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Neurologists offer concussion options


New "parameters" for managing concussion in athletes have been developed by the American Academy of Neurology (AAN) and endorsed by 14 medical and athletic organizations in an attempt to effect a consensus on the subject and educate healthcare professionals.

"People throw around the phrase 'minor concussion,' but there is no such thing," says James P. Kelly, MD, who cowrote the protocol and is director of the Brain Injury Program at the Rehabilitation Institute of Chicago. The practice options, published in the March 1997 issue of Neurology (1), were released March 12 at a press conference in New York City.

The same week the AAN article was released, the Centers for Disease Control and Prevention in Atlanta reported that an estimated 300,000 sports-related brain concussions occur each year in the United States (2). The CDC report also detailed two new cases of second-impact syndrome, which builds the body of medical literature about this often-deadly effect of successive concussions.

The new suggestions are based on recommendations published in 1991 by the Colorado Medical Society (3), which Kelly helped develop. The new protocol divides concussions into three grades:

  • Grade 1: no loss of consciousness, with symptoms lasting less than 15 minutes;
  • Grade 2: no loss of consciousness, with symptoms lasting more than 15 minutes; and
  • Grade 3: any loss of consciousness.

Less Conservative

The management recommendations are less cautious in some
respects than the Colorado guidelines (3), which are regarded by most team physicians as being very conservative (see "Guidelines for Managing Concussion in Sports," October 1996). "We used to keep all athletes with a concussion out of action for 20 minutes of observation, but that was considered by some to be too strict," Kelly said. "Some athletes clear more quickly and can go back in to play."

Differences between the Colorado guidelines and the AAN parameters are clearest in the management of grade 2 and 3 concussions. The Colorado guidelines say an athlete should be sidelined for a month after a second grade 2 concussion or a first grade 3 concussion, but the new recommendations allow a return to play when the athlete has been asymptomatic for 2 weeks in either case. And if unconsciousness (grade 3) lasts only a few seconds, the athlete can return to play in 1 week.

The 1997 recommendations in-clude a mental status test to rule out amnesia. Accompanying the parameters are two evaluation tools: a 3.5" x 7" palm card designed for sideline evaluation of concussion by a physician, coach, or athletic trainer, and a standardized assessment including the mental status test, neurologic screening, and exertional maneuvers.

The new practice options are designed primarily for football and ice hockey, in which concussion is common, but can be applied to almost any sport. They offer a systematic approach to prevent complications, such as second-impact syndrome and cumulative damage from multiple concussions, without needlessly limiting participation, says Jay H. Rosenberg, MD, who cowrote the article and is a staff neurologist at the Southern California Permanente Medical Group in San Diego.

Mixed Reviews

Two sports-oriented physicians contacted by The Physician and Sportsmedicine gave mixed reviews of the new concussion protocol. Robert J. Johnson, MD, says the return-to-play recommendations are more conservative than what most physicians do in practice. On the other hand, he says, the recommendations are safe and are "very educational," especially for physicians who don't have a lot of experience with concussion. "I don't think they will affect my practice that much," Johnson adds. "I use a synthesis from my own clinical experience and all of the other concussion criteria." Johnson is director of primary care sports medicine in the Department of Family Practice at Hennepin County Medical Center in Minneapolis and an editorial board member of The Physician and Sportsmedicine.

Robert C. Cantu, MD, who developed concussion guidelines (4) that are used by many team physicians and athletic trainers, was involved in several reviews of the AAN's parameters. "Most of my concerns about the document were alleviated by changes during the review process, but one that wasn't and that causes me continued concern is placing a brief loss of consciousness in the most severe category and placing posttraumatic amnesia in a less severe category," he says. "It's an issue with grading; you're automatically putting people with brief loss of consciousness into the most severe category when days of mental dysfunction implies a greater brain insult." Cantu is chief of neurosurgery and director of sports medicine at Emerson Hospital in Concord, Massachusetts, and an editorial board member of The Physician and Sportsmedicine.

Kelly, however, says the grading system is consistent with scientific literature. "If the athlete was unconscious, more or deeper brain matter was affected," he says. Long-lasting symptoms are important to monitor, but they aren't an indicator of the area or depth of the brain injury, he adds. "We stuck with what we knew was scientifically sound."

Cantu and Johnson both say they're concerned that the parameters, though not based on prospective studies, will be used against physicians in court. "These guidelines are published by an esteemed group, and team physicians will have to defend a lot of their actions," Johnson says.

Kelly replies that the document addresses that worry. "Our document is a practice option, and that's the lowest on the totem pole," he says. "It does not reach the level of a guideline, based on limited scientific evidence." As with other practice parameters, physicians can vary their treatment for logical, medically sound reasons, Kelly says.

Both Johnson and Cantu agree that the AAN recommendations are a valuable educational tool. Says Cantu, "Ten years ago concussions were thought of as something that was just part of sport—something that had no lasting ramifications." But concussions among high-profile athletes such as Brett Lindros, who retired from professional hockey at age 19 after suffering multiple concussions and postconcussion syndrome, have pointed up the risk of lasting harm. "They have brought out the reality that concussions are not innocuous," Cantu says. "There is a need for more research, better equipment, and injury prevention. These are all good issues to come forward."

The Brain Injury Association in Washington, DC, will distribute the guidelines through its Head Smart program in public schools and at a seminar, Concussion in Sports and Recreation, this June in Charlotte, North Carolina.

Mark L. Fuerst
Brooklyn, New York,
and staff editors


  1. Kelly JP, Rosenberg JH: Practice parameter: the management of concussion in sports (summary statement). Neurology 1997;48(3):581-585
  2. Centers for Disease Control and Prevention: Sports-related recurrent brain injuries: United States. MMWR 1997;46(10):224-227
  3. Colorado Medical Society Sports Medicine Committee: Guidelines for the Management of Concussion in Sports. Denver, Colorado Medical Society, 1991
  4. Cantu RC: Guidelines for return to contact sports after a cerebral concussion. Phys Sportsmed 1986;14(10):75-83



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