INJURY CLINIC Sports Med 2001; 31 (8): 629-636

0112-1642/01/0008-0629/$22.00/0

© Adis International Limited. All rights reserved.

Recommendations for Grading of

Concussion in Athletes
Suzanne Leclerc,1 Maryse Lassonde,2 J. Scott Delaney,1 Vincent J. Lacroix1 and
Karen M. Johnston1,3
1 McGill Sport Medicine Clinic, McGill University, Montreal, Canada
2 Neuropsychology Department, University of Montreal, Montreal, Canada
3 McGill University Health Centre, Neurosurgery Department, McGill University, Montreal, Canada

Contents
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 629
1. Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 630
2. Grading Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 631
3. Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 633
3.1 Case Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 633
3.2 Symptoms of Concussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 634
4. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635

Abstract Mild sports-related concussions, in which there is no loss of consciousness,

account for >75% of all sports-related brain injury. Universal agreement on con-
cussion definition and severity grading does not exist. Grading systems represent
expertise of clinicians and researchers yet scientific evidence is lacking. Most
used loss of consciousness and post-traumatic amnesia as markers for grading
concussion. Although in severe head injury these parameters may have been
proven important for prognosis, no study has done the same for sport-related
concussion. Post-concussion symptoms are often the main features to help in the
diagnosis of concussion in sport. Neuropsychological testing is meant to help
physicians and health professionals to have objective indices of some of the neuro-
cognitive symptoms. It is the challenge of physicians, therapists and coaches
involved in the care of athletes to know the symptoms of concussion, recognise
them when they occur and apply basic neuropsychological testing to help detect
this injury. It is, therefore, recommended to be familiar with one grading system
and use it consistently, even though it may not be scientifically validated. Then
good clinical judgement and the ability to recognise post-concussion signs and
symptoms will assure that an athlete never returns to play while symptomatic.

Concussion, as defined below, is an important mulative effects of concussion,[7-10] more aware-

public health problem with large numbers of peo- ness and understanding of this current problem in
ple sustaining this injury each year.[1] Because of sport is needed.
the generally young age at time of injury, the pos- Mild concussions, in which there is transient con-
sible long term disability,[2-6] and the potential cu- fusion but no loss of consciousness (LOC), are
630 Leclerc et al.

thought to account for >75% of all sports-related longed symptoms are very often described as post-
brain injury.[11] Although these mild injuries are the concussion syndrome.[19,20]
most frequently occurring injuries, they are also Kelly et al.,[21] in 1991, suggested a more straight-
the most difficult to recognise and diagnose. De- forward definition for concussion as: ‘a trauma-
spite recent scientific developments and ongoing induced alteration in mental status that may or may
research, in the year 2001, a thorough understanding not involve loss of consciousness.’ Compared with
of the pathophysiology of cerebral concussion is the previous one (refer to the definition of the Com-
still lacking, as is an explanation as to why the brain mittee of Head Injury Nomenclature of the Con-
of some athletes appear to become so vulnerable to gress of Neurological Surgeons, 1966), this defini-
a secondary injury after a seemingly mild first in- tion (refer to Kelly et al.[21]) clearly states that you
sult.[7-8,10,12,13]
do not need to lose consciousness to get a concus-
Because of the difficulty in recognising mild con-
sion.
cussions, and the significant risk for repeat cerebral
In 1997, the American Orthopaedic Society for
injury, early detection and documentation of the
Sports Medicine (AOSSM) Concussion Workshop
injury is critical to the management and disposition
Group proposed another definition of concussion
of the concussed athlete. Unfortunately, attempts
to characterise and classify the spectrum of concus- that attempts to be all inclusive: ‘any alteration in
sions by stratifying the signs and symptoms as in- cerebral function caused by a direct or indirect (ro-
dicators of relative severity have been difficult.[13] tation) force transmitted to the head resulting in
At the present time, there are numerous different one or more of the following acute signs or symp-
grading systems and none has been prospectively toms: a brief loss of consciousness, light-headed-
validated.[14] No scale answers the specific need of ness, vertigo, cognitive and memory dysfunction,
physicians to be simple, valid and practical.[15] No tinnitus, blurred vision, difficulty concentrating, am-
universally accepted recommendations for the man- nesia, headache, nausea, vomiting, photophobia, or
agement of concussion exist.[16] While the many a balance disturbance. Delayed signs and symptoms
guidelines differ in many respects, most if not all may also include sleep irregularities, fatigue, per-
agree that a concussed athlete should be completely sonality changes, an inability to perform usual daily
symptom-free before resuming any training or com- activities, depression, or lethargy.’[13] Including all
petition.[17] these symptoms in the definition may pose a prob-
lem. Some of these symptoms have been validated
by studies to be related to concussive injury,[22-27]
1. Definition
but some of them remain anecdotal and need to be
proven for their direct relationship to concussion
The definition of concussion remains vague. The
and not to other factors such as malingering, social
most widely quoted definition is the one proposed
environment, etc.
by the Committee of Head Injury Nomenclature of
the Congress of Neurological Surgeons in 1966. Attempts to better define concussion remain dif-
Concussion is defined as ‘a clinical syndrome char- ficult. It is important to keep in mind that this def-
acterised by immediate and transient impairment inition needs to be simple, clear and understandable
of neural functions, such as alteration of conscious- for parents, coaches, athletes, etc. Bearing these fac-
ness, disturbance of vision, equilibrium, etc. due to tors in mind,a new Canadian Academy of Sport
mechanical forces.’[18] Specific reference to LOC Medicine (CASM) endorsed website has been ded-
is not made. As well, this definition states that con- icated to education on sport-related concussion. Con-
cussion is both immediate in onset and transient.[14] cussion is defined as: ‘any direct or indirect hit to
In reality, symptoms may take some time to evolve the head that can cause a change in behaviour, aware-
and may persist longer than implied. These pro- ness, and/or physical feeling.’[28]

