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Concussion Identification, Evaluation and Management: A Step-By-Step Process

New guidelines for concussion mangement: from pre-season to on the field to sideline assessment, diagnosis, treatment and return to play

 

Management of sport-related concussion involves a step-by-step process say three recently issued concussion guidelines:[1-3]

1. Preseason

Preparation for the care of concussed athletes begins prior to any practice or competition with:

  • A pre-participation exam (PPE): The PPE should include the taking of a detailed concussion history.[1,2]
  • Baseline testing: The pre-season evaluation may include one or more of the following:
    • paper-and-pencil or computerized neuropsychological/neurocognitive (NP) testing (Note, however, as indicated below, that whether baseline NP testing is necessary, and, if so, for what athletes, is controversial;[1,2,12,13]
    • symptom scores on a concussion symptom scaleDamon Glass administering King Devick test
    • balance testing
    • a sideline evaluation tool testing neurocognitive function (memory, orientation to time and place etc.) (e.g. SCAT3. SAC)
    • a vision test (e.g. King-Devick) [Note: While the Zurich consensus statement on concussion[1] and a related study[5] says more research is needed before King Devick can be recommended for use in sideline assessment of concussion, one leading concussion expert, Dr. Robert Cantu,[6]  recommends that it be included as part of the baseline and post-concussion test battery.]
  • Development of an emergency action plan (EAP): to ensure that appropriate care is provided in a timely manner, an EAP should
    • include planning for responses to medical emergencies involving athletes, spectators, coaches, and officials;
    • be developed with input from an athletic health care team, administrators, coaches, facilities managers, parents, and members of the local EMS;
    • be reviewed before every sports season; and
    • periodically rehearsed with EMS.[2]

2. On the field

The first step is to check an athlete's airway, breathing and cardiac function (ABCs) followed by a physical evaluation to exclude brain injury or cervical spine injury.[1,2]

  • If a cervical spine injury cannot be eliminated, neck immobilization and immediate transfer to a hospital emergency department capable of advanced neurological imaging (CT/MRI)[2];
  • Emergency transfer should also occur if there are signs of a more serious brain injury such as deteriorating mental status, focal neurological findings (abnormal or unequal pupil reaction, etc.) or worsening of symptoms.[1,2]

 

3. Sideline assessment

A standardized approach using one or more of the following sideline assessment tools is recommended:

Note: the sensitivity (the likelihood that an athlete with concussion will be correctly identified) and specificity (the likelihood that an athlete without concussion will be correctly classified) of the diagnosis of concussion may increase when multiple concussion assessment tools are used.[2,10]
  • Where available, sideline tests results should be compared to a reliable preinjury baseline. 
    • Because results can vary widely from athlete to athlete and the results depend on age, sport, sex and pre-existing medical conditions, use of sideline tests without baseline results is difficult. 
    • Note, however, that a pair of 2012 studies[12,13]  suggest that comparing an athlete's post-concussion neuropsychological test results to those of athletes of the same age and gender (e.g. 'normative values') may be enough as a diagnostic tool, and that clinicians, can, in most cases, identify the same cognitive impairments in a concussed athlete by using normative neurocognitive values as by comparing their post-concussion performance to individual pre-injury baselines.
    • Baseline test results may change as part of the normal maturation and development process (which is why a new baseline is recommended periodically, although there is no agreement on how frequently) and can be dependent on current mood, fatigue[14] and other factors.[15-18]
  • The sensitivity, specificity, and the false-positive and false-negative rates vary for different sideline tests. With the current sideline tests, as sensitivity goes up, the specificity goes down, so some athletes without concussion may held out. Physicians evaluating concussions on the sideline are nevertheless encouraged to err on the side of safety ("when in doubt, sit them out.")
  • Test results may change over the course of a concussion (for instance, balance typically returns to normal after 3 days, making balance testing a potentially useful sideline test but not useful for a later follow-up), and are important considerations in the evaluation process.
  • Familiarity with an athlete is an important component in the sideline evaluation of a concussion, given the variability in the way concussion can present. This is one of the reasons why a certified athletic trainer should be on the sideline at every game and practice in a contact or collision sport.

Whatever sideline screening tools are used, it is important to remember that they are designed only for rapid concussion screening on the sports sideline and are not meant to replace comprehensive neuropsychological testing, which should ideally be performed by trained neuropsychologists, nor should they be used as a stand-alone tool for ongoing concussion management. [1-3]

  • Sequester an essential piece of playing equipment as a safety precaution. When a player is being evaluated for or has been diagnosed with a concussion, it is a good safety strategy to take from the player an essential piece of equipment (e.g.helmet, glove, catcher's mask etc.) to avoid an 'inadvertent' return to the game. [2]
  • Watch the player. A concussed athlete should not be left alone if the decision is made to keep the player on site, and regular monitoring for deteriorating physical status is essential.[1,2] If, after a complete sideline assessment determines that a concussion is not thought to have occurred, and the player is allowed to continue to play, the player should be periodically evaluated after their return to ensure the decision was correct.
  • Send home with instructions or transfer to hospital where appropriate. The sideline medical staff should:
    • arrange or discuss the follow-up evaluation with a parent/guardian [2,4]
    • arrange for the athlete to be accompanied or monitored once allowed to leave the competition area. [1,2]
    • provide 'take-home' information, ideally in written form, including:

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