When you think of sports that produce head injuries, you
may immediately think of football, hockey, or boxing. To a certain extent,
you are right! In fact, more than 250,000 head injuries occur in football
alone each year. But head injuries can and do occur in sports, such as
gymnastics, cycling, and even swimming, that are not considered contact
sports. Although major head injuries (skull fracture or blood clot) get
the most attention, minor head injuries should not be easily dismissed.
It is important that we recognize the severity of these injuries and provide
the proper treatment.
Determining the severity of head injuries
There are several grading systems used to classify a head injury.
The most frequently used system is the Colorado Medical Society's Guidelines
of the Management of Concussion in Sports. It provides the examiner with
a way to evaluate the athlete's head injury and to determine when the athlete
can safely return to competition.
Grade I
A
Grade I concussion, or mild bruising of brain tissue, is the most common
form of head injury. Unfortunately, it is also the most difficult to recognize.
It is commonly known as "having your bell rung." Although there
is no loss of consciousness, the athlete may briefly appear or act confused;
however, he or she is able to remember all events following the impact.
The athlete should be removed from competition for at
least 20 minutes and examined every 5 minutes to rule out the development
of postconcussive symptoms. Symptoms include headache and dizziness and
impaired orientation (knowing where you are, who you are, and what day
it is), concentration, and memory.
Athletes with a Grade I concussion cannot return to competition
until they show no symptoms of this injury while undergoing examinations,
both at rest and with exertion. After returning to competition, athletes
are watched carefully because they are susceptible to a second head injury.
If a second head injury does occur, the athlete is removed from competition
for the day.
An MRI or CT scan is recommended for any athlete who continues
to complain of a headache or other symptoms that persist for a week after
the initial injury. If a player sustains three Grade I concussions in a
season, it is recommended that the player be removed from competition for
the season and not be allowed to return to contact sports for at least
3 months. The athlete may only then return after showing no symptoms during
exertional testing.
Grade II
The difference between a Grade II and a Grade I concussion is the presence
of post-traumatic amnesia (loss of memory after the injury). After sustaining
a Grade II concussion, an athlete does not remember events following the
impact and may not be able to recall events that led up to the injury.
Athletes are removed from competition for the day after
suffering a Grade II concussion. A complete neurologic (nervous system)
examination of the athlete is performed immediately. If there are no neurologic
symptoms, the athlete may be sent home provided that friends or family
members are able to frequently check on the athlete over the next 24 hours.
Otherwise, the athlete may be required to stay in a hospital for a 24-hour
observation period.
The injured athlete is re-evaluated the following day
and again in one week by a physician. If there are no symptoms after one
week and no symptoms during testing (both at rest and with exertion), the
athlete may return to practice or competition. If an athlete suffers a
second Grade II concussion, he or she is removed from competition for a
period of one month. An injured athlete may return to play only after exertional
testing reveals no symptoms. If a third Grade II concussion occurs, the
athlete is removed from competition for the season.
Grade III
Unlike a Grade I head injury, Grade III head injuries are easily recognized
and apply to any athlete who loses consciousness for any period of time.
These athletes are examined on the field of play for neck
injuries, and they are properly immobilized and taken to a hospital by
an ambulance. Neurologic evaluation is done immediately. The athlete is
kept in the hospital if any neurologic symptoms persist. If the neurologic
exam is negative and the athlete's mental status is normal, the player
can go home provided that he or she is not alone. Again, frequent checks
must take place over the next 24 hours by friends or family members.
An athlete with a Grade III concussion may return to practice
only after being symptom free for a period of two weeks. Before returning
to action, the player must again be evaluated at rest and with exertion.
If symptoms return, the athlete is removed from play for the season. If
an athlete sustains two Grade III concussions or if an MRI or CT scan shows
an abnormality, his or her playing season is ended, and a return to any
contact sport in the future is discouraged.
P. Dean Cummings, M.D.
Columbus, Georgia