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Grading of Concussion in Athletes 631

Table I. Grading system from the subcommittee on classification of At least 16 different injury grading systems for
sports injury[31]
head injury have been published.[11,21,29-42] It is
Concussion grading system (1966)
beyond the scope of this paper to review in detail
Grade 1 No LOC
Slight confusion
all these grading systems. Some of them were de-
None or very transient memory loss signed to grade severe head injury by including
Very rapid recovery comatose stages in their grading.[29,30,37,39,41] Some
Grade 2 LOC <5 min others tried to distinguish less severe head injury
Momentary confusion by including PCS[31,33,35,38] in some grades. Most
Mild retrograde amnesia
of them were based on the duration of amnesia and
Complete recovery within 5 min
Grade 3 LOC >5 min
LOC.[11,21,34,36,40,42] Comments will be provided on
Confusion >5 min the ones that are the most often used and cited in
Prolonged retrograde amnesia sport medicine field.
Slow recovery (>5 min) The Subcommittee on Classification of Sports
LOC = loss of consciousness. Injury from the Congress of Neurological Surgeons
in 1966, proposed the first grading scale (table I).[31]
In his book Head and Neck Injuries in Football,
These definitions imply that the range of injury Schneider[31] states that the committee: ‘found it
is wide and subdivision of the term concussion is expedient to subdivide this newly defined term fur-
needed to grade the severity of the brain injury
ther into first, second, and third degrees of concus-
involved. Almost always, the signs and symptoms
sion based upon duration and severity of symp-
used to differentiate the different grades or severi-
toms.’ Interestingly, in this first grading system,
ties include confusion, post-concussion symptoms
they incorporate the time for recovery as a param-
(PCS), post-traumatic amnesia (PTA) and LOC.
eter to grade the severity of concussion.
In 1986, Cantu,[11] a neurosurgeon and team phy-
2. Grading Systems sician, combined elements of various definitions of
concussion and published an on-the-field grading
Although the biomechanics and physiology of scheme (table II). He uses both the duration of un-
brain injury are not elucidated, it remains impor- consciousness and PTA for his classification. For
tant to understand that all published grading scales example, PTA of greater than 24 hours may reflect
are not validated and represent a view from differ- a more severe brain insult than 30 seconds of un-
ent experts rather than a consensus of scientific consciousness and many agree. However it is not
evidence. The only exception to this is the Glasgow clear how to grade a player having had a concus-
Coma Scale, which was validated as a 6-hour as- sion without LOC and PTA, but with prolonged
sessment for moderate to severe brain injury PCS such as headache, dizziness and problems with
only.[29] concentration and balance. In practice, this is a com-

