Concussion management during sporting events or practice sessions is a challenge for physicians providing care for athletes. The decision to allow athletes to return to competition after a concussion has been based on published guidelines by professional organizations, but little research supports the guidelines. Guidelines from the American Academy of Neurology are based on transient confusion, no loss of consciousness, and concussion symptoms or mental status changes that resolve within 15 minutes of the injury. These concussions are rated as grade 1, and as long as athletes meet the criteria, they are allowed to return to play. Grade 1 concussions are the most common type of concussion and may be difficult to identify because there is no loss of consciousness. Recent data have suggested that even grade 1 concussions may have effects that go unrecognized, leading to lack of follow-up and the possibility of neuropsychologic dysfunction. Because of the latter issues, Lovell and associates evaluated the use of the current concussion management guideline in the management of mild concussion.
The trial design was a prospective study of neuropsychologic function before and after concussion in high school athletes. Before the start of the season, all of the athletes participating in contact sports had a neuropsychologic evaluation using a standardized computer program. After an injury, athletes were assessed using a sideline mental status evaluation, and decisions to return the athlete to the event were based on the results of this evaluation.
Athletes with concussion had two follow-up neuropsychologic tests during the days after the injury; the first at a mean of 36 hours, and the second at a mean of six days. During the study, athletes returned to participation in their sport only after the two neuropsychologic evaluations were completed, even though their concussions by definition met the grade 1 criteria and all symptoms present after the injury resolved within 15 minutes of the injury.
There were 43 high school athletes who met the inclusion criteria for the study. The memory composite score had a significant drop during the first neuropsychologic test after the concussion and returned to base-line at the second test. The athletes had significantly more postconcussion symptoms during the first test, which returned to baseline by the second test. The reaction time was the same at the first test as at baseline but improved significantly at the second test. The processing speed composite score showed the same pattern. Eleven athletes reported no symptoms, and seven had normal neuropsychologic testing at 36 hours after the injury. Only four athletes had no symptoms and normal neuropsychologic testing at 36 hours. By day six, most athletes had returned to baseline.
The authors conclude that athletes with grade 1 concussions have memory deficits and symptoms that persist after the injury. In addition, they state that the current recommendation to return an athlete with a grade 1 concussion to play 15 minutes after the injury may be too liberal.