The Six Pillars of Concussion Risk Management: The MomsTEAM Approach

Pillar Three: Early Identification

To minimize the risk of delayed recovery and long-term injury (or, in rare instances, catastrophic injury or death), it is critical that football players suspected of having sustained a concussion be removed from play as soon as possible, a step now required by law, at least at the high school level, in almost all states.

Because of an athlete's tendency to under-report or failure to recognize concussion symptoms, because the vast majority of sport-related concussions occur without loss of consciousness or other obvious neurological signs, and/or may not be the result of a specific concussive blow, identifying a concussion as early as possible requires a multi-pronged approach which utilizes every tool in the concussion toolbox.

That means using the Five "E's":

1. Employing a certified athletic trainer with specialized expertise in the identification of concussion on the sideline at every game and practice (a practice recently endorsed by the American Academy of Pediatrics in its 2015 Policy Statement on Tackling in Youth Football)^[24] ; and long advocated by MomsTEAM. 

2. Encouraging honest self-reporting by athletes of concussion symptoms, not just during game or practice action but in the hours and days after play (delayed onset of concussion symptoms is common, particularly among younger athletes), and using a "buddy system" in which players look for - and report - signs of concussion in designated teammates.  Research has consistently shown ^{[12-15, 26]} that the biggest barrier to honest reporting by athletes of concussion symptoms is not, contrary to conventional wisdom, a lack of concussion knowledge, but the negative of attitude of coaches towards reporting and the belief by athletes that they will be punished by the coach if they report concussion symptoms, or will be viewed by the coach, teammates and/or parents as "weak."   It is important to remember that, despite concerns about chronic under-reporting of concussion or the resulting symptoms by athletes, symptom assessment remains a critical component of concussion evaluation. ^[6]  

3. Equipping players with impact sensors (eg. accelerometers) - whether in their helmets, mouth guards,  chin straps, or head bands or behind their ear - to alert coaches, athletic trainers, team doctors, other sideline personnel and/or parents to impacts of sufficient force to possibly cause concussion, thus triggering either closer observation of the athlete to look for signs of concussion or a quick concussion sideline assessment.

While there are currently no published studies to support the use of impact sensor systems in this manner, and a precise "concussion threshold" is unknown, a 2013 study states that the "potential clinical utility" of impact sensors "should be carefully considered." ^[5]

A subsequent study by researchers at the University of Michigan^[19] notes that, while sensors may currently be beyond the reach of most football programs, a "number of companies are developing innovative, low-cost technologies that will make instrumentation both practical and feasible" in the future.  

Note: Based on MomsTEAM's extensive experience working with sensor companies and high school football programs (2012 and 2013), and youth football programs (2014 and 2015 season), however, it appears that the day when affordable and reliable impact sensors become available for widespread use in contact and collision sports is further off than we, and other concussion experts and observers, first believed.  

4. Evaluating players on the sideline (or in the locker room) utilizing scientifically-validated and reliable sideline assessment tools capable of detecting and quantifying the acute phase of concussion, including the:

• Sports Concussion Assessment Test version 3 (SCAT3) ^[3] or Child-SCAT3 ^[4] (for use by athletic trainers and other health care professionals);
• Standardized Assessment of Concussion (SAC) ^[2] (for use by athletic trainers and other health care professionals)(included as part of the SCAT3);
• Balance Error Scoring System (BESS) or Modified BESS (M-BESS)(for use by trained health care professionals, preferably on a hard surface)​(included as part of the SCAT3); and/or
  
• King-Devick (K-D) Test  (while aggressively marketed for use by parents, coaches, and other individuals without training in the identification and diagnosis of concussions, most experts recommend that K-D only be used by trained health care professionals to make removed-from-play decisions).

Three notes of caution, however, about sideline assessments: 

a.  A 2013 analysis of the peer-reviewed literature on date of injury assessments ^[6] found the SAC reliable in detecting and quantifying acute cognitive impairment, and the BESS to be an "important component" of the sideline assessment. but said further research was required to establish the reliability, sensitivity, and clinical utility of the SCAT2/3, and that it was too early to draw any conclusion regarding the eventual usefulness of the K-D Test or others yet in the development pipeline.  

The American Academy of Neurologists' updated concussion evaluation and management guidelines ^[10] likewise states the SAC is "likely" to identify the presence of concussion in the early stages post-injury with a high degree of sensitivity  (the ability of the test to correctly identify those having concussions, also called the "true positive rate") and specificity (the ability of the test to correctly identify those who do not have concussions, also called the "true negative rate"), and that the BESS was "likely to identify concussions with low to medium diagnostic accuracy);

b.  The full SCAT3 and Child-SCAT3 sideline assessment "remove from play" screening tools are designed for use on the sports sideline only by trained health care professionals (not necessarily a doctor). The SAC can be used by non-physicians. Thus, a coach/parent/volunteer should immediately remove a player from practice or play, arrange for an immediate evaluation by medical professional, and not allow the athlete to return to play that day, if he or she observes any of the following signs observed after a direct or indirect blow to an athlete's head: (a) loss of consciousness (however brief); (b) balance or coordination problems (unsteady gait, athlete stumbles, walks sideways, is labored in their movements); (c) disorientation or confusion (inability to respond appropriately to questions); (d) blank or vacant look; (e) visible facial injury in combination with any of the above. ^[3,4] 

c.  All four are quick screening tools; none are meant to diagnose ​concussion, which should be left to a qualified health care professional based on a formal symptom assessment and standardized testing of cognitive ability and balance and consideration of all clinical factors. Rather, they are intended for use to guide an initial "remove from play" decision.