At least 41 different grading systems have been used to classify the severity of mild traumatic brain injury documented in the literature.
6 Currently, the most widely used and accepted clinical guidelines were developed by the Colorado Medical Society, the American Academy of Neurology (AAN),
7 and Cantu
8 (
Table 1). Loss of consciousness is considered a grade III concussion in these grading scales.
9 The Colorado Sports Concussion Grading Scale incorporates the concepts from most grading scales, producing a progression of severity (grades).
The return-to-play guidelines incorporate the grade of concussion, number of prior concussions, and time between concussive episodes and the patient's postconcussive performance on neurologic, physical, and neuropsychologic examination. The return-to-play guidelines in
Table 2 are based on the most recent grading system of the AAN and are recommended for physicians to determine an athlete's ability to return to play.
7
Contrary to the AAN's use of concussion grading scales, the International Conference on Concussion recommends against using standard grading scales to ensure individualized care.
10 A stepwise approach to recovery is based on the Concussion in Sport Group's “11 R's”: recognize, remove, reevaluate, rest, rehabilitation, refer, recover, return to sport, reconsider, residual effects and sequelae, and risk reduction. This approach incorporates neuropsychiatric testing using tools such as the Standardized Assessment of Concussion and the Maddocks Questions Test. The fifth International Conference on Concussion in Berlin recommends a graduated return to sport, with each step encompassing 24 to 48 hours.
11 In addition, they recommend the use of the latest Sport Concussion Assessment Tool, as it is the most developed and established tool for evaluating concussion within the first 3 to 5 days.
11 For graduated return to sport, they recommend the following:
Symptom-limited activity
Light aerobic exercise
Sport-specific exercise
Noncontact training drills
Fully contact practice
Return to sport
The American Osteopathic Association also issued guidelines pertaining to return to play activity following concussion in Resolution No. H 352.
12
▪ Young athletes with concussion should stop playing the sport immediately.
▪ Sideline assessments for athletes with suspected concussion should be performed by appropriate licensed/certified professionals.
▪ If concussion is suspected after assessment, athletes should be examined by a physician.
▪ Physician will develop treatment plan for return to sport and return to learn.
A study
13 performed at the University of Pittsburgh Medical Center found that young athletes who continued to play a sport immediately after a concussion took twice as long to recover from their symptoms and had more severe symptoms compared with an equivalent group removed from play. Removal from play was the strongest predictor of a fast recovery, more so than any other factor, such as age or sex.
At the start of the athletic season, all athletes should receive baseline testing that evaluates their balance and cognitive function. For athletes who later sustain a concussion, these baseline assessments can be compared against postconcussion testing to determine whether their function has been affected. When the results of cognitive, physical, neurologic, and neuropsychiatric examinations are in doubt, players should be removed from play.