Repetitive Head Injury Syndrome Follow-up

Updated: Feb 08, 2017
  • Author: David Xavier Cifu, MD; Chief Editor: Craig C Young, MD  more...
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Follow-up

Return to Play

No good parameters have been proposed for repetitive head injury. As a result, most physicians use the parameters for concussion. The following systems present 2 options for concussion management, although many options are available. Note that in the following descriptions, asymptomatic means that the patient is symptom free at rest and with exertion.

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Concussion Scales With Return-to-Play Criteria

Cantu system

The Cantu system grading is as follows: [76, 77, 78]

  • Grade I – No loss of consciousness, or posttraumatic amnesia for less than 30 minutes
    • First concussion – Return to play if patient is asymptomatic for 1 week
    • Second concussion – Return to play if patient is asymptomatic for 2 weeks
    • Third concussion – Terminate season
  • Grade II – Loss of consciousness for less than 5 minutes, or posttraumatic amnesia for 30 minutes to 24 hours
    • First concussion – Return to play if patient is asymptomatic for 1 week
    • Second concussion – Return to play if, after at least 1 month, patient asymptomatic for 1 week
    • Third concussion – Terminate season
  • Grade III – Loss of consciousness for more than 5 minutes, or posttraumatic amnesia for longer than 24 hours
    • First concussion – Return to play if, after at least 1 month, patient asymptomatic for 1 week
    • Second concussion – Terminate season

Kelly system

The Kelly system grading is as follows: [79]

  • Grade I – No loss of consciousness, transient confusion for less than 15 minutes
    • First concussion – Return to play if patient is asymptomatic within 15 minutes
    • Second concussion in same contest – Remove from play
    • After fourth concussion in season – Terminate season
  • Grade II – No loss of consciousness, transient confusion for longer than 15 minutes
    • First concussion – Return to play if patient is asymptomatic for 1 week
    • Second concussion – Return to play if patient is asymptomatic for 2 weeks
    • Third concussion – Terminate season
  • Grade III – Loss of consciousness, brief (seconds) or prolonged (minutes)
    • First concussion with brief loss of consciousness – Return to play if patient is asymptomatic for 1 week
    • First concussion with prolonged loss of consciousness – Return to play if patient is asymptomatic for 2 weeks
    • Second concussion – Return to play if patient is asymptomatic for 1 month
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Complications

The most common complication at follow-up is further head injury and/or cognitive decline. Matser et al found that concussion is specifically associated with impaired performance in memory and planning functions. [16]

A retrospective study of 31,272 children by Jimenez et al found that mental health utilization after a mild traumatic brain injury does increase in children without previous mental health disorders, however, 86% of the children who received postinjury mental health care had previous mental health disorders. [80]

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Prevention

Equipment and rule changes have significantly reduced the number and severity of head injuries in American football over the last 25 years. The dramatic difference seen in football has sparked debate about equipment and rule changes in soccer because a significant number of concussions are now known to occur when players hit the ball with their head. A study by Stewart et al on 222 amateur soccer players found that intentional (heading) and unintentional head impacts are associated with moderate to very severe CNS symptoms such as dizziness and pain. [81, 82]

In preventing SIS, the recognition of a concussion is the key factor. Preventing an athlete from returning to play while he or she still has symptoms from a concussion and following the guidelines for concussion management may help avert a catastrophic outcome.

The American Academy of Neurology (AAN) has issued a brief position statement on sports concussion. The AAN recommends caution and protection first: If an athlete is suspected of having a concussion or closed head injury, then first remove the athlete from practice or competition, and do not allow return to play until he or she is evaluated by a physician with experience in treating concussions and cleared for return. [83]

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Prognosis

The prognosis varies with the severity of the injury. By definition, repetitive head injury is worse than a single minor concussion; neuropsychologic test results are worse in patients with repetitive minor concussions. Regarding SIS, rapid transport to a medical facility with neurosurgical specialists may prevent or limit the rapid decline often seen with SIS.

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Education

Educate athletes, coaches, and healthcare professionals about the potentially catastrophic effects of SIS. Coaches and healthcare professionals need to know how to prevent SIS by not allowing the athlete to return to play while he or she is still recovering from a previous head injury.

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