Look for neurologic deficits
If the cervical spine is cleared, you can do the rest of the assessment in a quiet location either on the sideline or in your office. Your history should include a narrative of how the injury occurred, an estimate of the force involved, the duration of any symptoms, and any previous concussions. The physical examination comes next, and should include a neurologic assessment and a full cognitive evaluation. Reassess frequently after the traumatic event to monitor for any signs of neurologic decline. If any neurologic deficits are found, the patient should be transported to the nearest medical facility for neuroimaging studies to rule out a structural brain injury.
The SCAT2: A convenient assessment tool
Standardized tools now exist to help you evaluate patients with concussion. The Pocket Sport Concussion Assessment Tool (SCAT2) on page 430 has been endorsed by the Zurich conference.5 It is a condensed version of the conference recommendations, suitable for use on the field of play. The SCAT2 includes a symptom scale, mental status tests, instructions on neurologic screening, and guidelines for return to play.
Pocket Sports Concussion Assessment Tool (SCAT2)
Adapted from: Pocket SCAT2. Available at: http://bjsm.bmj.com/content/43/Suppl_1/i89.full.pdf. Accessed July 7, 2010.
No system for grading severity is recommended
Many different classification systems for grading the severity of concussion have been proposed, but none of them is endorsed by the Zurich conference.5,7,12-15 The classification schemes that have been proposed are complex, not evidence-based, and unable to encompass the full range of concussion symptoms. Thus, the 3rd International Conference on Concussion in Sport abandoned all attempts to use or create classification systems, but recommended that each case be treated clinically on the basis of the symptoms displayed and the duration of the impairment.5 Athletes with severe impairment or prolonged symptoms may require referral to a sport medicine specialist with expertise in the management of concussion.
The third conference did agree on a range of “modifying factors” that may influence management and possibly predict the potential for prolonged or persistent symptoms (TABLE). The conference participants endorsed that any athlete displaying these features should be managed in a multidisciplinary manner coordinated by a physician with specific expertise in the management of concussive injuries.
TABLE
"Modifying factors” that may influence concussion management
| Symptoms | How many? |
| How long did symptoms last? (>10 days?) | |
| How severe? | |
| Signs | Loss of consciousness lasting >1 minute, amnesia |
| Sequelae | Concussive convulsions |
| Timing | Repeated concussions, concussions occurring close together in time, or recent concussion |
| Threshold | Repeated concussions with progressively less impact force or slower recovery after each |
| Age | Child or adolescent <18 years |
| Comorbidities | Migraine, depression, other mental health disorders, attention deficit hyperactivity disorder, learning disabilities, sleep disorders |
| Medications | Psychoactive drugs, anticoagulants |
| Behavior | Dangerous style of play |
| Sport in which injury occurred | High-risk, contact, and collision sports, “high sporting level” |
| Source: McCrory P, et al. Br J Sports Med. 2009.5 | |
Return to play is the crucial decision
Just as multiple systems for classifying severity have been proposed, so have guidelines for return to play.13-15 Again, each of the proposed guidelines has been based on expert opinion and no single set of guidelines has ever been proven to be accurate.10 There is, therefore, no universally accepted guide for making the decision of when an athlete can safely return to play. It is universally accepted, however, that no athlete should return to play if he or she is still symptomatic at rest or with any exertional maneuvers.3,7,16 Additionally, the athlete should not be taking any medication that could minimize any of the signs or symptoms of concussion when the physician is determining whether he or she can return to activity.
Once you are assured that the player has no symptoms at rest, you can start him or her on a graded, step-by-step regimen for returning to play. Athletes should spend 24 to 48 hours at each level before progressing to the next. If symptoms return at any point, instruct the athlete to drop back down a step for 24 hours and then proceed with the progression as tolerated.9,10 The stages of activity are: 3,10
- Light aerobic exercise
- Moderate to intense aerobic exercise
- Sport-specific activities/noncontact training drills
- Full contact activities
- Game play.
Neuropsychological testing can help you decide
In 1989, Barth and colleagues evaluated 2300 college football players, 200 of whom had suspected concussion.17 Neuropsychological testing at 24 hours, 5 days, and 10 days showed a decline from baseline following a concussion, with the majority of the athletes returning to baseline by 10 days postconcussion. This finding led researchers to believe that testing could help identify concussions, and several computer-based testing products were developed.11,18