Determining Concussion Severity: A New Approach

Older Guidelines Grade Concussions

Until the 2000's most concussions were graded at the time of injury. Begininning with the revised concussion guidelines issued by MomsTeam expert, Robert C. Cantu, M.D. in 2001, the trend among clinicians has been to place less weight on loss of consciousness and post-traumatic amnesia (PTA) as a potential predictor of subsequent impairment and additional weight on the overall persistence of post-concussion signs and symptoms, with grading of the severity of injury only after the athlete is symptom free.

Simple v. Complex

The 2nd International Conference on Concussion in Sport held in Prague in 2004 (Prague consensus statement) introduced a new approach to the grading scale dilemma by simply eliminating the use of a grading scale altogether. Like Dr. Cantu's revised guidelines, the Prague consensus statement focuses on whether the athlete is symptomatic or symptom free and determines severity retrospectively, after all post-concussion signs and symptoms have cleared, the neurological exam is normal, and cognitive function has returned to pre-injury level (e.g. baseline). It classifies concussions as either simple or complex depending on how long it takes for all concussion signs to clear:

A simple concussion is defined as one that progressively resolves without complications over seven to ten days. Simple concussions are:

• the most common form
• can be appropriately managed by the athlete's primary care physician or by certified athletic trainers (ATCs) working under medical supervision.
• Except for limiting playing or training while asymptomatic, no further intervention is required during the recovery period and the athlete typically resumes sport without further complications.
• The cornerstone of management is rest until the athlete is asymptomatic followed by a gradual increased exertion program before return to full participation in practices and games.

A complex concussion is either one in which:

• concussive symptoms persist, including recurrence with exertion, specific consequences (e.g. concussive convulsions, loss of consciousness (LOC) of one minute or more, prolonged cognitive impairment following injury), and/or
• a concussion suffered by an athlete with a history of previous concussions, and/or
• a concussion where repeated concussions occur with progressively less impact force.

Controversial approach

Some experts, including Dr. Cantu, don't like the use of the word "simple" to describe a concussion because they would not refer to a concussion with symptoms lasting as long as 10 days as a simple concussion and argue that it may not be a good choice for describing any concussion. The use of the concept of simple v. complex is an area of concern about the Prague statement and will be on of the areas covered in the consensus statement that will be issued, hopefully in the near future, as a result of the 3rd International Conference on Concussion in Sport held in St. Moritz, Switzerland in March 2008.