POSITION STATEMENT
GUIDELINES FOR THE ASSESSMENT AND MANAGEMENT
OF SPORT-RELATED CONCUSSION
(May 2000 - Published in the CJSM, Volume 10, Issue 3)
Introduction
Concussion is defined by the Congress of Neurological Surgeons as "a clinical syndrome
characterized by immediate and transient post traumatic impairment of neural function, such as
alteration of consciousness, disturbance of vision and/or equilibrium due to brain stem involvement".
Sports related concussions are a significant problem. Between 1931 and 1986, there were over 800
deaths from North American football alone and currently there are estimated to be 300,000 concussions
per year in contact sport in the United States.
A concussion may be sustained through a variety of mechanisms. A direct blow to the head,
blow to the jaw, sudden twisting or shearing force and a sudden deceleration of the head [similar to a
"whiplash" type injury] can all produce concussive signs and symptoms. In severe trauma, there may
be bleeding or obvious damage to brain structures. In the more typical sport related concussion, no
obvious damage is found on tests such as X-rays, CT scans and MRIs. It is unclear as to what happens
to the brain but, after injury, it may not function normally and is vulnerable to further damage for a
period of time. The exact length of this period of vulnerability is not known.
Concussion can cause a variety of symptoms. It is of critical importance to be aware of the fact
that one does not have to lose consciousness to have had a concussion! Typical post concussive
symptoms can include feeling dazed, "having your bell rung", memory problems, confusion, poor coordination, headache, and nausea. Return to play in a contact activity while still symptomatic is very
dangerous. The most severe consequence is the "second impact syndrome"; this is a rare but usually
fatal condition whereby even a seemingly mild blow to a previously concussed brain leads to massive
brain swelling. Return to play while symptomatic has also been shown to increase the risk of further
concussion, persistence of post concussive symptoms and other injury. Post concussive symptoms may
also increase with any type of exercise following injury, so a gradual increase in exercise and return to
play protocol should be used. It has also been shown that multiple concussions can lead to permanent,
irreversible changes, such as memory loss, concentration problems, headaches etc.
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While much has been learned about concussion, considerable controversy still exists in several
areas. Numerous concussion-grading systems have been proposed, but are not based on scientific
evidence. There is controversy related to the relative importance of loss of consciousness,
posttraumatic amnesia, and post concussive symptoms in grading injury severity. It is therefore
difficult to endorse any specific guideline. Return to play guidelines are similarly based on experience
rather than evidence; it is still not known how long the brain is vulnerable following the concussive
injury. Therefore, it is prudent to err on the side of caution in returning an athlete to play.
Protective equipment has been shown to reduce the risk and severity of head injury in sports.
Approved helmets should be worn in all collision sports or activities with a risk of head trauma (e.g.
cycling, in-line skating). Helmets should be kept in good condition and worn properly.
Currently, there is considerable interest in the medical and public sectors, as well as amateur
and professional sport groups, in learning more about concussion, its safe management, and prevention.
Important questions still exist, and there is an urgent need for answers. With this mandate, the
Canadian Academy of Sport Medicine [CASM] Committee on Concussion has brought together a
national group of interested and qualified CASM members to undertake the task of addressing these
issues in the scientific, practical manner in order for CASM to authoritatively develop a guideline on
this topic. CASM is attempting to provide leadership in this controversial field. Following a meeting
of the committee at our annual conference, the following guidelines were agreed upon by the
membership. The literature as pertains to each members’ area of expertise was reviewed, presented,
and discussed. While the guideline is by no means a comprehensive accumulation of all available data,
it is agreed that it represents a practical, usable consensus for use in the management of sport related
concussion. As such, we have made a first step in the development of an ongoing critical update on
this important injury.
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CASM CONCUSSION GUIDELINES
A) SIGNS AND SYMPTOMS OF CONCUSSION
If any one of the following symptoms or problems is present, a head injury should be suspected and
appropriate management provided:
A player does not need to have lost consciousness to have had a concussion!!
1) Memory or Orientation Problems
Unaware of time, date, place
Unaware of period, opposition, score of game
General confusion
2) Typical Symptoms
Headache
Dizziness
Feeling “dinged” or stunned
“Having my bell rung”
Feeling dazed
Seeing stars or flashing lights
Ringing in the ears
Sleepiness
Loss of field of vision
Double vision
Feeling “slow”
Nausea
3) Physical Signs
Poor coordination or balance
Vacant stare/glassy eyed
Vomiting
Slurred speech
Slow to answer questions or follow directions
Easily distracted, poor concentration
Displaying unusual or inappropriate emotions (e.g. laughing, crying)
Personality changes
Inappropriate playing behaviour (e.g. skating or running the wrong direction)
Significantly decreased playing ability from earlier in the game/competition
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B)
ACUTE RESPONSE
When a player shows ANY symptoms or signs of a concussion:
1) The player should not be allowed to return to play in the current game or practice.
