RETURN TO PLAY GUIDELINES

There are many "return-to-play" grading scales, but none are universally agreed upon. Here are the American Academy of Neurology guidelines for concussion:

GRADE 1

Symptoms: Momentary confusion but no loss of consciousness. Mental status abnormalities last less than 15 minutes.

Management: The athlete must be removed from the game and be examined immediately and at five minute intervals for signs of disorientation. The athlete may return to the game only if confusion and other symptoms clear within 15 minutes. Any athlete who incurs a second Grade 1 concussion the same day should be removed from play until symptom-free for one week.

GRADE 2

Symptoms: Brief confusion, but no loss of consciousness. Mental status abnormalities last more than 15 minutes but less than 60 minutes.

Management: The athlete must be removed from the game and not allowed to return. A medical exam is necessary. If symptoms persist a more extensive diagnostic evaluation is required. Get an MRI of the brain if symptoms persist for more than one week. The athlete may resume playing only after one week without symptoms. Any athlete who incurs a Grade 2 concussion subsequent to a Grade 1 concussion on the same day should be removed from play until symptom-free for two weeks.

GRADE 3

Symptoms: Loss of consciousness, either seconds (brief) or minutes (prolonged). Mental status abnormalities last greater than 60 minutes.

Management: If the athlete is unconscious or if abnormal neurological signs are present at the time of initial evaluation, the athlete should be transported to the nearest emergency room. No sports for at least a week after brief loss of consciousness (seconds) and two weeks after prolonged loss of consciousness (minutes). If subsequent brain scan shows brain swelling, contusion or other intracranial pathology, the athlete should be removed from sports for the season and must discuss the findings with the doctor. Returning to contact sports is discouraged. 1

The NCAA does not endorse any particular grading scale of concussion, but it does state, "The attending medical staff should not allow a player to resume participation in physical activity while the injured student-athlete is recovering from his/her post-concussive symptoms.

Another assessement tool is the Standardized Assessment of Concussion Exam. This exam was developed to establish a standardized sideline evaluation for the injured athlete.

Orientation: Time, place, person, situation
Concentration: Count digits backwards, count months of the year in reverse order.
Memory: Names of teams, recall three words and three objects.
Exertional Provocative tests: 40 yard sprint
Neurological Tests: Strength (push-ups), Sensation (pin prick), Coordination (stand on one leg), Agility (run and cut right/left).

All individuals involved in sports, including coaches, athletic trainers, team physicians, student-athletes and parents, should be educated in the symptoms of concussion and the need for medical attention in the event of such an injury." 3 (bold, color and italics added)

Three recent studies show the importance of proper assessement of the concussed athlete and support the removal of ANY concussed player from a practice or game.

Zemper ED: Two-year prospective study of relative risk of a second cerebral concussion. Am J Phys Med Rehabil 2003;82(9):653-659.

This study reported that the relative risk for patients who had a history of concussion was almost 6 times greater than those who did not.

Guskiewicz KM, et al: Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA Concussion Study. JAMA 2003;290(19):2549-2555.

The players who reported a history of three or more concussions were three times more likely to have another concussion than players without a history of concussion. Also, a history of multiple concussions was associated with slowed recovery.

McCrea M, et al: Acuter effects and recovery time following concussion in collegiate football players: the NCAA Concussion Study. JAMA 2003;290(19):2556-2563.

Players with concussions had more severy symptoms, cognitive impairment, and balance problems immediately after sustaining a concussion. Symptoms gradually resolved by day 7.

2004 - New Guidelines from the NATA

HOW TO REDUCE SEVERITY OF SPORT-RELATED CONCUSSION AND IMPROVE RETURN-TO-PLAY DECISIONS

In recent years, new scientific research and clinical-based literature have given the athletic training and medical professions a wealth of updated information on the treatment of sport-related concussion.

To provide certified athletic trainers (ATCs), physicians, other medical professionals, parents and coaches, with recommendations based on these latest studies, the National Athletic Trainers’ Association (NATA) issued an advance review of its position statement on sport-related concussion at its 55th Annual Meeting in Baltimore on June 16. The entire statement will be published The Journal of Athletic Training in September 2004. Below are some of the highlights:

Defining & Recognizing the Concussion

The term “ding” should not be used to describe a sport-related concussion as it generally diminishes the seriousness of the injury. If an athlete shows concussion-like signs and reports symptoms after a contact to the head, the athlete has, at the very least, sustained a mild concussion.

Signs of concussion include: fluctuating levels of consciousness, balance problems, memory and concentration difficulties and self-reported symptoms, such as headache, ringing in the ears and nausea.

