202 SECTION 3 • MEDICAL PROBLEMS IN THE ATHLETE
posttraumatic head injury athlete who is suspected of
having neuropsychologic symptoms.
•Testing and treatment of postconcussive athletes
includes standard neuroimaging along with more
specific evaluations to include audiologic testing,
electronystagmography, posturography, and a bat-
tery of tests to evaluate everything from orientation
and attention to visual scanning and motor coordi-
nation.
•Treatment of postconcussive syndrome is symptom
related and can include analgesics, nonsteroidal
anti-inflammatories, antidepressants, and muscle
relaxants. Education and reassurance that most
patients with postconcussive syndrome have completeTABLE 34-3 Guidelines for Return to Sports After Cerebral Concussion
GRADE FEATURES MANAGEMENT RETURN TO PLAY
1 (mild) No loss of consciousness Remove from contest May return if asymptomatic at rest and with
exertion (no headache, dizziness, or
impaired concentration plus full recall of
the events occurring before injury)
Posttraumatic amnesia less than 30 min Observe on the sidelines Second grade 1 concussion: May return in
2 weeks if asymptomatic at that time
for 1 week
Third grade 1 concussion: terminate season,
may return next year if asymptomatic
2 (moderate) Loss of consciousness less than Remove from contest and Return after asymptomatic for 1 week
5 min or posttraumatic amnesia disallow return that day
longer than 30 min Athlete should be evaluated Second grade 2 concussion: wait at least
by a neurologist at a 1 month, may return then if asymptomatic
medical facility for 1 week, consider terminating season
Cervical spine precautions Third grade 2 concussion: terminate season,
as indicated may return next year if asymptomatic
3 (severe) Loss of consciousness longer than Transport athlete to nearest hospital Wait at least 1 month, may return then if
5 min or posttraumatic amnesia with neurosurgical facilities with asymptomatic for 1 week
longer than 24 h head and neck immobilization
Admit to hospital to check for Second grade 3 concussion: terminate season,
intracranial bleeding may return next season if asymptomatic
SOURCE: Cantu R: Guidelines for return to contact sports after a cerebral concussion. Phys Sportsmed14:75–76, 79, 83, 1986. (With permission)
TABLE 34-4 Guidelines for Management of Concussion in Sports
GRADE FEATURES MANAGEMENT RETURN TO PLAY
1 Confusion without amnesia Remove from contest May return if asymptomatic at rest and with
exertion for at least 20 min
No loss of consciousness Examine immediately and at 5-minute Second grade-1 concussion in same contest:
intervals for development of mental status disqualify athlete for that day
abnormalities or postconcussive symptoms Third grade-1 concussion: terminate season
at rest with exertion
2 Confusion with amnesia Remove from contest and disallow return May return after 1 full asymptomatic week at rest
that day and with exertion
No loss of consciousness Examine on site frequently for signs of Second grade-2 concussion: return to play after
evolving intracranial pathology 1 month symptom free at rest and with exertion,
consider termination of season
CT scan or MR imaging if symptoms worsen Third grade-2 concussion: terminate season
or persist for longer than 1 week
3Any loss of consciousness Transport athlete to nearest emergency May return after 1 month if asymptomatic at rest
department by ambulance with cervical spine and with exertion for at least 2 weeks
precautions, if necessary Second grade-3 concussion: terminate season, return
to any contact sport seriously discouragedSOURCE: Colorado Medical Society Sports Medicine Committee: Guidelines for the Management of Concussion in Sports.Denver, CO, Colorado
Medical Society, 1991. (With permission)