Concussion in Sport
“When in Doubt, Sit Them Out”
What is a concussion?
Concussion is described as any transient, post-traumatic alteration in mental status. A common misconception was that a concussion occurred only when there was a loss of consciousness. A concussion can be the result of a direct blow to the head, face or jaw or due to a whiplash effect on the neck. Some signs and symptoms of concussion include:
- confusion and inability to focus attention (easily distracted and unable to follow instructions)
- disorientation (walking in the wrong direction, unaware of time, date and space)
- memory loss or deficits, unable to remember what happened or recent events, asking the same question repeatedly, inability to remember words or objects (retrograde amnesia or post-traumatic amnesia)
- delayed verbal and motor responses (slow to answer questions or follow instructions)
- loss of consciousness (momentary or prolonged, unresponsive to verbal or physical arousal)
- slurred or incoherent speech (making disjointed or incomprehensible statements)
- incoordination or dizziness (stumbling, inability to walk a straight line)
- inappropriate emotions (distraught, drying for no apparent reason, anger)
- blurred vision or vacant stares
- nausea or vomiting
- tinnitus (ringing in the ear)
- headache
Grades of concussion
There are various scales and grading systems for concussions, and unfortunately there is no single universally accepted measure. The guidelines that are approved by the Canadian Brain Injury Coalition and the Canadian Hockey Association are:
Grade One
- No loss of consciousness
- Symptoms or mental status abnormalities on examination resolve in less than 15 minutes
- Temporary confusion
- Dizziness, headaches, nausea, lethargy, may have some memory loss
Grade Two
- No loss of consciousness
- Symptoms or mental status abnormalities last more than 15 minutes
- Temporary confusion
- Dizziness, headaches, nausea, lethargy, may have some memory loss
Grade Three
- Any loss of consciousness – seconds to minutes
- Dizziness, headaches, lethargy, nausea, may have some memory loss
An unconscious athlete or an athlete with significant changes in mental status must be transported to the nearest emergency department by ambulance.
Return to play guidelines
There are a variety of guidelines and management recommendations for return to play for an athlete. According to the Justice Inquiry into the death of David Caliguiri, a Manitoba Judoka, Judge Chartier stated “…that the most important factor in preventing a serious outcome from a sports related head injury is to ensure an adequate amount of recovery time before allowing an athlete to return to the sport.” Recommendation #1 by the judge was the 1986 Cantu guidelines for dealing with concussions in children, as they are the most conservative in return to play recommendations. Please see chart below.
The Management recommendations of the Canadian Brain Injury Coalition and the Canadian Hockey Association differ slightly from the Cantu guidelines. These guidelines were adapted from the American Academy of Neurology Standards Committee practice parameters. The Management Recommendations for First Concussion and the Management Recommendations for Second or More Concussions are found on the following page.
In all cases of concussion and head injury, the athlete must be cleared for return to play by a physician. It should also be noted that in both sets of guidelines, that return to play is dictated by a length of time without symptoms of head injury, and not the length of time from when the head injury or concussion occurred. These symptoms must be tested with physical exertion that is comparable to the player’s sport. The athlete may not have any symptoms at rest, but they may return with intense activity.
Other recommendations
Judge R. Chartier put forth four other recommendations from the David Caliguiri Inquiry.
#2. That once a youth suffers any injury to the head, a Notice Advisory be issued to the parent/guardian of a child who sustains such a head injury
#3. That the Health Record Forms used in athletic events be amended to add a special section dealing with head injuries to ascertain whether the youth has received any previous concussions.
#4. That the Amateur Sport Organizations of Manitoba should consider allowing referees the discretion to hand out medical suspensions if he/she thinks that an athlete has sustained a concussion.
#5. That the Amateur Sport Organizations of Manitoba must ensure that coaches encourage young athletes to share with them any aches and pains they may have sustained while participating in their sport and of the inherent dangers resulting from this lack of communication between young athletes and coaches.
1986 CANTU GUIDELINES FOR RETURN TO PLAY AFTER A CONCUSSION
| |
Signs of Impairment |
If First Concussion |
If Second Concussion |
If Third Concussion |
| GRADE 1 (Mild) |
No loss of consciousness and head injury symptoms* exist for less than 15 minutes |
May return to play if is without head injury symptoms* for 1 week |
May return to play in 2 weeks if is without head injury symptoms* at that time for 1 week |
Terminate season: May return to play next season if is without head injury symptoms* |
| GRADE 2 (Moderate) |
No loss of consciousness but head injury symptoms* persist for more than 15 minutes |
May return to play if is without head injury symptoms* for 1 week |
Out of play minimum of 1 month: May return to play then if is without head injury symptoms* for 1 week. Consider terminating the season |
Terminate season: May return to play next season if is without head injury symptoms* |
| GRADE 3 (Severe) |
Loss of consciousness |
Out of play minimum of 1 month: May return to play then of is without head injury symptoms* for 1 week |
Terminate season: May return to play next season if is without head injury symptoms* |
|
*Head injury symptoms means headache, dizziness, confusion, blurred vision, poor concentration, loss of coordination, nausea/vomiting, delayed verbal and/or motor responses.
