Concussion grading systems

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Concussion grading systems
Purposedetermine severity of concussion

Concussion grading systems are sets of criteria used in sports medicine to determine the severity, or grade, of a concussion, the mildest form of traumatic brain injury. At least 16 such systems exist, [1] and there is little agreement among professionals about which is the best to use. [2] Several of the systems use loss of consciousness and amnesia as the primary determinants of the severity of the concussion. [2]

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The systems are widely used to determine when it is safe to allow an athlete to return to competition. Concern exists that multiple concussions received in a short time may present an added danger, since an initial concussion may leave the brain in a vulnerable state for a time. Injured athletes are prohibited from returning to play before they are symptom-free during rest and exertion and their neuropsychological tests are normal again, in order to avoid a risk of cumulative effects such as decline in mental function and second-impact syndrome, which may occur on very rare occasions after a concussion that occurs before the symptoms from another concussion have resolved.

It is estimated that over 40% of high school athletes return to action prematurely [3] and over 40,000 youth concussions occur annually. [4] Concussions account for nearly 10% of sport injuries, and are the second leading cause of brain injury for young people ages 15–24. [5]

Three grading systems are followed most widely: the first by neurosurgeon Robert Cantu, another by the Colorado Medical Society, and a third by the American Academy of Neurology. [6] The Cantu system has become somewhat outdated. Grade I Grade one concussions come with no loss of consciousness and less than 30 minutes of post-traumatic amnesia. Grade II Grace two concussion patients lose consciousness for less than five minutes or have amnesia for between 30 minutes and 24 hours. Grade III People with grade three concussions have a loss of consciousness lasting longer than five minutes or amnesia lasts for 24 hours. Originally developed by Teasdale and Jennett (1974), the Glasgow Coma Scale (GCS) (see Table C-1) is a scoring scale for eye opening, motor, and verbal responses that can be administered to athletes on the field to objectively measure their level of consciousness. A score is assigned to each response type for a combined total score of 3 to 15 (with 15 being normal). An initial score of less than 5 is associated with an 80 percent chance of a lasting vegetative state or death. An initial score of greater than 11 is associated with a 90 percent chance of complete recovery (Teasdale and Jennett, 1974). Because most concussed individuals score 14 or 15 on the 15-point scale, its primary use in evaluating individuals for sports-related concussions is to rule out more severe brain injury and to help determine which athletes need immediate medical attention (Dziemianowicz et al., 2012).

American Academy of Neurology guidelines

The guidelines devised in 1997 by the American Academy of Neurology (AAN) were based on those formulated by the Colorado Medical Society., [7] however, in 2013 the AAN published a revised set of guidelines that moved away from concussion grading, emphasizing more detailed neurological assessment prior to return to play. [8] The guidelines emphasized that younger patients should be managed more conservatively and that risk of recurrent concussion was highest within 10 days following the initial injury. Risk of concussion was also stratified by sport, training time, and player Body Mass Index.

The guideline also called into question the existence of the "second impact syndrome", proposing instead that athletes with a previous concussion may be more vulnerable to severe injury due to decreased reaction time and coordination, symptoms of the initial injury.

Colorado Medical Society guidelines

The Colorado Medical Society guidelines were published in 1991 in response to the death of a high school athlete due to what was thought to be second-impact syndrome. [9] According to the guidelines, a grade I concussion consists of confusion only, grade II includes confusion and post-traumatic amnesia, and grade III and IV involve a loss of consciousness. [2]

By these guidelines, an athlete who has suffered a concussion may return to sports after having been free of symptoms, both at rest and during exercise, as shown in the following table: [10] [11]

Colorado Medical Society guidelines for return to play
GradeFirst concussionSubsequent concussions
I15 minutes1 week
II1 week2 weeks, with
physician approval
IIIa (unconscious
for seconds)		1 month6 months, with
physician approval
IIIb (unconscious
for minutes)		6 months1 year, with
physician approval

See also

Related Research Articles

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A head injury is any injury that results in trauma to the skull or brain. The terms traumatic brain injury and head injury are often used interchangeably in the medical literature. Because head injuries cover such a broad scope of injuries, there are many causes—including accidents, falls, physical assault, or traffic accidents—that can cause head injuries.

The Glasgow Coma Scale (GCS) is a clinical scale used to reliably measure a person's level of consciousness after a brain injury.

A vegetative state (VS) or post-coma unresponsiveness (PCU), is a disorder of consciousness in which patients with severe brain damage are in a state of partial arousal rather than true awareness. After four weeks in a vegetative state, the patient is classified as being in a persistent vegetative state (PVS). This diagnosis is classified as a permanent vegetative state some months after a non-traumatic brain injury or one year after a traumatic injury. The term unresponsive wakefulness syndrome may be alternatively used, as "vegetative state" has some negative connotations among the public.