Table II. Concussion grading systems

Grade Cantu[11] Colorado[21] Roberts[40] American Academy of Neurology[42]
0 ‘Bell ringer’; no LOC; no PTA
1 No LOC; PTA <30 min No LOC; confusion No LOC; PTA <30 min No LOC; transient confusion; concussion symptoms
without amnesia or mental status abnormality resolve in <15 min
2 LOC <5 min; PTA >30 min No LOC; confusion LOC <5 min; PTA >30 min No LOC; transient confusion; concussion symptoms
and <24h with amnesia and <24h or mental status abnormality last >15 min
3 LOC >5 min or PTA >24h LOC LOC >5 min or PTA >24h Any LOC, either brief or prolonged
LOC = loss of consciousness; PTA = post-traumatic amnesia.

© Adis International Limited. All rights reserved. Sports Med 2001; 31 (8)
632 Leclerc et al.

mon problem faced by sport medicine doctors on a though these 2 parameters may be important for
regular basis. Will it be classified as a grade 1 or a prognosis of severe brain injury, the usefulness of
grade 3? their extrapolation to milder grades of brain injury
In 1991, after a death in football, Kelly and his has not been proven.[22,44-46]
associates[21] proposed another classification (Col- Our McGill Grading system,[47] designed pri-
orado guidelines) [table II]. In this grading system, marily as a research tool, has been presented as a
any LOC is considered a sign of severe concussion new classification system for grading concussion
and LOC is used as a key symptom to guide man- and as other current grading systems, has not yet
agement. It is supposed that any LOC indicates that been validated (table III). As in the Cantu and AAN
both hemispheres of the brain or brainstem have grading systems the authors kept 3 major grades of
been directly affected. No attention is given to the concussion to facilitate consistent use by therapist
duration of confusion, amnesia or LOC. It is the and physician. One salient difference between this
presence or absence of these parameters that is used grading system and most others is the subdivision
to grade the concussion. of grade 1 into A, B and C emphasising the impor-
Roberts[40] proposed in 1992 the use of a classi- tance of evaluating the duration of PCS. This new
fication based on Cantu but added a ‘bell ringer’ classification is intended to identify the lowest grade
category (table II). In doing this, his main goal was of concussion, that is, 75% of all sports-related con-
to ‘show athletes and coaches that a head injury cussion which are thought to be mild, in which PTA
does not automatically exclude further activity.’[40] and LOC is not the predominant sign. In this way,
In 1997, The American Academy of Neurology important information and insights may be gained
(AAN) put forward a practice parameter[42] (table about these low grade injuries and their potential
II) based on the Colorado guidelines published by sequelae.
Kelly et al.[21] This was developed after a Medline The multitude of grading systems reflects the
search to identify Class I, II and III evidence, po-
lack of consensus, which results from the absence
tentially resulting in treatment standards, guidelines
of evidence-based data. Explanations for this di-
or options, respectively. No class I studies existed
lemma have been proposed. Every grading scale is
and the best that could be achieved by this method
trying to be ‘all-inclusive’, both for the sake of com-
were practice options. Recommendations classified
pleteness and the safety of the athlete. Many of
as options are defined as ‘other strategies for pa-
tient management for which there is unclear clini-
cal certainty (i.e. based on inconclusive or conflict- Table III. McGill concussion grading system
ing evidence or opinion).’[42] PTA and duration of Grade 1 No LOC, no PTA
unconsciousness are still given a high priority al- 1Aa No PCS, only seconds of confusion
though confusion and any disturbance of neural func- 1B PCS and/or confusion that resolved within 15 min
1C PCS and/or confusion that do not resolved within
tion have been added in the grading system. Any
15 min
LOC is still classified as a grade 3.[42] Grade 2 PTA <30 min and/or LOC <5 min
The biggest difference between the Cantu and Grade 3 PTA >30 min and/or LOC >5 min
AAN classifications (the 2 most often currently used a May include visual phenomena, tinnitus resolved by the time
in sport medicine) is their respective emphasis on the athlete is evaluated.
Confusion = disorientation and more subtle abnormalities such as:
PTA or LOC. In these 2 scales, the duration of PTA (i) disturbance of vigilance with heightened distractibility; (ii) inability
and LOC become the prime determinants of injury to maintain a coherent stream of thought; and (iii) inability to carry
severity. For Cantu, ‘placing a case with a history out a sequence of goal-directed movements;[48,49] LOC = loss of
consciousness; PCS = post-concussion symptoms (blurred vision,
of a few seconds of unconsciousness in the most nausea, vomiting, headache, dizziness, photophobia); PTA = post-
severe category and a case with hours of PTA in a traumatic amnesia, the length of the time after trauma during which
less severe category, is frankly incorrect.’[43] Al- the person is unable to store ongoing events.

