William J. Mullally, MD
In the 15-24 age group, which is what we’re dealing with in athletes, sports is the second most common cause of head injury, next to motor vehicle accidents.
I think that it's very important that we have a grading system and return to play guidelines to help the clinician who takes care of athletes make a cogent decision on what should be done for this athlete and when they will be able to return to play, because our main goal is to protect the athlete.
So, when an athlete suffers head injury during play, the first rule is they should never return to play that day. No same day return to play, because you're not always sure what happened. So, it's better to get an idea of the situation, be able to evaluate, see whether they do testing on the sideline to get an idea of the severity of the injury. Now, it could be conceivable that it was nothing serious, that all they did was have a bump on the head, that it wasn't going to be anything to keep him out of play. But I think to be safe they shouldn't be allowed to go back that day.
The neurocognitive testing is getting to be routine now. The athletes take the test before they're going to participate in sports. We now have a baseline. If they have a head injury, then they do another test and we compare it to baseline. It's just another bit of information that helps you make a decision when it's safe to return to play.
I have these five grades of head injury, and the first being the bump on the head, the second the trauma-induced headache, which is often a migraine-like headache, and then the third, fourth and fifth categories are the traumatic brain injuries.
The grade 3 injury is based on some of the data in the medical literature and personal experience and also consensus, that if the athlete is unconscious for less than one minute or if the amnesia is less than 30 minutes, I consider that a mild brain injury or a grade 3.
So, with grade 4 injuries, I think that it's an athlete who has been unconscious for more than a minute, less than five minutes, or amnesia more than 30 minutes, but less than 24 hours.
A grade 5 injury are the severe head injuries. Now, many of these we know and we know how to handle. There is bleeding into the brain. There are shearing injuries where you tear the axons or you tear the brain itself. There can be increased intracranial pressure. There can be a subdural hematoma, which is below the membrane covering the brain or above it, the epidural. These can all be life threatening. In that category I do include patients or athletes who have been unconscious for more than five minutes or have amnesia for more than 24 hours.
There is new information that athletes with repetitive mild traumatic brain injuries, seemingly mild traumatic brain injuries have a progressive, what they call tauopathy, similar to what you see in Alzheimer's disease and they'll develop a dementia and they'll develop personality changes and they call this chronic traumatic encephalopathy.
With the first category and the first grade of the bump on the head, contusion, laceration, there will be just pain in that one site. The minute they're cleared to play and there is healing of the area, I think they can return to play.
With the second category, and that's the post traumatic headache, the headache that was induced by the head trauma, but there wasn't evidence of a traumatic brain injury clinically. I think that they can start what we call the return to play protocol once the symptoms have resolved. If the protocol is a five-stage gradual increase in activity that if the athlete tolerates they can then safely return to play. With that grade I think that they should have their neurocognitive testing performed.
Grade 3 injury, now we have a traumatic brain injury. We have those chemical changes that occur in the brain, usually the mild injury or it can have permanent damage, but they could because there is no way to tell right now. We just don't know that.
Not only do they have to be asymptomatic and go through the five-day progression protocol, but I make them wait at least 10 days before they're subjected to any type of activity where they can potentially have head trauma. And the reason for that is the syndrome called the Second Impact Syndrome, that if patients are in the throes of a traumatic brain injury, they're still symptomatic and they have another traumatic brain injury, there are case reports that say that that could be catastrophic and could result in death.
With my grade 4 injury, and again, that's the one where they're unconscious for one minute to five minutes or have amnesia from 30 minutes to 24 hours, I'd keep them out longer. The first injury is 30 days, and then it increases to 90 days and then 180 days. I limit grade 4 to three such injuries. Let's say somebody has had a grade 4 in the past and then they have a grade 3, I still treat that as a grade 4. So, I always treat them by the highest grade that they’ve ever sustained.
With a grade 5, this is a very difficult situation. If we see hemorrhage in the brain and we see evidence of a contusion, increased intracranial pressure, that's a severe head injury. I probably would say they should never go back.
But let's say that they're unconscious for five to 10 minutes or they had amnesia for two days, there was nothing on the brain MRI scan or maybe only a skull fracture that didn't do trauma inside the brain, intracranial damage, just the fracture, well, if they're stable, they're cleared by neurology or neurosurgery, I think that after probably, six months they could return to play. But again, it will be up to the judgment of the neurologist, neurosurgeon or sports medicine practitioner to decide at that point should they go back.
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