and On-Field Management of Sports-Related Concussion

Test

Response

Score

Eye opening

Spontaneous

To speech

To pain

None

Verbal response

Oriented

Confused

Inappropriate

Incomprehensible

None

Motor response

Obeying

Localizing

Withdrawal

Flexing

Extending

None

Table 4.2

Red flags during the on-field survey^a

Fluctuating level of consciousness	Inability to recognize people or places
Increasing confusion	Increasingly irritable/restless/combative
Neck pain or tenderness	Persistent/worsening extremity numbness or paresthesia
Unequal pupil size	Double vision
Vomiting	Seizure or convulsion
Slurred or altered speech	Worsening headache

^aWarrants transfer to emergency center immediately

Secondary Survey (Sideline Evaluation)

If an athlete requires an on-field assessment for any reason, after sustaining an impact or injury to the head and/or neck area, a thorough secondary survey is warranted once the athlete reaches the sideline. Once a clinical evaluation for cervical spine trauma and other life-threatening injuries has been completed, the athlete should be moved to a safe area for a complete sideline evaluation. At this point, the evaluating clinician should repeat the primary survey and complete a more comprehensive evaluation. Again, the emphasis must be on identifying any evolving cervical spine or intracranial pathology first and diagnosing concussion, or other injury, second. Each individual practitioner will develop his or her own system for evaluation, but we recommend the inclusion of at least the following components: observation and history, focused neurological exam including a cervical spine evaluation, and functional testing.

Observation and History

The first step in evaluating an athlete who has sustained trauma to the head and neck region is establishing the mechanism of injury and the sequence of events leading up to and immediately following the injury. Often the evaluating clinician will have witnessed the injury and may have an established mechanism of injury in mind based on his or her observation of the incident. Nonetheless, it is worthwhile obtaining a history from the athlete directly as this may provide added insight in regard to mechanism and offer an opportunity to assess any evidence of change in affect, aphasia, or amnesia – anterograde or retrograde [64]. Additionally, collateral information from other athletes, coaches, medical staff, or other observers can be very helpful. At higher levels of competition, such as collegiate or professional sports, video may be available for review as well. As is the case with most of medicine, any additional information can be helpful.

Standard orientation questions – person, place, and time – have been found to be unreliable in the setting of sport and the injured athlete. Rather, the recommended assessment of orientation uses some variation of the following five questions (Maddocks Questions) [65, 66]: What venue are we at today? Which period (quarter, half, etc.) is it now? Who scored last in this match? What team did you play last week/game? Did your team win the last game? These questions can, and should, be modified as necessary to more appropriately reflect the sport and/or competition at hand.

According to the Consensus Statement from the 2016 International Conference on Concussion in Sport [9], the diagnosis of SRC may include disturbances in the following clinical domains:

(a)

Symptoms: somatic (e.g., headache), cognitive (e.g., feeling like in a fog), and/or emotional symptoms (e.g., lability)
(b)

Physical signs (e.g., loss of consciousness, amnesia, neurological deficit)
(c)

Balance impairment (e.g., gait unsteadiness)
(d)

Behavioral changes (e.g., irritability)
(e)

Cognitive impairment (e.g., slowed reaction times)
(f)

Sleep/wake disturbance (e.g., somnolence, drowsiness)

Thus, one should specifically look for and/or ask about these signs and symptoms. Several resources for evaluating for such signs and symptoms are available, but the following are two commonly utilized tools: Concussion Recognition Tool 5 from the Concussion in Sport Group [67] and The Graded Symptom Checklist (GSC) [11, 68]. Additional symptom scales include the Acute Concussion Evaluation (ACE) , Concussion Symptom Inventory (CSI) , Health and Behavior Inventory (HBI) (primarily for pediatric patients), Post-Concussion Symptom Inventory (PCSI) (primarily for pediatric patients), Post-Concussion Symptom Scale (PCSS) (primarily studied in adolescent athletes), and Rivermead Post-Concussion Symptoms Questionnaire (RPCSQ) among several others [69, 70].

The Graded Symptom Checklist (GSC) is the mostly widely discussed symptom scale, at least in the sports medicine literature, and its use is recommended by the National Athletic Trainers Association [11, 68]. Additionally, one may choose to ask the athlete being evaluated to grade his or her symptoms on a scale of 0–6 (0, not present; 1, mild; 3, moderate; 6, most severe) and then calculate a total symptom score. When used in this manner, the evaluation is referred to as the Graded Symptom Scale (GSS) .

Most of disturbances noted as a result of concussion are symptomatic in nature, and one must rely on subjective assessment and reporting to detect these changes. This underscores the importance of the observation and history portion of the evaluation, and thus emphasis should be placed on this assessment.

