To the Editor: In the Clinical Practice article on concussionby Ropper and Gorson (Jan. 11 issue),1 the discussion of sport-relatedconcussion is outdated — especially, the definition ofconcussion. The review is also inaccurate regarding the riskof recurrent concussion and the second impact syndrome. Theauthors do not address and are at odds with recent collaborativeconsensus statements on concussion, which provide the followingguidance.2,3,4,5,6 Loss of consciousness is rarely present insport-related concussion, and a brief loss of consciousnessdoes not correlate with the severity of the injury. The type,severity, and duration of the symptoms are the most useful criteriafor determining the severity of concussion. Assessment and treatmentof the concussed athlete must be individualized. Factors thatmust be considered include age, sport in which the injury occurred,presence or absence of a history of concussion, and if therehave been previous concussions, their proximity to the currentinjury and their severity. Symptomatic athletes should not beallowed to return to play. Neuropsychological testing may helpin evaluating the athlete's cognitive functioning and in decisionmaking about the return to play. Physical and mental rest appearto be important for recovery. Younger athletes should be treatedmore conservatively than older athletes. The athlete's returnto activity should be gradual and progressive.
Robert C. Cantu, M.D. Brigham and Women's Hospital Boston, MA 02115
Stanley A. Herring, M.D. University of Washington Seattle, WA 98104-2499
Margot Putukian, M.D. Princeton University Princeton, NJ 08544
for the American College of Sports Medicine
References
Ropper AH, Gorson KC. Concussion. N Engl J Med 2007;356:166-172. [Free Full Text]
Cantu RC, Aubry M, Dvorak J, et al. Overview of concussion consensus statements since 2000. Neurosurg Focus 2006;21:E3-E3. [Medline]
Concussion (mild traumatic brain injury) and the team physician: a consensus statement. Med Sci Sports Exerc 2005;37:2012-2016.
Guskiewicz KM, Bruce SL, Cantu RC, et al. National Athletic Trainers' Association Position Statement: management of sport-related concussion. J Athl Train 2004;39:280-297. [Web of Science][Medline]
Johnston KM, Aubrey M, Cantu RC, et al. Summary and agreement statement of the First International Conference on Concussion in Sport, Vienna 2001. Phys Sportsmed 2002;30:57-63.
McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med 2005;39:196-204. [Free Full Text]
To the Editor: Ropper and Gorson state that loss of consciousnessand amnesia define a concussion, even though loss of consciousnessis relatively unusual in concussive head trauma. Current guidelinesemphasize the presence of amnesia and characteristic symptomsas better predictors of concussion and its resolution.1,2,3,4
Sports physicians have abandoned strict grading systems in favorof an individualized approach to assessment and treatment thatis based on an evaluation of risk factors, such as age, presenceor absence of a history of concussion, duration of symptoms,and response to exercise, and an assessment of cognitive functioning,with computed tomographic (CT) scanning reserved for patientswith possible intracranial bleeding. Extensive research supportsneuropsychological testing as a tool for assessing the severityof concussion.5 Dramatic progress and collaborative effortsregarding concussion should not be overlooked.
Paul R. Stricker, M.D. James Moriarity, M.D. Francis G. O'Connor, M.D., M.P.H. American Medical Society for Sports Medicine Overland Park, KS 66210 stricker.paul{at}scrippshealth.org
References
Concussion (mild traumatic brain injury) and the team physician: a consensus statement. Med Sci Sports Exerc 2006;38:395-399.
Guskiewicz KM, Bruce SL, Cantu RC, et al. National Athletic Trainers' Association Position Statement: management of sport-related concussion. J Athl Train 2004;39:280-297. [Web of Science][Medline]
Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the First International Symposium on Concussion in Sport, Vienna 2001. Clin J Sport Med 2002;12:6-11. [CrossRef][Web of Science][Medline]
McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med 2005;39:196-204. [Free Full Text]
Van Kampen DA, Lovell MR, Pardini JE, Collins MW, Fu FH. The "value added" of neurocognitive testing after sports-related concussion. Am J Sports Med 2006;34:1630-1635. [Free Full Text]
To the Editor: The American Academy of Pediatrics Council onSports Medicine and Fitness is concerned that the definitionof concussion used by Ropper and Gorson will result in significantunderrecognition of mild traumatic brain injury, especiallyin children. A more appropriate definition is a traumaticallyinduced alteration in mental status, often manifested as confusionor amnesia that is not necessarily associated with loss of consciousness.Research has shown that young age may significantly prolongthe recovery time because of the immaturity of the brain.1
The article by Ropper and Gorson does not discuss long-termsequelae in children. Studies suggest that such sequelae includelow self-esteem, loneliness, antisocial behavior,2 and prolongedmemory deficits. Even though the second impact syndrome hasrecently come under scrutiny, several reported cases fit thedefinition of this syndrome and have occurred only in children.3
Decisions about return to play may be particularly difficultin the case of children with concussion. Research suggests thathigh-school athletes have poorer memory functioning 7 days afterthe injury than at day 1 or day 2, making the timing of evaluationsdifficult. We recommend a graduated return to play, with individualizedevaluations as delineated by the Prague guidelines.4
Teri M. McCambridge, M.D. Eric Small, M.D. David T. Bernhardt, M.D. American Academy of Pediatrics Elk Grove Village, IL 60007 terimccambridge{at}comcast.net
References
Field M, Collins MW, Lovell MR, Maroon J. Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. J Pediatr 2003;142:546-553. [CrossRef][Web of Science][Medline]
Andrews TK, Rose FD, Johnson DA. Social and behavioral effects of traumatic brain injury in children. Brain Inj 1998;12:133-138. [CrossRef][Web of Science][Medline]
McCrory PR, Berkovic SF. Second impact syndrome. Neurology 1998;50:677-683. [Free Full Text]
McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med 2005;39:196-204. [Free Full Text]
To the Editor: Although Ropper and Gorson provide a comprehensivereview of concussion, pediatrics is misrepresented. The authorsstate that "imaging is routinely recommended for children youngerthan 16 years," which is a broad generalization that warrantsreconsideration. Such a recommendation would lead to unnecessaryCT scanning and exposure to radiation, which is a special concernin pediatrics.1
The American Academy of Pediatrics has published criteria foridentifying high-risk patients in whom CT studies are warranted.These criteria include an age of less than 3 months, the presenceof a skull fracture, depressed mental status, and focal neurologicdeficits. The academy also identified a low-risk group of patientsin whom no radiographic imaging is required.2 Palchak et al.3also showed that isolated loss of consciousness, amnesia, orthe combination was not predictive of either CT evidence oftraumatic brain injury or injury requiring acute intervention.Thus, Ropper and Gorson should consider modifying their broadrecommendation for routine imaging in children younger than16 years.