INFORMATION ONLY - DO NOT ATTEMTP TO TREAT A CONCUSSION
RETURN TO PLAY ONLY WITH APPROVAL BY A PHYSICIAN
Following a concussion at home
After an athlete has received a head injury it is important for the parents or guardians to remain alert for signs and symptoms 24–48 hours following that may indicate a worse condition. Even if an athlete has been evaluated by a physician and sent home, the following precautions are recommended:
- Awaken the athlete every two hours overnight
- Assess the following:
- orientation (who, where, when)
- memory
- coordination (walk, use both hands)
- worsening headache
- Give clear fluids if nausea or vomiting
- No alcohol consumption
- No asprin or pain relieving medication
It should be considered an emergency if any of the following symptoms occur:
- Severe or increasing headache
- Neck pain
- Disorientation / confusion
- Increased vomiting (3-4 times in two hours)
- Abnormal behaviour
- Difficulty wakening
- Seizures
- Slurred speech
- Blurry or double vision
- Fever
- Drowsiness
- Weakness of an arm or leg; inability to walk normally
Any symptoms which persist longer than 24 hours should be re-evaluated by a physician.
"Close observation and assessment of the injured athlete could be critical to the prevention of catastrophic brain injury and cumulative neuropsychological deficits.”
American Academy of Neurology
Resources
Resources used for this article include:
Canadian Brain Injury Coalition: www.cbic.ca “Fact Card on Concussion in Sport”
Concussion in Sport Seminar: Sport Medicine Council of Manitoba. October 1999. Speaker notes:
“Concussions in Sport” Russ Horbal, BMR.PT.
“Sideline Evaluations” Dr. E.J. Pilat, MD, CCFP
“Concussion: The Next 24 Hours” Dr. M. Zetaruk, FRCPC
Manitoba Fatality Inquiries Act: Report by Provincial Judge on Inquest Respecting the death of: David J. Caliguiri
MANAGEMENT RECOMMENDATIONS FOR FIRST CONCUSSION - Canadian Brain Injury Coalition
GRADE 1
- Remove from contest.
- Examine immediately and at 5 minute intervals for the development of mental status abnormalities or post-concussive symptoms at rest or with exertion.
- Always check for a neck injury
- SHOULD NOT RETURN TO PLAY WITHOUT APPROVAL OF PHYSICIAN AND AT LEAST 24 HOURS REST.
|
GRADE 2
- Remove from contest and disallow return that day.
- Examine immediately and at 5 minute intervals for the develpment of mental status abnormalities or post-concussive symptoms at rest or with exertion.
- A physician should examine the athlete the same day.
- Always check for a neck injury
- A PHYSICIAN SHOULD PERFORM A NEUROLOGICAL EXAMINATION TO CLEAR THE ATHLETE FOR RETURN TO PLAY AFTER 1 FULL WEEK WITHOUT SYMPTOMS AT REST OR WITH EXERTION.
|
GRADE 3
- Transport the athlete from the field to the nearest emergency department by ambulance, if still unconscious, or if worrisome signs are detected (with cervical spine immobilization if indicated).
- A thorough neurologic evaluation should be performed immediately, including appropriate neuroimaging procedures when indicated. Hospital admission is advised if the mental status of the athlete remains abnormal.
- A PHYSICIAN SHOULD CLEAR THE ATHLETE FOR RETURN TO PLAY AFTER AT LEAST ONE WEEK OF SYMPTOM FREE REST FOR UNCONSCIOUSNESS OF LESS THAN 1 MINUTE; AND TWO WEEKS FOR UNCONSCIOUSNESS FOR MORE THAN A MINUTE AND LESS THAN FIVE MINUTES.
|
MANAGEMENT RECOMMENDATIONS FOR SECOND OR MORE CONCUSSIONS
- For a second Grade 1 or Grade 2 concussion consider terminating the season, but there should be a minimum of 1 month of no play and a physician should clear the athlete for return to play only after 1 week free of symptoms.
- For a second Grade 3 concussion: terminate the season; may return to play the next season with approval of attending physician.
- For a third concussion of any grade: terminate the season.
INFORMATION ONLY - DO NOT ATTEMPT TO TREAT A CONCUSSION
RETURN TO PLAY ONLY WITH APPROVAL BY A PHYSICIAN
***For more information,
see the "Summary and Agreement Statement of the Second International Symposium on Concussion in Sport" in the:
Clinical Journal of Sport Medicine 2005; 15(2): 48-55
British Journal of Sports Medicine 2005; 39(4): 196-204
Physician in Sportsmedicine 2005; 33(4): 29-44
_________________________________________________________
| Title: |
Concussion in sport: "when it doubt, sit them out" |
| Author: |
|
| Publisher: |
Sport Medicine Council of Manitoba |
| Source: |
The Responder (Winnipeg, Man.) |
| Volume (Issue): |
1(3) |
| Date: |
1999 |
| Page: |
1-3 |
| SIRC Article #: |
S-659756 |
This material has been copied under license from the Publisher. Any resale for profit or further copying is strictly prohibited.
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