Current literature and experts suggest a comprehensive approach using a clinical evaluation, symptom assessment, balance assessment, and neurocognitive assessment. Broglio et al68 reported that using a combination of a symptom checklist, balance assessment, and neuropsychological testing yields sensitivity of greater than 90%, whereas neurocognitive testing alone is about 79%, symptom
In addition, Register-Mihalik et al69 identified this multimodal approach as significantly more sensitive than any measure used in isolation.
A symptom checklist is one of the most commonly used clinical measures in the assessment of concussion. Symptom checklists (Table 6-1) have been used in various studies and have been shown to be valid and reliable.70-72 Studies suggest that variations of the tool are reliable and valid when administered by clinicians and across age groups, from children to adults.70*72 However, these tools are all based on self-reports, which can be subjective; thus, there is need for a comprehensive approach inclusive of more objective measures.
Computerized neurocognitive assessments provide an objective assessment of cognitive function and, thus, have risen to the forefront of concussion evaluation over the past 15 years.73-76 Recent literature questions the utility of many of these tests and batteries due to low reliability and limited psychometric research.77,78 In addition, these tests were developed from the framework of more traditional paper and pencil neuropsychological tests, which have more clinician interaction. Research on the reliability of these computerized tasks is limited by the testing environment and the time elapsed between test sessions. The environment, such as a noisy room or the presence of many other athletes, also often limits many studies related to neuropsychological performance. Various products are available for computerized assessment, including the ImPACT (ImPACT Applications, Inc), Concussion Vital Signs (CNS Vital Signs), and Cogstate CCAT (Axon Sports). Each of these measures some form of cognition, and all have the limitations previously mentioned.
Figure 6-3. Balance Error Scoring System. (Reprinted with permission from Stiffler M, Mihalik JP, Register-Mihalik JK, Ingriselli JM. Cognition and balance performance following a single-task training intervention in healthy collegiate recreational students: A preliminary study. Athletic Training & Sports Health Care. 2013;5(2):63-68.)
Nonetheless, these tests can provide valuable information following possible injury. Many consensus statements have recommended the use of some form of neurocognitive assessment in the evaluation of concussion.79-81 Measurement of basic cognitive function involves use of a mental status examination, such as the Standardized Assessment of Concussion (SAC). The SAC has been shown to be sensitive to concussion and is often used in research studies assessing the acute effects of concussive injury. It is most useful and sensitive within the first 48 hours following a concussion.82
Balance assessment has also been recommended as a component in a concussion assessment program. Like neurocognitive testing, there are many ways to assess balance, from a simple Romberg test to computerized force-plate measures.76 The clinical field test, the Balance Error Scoring System, offers a cheap, objective way to assess balance on the field following a possible concussive injury (Figure 6-3). The athlete performs 6 trials consisting of 3 different stances done on firm and foam surfaces. The stances include double leg, single leg (on the stance leg), and tandem (with the stance leg in the back). Errors are recorded if individuals lift their hands off of their iliac crest; abduct or flex their hip to greater than 30 degrees; step, stumble or fall; open eyes; lift their toes; or remain out of the testing position for greater than 5 seconds. A higher score indicates a greater deficit in postural stability. Due to individual variability, baseline measures are important to determine the severity of deficit following injury.83
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The Sport Concussion Assessment Tool-3 (SCAT-3) encompasses some form of all of the aforementioned pieces in the concussion assessment.4 Recently revised, it now includes sectioned scoring instead of a composite score and asks more questions about the athlete’s injury. The SCAT-3 is free to the public, and all athletic trainers have access to the tool. The tool encompasses a Sideline Checklist, a Background section, the Glasgow Coma Scale, Maddux questions, Symptom Evaluation (with checklist), the SAC, a neck examination, the modified Balance Error Scoring System, and a tandem gait task. The tool also provides general RTP information and interpretation of the information for each of the tasks included in the tool. The SCAT-3 may be a useful and cost-effective way to ensure that the essential pieces of a concussion evaluation are being included in the process in an objective fashion for athletic trainers with limited resources.
Additional measures, such as the King-Devick test84 and the Vestibular Oculomotor Screening,85 may provide even more objective information to the assessment process. The King-Devick test incorporates visual scanning and assesses a patient’s ability to scan quickly and accurately. The Vestibular Oculomotor Screening assesses visual and oculomotor function and may provide indications of vestibular-ocular dysfunction. These additional tests are supplemental tools for clinicians to use in the assessment and management of concussion.
Position and Consensus Statements
Numerous position and consensus statements exist concerning concussion. These statements likely lead to increased awareness and identification of head injuries among medical personal, contributing to the increased concussion incidence. Although they vary in content and are directed at different audiences, these position statements all recommend a comprehensive approach to concussion assessment, including the multimodal assessment approach presented in the literature.
The position statements are guidelines for what is considered best practice. For athletic trainers specifically, knowledge of the NATA’s recently updated position statement concerning concussion is essential.3 The most widely cited of these consensus documents is that of the International Concussion in Sport Group.4 A summary of best practices from the NATA and International Concussionin Sport Group includes gathering baseline data when feasible and possible, serial evaluation of the injury, appropriate home care instructions, symptom free prior to return to physical activity, management of academic conditions as needed, and a gradual increase in volume and intensity in physical activity prior to full return to sport. These position statements often drive clinical practice and research metrics, which can lead to changes in the epidemiological profile of the injury. These position statements, in addition to a recent Institute of Medicine report on youth concussion,24 highlight the need for better concussion surveillance across all levels of sport.
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