Concussion Treatment and Referral

Assessment

How are concussions detected?

    Concussions are primarily detected through the observation of appropriate signs and symptoms displayed by the injured participant. Clinical tests have been developed to aid in detecting the presence of a concussion and include objective measures to assess brain function and balance/coordination impairment. Concussions are most often detected through the presentation of the signs and symptoms mentioned previously. More recently, there has been a trend to add more objective tests that assess cognition and coordination. These tests will be briefly described in the subsequent sections.

What do I do if my child has a concussion?

• If you suspect a concussion, it is recommended that your child be immediately removed from competition or practice.
• No child should be allowed to return to activity while still experiencing symptoms.
• Your child should be referred to a medical professional with a background in sport-related concussion treatment.
• If your child is exhibiting signs or symptoms that warrant immediate medical attention, 911 should be activated and an emergency action protocol initiated.
• If your child has any “Red Flag” Signs and Symptoms you should transport them immediately to an emergency room.

Objective Tests

Neuroimaging – Diagnostic Imaging Techniques

    Concussions will most often not be positive on most neuroimaging. Conventional diagnostic imaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI) are often used when a more serious brain injury is suspected, such as a subdural or epidural hematoma.

Concussions will most often not be positive on most neuroimaging.

    The leading researchers on sport-related concussion have suggested that CT and MRI provide very little help to concussion evaluation because the neuroimaging often reveals normal structural results.^{1, 2} More recent studies involving the use of other imaging modalities have been conducted and have shown some promise in the research setting but are still not recommended for regular clinical use in sport-related concussion management. Every head injury must still be handled with caution, just because your son or daughter has imaging with negative results, it does NOT mean they did not suffer a concussion.

Self-Reported Symptom Scales

    One of the most identifiable ways to evaluate a sport-related concussion is through self-reported symptoms. Self-reported symptoms are symptoms that the athlete reports to you, their coach, athletic trainer or other medical provider. The use of a symptom checklist or graded symptom scale allows the sports medicine practitioner to clinically measure your child’s symptoms post-concussion and to systematically track the progression of your child over the course of their recovery.

    A self-reported concussion symptom scale typically contains a list of symptoms commonly associated with a concussion. A Likert-type scale is also added to allow the child/athlete to rate/describe the severity of the symptom(s) experienced. For example, a child can rate his/her headache on a scale from 0-6, where each number corresponds to a specific response option. Response options range from “never” (0) to “always” (6). A total overall score is summed to provide a quantitative measurement which can be used as a comparison for follow-up assessments. Higher scores on the symptom scale reflect greater impairments experienced by the child/athlete. An example of a graded symptom scale (embedded in a sideline tool) can be found here.

    Headache is the most commonly experienced symptom by the concussed athlete. It also tends to linger for a longer period of time as compared to the others on the list. Post-concussion symptom scale scores typically remain higher, compared to baseline measurements, for 3-5 days, however this can vary greatly between individuals. Regardless of the symptoms present or the timeline, no athlete should return to physical activity while they still are experiencing symptoms.

    Several studies have found the graded symptom scales to be reliable and valid to the effects of sport-related concussion in high school and college aged athletes.^{3, 4} Although the self-reported symptom scales are accurate in detecting the presence of concussion, it should not be used as the sole assessment tool in managing a concussion. It is also important to note that age appropriate symptom checklists are still needed for the pediatric athlete; therefore these recommendations may not apply to your child. Lastly, these objective clinical tests are designed for use by trained medical and healthcare professionals, so please seek the appropriate medical attention when dealing with a concussion.

Balance and Coordination

    Following a concussion, your child may experience trouble with maintaining his/her balance due to conflicting or insufficient information being sent to the injured brain. Therefore, a thorough postural stability/balance assessment is warranted to determine the presence of any dysfunction. One method to assessing postural instability, known as the Balance Error Scoring System (BESS), was developed as an alternative to the more traditional force platforms, which incorporates the use complex equipment.