Focused Neurological Examination Including Cervical Spine Evaluation

The focused neurological examination should start with the bony structures of the face and cranium to assess for any obvious evidence of craniofacial fracture and, next, palpation of the cervical spine for any sign of midline tenderness or pain with range of motion of the cervical spine. If these are normal, provocative exam maneuvers, such as Spurling’s maneuver , may be considered. If the athlete demonstrates midline tenderness to palpation and/or pain with range of motion, he or she should be placed into a cervical collar as these findings may represent findings of an unstable cervical spine injury and further evaluation with advanced imaging (typically a CT scan) may be warranted [71]. Additionally, an assessment of sensory and motor function in at least the major upper (C5-T1) and lower extremity (L2-S1) dermatomes and myotomes should be included. Finally, a brief cranial nerve examination, including an assessment of eye movement/extraocular muscles as well as pupillary function, should be completed.

Functional Testing

Presuming the athlete demonstrate s no positive signs/symptoms of head injury or concerning physical exam findings, assessment of functional activities should be the final step in the sideline evaluation. This includes evaluation of speech pattern and gait. If walking gait is found to be normal, the evaluation should progress to running and then athletics movements such as pivoting or cutting. It is important to evaluate for not only signs of ataxic movement or difficulties with balance but also to question the athlete about the development of any symptoms with exertion.

If the secondary survey, or sideline evaluation, elicits any positive findings concerning for SRC or other neurological injury, the athlete should be escorted to the locker room or training room for a complete tertiary survey and withheld from returning to play until the full evaluation is completed [72]. If the full secondary survey is found to be negative, the medical staff may should then make a clinical decision as to if the athlete may safely and appropriately return to play. It is essential for all involved parties, especially athletes and the coaching staff, to recognize that a sideline evaluation does not mean that a player is to be automatically removed from competition. The hope in such a design, in combination with extensive preseason and continuing athlete education, is to minimize the desire for athletes to hide head injuries and/or avoid formal evaluation.

Tertiary Survey (Locker Room/Training Room Evaluation)

If the secondary survey (sideline evaluation) is deemed to reveal any positive findings or found to be indeterminate for SRC or other head/neck injury, the athlete should be taken to the locker room, training room, or other quiet, controlled environment for a comprehensive examination. This examination should include, at minimum, a complete neurologic examination and some form of a multimodal concussion-specific assessment.

Complete Neurological Examination

Though components of a comprehensive neurological examination have been performed in the primary and secondary surveys, those portions should be repeated in evaluating the athlete in the training room or locker room. The signs and symptoms of SRC are often subtle, and this level of redundancy helps to ensure that mild disturbances are recognized. Though a variety of physical exam maneuvers may be incorporated into a complete neurological examination, the details of these are beyond the scope of this chapter. Briefly, at least the following components should be included: spine evaluation (palpation, range of motion, upper and lower extremity motor function, full sensory examination, reflex assessment); complete cranial nerve evaluation (including assessment of eye motion and extraocular muscles, pupillary reactivity to light, and pupillary accommodation); and cerebellar function testing including assessment of balance and coordination. The goal of this evaluation is to rule out some other form of neurologic injury – such as spinal cord injury, brainstem injury, intracranial hemorrhage, etc. – and to assess for subtle neurologic disturbance that may be attributed to SRC.

Application of Concussion-Specific Tests and Tools

A number of concussion-specific assessment tools have been developed and are available for use, but it is important to recognize that none of these tools have demonstrated adequate sensitivity and specificity to be considered an optimal diagnostic tool. Additionally, most concussion assessment tools are susceptible to influence of underlying mental health conditions, such as depression or anxiety [73]. Thus, most authors recommend a multimodal approach toward diagnostic evaluation using an assessment that evaluates for some combination of the following: symptoms of concussion, orientation, short-term/immediate recall, concentration, balance, and delayed recall.

The Sports Concussion Assessment Tool, 5th Edition (SCAT5©), was developed by the Concussion in Sport Group and represents a systematic, multimodal assessment. The SCAT5© is a resource that is readily available to all sports medicine practitioners and includes an approach that is based on the best available evidence. It incorporates Maddocks Questions, the Glasgow Coma Scale (GCS) , a cervical spine assessment, a symptom evaluation tool, the Standardized Assessment of Concussion (SAC) , a neurological screen, and the Modified Balance Error Scoring System (mBESS) [9, 61, 62, 65, 74, 75]. The Standardized Assessment of Concussion (SAC) was developed as a quick, reliable assessment tool for screening for signs and symptoms of concussion and has been validated with reasonable sensitivity and specificity when administered immediately post-injury [66, 74, 76, 77].