Evaluating and Making the Return-to-Play Decision

For athletes playing sports with a high risk of concussion, baseline cognitive and postural-stability testing should be considered. If an athlete is injured, the time of the initial injury should be recorded. Serial assessments of the athlete should be documented, noting the presence or absence of signs and symptoms of injury. The ATC should monitor vital signs and level of consciousness every 5 minutes after a concussion until the athlete’s condition improves. The athlete should also be monitored over the next few days after the injury for the presence of delayed signs and symptoms and to assess recovery.

Concussion Assessment Tools

Formal cognitive and postural-stability testing is recommended to assist in determining injury severity and readiness to return to play (RTP). Once symptom-free, the athlete should be reassessed to establish that cognition and postural stability have returned to normal for that player.

When to Refer to a Physician

An athlete with a concussion should be referred to a physician on the day of injury if he or she lost consciousness or experienced amnesia lasting longer than 15 minutes. A team approach should be used in making RTP decisions after concussion. This approach should involve input from the ATC, physician, athlete, and any referral sources.

When to Disqualify

Athletes who are symptomatic at rest and after exertion for at least 20 minutes should be disqualified from returning to participation in a sport on the day of the injury. Athletes who experience loss of consciousness or amnesia should be disqualified from participating on the day of the injury. Athletic trainers should be more conservative with athletes who have a history of concussion.

Special Considerations for Young Athletes

Because damage to the maturing brain of a young athlete can be catastrophic, athletes under age 18 years should be managed more conservatively.

Home Care

An athlete with a concussion should be instructed to avoid taking medications, unless acetaminophen or other medications are prescribed by a physician. Any athlete with a concussion should be instructed to rest, but complete bed rest is not recommended. The athlete should resume normal activities of daily living as tolerated, while avoiding activities that potentially increase symptoms.

Equipment Issues

The ATC should enforce the standard use of helmets for protecting against catastrophic head injuries and reducing the severity of cerebral concussions. The ATC should enforce the standard use of mouthguards for protection against dental injuries.

National Athletic Trainers' Association position statement: sport-related concussion. J Athl Train. 2004;39(3).

The Standard Assessment of Concussion takes approximately 5 minutes to administer and includes measures of:

Orientation (month, date, day of week, year, time)
Immediate memory (recall of 5 words in 3 separate trials)
Neurologic screening
Loss of consciousness (occurrence, duration)
Post-traumatic Amnesia (PTA) (either retrograde or anterograde) (recollection of events pre- and post-injury)
Strength
Sensation
Coordination
Concentration (reciting numbers backwards; months in reverse order)
Exertional maneuvers (jumping jacks, sit-ups)
Delayed recall (5 words)

The Balance Error Scoring System (BESS)

One of the signs of a concussion is poor balance. An athlete's balance and equilibrium can be tested quickly on the sideline through use of the Balance Error Scoring System (BESS). The BESS consists of 3 tests lasting 20 seconds each, performed on two different surfaces, firm and foam:

The athlete first stands with the feet narrowly together, the hands on the hips, and the eyes closed (double leg stance). The athlete holds this stance for 20 seconds while the number of balance errors (opening the eyes, hands coming off hips, a step, stumble or fall, moving the hips more than 30 degrees, lifting the forefoot or heel, or remaining out of testing position for more than 5 seconds) are recorded.

The test is then repeated with a single-leg stance using the non-dominant foot, and

A third time using a heel-toe stance with the non-dominant foot in the rear (tandem stance).

All three tests are performed on a firm surface (grass, turf, court), and again on a piece of medium-density foam (a piece of foam can easily be carried in a travel trunk or equipment bag for road games).

PREVENTION

Learn proper tackling techniques in football. NO SPEARING, i.e. LEADING WITH THE HEAD!
Perform proper strength and conditioning, especially neck strengthening exercises.
Provide and properly fit equipment. Proper equipment maintenance is critical.
Remind all involved in sports that that they should expect an unconscious athlete to have a cervical spine injury until proven otherwise.
Learn proper helmut removal and transportation techniques.

Shulman, Polly. "Blowing the Whistle on Concussions." ScientificAmerican Presents, 11(3):44-51, Fall, 2000.
A collection of articles on brain injury in high school, college and professional athletes can be found in the Journal of the American Medical Association, 22(22); September 8, 1999.
NCAA Sports Medicine Handbook 2003-2004

MORE INFORMATION:

Concussion Guidelines
Concussion Guidelines, Robert Cantu, MD
Concussion Safety
The Concussion Puzzle: 5 Compelling Questions
Summary and Agreement Statement of the First International Conference on Concussion in Sport, Vienna 2001
Summary and Agreement Statement of the 2nd International Conference on Concussion in Sport, Prague 2004
Assessment and Management of Concussion in Sports
Inter-Association Task Force for Appropriate Care of the Spine-Injured Athlete
Can Contact Sports Lower Your Intelligence?
Making Headway

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