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Repetitive Head Injury Syndrome David Cifu, MD, eMedicine.com (page 6 of 8) Page 6 of 8

Concussion scales with return-to-play criteria

Cantu system ^{29, 30, 31}

• Grade I – No loss of consciousness, or posttraumatic amnesia for less than 30 minutes
  • First concussion – Return to play if patient is asymptomatic for 1 week
  • Second concussion – Return to play if patient is asymptomatic for 2 weeks
  • Third concussion – Terminate season
• Grade II – Loss of consciousness for less than 5 minutes, or posttraumatic amnesia for 30 minutes to 24 hours
  • First concussion – Return to play if patient is asymptomatic for 1 week
  • Second concussion – Return to play if, after at least 1 month, patient asymptomatic for 1 week
  • Third concussion – Terminate season
• Grade III – Loss of consciousness for more than 5 minutes, or posttraumatic amnesia for longer than 24 hours
  • First concussion – Return to play if, after at least 1 month, patient asymptomatic for 1 week
  • Second concussion – Terminate season Kelly system³²
• Grade I – No loss of consciousness, transient confusion for less than 15 minutes
  • First concussion – Return to play if patient is asymptomatic within 15 minutes
  • Second concussion in same contest – Remove from play
  • After fourth concussion in season – Terminate season
• Grade II – No loss of consciousness, transient confusion for longer than 15 minutes
  • First concussion – Return to play if patient is asymptomatic for 1 week
  • Second concussion – Return to play if patient is asymptomatic for 2 weeks
  • Third concussion – Terminate season
• Grade III – Loss of consciousness, brief (seconds) or prolonged (minutes)
  • First concussion with brief loss of consciousness – Return to play if patient is asymptomatic for 1 week
  • First concussion with prolonged loss of consciousness – Return to play if patient is asymptomatic for 2 weeks >
  • Second concussion – Return to play if patient is asymptomatic for 1 month

Kelly system32

• Grade I – No loss of consciousness, transient confusion for less than 15 minutes
  • First concussion – Return to play if patient is asymptomatic within 15 minutes
  • Second concussion in same contest – Remove from play
  • After fourth concussion in season – Terminate season
• Grade II – No loss of consciousness, transient confusion for longer than 15 minutes
  • First concussion – Return to play if patient is asymptomatic for 1 week
  • Second concussion – Return to play if patient is asymptomatic for 2 weeks
  • Third concussion – Terminate season
• Grade III – Loss of consciousness, brief (seconds) or prolonged (minutes)
  • First concussion with brief loss of consciousness – Return to play if patient is asymptomatic for 1 week
  • First concussion with prolonged loss of consciousness – Return to play if patient is asymptomatic for 2 weeks
  • Second concussion – Return to play if patient is asymptomatic for 1 month

Complications

The most common complication at follow-up is further head injury and/or cognitive decline. Matser et al found that concussion is specifically associated with impaired performance in memory and planning functions.¹⁶

Prevention

Equipment and rule changes have significantly reduced the number and severity of head injuries in American football over the last 25 years. The dramatic difference seen in football has sparked debate about equipment and rule changes in soccer because a significant number of concussions are now known to occur when players hit the ball with their head.

In preventing SIS, the recognition of a concussion is the key factor. Preventing an athlete from returning to play while he or she still has symptoms from a concussion and following the guidelines for concussion management may help avert a catastrophic outcome.

Prognosis

The prognosis varies with the severity of the injury. By definition, repetitive head injury is worse than a single minor concussion; neuropsychologic test results are worse in patients with repetitive minor concussions. Regarding SIS, rapid transport to a medical facility with neurosurgical specialists may prevent or limit the rapid decline often seen with SIS.

Education
Educate athletes, coaches, and healthcare professionals about the potentially catastrophic effects of SIS. Coaches and healthcare professionals need to know how to prevent SIS by not allowing the athlete to return to play while he or she is still recovering from a previous head injury.

Miscellaneous

Medical/Legal Pitfalls

Allowing a player to return to play while the symptoms from a previous head injury persist can lead to his or her death. This outcome can result in a significant malpractice action.

Acknowledgements

Invaluable assistance in the preparation of this manuscript was received from Ingrid A. Prosser, MD.

Author: David Cifu, MD, The Herman J Flax, MD Professor and Chairman, Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University; Chief of PM&R Services, Virginia Commonwealth University Health System, Medical College of Virginia Hospital; Co-Principal Investigator of the NIDRR Traumatic Brain Injury Model Systems and NIH Traumatic Brain Injury Network Sistes Programs, Virginia Commonwealth University

David Cifu is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Congress of Rehabilitation Medicine, American Medical Association, Association of Academic Physiatrists, Brain Injury Association, and National Stroke Association

From eMedicine.com. Reprinted with permission. www.emedicine.com/sports/TOPIC113.HTM.

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