From time to time, I like to reflect and refresh on many things, but this is a good time to look at concussions; where we have been and where we currently are. Today I will take a very quick look into the management of concussions.
For years as a health care provider we were guided by early work of Dr. Robert Cantu and others for guidance with concussions. The information that was first published as early as 1986 and endorsed/accepted by the American Academy of Pediatrics and American Academy of Family Physicians in 1999.
Concussion Grading Scales
Concussion grades and definitions Guideline 1 2 3 Cantu5 No loss of consciousness Loss of consciousness for fewer than 5 minutes Loss of consciousness for more than 5 minutes Post-traumatic amnesia for fewer than 30 minutes Post-traumatic amnesia for more than 30 minutes Post-traumatic amnesia for more than 24 hours Colorado Medical Society6 No loss of consciousness No loss of consciousness Loss of consciousness of any duration No post-traumatic amnesia Confusion Post-traumatic amnesia Confusion American Academy of Neurology7 No loss of consciousness No loss of consciousness Loss of consciousness of any duration Concussion symptoms for fewer than 15 minutes Concussion symptoms for more than 15 minutes
Management of First Concussion Based on Grade
Concussion grades and management recommendations* Guideline 1 2 3 Cantu5 Athlete may return to play if asymptomatic for one week (if athlete is totally asymptomatic, return to play on same day may be considered). Athlete may return to play if asymptomatic for one week. Athlete may not return to play for at least one month; athlete may then return to play if asymptomatic for one week. Colorado Medical Society6 Athlete may return to play if asymptomatic for 20 minutes. Athlete may return to play if asymptomatic for one week. Athlete should be transported to a hospital emergency department; athlete may return to play one month after injury if asymptomatic for two weeks. American Academy of Neurology7 Athlete may return to play if asymptomatic for 15 minutes. Athlete may return to play if asymptomatic for one week. Athlete should be transported to a hospital emergency department; if athlete had brief loss of consciousness (i.e., seconds), may return to play when asymptomatic for one week; if athlete had prolonged loss of consciousness (i.e., minutes), may return to play when asymptomatic for two weeks.
*—In each guideline, “asymptomatic” means that the athlete with a concussion has no somatic, behavioral or cognitive symptoms at rest or with exertion.
Since I have begun the endeavor of concussion education, most of the people (coaches, teachers, parents) and professionals (doctors, athletic trainers, therapists) I talk with can recall the above information, or are using the above guidance to this day. It is not “wrong,” nor will it harm the individual (except for early return), but the more education and research we gain in this area warrants the changes. I believe that it is very important that everyone get on the same page. Let’s take a closer look as to what has changed:
- No more grading
- ALL concussions are severe/major and serious and shall be treated as such (more a media issue)
- Loss of consciousness is not an indicator of severity
- VERY important to understand that you can have a concussion WITHOUT LOC
- Confusion and amnesia are higher indicators on longevity of injury
- Athletes and returning to play
- NO MORE return on same day
- New graded return to play based on symptoms
- Number of concussions are not limiting
- Rather they are taken into consideration
Longevity of injury is more applicable than severity however, we as a society like “flashy/sexy/gory” headlines and attention grabbers. So when the press/media/doctor tell you that you have a mild concussion it indicates possible short length. As opposed to the “severe” tag that some get, possibly indicating a long recovery period.
Consensus Statement on Concussions in Sport from Zurich, 2008, 3rd International Concussion in Sport Conference, the bullet points are consistent with those people that are MUCH smarter than I, the last blurb is a comment from me.
As with anything there are faults and evidence that will change thoughts and processes. Once society decides that a concussion is very serious and not just a “rung bell,” then we can get more and more research done in the area. It is my opinion that a lot of the unreported or under-reported concussions are due to that exact problem. Minimizing this injury is not only shortsighted, but really naive and neglectful. Missing a game is better than the alternative. The youth is who we should be worried about, and being a parent involves educating our children and protecting them, even from themselves.
So there you go… a very quick piece on how we used to treat concussions (I hope it is in the past tense, but some MD’s have yet to come around on this) and where we are currently.