When Can an Athlete Return to Play After a Concussion?

Patient Presentation
A 15-year-old female comes to clinic with a 2 day history of mild generalized headache. The headache began immediately after she fell while ice skating in the late afternoon. She also had blurry vision and confusion about what had occurred in the early evening, but they resolved. The following day she had mild headache which got better with ibuprofen. She went to basketball practice and the headache returned but did not increase in intensity or change character. Today she continues to have the generalized headache and feels that she has to “think to do things.” The headache is generalized over her entire head.
Her social history shows her to be an active athlete.
The review of systems reveals no fever, nausea/emesis, visual or auditory changes, ataxia or movement problems, dizziness/vertigo, numbness/tingling, difficulty speaking/chewing/swallowing, neck pain or sleep problems.
The pertinent physical exam shows her to be a well developed female with non-specific bruising on her shins and left iliac crest. Her head had a small elevated contusion on the left temporal/parietal area. Her pupils and extraocular movements are normal. Her mental status and neurological examination are also completely normal including short and long term memory.
Because of her history of trauma, continued headache, and new subjective mental status changes, a radiologic evaluation by head CT scan was completed and showed no brain edema, bleeding or mass.
The diagnosis of a Grade 2 Concussion is made and the patient is told to use Ibuprofen more consistently for her headache. She is to refrain from any sports activities or exertion for 1 week. She will have telephone follow-up in 3 days and an office appointment will be made at that time. She is to return sooner if her symptoms worsen.

Discussion
Head injuries in children are very common and thankfully, often are mild. Intracranial pathology is worrisome and includes concussion, contusion, hemorrhage and diffuse axonal injury. Common worrisome symptoms include loss of consciousness, amnesia, persistent emesis, seizures, drowsiness or personality changes.

Concussion is defined as a change in mental status that is caused by trauma and which may or may not involve loss of consciousness. Amnesia and confusion are hallmarks. The confusion and amnesia may occur immediately after the injury or several minutes later.

Early symptoms of concussion (minutes to hours) including headache, dizziness, vertigo, nausea or emesis and lack of situational awareness. Late symptoms (days to weeks) include light headedness, persistent low grade headache, visual or auditory intolerance or changes, easy fatigability, memory problems, poor attention and concentration, irritability and low frustration tolerance, anxiety or depressed mood and sleep problems.

Concussions are graded by confusion, loss of consciousness and time. The American Academy of Neurology recommends management options based on this grading system.

  • Grade 1 – Most common
    • Confusion: Transient

    • Loss of consciousness: None
    • Timing: less than 15 minutes for complete resolution of concussion symptoms or mental status abnormalities on examination
    • Miscellaneous: This is hard to recognize as the momentary confusion is very qualitative and subjective. Athletes sometimes call this “getting their bell rung” or being “dinged.”
    • Treatment:

      • Remove from contest

      • Examine immediately and at 5 minute intervals for the development of mental status abnormalities or postconcussive symptoms at rest and with exertion
      • Return to competition if mental status abnormalities or post-concussive symptoms clear within 15 minutes
      • A second Grade 1 concussion in the same contest eliminates the player from competition that day
      • Return to competition if asymptomatic for one week at rest and with exercise
  • Grade 2
    • Confusion: Transient

    • Loss of consciousness: None
    • Timing: More than 15 minutes for complete resolution of concussion symptoms or mental status abnormalities on examination
    • Miscellaneous: Any symptoms lasting more than one hour should be observed medically.
    • Treatment:
      • Remove from contest and do not allow return that day

      • Frequently examine at the contest site for signs of evolving intracranial pathology
      • A trained person should reexamine the athlete the next day
      • A physician should perform a neurologic examination to clear the athlete for return to play after 1 full asymptomatic week at rest and with exertion
      • If headache or other associated symptoms worsen or persist longer than one week, a CT or MRI scanning is recommended in all instances
      • Following a second Grade 2 concussion, return to play should be deferred until the athlete has had at least two weeks symptom-free at rest and with exertion
      • Any abnormality on CT or MRI scan consistent with brain swelling, contusion, or other intracranial pathology terminates the season for that athlete
  • Grade 3
    • Confusion: Any

    • Loss of consciousness: Any loss of consciousness either brief (seconds) or prolonged (minutes)
    • Timing: Any
    • Miscellaneous: This is usually easily recognized as the athlete is unconscious for any time period.
    • Treatment:
      • If still unconscious or worrisome signs are observed, transport the athlete to the nearest emergency department by ambulance with cervical spine immobilization, if appropriate

      • An emergent, complete neurologic evaluation should be performed and neuroimaging procedures also performed when indicated
      • Hospital admission is indicated if any signs of pathology are detected, or if the mental status of the athlete remains abnormal
      • If findings are normal at the time of the initial medical evaluation, the athlete may be sent home with explicit written instructions to help the family or responsible party observe the athlete
      • Neurologic status should be assessed daily until all symptoms have stabilized or resolved
      • Prolonged unconsciousness, persistent mental status alterations, worsening postconcussive symptoms, or abnormalities on neurologic examination require urgent neurosurgical evaluation or transfer to a trauma center
      • After a brief (seconds) Grade 3 concussion, the athlete should not play until asymptomatic for 1 week at rest and with exertion
      • After a prolonged (minutes) Grade 3 concussion, the athlete should not play until asymptomatic for 2 weeks at rest and with exertion
      • Following a second Grade 3 concussion, the athlete should not play for a minimum of 1 asymptomatic month. The evaluating physician may elect to extend that period beyond 1 month, depending on clinical evaluation and other circumstances
      • CT or MRI scanning is recommended for athletes whose headache or other associated symptoms worsen or persist longer than 1 week
      • Any abnormality on CT or MRI scan consistent with brain swelling, contusion, or other intracranial pathology, terminates the season for that athlete. Future return to play should be seriously discouraged in discussions with the athlete

Learning Point
The time courses for athletes to return to play following concussion, can be summarized as follows:

  
Grade of concussion             Time until return to play
	Grade 1                        15 minutes or less

	Multiple Grade 1               1 week

	Grade 2                        1 week

	Multiple Grade 2               2 weeks

	Grade 3 - brief loss of        1 week
	   consciousness (seconds)

	Grade 3 - prolonged loss of    2 weeks
	   consciousness (minutes)

	Multiple Grade 3               1 month or longer,
	                               based on clinical decision of
	                               evaluating physician

Questions for Further Discussion
1. What should be included in the side-line evaluation of an athlete for possible concussion?
2. When should a head CT or MRI be done for head trauma?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Head Injuries.

American Academy of Neurology Quality Standards Subcommittee. Management of Concussion in Sports. Neurology, 1997;48:581-585,
Available from the Internet at http://www.aan.com/professionals/practice/guideline/index.cfm (rev.Mar 1997 cited 1/6/05).

Woodhead JC. Pediatric Clerkship Guide. Mosby. St. Louis MO, 2003:464-468.

Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

Date
January 31, 2005