Concussions in Sports

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