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Early return to play after concussions could be deadly
Using a concussion grading system may improve long-term prognosis and prevent second incidents.
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WASHINGTON — Concussions account for a lot of missed games for young athletes in any given season — a minor inconvenience compared to the fact that each year they lead to one fatality for every 300,000 kids participating in sports.
Direct or indirect blows can cause concussions, producing a rapid onset of short-lived neurologic impairment. This pathological process ultimately affects the brain, according to Walton W. Curl, MD. “It’s a functional disturbance and not necessarily a structural disturbance.”
During an instructional course lecture at the American Academy of Orthopaedic Surgeons 72nd Annual Meeting, Curl offered information about how concussions present, how to perform an acute evaluation, and how to manage an athlete who has suffered one. He practices at the Sports Medicine Center at the Medical College of Georgia in Augusta.
When evaluating a player or managing his/her post-concussion recovery, preventing a second concussion is paramount. This is particularly important for football, hockey and soccer players, who face the highest concussion risk due to the nature of their sports and the gear they use. Concussion risk runs higher, as well, in college vs. high school level athletes due to the higher impact forces in collegiate games.
Among the 1.5 million U.S. high school and 75,000 college football players each year, one in five experience a concussion, leading to 300,000 injuries each fall. With such high occurrence rates, “after that first concussion, their chance of getting re-concussed is about four to six times,” Curl said.
Some efforts are underway to make these sports safer in order to prevent concussions, like altering game rules and having players wear more protective gear. But that alone has not been sufficient to improve these statistics. “The key is educating the coaches, the parents and the athletes about [concussions]. … It’s important to know about concussions, and athletes need to report it if they’re having problems after the game so we don’t get second impact syndrome.”
A variety of standardized guidelines exist that team doctors can use at games when evaluating a player for a suspected concussion. Among them: those developed by the American Academy of Neurology, the Colorado State Medical Society and R.C. Cantu, a physician. They call for checking orientation, immediate memory, concentration, external maneuvers and delayed recall. Some guidelines focus on grading concussion severity, with player management based on that.
He also encouraged orthopedists to order neuropsychological testing of athletes suspected of having a concussion. He recommended contacting an organization called ImPACT for information on pre- and postseason tests that detect subtle but important neuropsychological changes.
Return to play
Signs of a mild, grade 1 concussion include transient confusion without loss of consciousness and concussion-like symptoms that resolve in less than 15 minutes. These players need to rest considerably before they return to play (RTP). With grade 2, it takes more than 15 minutes for abnormalities to resolve. Any situation where a player loses consciousness, brief or prolonged, is deemed grade 3. The doctor should look for cervical spine injuries, limiting movement of the player’s head and neck, and seek emergency room treatment immediately if a skull fracture is suspected or the athlete’s condition deteriorates.
RTP depends on how long the unconsciousness lasted. If up to three seconds, they can RTP after a full week of being asymptomatic, but if they were out for a prolonged period they must be asymptomatic for two weeks before RTP. “If they have an abnormal computed tomography or MRI, they terminate the season and we really talk about cessation of sports if they start having repeated episodes of getting knocked out in games,” Curl said.
For information on neuropsychological concussion testing, go to http://www.impacttest.com.
For more information:
- Curl WW. Concussions and stingers in adolescent athletes. ICL#211. Presented at the American Academy of Orthopaedic Surgeons 72nd Annual Meeting. Feb. 23-27, 2005. Washington.