<span class="mw-page-title-main">Brain damage</span> Destruction or degeneration of brain cells

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<span class="mw-page-title-main">Concussion</span> Medical condition

A concussion, also known as a mild traumatic brain injury (mTBI), is a head injury that temporarily affects brain functioning. Symptoms may include loss of consciousness; memory loss; headaches; difficulty with thinking, concentration, or balance; nausea; blurred vision; dizziness; sleep disturbances, and mood changes. Any of these symptoms may begin immediately, or appear days after the injury. Concussion should be suspected if a person indirectly or directly hits their head and experiences any of the symptoms of concussion. Symptoms of a concussion may be delayed by 1–2 days after the accident. It is not unusual for symptoms to last 2 weeks in adults and 4 weeks in children. Fewer than 10% of sports-related concussions among children are associated with loss of consciousness.

<span class="mw-page-title-main">Traumatic brain injury</span> Injury of the brain from an external source

A traumatic brain injury (TBI), also known as an intracranial injury, is an injury to the brain caused by an external force. TBI can be classified based on severity ranging from mild traumatic brain injury (mTBI/concussion) to severe traumatic brain injury. TBI can also be characterized based on mechanism or other features. Head injury is a broader category that may involve damage to other structures such as the scalp and skull. TBI can result in physical, cognitive, social, emotional and behavioral symptoms, and outcomes can range from complete recovery to permanent disability or death.

Post-concussion syndrome (PCS), also known as persisting symptoms after concussion, is a set of symptoms that may continue for weeks, months, or years after a concussion. PCS is medically classified as a mild traumatic brain injury (TBI). About 35% of people with concussion experience persistent or prolonged symptoms 3 to 6 months after injury. Prolonged concussion is defined as having concussion symptoms for over four weeks following the first accident in youth and for weeks or months in adults.

<span class="mw-page-title-main">Chronic traumatic encephalopathy</span> Neurodegenerative disease caused by head injury

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease linked to repeated trauma to the head. The encephalopathy symptoms can include behavioral problems, mood problems, and problems with thinking. The disease often gets worse over time and can result in dementia.

Second-impact syndrome (SIS) occurs when the brain swells rapidly, and catastrophically, after a person has a second concussion before symptoms from an earlier one have subsided. This second blow may occur minutes, days, or weeks after an initial concussion, and even the mildest grade of concussion can lead to second impact syndrome. The condition is often fatal, and almost everyone who is not killed is severely disabled. The cause of SIS is uncertain, but it is thought that the brain's arterioles lose their ability to regulate their diameter, and therefore lose control over cerebral blood flow, causing massive cerebral edema.

Post-traumatic amnesia (PTA) is a state of confusion that occurs immediately following a traumatic brain injury (TBI) in which the injured person is disoriented and unable to remember events that occur after the injury. The person may be unable to state their name, where they are, and what time it is. When continuous memory returns, PTA is considered to have resolved. While PTA lasts, new events cannot be stored in the memory. About a third of patients with mild head injury are reported to have "islands of memory", in which the patient can recall only some events. During PTA, the patient's consciousness is "clouded". Because PTA involves confusion in addition to the memory loss typical of amnesia, the term "post-traumatic confusional state" has been proposed as an alternative.

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Traumatic brain injury can cause a variety of complications, health effects that are not TBI themselves but that result from it. The risk of complications increases with the severity of the trauma; however even mild traumatic brain injury can result in disabilities that interfere with social interactions, employment, and everyday living. TBI can cause a variety of problems including physical, cognitive, emotional, and behavioral complications.

The fencing response is an unnatural position of the arms following a concussion. Immediately after moderate forces have been applied to the brainstem, the forearms are held flexed or extended for a period lasting up to several seconds after the impact. The fencing response is often observed during athletic competition involving contact, such as combat sports, American football, Ice hockey, rugby union, rugby league and Australian rules football. It is used as an overt indicator of injury force magnitude and midbrain localization to aid in injury identification and classification for events including on-field and/or bystander observations of sports-related head injuries.

Concussions and play-related head blows in American football have been shown to be the cause of chronic traumatic encephalopathy (CTE), which has led to player deaths and other debilitating symptoms after retirement, including memory loss, depression, anxiety, headaches, stress, and sleep disturbances.

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A sports-related traumatic brain injury is a serious accident which may lead to significant morbidity or mortality. Traumatic brain injury (TBI) in sports are usually a result of physical contact with another person or stationary object, These sports may include boxing, gridiron football, field/ice hockey, lacrosse, martial arts, rugby, soccer, wrestling, auto racing, cycling, equestrian, rollerblading, skateboarding, skiing or snowboarding.