2) The player should not be left alone; monitoring for deterioration is essential.
3) The player should be evaluated by a medical doctor.
4) Return to play must follow a gradual process, monitored by a medical doctor.
A player should never return to play while symptomatic!! “When in doubt, sit them out!”
C)
CONCUSSION GRADING AND RETURN TO PLAY GUIDELINES
Numerous concussion severity grading systems and return to play guidelines exist. None are
based on scientific evidence. The area is still controversial, and no consensus exists amongst
experts. Therefore, it is not possible to endorse a specific guideline. At this point, medical
doctors should choose a system they are comfortable with to help them in this area. It would be
prudent to choose a guideline which is conservative, and errs on the side of caution. Again, it is
important to emphasize that no player should ever resume play while still symptomatic.
D) STEPS TO RETURN TO PLAY FOLLOWING A CONCUSSION
1) No activity, complete rest. Once asymptomatic, proceed to level (2). Continue to proceed to
the next level if asymptomatic. If symptoms occur, drop back to a level where there are no
symptoms, and try to progress again.
2) Light exercise such as walking or stationary cycling.
3) Sport specific activity (e.g. skating in hockey)
4) “On field” practice without body contact.
5) “On field” practice with body contact, once cleared to do so by a medical doctor. The time
required to progress from full non-contact exercise to contact will vary with the severity of
the concussion.
6) Game play.
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E)
PREVENTION
The risk of head injury is reduced by:
1)
Wearing appropriate protective equipment. The equipment should be worn properly, and
replaced when damaged.
2)
Adhere to the rules of your sport. Play fair and play smart!
3)
Respect your opponent.
Critical Points!
1) You do not have to lose consciousness to have had a concussion. Symptoms are often
subtle.
2) Never return to play while symptomatic.
3) Follow a step-wise return to play.
4) Wear proper protective equipment.
These guidelines have been:
1) Reviewed and agreed upon by the CASM Concussion Committee and the CASM Board of
Directors.
2) Modified from the “Heads Up” campaign, Sport Medicine Council of Alberta
3) Generalized to apply to child, youth, and adult amateur and elite sport. However, it is recognized
that particular problems may be specific to the pediatric population and ongoing endeavors in this
area are required.
4) Designed for use by athletes, coaches, trainers, therapists, and medical doctors to aid in concussion
identification, reporting and decision making.
Primary Authors:
Dr. James Kissick
Dr. Karen Johnston
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REFERENCES
1. Cantu, R. C. Reflections on head injuries in sport and the concussion controversy. Clin J Sports
Med 1997; 7: 83-84.
2. Cantu, R. C. Return to play guidelines after a head injury. Clin Sport Med 1998;17 (1): 45-60.
3. Fick, D. S. Management of concussion in collision sports: Guidelines for the sidelines.
Postgraduate Med 1995; 97(2); 53-60.
4. Kelly, J. P. Rosenberg, J. H. Diagnosis and management of concussion in sports. Neurology 1997;
48:575-580.
5. Kelly, J.P., Nichols, J. S., Filley, C. M., Lillehei, K. O., Rubinstein, D., Kleinschmidt-DeMasters,
B. K. Concussion in sports. JAMA 1991; 266(20): 2867-2869.
6. King, NS. Mild Head Injury: Neuropathology, sequelae, measurement and recovery. Br. J. Clinical
Psychology. 36:161-184. 1997.
7. McCrea, M., Kelly, J. P., Kluge, J., Ackley, B., Randolph, C. Standardized assessment of
concussion in football players. Neurology 1997; 48:586-588.
8. McCrory, PR and Berkovic, SF. Second Impact Syndrome. Neurology 50(3): 677-83. 1998.
9. Report of the Quality Standards Subcommittee. Practice parameter: The management of concussion
in sports. Neurology 1997; 48:581-585.
10. Roos R. Guidelines for managing concussion in sports. The physician and sportsmedicine 1996;
24(10): 67-74.
11. Thurman, DJ, Branche, CM and Sniezek, JE. The Epidemiology of Sports Related Traumatic Brain
Injuries in The United States: Recent Developments. J. Head Trauma Rehab. 13(2)1-65. 1998.
12. Warren, W. L., Bailes, J. E. On field evaluation of athletic head injuries. Clin Sports Med 1998; 17
(1): 13-26.
13. Lovell MR, Iverson GL, Collins MW, McKeag D, Maroon J. Does Loss of Conciousness Predict
Neuropsychological Decrements After Concussion? Clin J Sport Med 1999; 9:193-198.
14. Wotjys EM, Hovda D, Landry G, Boland A, Lovell M, McCrea M, Minkoff J. Concussion In
Sports. Am J Sports Med 1999; 27(5):676-686
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