    The BESS is comprised of six different balance conditions each of which lasts 20 seconds. The balance test comprise of three stance settings, double leg, single leg and tandem which are performed on two surfaces, stable/firm and unstable/foam. A foam pad is used to simulate an unstable surface. The score is measured in the amount of errors recorded during the different balance conditions. One point is given for each BESS error during the six 20-second balance tests. An increased number of errors on the BESS reflect a greater disturbance in balance and coordination following a concussion. The BESS scoring sheet can be viewed here.

    The National Athletic Trainers’ Association (NATA) highly supports the use of the BESS as a brief concussion assessment tool along the sidelines. Clinical research has shown that individuals who demonstrated postural instability following a concussion were unable to meet “normal” baseline measurements until an average of 3-5 days post-injury.^5-7 Again however, this timeframe can vary greatly between individuals.

Neuropsychological Testing

    Neuropsychological testing has been found to be a significant tool in evaluating cognitive deficits, measuring patient recovery, and determining return-to-play criteria in concussed individuals.^{6, 8} The cognitive impairments that follow a sport-related concussion typically include deficits in memory, attention, concentration, processing speed and other executive functions.⁹ It has been reported that these impairments are detectable for up to 5-7 days post-injury.⁶

Paper-and-Pencil Format

    Several forms of cognitive testing currently exists which include the conventional pencil-and-paper tests, computer-based programs, and brief mental status screenings. The conventional pencil-and paper format is typically administered and interpreted by a trained neuropsychologist. This often requires direct one-on-one interaction with your child and can be very time consuming and costly. These factors, along with others, likely restrict the routine use of neuropsychological testing for sport-related concussion, especially in the adolescent and pediatric population.¹

    Examples of paper-and-pencil tests include the Hopkins Verbal Learning Test, Trail Making Test, Digit Span and Stroop Test. The table below lists the brain function(s) being measured and briefly describes the components of each test. The National Athletic Trainers’ Association (NATA) and the National Academy of Neuropsychology (NAN) have come together in an effort to educate the public by creating a video about concussions in sports. You can view the video along with other information here.

Source: Guskiewicz et al., 2004¹; Randolph, 2005⁹

Test	Brain Function	Description
Hopkins Verbal Learning Test	Verbal learning, immediate and delayed memory	This test consists of a 12-word list that is repeated over 4 learning trials for immediate recall. After a delay, free recall and recognition of the words are tested
Trail Making Test	Visual scanning, attention, information processing speed, psychomotor speed	This test requires subjects to search an array of circles that each contain a letter or number and to connect the circles in order by drawing lines between them. The score is the time required to complete the task.
WAIS-III Digit Span Test	Working memory, attention, concentration	A subtest of the Wechsler Adult Intelligence Scale-III, this test involves repeating strings of numbers of increasing string length. This includes both forward span (exact repetition) and backward span (repeating the strings in reverse order).
Stroop Test	Attention, information processing speed, executive	This is a measure of response inhibition. Subjects are given a page with columns of color names (red, green, blue). The names are printed in various colors, and subjects are asked to say the name of the color in which each word is printed, inhibitiing the natural tendency to read the words themselves. The test is timed and scored for the total number correct (typically within 45 seconds).

Mental Status Screenings

    Brief mental status screenings were developed to confront some of the limitations associated with the conventional neuropsychological tests. For example, the Standardized Assessment of Concussion (SAC), was specifically designed to be a uniform, objective assessment tool that could quickly evaluate deficits in neurocognitive function immediately after sustaining a concussion. This sideline tool was developed for clinicians with minimal experience in neuropsychological testing and can be administered within a few minutes.