Amy H. Kaji, M.D., M.P.H. Harbor–UCLA Medical Center Torrance, CA 90509 akaji{at}emedharbor.edu
References
Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol 2001;176:289-296. [Free Full Text]
Schutzman SA, Barnes P, Duhaime AC, et al. Evaluation and management of children younger than two years old with apparently minor head trauma: proposed guidelines. Pediatrics 2001;107:983-993. [Free Full Text]
Palchak MJ, Holmes JF, Vance CW, et al. Does an isolated history of loss of consciousness or amnesia predict brain injuries in children after blunt head trauma? Pediatrics 2004;113:e507-e513. [Free Full Text]
To the Editor: The likelihood that the 64-year-old woman describedin the vignette has a driver's license is 89%.1 Blows to thehead, even in elite athletes, can cause prolongation of reactiontimes for days.2 The AAA Foundation for Traffic Safety reportsthat about 20 major decisions are needed for each mile a persondrives and that drivers frequently have less than half a secondto make these decisions correctly in order to avoid a collision.3
Neuropsychological testing is the gold standard, but it is costly,delays management, and is unavailable in rural areas. Self-administeredscreening tools, such as the CNS Vital Signs and NeuroTrax systems,offer rapid, affordable, objective assessment of cognitive functioning.Any patient who has concussion as a result of an unobservedinjury or with witnessed confusion should undergo screeningto ascertain whether further assessment or rehabilitation isneeded. Patients who have good cognitive functioning shouldbe told that they can drive, whereas those who do not have goodcognitive functioning should be medically advised not to drive,with charted documentation that protects the physician fromliability.4
Ian A. Gillespie, M.D. British Columbia Medical Association Vancouver, BC V6J 5A9, Canada iangillespie{at}telus.net
Warden DL, Bleiberg J, Cameron KL, et al. Persistent prolongation of simple reaction time in sports concussion. Neurology 2001;57:524-526. [Free Full Text]
The authors reply: In a field dominated by expert opinion, wesought to provide an evidence-based review and to limit commentwhen such evidence was absent or equivocal or when studies hadserious limitations. The Prague guidelines and various symposiaon sport-related concussion cited by the correspondents admirablyfill a void and meet the need for conservatism and are citedin our review. They are not, however, supported by clinicalevidence at this point, a problem that is reflected by the revisionsbased on successive national and international meetings andby the differences from one set of guidelines to another.
The points made by Cantu and colleagues are useful, and in ourreview, we stress the importance of the type and severity ofpostconcussive symptoms as well as the need to individualizemanagement decisions. We also indicate that brief confusion,amnesia, or headache may occur while alertness is preservedafter a minor head injury. However, it is not known whetherthese symptoms share the same mechanism (i.e., a mechanism requiredfor the maintenance of consciousness). Moreover, it has notbeen determined whether such limited symptoms have the sameimplications for cognitive decline or the risk of intracranialbleeding. Classifying minor symptoms as a concussion is thereforearbitrary. At the root of this uncertainty is the oldest questionabout the cause of the concussive symptoms: Are the cerebralhemispheres "shaken up" (commotio cerebri) and does this conditionexist on a continuum with diffuse axonal injury, or is the effecta transient one in the thalamic–midbrain region?
We agree that the available grading systems for concussion andthe guidelines of the American Academy of Neurology have limitations.(We were unsuccessful in obtaining information on a pendingrevision of these guidelines.) However, the guidelines do makethe important point that there are no class I studies to guidetreatment of concussion or decisions on the return to play —a point that remains true with the possible exception of theCT decision rules presented in our review.
As we point out in our review, the original descriptions ofthe second impact syndrome were lacking in quality. We foundthe analysis by McCrory and Berkovic1 persuasive in questioningwhether there is a risk of diffuse brain edema after a secondblow.
The differences in opinion reflected in the correspondence reflectthe many uncertainties involved in the management of concussion.Further research is needed to gain a better understanding ofconcussion, its effects, and its optimal management.
Allan H. Ropper, M.D. Kenneth C. Gorson, M.D. Caritas St. Elizabeth's Medical Center Boston, MA 02135
References
McCrory PR, Berkovic SF. Second impact syndrome. Neurology 1998;50:677-683. [Free Full Text]
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