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Grading of Concussion in Athletes 633

these grading scales attempt to put concussion in 3.1 Case Example

context with the continuum of mild brain injury, as
As a doctor for a University ice hockey team,
concussion represents a subset of mild brain injury
you are covering the game on a Saturday night. In
at the lowest end of the brain injury spectrum.[44]
the third period, you see one of the defensive play-
Finally, most of the scales are biased toward iden-
ers hit by an other player along the board. He falls
tification of the most severe injury although in prac-
on the ice, gets up almost immediately, shakes his
tice, the need is for a scale which will help distin-
head and is going to continue to play. His coach
guish the marginal injury from the mild to moderate calls him to come back to the bench. When you eval-
one.[15] Although no prospective research has val- uate him, he remembers how he was hit and that
idated any of the grading systems, they are all in- his coach had called him back to the bench. He
tended to prevent catastrophic outcomes, refractory does not remember who they played last week, he
PCS, and the more subtle cognitive and neuropsycho- is not sure of the score of the present game and is
logical impairments that may occur after repetitive confused about the period of the game. He is com-
mild brain injury.[44] plaining of dizziness and he is having trouble fo-
At this point in time, acknowledging that some cusing. He denies any complaints of headache,
of these clinical decisions may be difficult, medical nausea, photophobia or any other symptoms. 15
doctors should choose one grading system that they minutes later, you reevaluate the player and he is
are familiar with and use it in a standardised and still somewhat dizzy and he is now complaining of
consistent way. It will provide a framework for judg- a mild headache and of feeling ‘out of it’. On fur-
ing the grade and severity of concussion and help ther bench-side examination, he has some concen-
to determine whether the athlete requires observa- tration and memory problems on the different tasks
tion, hospitalisation or neuroimaging. Always re- you ask him to perform. 24 hours later you reassess
member that clinical judgement and erring on the the player. He still complains of a headache, as well
side of caution, even if it varies from the guideline as balance problems, dizziness, sleep disturbance
used, should not be judged inappropriate. The goal and fatigue. He also says he is having trouble con-
should be to prevent and avoid further injury and centrating and he has trouble remembering things
tragic consequences.[16] he tries to study. On examination, he has a grossly
normal neurological examination, but he still per-
forms poorly on simple tasks such as recalling words
3. Evaluation and repeating numbers backwards.
Players involved in contact sport may often
During the 1997 Canadian football league sea-
present as in the present example. The standard
son, Delaney et al.[10] reported, from a retrospec-
approach of asking general orientation questions
tive survey, that >4 out of 5 concussed players did (day, date, year, time etc.) has been shown to be
not realise they had experienced a concussion even unreliable following concussion in sport.[22] This
if they had PCS. In the same survey, confusion (get- cognitive function remains relatively intact in sport-
ting dinged) was the most common symptom fol- related concussion and does not show the sensitiv-
lowed by headache for both those who recognised ity seen in more severe head injury, as in a motor
they had experienced a concussion and those who vehicle accident.[22,50] More useful questions are
did not recognise that they had a concussion. For those involving recent memory as listed in table
this reason, physician, therapist and coaches re- IV. The ongoing process of short term memory fix-
sponsible for the care of athletes must know what ation may be interrupted by concussive injury.[51]
to look for and be aware of the obvious signs and Questions of short term memory have been shown
symptoms of concussion. to be more sensitive in differentiating concussed

© Adis International Limited. All rights reserved. Sports Med 2001; 31 (8)
634 Leclerc et al.