    The SAC consists of four categories which focus on orientation, immediate memory, concentration and delayed recall memory. Each category of the SAC is tested and scored separately, then summed to obtain an overall score. A lower SAC total score indicates greater cognitive dysfunction. Orientation tests attempt to determine your child’s awareness of their environment. The tests include specific questions about the event such as the score, who they are playing, where they are, and what time it is. Immediate memory tests are designed to assess the concussed child’s ability to retain and repeat a list of words. The words are provided by the examiner and are to be repeated in any order without delay. Concentration tests are aimed at assessing the concussed individual’s ability to process given information. For example, your child may be asked to recite the months of the year in reverse sequence. Delayed recall memory is linked to the immediate memory tests. After a given period of time, your child is asked once again to recite the list of words that were provided to him/her at the beginning of the memory assessment.

    The Sport Concussion Assessment Tool 2 (SCAT2)² has been developed as a standardized method of evaluating a sport-related concussion. It is intended to be used by medical and health professionals and is applicable in athletes from 10 years of age and older. The previous version of the SCAT was evaluated for face and content validity.¹⁰ The SCAT2 is comprised of eight assessments focusing on postconcussion symptoms, neurocognitive function, and balance and coordination. Specifically, the SCAT2 measures the injured athlete’s symptoms, physical signs, Glasgow Coma score, Maddocks score, Standardized Assessment of Concussion (SAC) total score, modified Balance Error Scoring System (BESS) total errors, and upper limb coordination score. Each assessment is scored separately. The SCAT2 total score is out of 100 and does not include the Maddocks questions score because it is only validated for sideline diagnosis of concussion.¹⁰ Scores from each separate assessment will be added together to obtain the total overall SCAT2 score.

Computer-based Format

    Computerized neuropsychological testing has many practical advantages in the athletic setting. And in recent years, numerous computerized testing programs have undergone clinical investigation. Some of the proposed advantages of the computerized version, over the traditional pencil-and-paper format, are believed to be ease of administration, prompt scoring, variable testing paradigms, and accessibility for clinical use.^{1, 11} Some examples of computer-based neurocognitive tests include the Automated Neuropsychological Assessment Metrics (ANAM), CogSport, Concussion Resolution Index, and the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). Each neuropsychological test examines various cognitive domains ranging from reaction time, visual recognition, symbol scanning, verbal memory, and information processing speed. The table below briefly indicates what areas of brain function each test assesses.

Source: Guskiewicz et al., 2004¹; Randolph, 2005⁹

Test	Brain Function	More Information
HeadMinder Concussion Resolution Index (CRI)	Reaction time, processing speed	www.headminder.com
Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)	Attention, memory, processing speed, reaction time	http://www.impacttest.com/
Computerized Cognitive Assessment Tool (Axon Sports CCAT, formerly CogSport)	Psychomotor, decision making, problem solving, memory	www.axonsports.com
Automated Neurophysiological Assement Metrics (ANAM)	Reaction time, processing speed, visual working memory, sustained attention	_

Referral

    Although most concussions are considered to be mild head injuries, there is a potential for your child’s condition to deteriorate and a life-threatening injury to occur, especially if inadequate care is taken. Appropriate medical coverage is essential and will allow for immediate assessment and diagnosis of the injury. Ideally, the medical personnel should have experience in dealing with sport-related concussions. In the event that no medical coverage is provided or medical personnel is not available, and you suspect your child has sustained a concussion, immediate referral to a physician should be arranged. Close monitoring of your child’s post-concussion symptoms are needed to assess their recovery and to determine if other actions are necessary.

When should I refer my child?

• Worsening of symptoms (i.e. headaches)
• Vomiting
• Decrease in level of consciousness
• Seizures
• Brain function deteriorating
• Difficulty breathing
• Mental Status Changes
• Pupil are unequal
• Slurred speech
• Weakness or numbness in arms/legs
• Unusual behavioral changes

Who should I refer my child to?

    The concussed athlete should be monitored closely over the next couple of hours and days for delayed signs and symptoms. If your child is exhibiting any “Red Flag” signs and symptoms he/she should be immediately transported to the nearest hospital or emergency department.