Approaches Vary Widely
Concussion Management: Pure Guesswork?
Many Don't Use Any Grading System At All

How soon to return to play after a head injury and the consequences of repeated concussions are two of the most important health-related issues in sports today. The approaches used by sports physicians in managing athletes who sustain concussions vary widely:

• In 1994 survey, members of the American Medical Society for Sports Medicine ("AASSM"), two thirds of who worked as team physicians, were asked whether they would allow a rugby player, after being struck in the head by an opponent's knee, to re-enter a game if (a) he had no history of head injury, (b) did not lose consciousness, (c) had a normal neurological exam, but exhibited confusion and post-traumatic amnesia (PTA) that persisted for 10 minutes before the symptoms cleared. Thirty percent said they would let the player resume play the same day, 44% said they would keep him out for 1 week, and 21% said they would let him return the next day.
  
  

• Sixteen different grading systems for concussions are proposed in the medical literature; some list only three grades of concussion, while others include as many as six. (For a comparison of the three most widely known and used grading systems and return-to-play guidelines, click here).

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Concussion Management: Pure Guesswork?

The reason is a scarcity of scientific evidence that makes practical decisions about when an athlete can safely return to the field difficult. In other words, there is no simple way to determine the seriousness of an injury or whether a player has fully recovered. As Dr. Robert Johnson, Director of Primary Care Sports Medicine in the Department of Family Practice at Hennipin County (Minnesota) Medical Center noted in a 1996 article on the lack of consensus in concussion management in The Physician and Sportsmedicine, "Anybody's estimate has just been purely guesswork." Another team physician interviewed for the same article characterized the subject as a "mine field, fraught with a lot of controversy, opinion, and a considerable lack of consensus."

As the article noted, however, the "seriousness of the risk brings an urgency to the controversy. Even if an athlete never returns to contact sports, a single concussion can be life threatening. A closed head injury may involve intracranial hemorrhage [bleeding] considered the leading direct cause of death in contact sports. And no physician wants to send a brain-injured player back into a game, where he or she would be vulnerable to a second head injury." The biggest concern in returning an athlete to play is second-impact syndrome a rare, but rapid, fatal brain swelling that may occur if a person suffers another head impact - even a minor one - before the symptoms of the previous concussion have fully cleared.

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Many Don't Use Any Grading System At All

The difficulty in using the current grading scales for evaluating concussions is that most are based on loss of consciousness (LOC) and the presence of PTA which occur very infrequently, while essentially ignoring multiple symptoms that present in a variable pattern. The result is that certified athletic trainers (ATC) and physicians have difficulty distinguishing among the various degrees of concussion (The exception is Dr. Cantu's revised Evidence Based Grading Scale published in 2001.

The confusion and frustration with the current scales have resulted in many sports medicine professionals not using any of the grading scales for evaluations purposes. In a recent study, a clear majority (63%) of ATCs reported not using any scale for evaluating concussions. The ramifications of not using a grading scale are compounded by the lack of any clear signs for making return-to-play decisions.

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Article Updated and reviewed August 1, 2007

	Reprint Policy Return to Head Injury Home Page

 Determining Loss Of Consciousness In Athletes
 Post-Traumatic Amnesia
 Certified Athletic Trainers: On The Frontline In The Treatment Of Head And Neck Injuries
 Concussion Grading Systems And Return-To-Play Guidelines: A Comparison
 Concussions: Advice For Parents Of Youth Athletes

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