Table IV. Orientation questions (recent memory items)[22] of the year in reverse order) and delayed recall (of
At which ground are we? the original 5-words list). As shown by McCrea et
Which quarter is it? al.,[58] the SAC was sensitive in detecting mental
How far into the quarter is it – the first, middle or last 10 min?
status abnormalities and differentiating injured from
Which side kicked the last goal?
Which team did we play last week?
noninjured players in mild concussion. The SAC
Did we win last week? was not designed to replace a thorough neuropsycho-
logical examination, but rather to detect cognitive
deficits and identify the need for further evalua-
from nonconcussed athletes[22] and represent a good tion.
indicator of concussive injury in sport. When following a patient who has sustained a
concussion, the clinician should remember that it
3.2 Symptoms of Concussion may be difficult to predict time to resolution of
symptoms. It is worthwhile to note that recovery
PCS commonly reported after concussion can be
rates vary considerably between individuals rang-
grouped into 3 main categories: somatic (headaches,
dizziness, blurred vision, balance problems, nausea), ing from days to weeks.[59,60] This has obvious im-
cognitive (memory, concentration and processing plications when determining return to play deci-
speed problems) and affective (anxiety, sleep dis- sions and guidelines.[15] As demonstrated in the case
turbance, depression).[52,53] Acute symptoms (head- example, PCS often are the only features that help
ache, dizziness, confusion, blurred vision, nausea) to diagnose a concussion. PTA and LOC are not
and delayed symptoms (drowsiness, sensitivity to always seen in sport-related concussion. Therefore
light and noise, feeling slowed down and foggy,
memory and concentrating problems) are described
Table V. Post-concussion symptoms (PCS) scale[55]
in association with mild concussion.[22-27] In serial
PCS Severity scale (0 = none; 6 = severe)
assessment of a concussed athlete, the Rivermead Dizziness 0 1 2 3 4 5 6
study[54] showed the reliability of a self-administered Headache 0 1 2 3 4 5 6
and clinician-administered rating questionnaire on Nausea 0 1 2 3 4 5 6
PCS. Athletes rate from zero to 6 the severity of their Vomiting 0 1 2 3 4 5 6
somatic, cognitive and affective symptoms (table Balance problems 0 1 2 3 4 5 6
V).[55] Trouble falling 0 1 2 3 4 5 6
asleep
Players may be reluctant to report symptoms. Sleeping more than 0 1 2 3 4 5 6
Therefore, the use of neuropsychological testing as usual
objective indices of concussion may be useful in Drowsiness 0 1 2 3 4 5 6
helping to diagnose and grade a concussion.[48,55,56,57] Sensitivity to light 0 1 2 3 4 5 6
Unfortunately, complete neuropsychological assess- Sensitivity to noise 0 1 2 3 4 5 6
More emotional than 0 1 2 3 4 5 6
ment is not available on the field where decisions
usual
need to be made immediately. The Standardised Irritability 0 1 2 3 4 5 6
Assessment of Concussion (SAC)[58] has been pro- Sadness 0 1 2 3 4 5 6
posed for immediate assessment of concussion on Nervousness 0 1 2 3 4 5 6
the sideline and was developed to objectively doc- Numbness or tingling 0 1 2 3 4 5 6
ument the presence and severity of neurocognitive Feeling slowed down 0 1 2 3 4 5 6
impairment associated with concussion.[13] The SAC Feeling like ‘in a fog’ 0 1 2 3 4 5 6
Difficulty 0 1 2 3 4 5 6
includes measures of orientation (day, month, year, concentrating
time), immediate memory (5-word list), concentra- Difficulty 0 1 2 3 4 5 6
tion (repeat in reverse order strings of digits that remembering
increase from 3 to 6 numbers and reciting the months Other 0 1 2 3 4 5 6

© Adis International Limited. All rights reserved. Sports Med 2001; 31 (8)
Grading of Concussion in Athletes 635

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