Balance and postural stability deficits following concussion have been well-documented; however, early research in this domain focused on objective, quantifiable assessments using sophisticated force-plate systems for evaluation. The Balance Error Scoring System (BESS) was developed in an effort to create a practical and objective sideline assessment of balance and postural stability [75]. To perform the tests, athletes are asked to maintain three positions (double-leg stance, single-leg stance, tandem stance) with their hands on their iliac crests and their eyes closed for a period of 20 s each while an evaluator counts errors (hands lifted off iliac crests, opening eyes, step/stumble/fall, move hip into more than 30° of flexion or abduction, lift forefoot/heel, remaining out of testing position for more than 5 s) and scores the exam [75]. In its initial design, the series of three tests was completed once on a firm surface and then repeated on a piece medium-density foam, but it has since been modified (mBESS) to be performed as a single series on one surface – preferably the same surface upon which baseline testing was completed. For sports using special footwear, such as cleats, this testing should be completed in competition footwear.

Neuropsychological Testing

Neuropsychological testing , such as the Immediate Post-Concussion and Cognitive Testing (ImPACT) , represents another tool that can be useful in the evaluation of SRC. ImPACT is a computerized injury assessment tool and is most commonly applied using a desktop version. The difficulty with this approach, however, is that the testing can be fairly cumbersome and time-consuming, and the assessments must be applied and interpreted by trained neuropsychologists and/or technicians [78]. This limits the usefulness of such testing in the on-field evaluation and management of SRC; however, the information garnered from neuropsychological testing may be useful in assessing recovery progression when compared to baseline. As is the case with most diagnostic tools for SRC, the psychometric properties of ImPACT are insufficient for such an assessment to be considered diagnostic on its own [79, 80].

The King Devick (K-D) test is another neurocognitive test that incorporates visual pathways into the assessment. This test entails a 2-min rapid number naming exercise in which the athlete quickly reads numbers from a screen or card. This activity involves eye movements (saccades, convergence, accommodation), attention, and language function – all of which may be affected by SRC [81]. As is the case with ImPACT testing, results of K-D testing can be susceptible to variation due to underlying conditions, such as learning disability and/or attention disorders, such as attention deficit hyperactivity disorder [41, 82, 83]. This underscores the role of baseline testing and also the importance of considering the results of such testing on an individual basis. While further research is necessary, there is some hope that a rapid neurocognitive assessment, such as the K-D test, may eventually serve as a primary sideline diagnostic tool.

Other Emerging Diagnostic Technologies

The lack of a definitive diagnostic test for SRC has been the focus of much research and innovation. Significant efforts have been placed toward evaluating serum biomarkers indicative of intracranial trauma and/or hemorrhage . While these studies show some promise in aiding the diagnosis of concussion in the hospital setting, they offer little value to the sideline clinician in their current states. If one of these lab tests reaches clinically significant sensitivity/specificity for evaluation, there is some hope that a finger stick, point-of-care test could later be developed [84, 85]. Other studies suggest that alterations in cerebral blood flow may be responsible for some of the neurologic disturbances associated with concussion, and thus, multiple brain MRI protocols have been developed to assess cerebrovascular reactivity after concussion [86, 87]. Assessment of ocular movements and pupillary reflex is a common part of several recommended examination protocols for evaluation for SRC. Some researchers have found that the incorporation of automated binocular pupillometry may help to more objectively measure pupillary function and may be useful diagnostically [88]. Brain Network Activation assesses changes in brain activity and functional connectivity after concussion using high-density, multichannel electroencephalogram mapping of event-related potentials (EEG-ERP) [89]. While all of these technologies are exciting and show promise in terms of potential future applications, none demonstrates the appropriate sensitivity and specificity to serve as a tool for on-field management and diagnosis of SRC at this time.

Removal from Competition and Next Steps

After completion of the full evaluation, including the primary/on-field, secondary/sideline, and tertiary/locker room portions when necessary, one must make the critical decision as to if the athlete may or may not return to play. The goal of the systematic and comprehensive assessment is to detect any signs of injury and/or subtle neurologic disturbance. At this point, the clinician is in charge of decision-making and must determine if the athlete may return to play. With that being said, a properly designed head trauma evaluation and management policy will result in a significant number of athletes being identified as having suffered an at-risk impact and indicated for a formal assessment, but found to have a completely normal evaluation. It should go without saying that the most prudent advice when making this decision is to error on the side of caution and protecting the athlete. The consequences of second impact syndrome are significant, and, if there is any question, the athlete should be held out from play [30–36]. Finally, it is important to recognize that a concussion is an evolving pathophysiologic process and continued evaluation and monitoring are necessary [9]. Thus, any athlete who is indicated for a formal assessment, even if he or she has a completely normal evaluation, should receive follow-up evaluation after the event. The athlete should also be re-evaluated at some scheduled interval within the next several days to ensure that an evolving SRC has not been missed.

