 |
| Concussion grading systems | |
|---|---|
| Purpose | determine 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]
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The Cantu system has become somewhat outdated.[ citation needed ]
Originally developed by Teasdale and Jennett in 1974, the Glasgow Coma Scale (GCS) 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. [7] 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. [8]
The guidelines developed by the Colorado Medical Society 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]
| Grade | First concussion | Subsequent concussions |
|---|---|---|
| I | 15 minutes | 1 week |
| II | 1 week | 2 weeks, with physician approval |
| IIIa (unconscious for seconds) | 1 month | 6 months, with physician approval |
| IIIb (unconscious for minutes) | 6 months | 1 year, with physician approval |
The guidelines devised in 1997 by the American Academy of Neurology (AAN) were based on those formulated by the Colorado Medical Society. [12] 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. [13] 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.
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.
Brain injury (BI) is the destruction or degeneration of brain cells. Brain injuries occur due to a wide range of internal and external factors. In general, brain damage refers to significant, undiscriminating trauma-induced damage.
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.
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.
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.
The Rivermead Post-Concussion Symptoms Questionnaire, abbreviated RPQ, is a questionnaire that can be administered to someone who sustains a concussion or other form of traumatic brain injury to measure the severity of symptoms. The RPQ is used to determine the presence and severity of post-concussion syndrome (PCS), a set of somatic, cognitive, and emotional symptoms following traumatic brain injury that may persist anywhere from a week, to months, or even more than six months.
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.
Amnesia is a deficit in memory caused by brain damage or brain diseases, but it can also be temporarily caused by the use of various sedative and hypnotic drugs. The memory can be either wholly or partially lost due to the extent of damage that is caused.
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.
Concussion, a type of mild traumatic brain injury that is caused by a direct or indirect hit to the head, body, or face is a common injury associated with sports and can affect people of all ages. A concussion is defined as a "complex pathophysiological process affecting the brain, induced by biomechanical forces". A concussion should be suspected in any person who falls or has a hit to their face or their body and has a visible sign/clue that they may have a concussion or experiences any symptoms of concussion. The Concussion Recognition Tool 6 (CRT6) can be used to help non-medically trained people manage sport related concussion on the sideline to ensure that they are directed to the appropriate care. Symptoms of concussion can be felt right away or appear over the first 1-2 days after an accident. If an athlete has a suspected sport-related concussion they should not return to play that day, not be left alone for the first three hours after their injury, not drive until cleared by a medical professional, and not return to any activity that has a risk of hitting their head or falling until they have a medical assessment. If the person has worsening symptoms or any 'red flag symptoms', they need immediate medical attention. Concussions cannot be seen on X-rays or CT scans.
The Glasgow Outcome Scale (GOS) is an ordinal scale used to assess functional outcomes of patients following brain injury. It considers several factors, including a patient's level of consciousness, ability to carry out activities of daily living (ADLs), and ability to return to work or school. The scale provides a structured way to classify patient outcomes into five broad categories: death, vegetative state, severe disability, moderate disability, or good recovery.
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.
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.