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Severity Guidelines

One of the most common ways to categorize concussion is the ACSM/Cantu Guidelines developed by neurologist Robert Cantu.

Grade 1 or mild concussion includes no loss of consciousness combined with post-traumatic amnesia (PTA) lasting less than 30 minutes. Identifying PTA includes digit recall, simple arithmetic, reverse numbering, and word pairs asked immediately and at 1, 3 and 5 minutes. Orientation to time including who the president is, who their principal is and today's date are useful questions for evaluation.

Grade 2 or moderate concussion includes loss of consciousness for less than 1 minute or PTA that lasts for more than 30 minutes and less than 24 hours. Post-concussion signs and symptoms that last for more than 24 hours, but less than six days, are also considered to be Grade 2.

Grade 3 or severe concussion occurs with loss of consciousness exceeding 1 minute, PTA for more than 24 hours or post-concussion signs and symptoms (PCSS) for more than seven days. Depending on the number of concussions and grade severity, referral for neurologic evaluation and brain imaging will be required. If you are a doctor on the field of play, remember, "When in doubt, keep them out!" Nothing is worth chancing the devastating consequences of head injury.

Other Considerations

Treatment of concussion includes cognitive and physical rest until symptoms resolve, followed by a graded program of exertion prior to medical clearance and return to play. Special consideration to treating each person with concussion as an individual is necessary. The recovery and outcome of concussion depends on a variety of factors that may require a sophisticated treatment and management strategy that includes a step-by-step progression.

Guidelines are used as a standardized reference, but observation, clinical skill and common sense are always better than a standardized guideline. Evaluations and recommendations need to be individualized for the individual, keeping in mind that the effect of concussion on children can be much more damaging than adults since neurophysiologic maturity is not reached until the mid-20s.

An athlete who doesn't exhibit many of the same symptoms of PCSS like dizziness, vomiting or memory loss can still have the same changes in brain activity as one with a diagnosed concussion. Even one of the standard neurologic tests used to measure concussive blows, the ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing), doesn't always measure an athlete's readiness to return to play because the test can be cheated on.

Protective Legislation

Legislation has been introduced in many states to protect student athletes from the damaging and often-devastating effects of head injury. Special concern is being placed on return-to-play guidelines that are designed to avoid second-impact syndrome and its potentially deadly consequences.

In 2009, Washington introduced the Zachary Lystedt Law, requiring any athlete under 18 years of age suspected of having a concussion injury to receive written medical authorization from a licensed physician before returning to play. Other states are following suit; for example, beginning in January 2012, California requires written authorization for return to play for children under 18 years old. Doctors of chiropractic are included in this law as qualified health care providers.

Talk to Your Chiropractor

The use of doctors of chiropractic in high-school, college, amateur, and professional athletics is growing rapidly. Whether your doctor of chiropractic is a team chiropractor for the Olympics, a professional football team or your child's soccer or Pop Warner team, or has patients who play contact sports, knowledge of sports injuries and especially evaluation of concussion is a vital part of their role as a health care provider. Talk to your DC about the dangers of concussions and make sure you know what to do if you or someone you love suffers a head injury.

Dr. Robert "Skip" George co-owns Optimum Fitness and Health in La Jolla, Calif., integrating chiropractic, rehabilitation and sports-performance training into his practice.