Concussions

Jonathan Cluett, M.D

Information about sports-related head injuries

What is a concussion?
A concussion is an injury to the brain that causes immediate impairment of neurologic function as the result of a forceful blow to the head. Simply put, a concussion is a temporary injury to the brain tissue. Depending on the force of the injury the concussion can have variable types and duration of symptoms.

The brain is a soft structure contained within the rigid, hard confines of the skull. When the head is struck, the brain risks being injured because of the forces absorbed by the brain tissue. When the brain is injured, normal signal pathways that send messages from our brain to the body are interrupted.

What are the signs of a concussion?
There are many common signs of a concussion that include, but are not limited to:

• Loss of consciousness
• Confusion
• Posttraumatic amnesia
• Retrograde amnesia
• Disorientation
• Headache
• Nausea/Vomiting
• Visual disturbance (blurred vision, double vision)
• Dizziness
• Slurred speech
• Drowsiness

The most common feature of a concussion is confusion.

How can I tell how severe the concussion is?
Concussions are graded on a scale of I to III. Different sources have specific criteria for grading the concussion, but most experts agree on the following general classification:

1. Grade I: A mild concussion, occurs when there is a head injury, and perhaps some confusion, but full memory of the event.
2. Grade II: A moderate concussion, with confusion, and difficulty recalling the event, but no loss of consciousness.
3. Grade III: A severe concussion, when there is a loss of consciousness and no memory of the event.

When should special tests, such as a CAT scan, be performed?
It is not entirely clear when imaging of the head is absolutely necessary following a concussion, but there are a few guidelines that are helpful. Imaging should be considered:

• if there is loss of consciousness longer than 5 seconds,
• if there is concern that a skull fracture may be present, or
• if there is any evidence of a focal neurologic deficit.
• If an athlete has a head injury, followed by a so-called "lucid interval," a period of time or normal function followed by loss of consciousness or worsening neurologic function, they should have some type of diagnostic imaging. Also, if an athlete's symptoms continue to worsen, diagnostic imaging should be performed.

An athlete should never be left alone following a concussion -- they should be re-evaluated by a responsible caregiver regularly for a period of 12-24 hours. If this cannot be done safely, in-patient observation (hospitalization) can be considered.

When can an athlete return to play following a concussion?
Although guidelines are useful, every case must be considered individually. The following guidelines are only a reference to consider--each patient who sustains a concussion must be evaluated by their physician before being cleared to return to activity!

In general, athletes will be allowed to return to play according to the following schedule:

• For Grade I Concussions:
  The athlete can return if they are asymptomatic for at least 15 minutes.
• For Grade II Concussions:
  The athlete can return to play after one week, if asymptomatic during that time period.
• For Grade III Concussions:
  The athlete is removed from competition and transported to the emergency department. Length of time out of competition can be discussed with the physician.

All patients who sustain a concussion must not return to play until cleared by someone trained in management of these injuries (e.g. the team physician). Foremost, any athlete should not return to play until ALL symptoms have resolved. Even a mild headache should exclude a player from returning to competition.

Athletes who sustain multiple concussions must not return to play until properly evaluated. In general, athletes who sustain three concussions, no matter what grade, will be removed from competition for at least one season. The dangers of multiple concussions are not well understood, but athletes, coaches, and team doctors must be willing to play it safe.

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