Return to Sport and the Management of Post-Concussive Syndrome

Return to sport after concussion and the management of post-concussive syndrome are beyond the scope of this chapter. The consensus statements from several national and international organizations are, however, in agreement with some variation of the following stepwise approach: (1) medical assessment, (2) rest, (3) symptom-limited activity, (4) light exercise, (5) sports-specific exercise, (6) noncontact training, (7) medical clearance, (8) full-contact practice, and (9) return to sport [9, 90]. An SRC-specific return to sport protocol should be designed and implemented as a portion of the head trauma evaluation and management policy for each specific team, sport, competition, etc. While protocols vary, most are centered around a principle of gradually returning athletes to exertional exercise and eventually competition in a stepwise and controlled manner. It is important to note that each individual athlete will progress through a stepwise return to sport protocol at a different rate and the athlete should not be permitted to progress to the next step in the protocol until able to complete the previous step entirely symptom-free.

Post-concussive syndrome can vary widely from athlete to athlete, and it is important to ensure that recovery and treatment are individualized to fit each player and each injury. Additionally, it is helpful if the same person, whether it be a physician, athletic trainer, or otherwise, evaluates the athlete on a regular basis as he or she recovers from an SRC. This allows for consistent evaluation of progress and helps to ensure that the athlete is not inappropriately allowed to move to the next phase of the protocol without successfully completely the previous step. It is also important to recognize that the rate of recovery can vary drastically from athlete to athlete. In the case of children and adolescents, recovery may take up to 4 weeks, compared to the typical 1–2 weeks in adults [91].

Expert Opinion

Despite the significant effort and resources directed toward the study of SRC over the past 50 years, we are, unfortunately, still left with more questions than answers with regard to how this condition is best managed. This renders SRC an incredibly difficult entity to understand, recognize, and treat. For all the valuable information included in the Consensus Statement from the 2016 International Conference on Concussion in Sport, the most telling portion of the document may be its final line: “…the science of concussion is incomplete and therefore management and return-to-play decisions lie largely in the realm of clinical judgement on an [individualized] basis” [9]. This speaks to the importance of continued learning and maintaining an up-to-date understanding on the current literature regarding SRC.

Our experience in the diagnosis and management of SRC, at least over the past several years, has been primarily with professional football players. The National Football League Head, Neck and Spine Committee’s Concussion Diagnosis and Management Protocol is reviewed and updated prior to each season and the 2017–2018 season version is published and available for reference as an example of a comprehensive concussion program in a high-level collision sport [6]. This protocol is one example of a succinct, summary document that can be provided to all involved personnel to guide the management of head and neck injuries, including SRC. Additionally, the National Football League’s “Concussion Game Day Checklist” is included in this protocol [63, 92]. We recommend that each and every sports medicine team create a similar written policy for the management of head and neck injuries as well as a well-defined game day evaluation checklist. This will make practice and game day roles clear and the assessment of these injuries systematic. Taking such an approach will help to ensure that head and neck injuries are appropriately evaluated and properly managed.

Additionally, we recommend an all hands – or, more appropriately, all eyes – on deck approach. Any trainer, physician, coach, player, official, parent, etc. who observes a concerning impact should not only be allowed, but encouraged, to speak up and ensure that the player receives an appropriate evaluation. Developing this culture takes a significant effort in terms of education and communication, but, ultimately, helps ensure that each and every athlete is properly cared for. Also, comprehensive educational efforts can help encourage athletes to advocate for themselves. We know from the literature that athletes hiding head injuries and SRCs is not uncommon [44]. In our experience this has become less of an issue with our professional athletes as the potential long-term effects of these injuries have come to light and we have improved our efforts with regard to education.

Until we as a medical community are able to develop and scientifically validate a reliable sideline diagnostic tool, SRC will remain a clinical diagnosis. In that same vein, any and all available resources should be utilized in gathering information to inform clinical decision-making. At the professional level, video review of the injury or impact at hand can be incredibly helpful in understanding the mechanism and/or severity of the impact sustained [93].

Finally, we encourage anyone evaluating and managing these injuries to take the conservative approach. If there is any doubt whatsoever, hold the athlete out for further evaluation. The safety and long-term health of the athlete must always be held paramount.