The Galveston Orientation and Amnesia Test (GOAT) is a measure of attention and orientation, especially to see if a patient has recovered from post-traumatic amnesia (PTA) after a traumatic brain injury. This was the first measure created to test post-traumatic amnesia, and is still the most widely used test. The test was created by Harvey S. Levin and colleagues (1979), and features ten questions that assess temporal and spatial orientation, biographical recall, and memory. Points are awarded for responses to each question, with a 100 points possible. A score greater than 78 for three consecutive days is considered the threshold for emergence from post-traumatic amnesia. This test is intended for patients aged 15 years or older. Younger patients are given a modified version of the test, known as the Children's Orientation and Attention Test (COAT).

A traumatic brain injury (TBI) is a blow, jolt or penetration to the head that disrupts the function of the brain. Most TBIs are caused by falls, jumps, motor vehicle traffic crashes, being struck by a person or a blunt object, and assault. Student-athletes may be put at risk in school sports, creating concern about concussions and brain injury. A concussion can be caused by a direct blow to the head, or an indirect blow to the body that causes reactions in the brain. The result of a concussion is neurological impairment that may resolve spontaneously but may also have long-term consequences.

<span class="mw-page-title-main">Concussions in Australian sport</span>

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A pediatric concussion, also known as pediatric mild traumatic brain injury (mTBI), is a head trauma that impacts the brain capacity. Concussion can affect functional, emotional, cognitive and physical factors and can occur in people of all ages. Symptoms following after the concussion vary and may include confusion, disorientation, lightheadedness, nausea, vomiting, blurred vision, loss of consciousness (LOC) and environment sensitivity. Concussion symptoms may vary based on the type, severity and location of the head injury. Concussion symptoms in infants, children, and adolescents often appear immediately after the injury, however, some symptoms may arise multiple days following the injury leading to a concussion. The majority of pediatric patients recover from the symptoms within one month following the injury. 10-30% of children and adolescents have a higher risk of a delayed recovery or of experiencing concussion symptoms that are persisting.

References

  1. ↑ Hayden MG, Jandial R, Duenas HA, Mahajan R, Levy M (2007). "Pediatric Concussions in Sports: A Simple and Rapid Assessment Tool for Concussive Injury in Children and Adults". Child's Nervous System. 23 (4): 431–435. doi:10.1007/s00381-006-0277-2. PMID   17219233. S2CID   33259313.
  2. 1 2 3 Cantu RC (2001). "Posttraumatic Retrograde and Anterograde Amnesia: Pathophysiology and Implications in Grading and Safe Return to Play". Journal of Athletic Training. 36 (3): 244–248. PMC   155413 . PMID   12937491.
  3. ↑ Concussions Extra Dangerous to Teen Brains, CNN, 4 February 2010
  4. ↑ Heading Off Sports Injuries, Newsweek, 5 Feb 2010
  5. ↑ High School Athletes Face Serious Concussion Risks, USA Today, 4 May 2009
  6. ↑ Cobb S, Battin B (2004). "Second-Impact Syndrome". The Journal of School Nursing. 20 (5): 262–7. doi:10.1177/10598405040200050401. PMID   15469376. S2CID   38321305.
  7. ↑ Silver JM, McAllister TW, Yudofsky SC (2005). "Textbook of Traumatic Brain Injury". American Psychiatric Pub., Inc. ISBN   1-58562-105-6.
  8. ↑ Giza, C. C.; Kutcher, J. S.; Ashwal, S; Barth, J; Getchius, T. S.; Gioia, G. A.; Gronseth, G. S.; Guskiewicz, K; Mandel, S; Manley, G; McKeag, D. B.; Thurman, D. J.; Zafonte, R (2013). "Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology". Neurology. 80 (24): 2250–2257. doi:10.1212/WNL.0b013e31828d57dd. PMC   3721093 . PMID   23508730.
  9. ↑ Collins MW, Iverson GL, Gaetz M, Lovell MR (2006). "24: Sport-Related Concussion.". In Zasler ND, Katz DI, Zafonte RD (eds.). Brain Injury Medicine: Principles And Practice. Demos Medical Publishing, LLC. ISBN   1-888799-93-5.
  10. ↑ "Heads Up: Concussion in High School Sports: Management of Concussion in Sports". Centers for Disease Control and Prevention. Archived from the original on 12 October 2007. Retrieved 7 January 2008.
  11. ↑ Cuccurullo S, Ed. "Table 2–16. When to Return to Play—Colorado Medical Society Guidelines.". Physical Medicine and Rehabilitation Board Review. Demos Medical Publishing, Inc. Retrieved 9 January 2008.

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