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Determining Extent Of Injury To Brain Is Difficult
Factors Complicating Concussion Recognition And Management
Concussion Work-Up
Importance Of Prior Concussions
Computerized Neuropsychological Assessment: Replacing Pen And Paper Tests
The Balance Error Scoring System: A Useful Test
When A CT Or MRI Is Recommended
Concussion Management And Return To Play Guidelines
Final Recommendations

Evaluating and managing concussions starts with the recognition that the athlete has actually suffered a concussion. It is important to realize, as mentioned previously, that loss of consciousness is an uncommon finding with athletic concussions and when it does occur it usually lasts seconds to less than a minute.

A concussion is diagnosed when an athlete receiving a direct or indirect acceleration forces to the head, experiences either of the following:

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• Post concussion symptoms or signs (PCCS). A PCSS checklist is used not only for the initial evaluation, but for each subsequent follow-up assessment, which is periodically repeated until all PCSS have cleared at rest and exertion.

• post-traumatic amnesia (PTA).

  • Many consider the duration of PTA the best indicator of traumatic brain injury severity and the most dependable factor in predicting outcome, even in cases of mild concussions. PTA includes retrograde amnesia (a partial or total loss of ability to recall events that have occurred prior to brain injury) and anterograde amnesia (a reduced ability to form new memory after the accident), which may lead to decreased attention and inaccurate perception. Anterograde memory is frequently the last function to return after the recovery from loss of consciousness.

  • Two large recent studies of concussion found that the presence of anterograde/retrograde amnesia best correlates with abnormal neuropsychological testing at 48 hours post-concussion, as well as correlating with the duration and number of other PCSS.

• Because on-the-field amnesia appears to be a significant predictor of subsequent impairment and should be looked at very carefully, I have revised slightly the system for grading of concussion severity I first issued in 1986 to place additional emphasis on PTA.

• When checking for orientation and retrograde amnesia on the field, asking the athlete the current quarter, the score, what happened, and the names of current and last week's opponents are useful. When checking for attention or anterograde amnesia deficits, useful tests are repeating 4 words immediately and 2 minutes later, repeating 5 numbers forward and especially backward, and repeating months of the year backward.

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In addition to the history of concussion symptoms and neurological examination for concussion signs, a very detailed history of all prior concussions including severity of impact and duration of symptoms must be obtained. While research suggests that those with prior concussions do not necessarily suffer more neurocognitive impairment following a re-injury, they have been found to be at increased risk for subsequent concussion and more likely to develop persistent post-concussion symptoms.

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Article Updated August 15, 2006

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