Adapted from the Centers for Disease Control Heads Up Concussion Campaign; From Grady MF, Goodman A: Concussion in the adolescent athlete, Curr Prob Pediatr Adolesc Health Care 40:153–169, 2010.

Table 680-3 LOW-RISK CHARACTERISTICS FOR CLINICALLY IMPORTANT BRAIN INJURIES

Normal mental status

No loss of consciousness

No vomiting

Nonsevere injury mechanism

No signs of basilar skull fracture

No severe headache

From Grady MF, Goodman A: Concussion in the adolescent athlete, Curr Prob Pediatr Adolesc Health Care 40:153–169, 2010.

Sports concussion is a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces. Definition, evaluation, and treatment have evolved significantly since the 1970s. Grading scales were published to evaluate concussion severity, although controversy remained due to multiple guidelines. In November 2008, the 3rd International Symposium on Concussion in Sport confirmed that injury-grading scales should no longer be used. The participants also abandoned the simple vs complex classification suggested in the 2nd symposium in 2005. Instead, individual response should guide evaluation and return-to-play decisions. When a concussion is suspected, the athlete should be removed from the activity and medically evaluated. Regular monitoring over the initial few hours following injury is important. The group suggested use of an assessment tool called SCAT (Sport Concussion Assessment Tool) to assist the clinician in assessing the athlete.

Concussions usually resolve over 7-10 days and do not involve complications. In a large-scale study among college athletes, balance deficits resolved in 3-5 days, baseline cognitive functioning returned in 5-7 days, and other symptoms resolved by 7 days; it is not known if high school athletes respond similarly. The athlete is held out of activity until he or she is asymptomatic, after which return to activity is gradual. “Cognitive rest,” during which young athletes limit exertion during routine daily tasks as well as with schoolwork, is important in recovery as well.

Return to play should progress through a system of tasks, with the athlete advancing only if asymptomatic (Table 680-4):

1 Rest until asymptomatic

2 Light aerobic exercise; no resistance training

3 Sport-specific training

4 Noncontact drills

5 Full-contact drills

6 Game play

Table 680-4 GRADUATED RETURN-TO-PLAY PROTOCOL

1 No activity: Complete physical and cognitive rest until asymptomatic at rest.

Once an athlete is symptomatic at rest, progress through following stages.

Each stage should take a minimum of 24 hours to complete.

Progress to the next stage only if asymptomatic with the new activities.

If the new stage provokes symptoms, return to the previous stage for at least 24 hours.

2 Low levels of physical exertion as tolerated (symptoms do not get worse or come back during or after the activity).

This includes walking, light jogging, light stationary biking.

3 Moderate levels of physical exertion as tolerated.
This includes sport-specific exercises such as skating drills in ice hockey, running drills in soccer, but no head-impact activities.

4 Noncontact sport specific-training drills including passing drills in football and ice hockey; may start progressive weight training.

5 Full contact practice following medical clearance, participate in normal training activities.

6 Normal game play.
In general, the athlete progresses from 1 step to the next as long as he or she remains asymptomatic for 24 hours at each step. If the athlete becomes symptomatic during 1 of these steps, he or she returns to the previous step for at least 24 hours. Athletes must be off any medications that are being used to treat symptoms to be considered symptom-free at rest.

From Grady MF, Goodman A: Concussion in the adolescent athlete, Curr Prob Pediatr Adolesc Health Care 40:153–169, 2010.

If the athlete exhibits any of the symptoms of concussion (see Table 680-2), he or she should not return to the task for at least 24 hr. The athlete should not be using medications to treat symptoms during the return-to-play program.

Athletes who have symptoms from multiple concussions might need to be handled more conservatively. Persistent symptoms of cognitive impairment include poor attention or concentration, memory dysfunction, irritability, anxiety, depressed mood, sleep disturbances, persistent low-grade headache, lightheadedness, and/or intolerance of bright lights or loud noises. Exertion typically exacerbates concussion symptoms. Work-up is more extensive in the athletes with recurrent injuries. Physicians who specialize in treating this injury should manage these patients.

In concussion, CT and MRI are usually normal. For most concussions, neuroimaging is usually not necessary. However, neuroimaging should be used when there is suspicion of intracranial structural pathology, due to a focal finding on neurologic examination or symptoms that are worsening. The risk of intracranial pathology is increased in the presence of continued emesis, prolonged headache, persistent antegrade amnesia (poor short-term memory), seizures, Glasgow Coma Scale score <15, and signs of basal skull fracture or depressed skull fracture.