CONCUSSION

Few concussed athletes will exhibit all of the features of concussion and it is possible that some will not dis- play any at all.

particularly injuries to the cervical spine. Unconscious players should be fitted with a neck brace and removed from the pitch on a spinal board. This should be carried out by someone with appropriate training.

The patient should then be removed to somewhere quiet where a full neurological examination can take place. The main pri- ority is to check for an indication that an urgent referral is required (see box 2).

Grading of concussion There are many grading systems currently utilised by governing bodies of sports in the United States alone. One common fea- ture is that no athlete should return to sport if they have any post–concussion syndrome symptoms.

Post-concussion symptoms

include ● Persistent low grade headache ● Light-headedness ● Sleep disturbance ● Poor memory ● Irritability and intolerance of noise ● Light intolerance ● Tiredness ● Easily fatigued ● Low mood state ● Anxiety ● Poor attention and concentration

The most widely used guidelines are the Cantu (1) (see table 2) and the American Academy of Neurology guidelines (AAN) (2). Both sets are based on three grades of concussion but each differs slightly in the criteria for classification. These guidelines are useful but rely on an accurate mea-

Regular, ongoing assessment is essential as change in the clinical condition is an important factor.

Box 1 Common features and indicators of concussion 1. Vacant stare

3. Confusion and the inability to focus attention

4. Disorientation 5. Slurred or incoherent speech 6. Gross observable incoordination

7. Emotions out of proportion to circumstances

8. Memory deficits

- confused facial expression

2. Delayed verbal and motor responses - slow to answer questions or follow instructions

- easily distracted and unable to

follow through with normal activities

- walking in the wrong direction, unaware of time, place, date

- making disjointed or incomprehensible statements

- stumbling, inability to walk tandem/straight line

- distraught, crying for no apparent reason

- exhibited by the patient repeatedly asking the same question that has already been answered, or inability to memorise and recall 3 of 3 words or 3 of 3 objects in 5 minutes

9. Any period of loss of consciousness - paralytic coma, unresponsiveness to arousal

surement of the length of LOC and PTA.

The importance of asking the right questions Research has shown that asking concussed athletes and non-concussed controls a set of traditional orientation questions (ie. name, age, date of birth, year) gave little variation in response and were subsequent- ly bad for assessing post-traumatic amne- sia (3).

Tests of recent memory were far more effec- tive at detecting PTA (see table 3). The questions shown mainly relate to Australian Rules football but similar ques- tions of recent memory could be devised for any sport.

Returning to play Cantu (1) and the AAN (2) have developed a method of determining when a con- cussed athlete should be safe to return to play (see table 4). The guidelines are based on years of experience and are use-

Table 2 Cantu Guidelines grading of concussion LOC

PTA Grade 1 (mild)

Grade2 (Moderate) Grade 3 (severe)

None

< 5mins > 5 mins

or or

< 30 mins

>30mins < 24 hrs >24 hrs

Adapted from Cantu RC Guidelines for return to contact sports after a cerebral concussion Physician & Sportsmedicine 1986 Vol (14) 10, pp 75-83

ful but have no scientific validation to support them.

These guidelines should be used in con- junction with the appropriate grading sys- tem. It is advisable to read the original papers in full before including these guidelines in your clinical practice.

Fixed interval return to play regulations The problem with using such guidelines is that many athletes are fit to return well before the end of the statutory period. Therefore fixed exclusion periods may encourage athletes to conceal concussion. Medical teams should be encouraged to promote education about concussion and its symptoms to both coaches and ath- letes – this should result in players with symptoms presenting more readily to the medical team.

Second impact syndrome People who have suffered one concussion impact and still have post-concussion symptoms are prone to second impact syndrome.

This syndrome involves

swelling in the brain which may lead to brainstem herniation and death and can occur with a relatively minor second impact. Better education of players coaches and managers about this poten- tial problem following a concussion is the only way to reduce the incidence.

SportEX 29

TIP

TIP