Outpatient sports-related concussion (SRC) management continues to evolve as evidence emerges supporting a multidisciplinary approach to the clinical assessment of SRC. Early active rehabilitation has replaced strict cognitive and physical rest. With this paradigm shift in management, pragmatic approaches are highly sought by busy clinicians that provide direction to individualized treatment, which can potentially expedite symptom resolution. Treatment strategies that address domain-based symptom constellations continue to be developed by clinician researchers. Although the optimal timing and dose of these domain-specific therapies has yet to be determined, future directions of SRC treatment will answer these and other questions regarding SRC management.
Key points
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Outpatient management of sports-related concussion (SRC) has undergone a paradigm shift from strict cognitive and physical rest to active rehabilitation, because emerging evidence supports a multidisciplinary approach to the clinical assessment of SRC.
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SRC symptoms are typically clustered into five specific domains: somatic, cognitive, affective, vestibular, and sleep/wake disturbances. Domain-based therapy is now recommended and should be individualized.
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Although computerized neurocognitive testing (CNT) remains a frequently used assessment tool in clinical practice, the role of baseline CNT in SRC management has recently been questioned, because cost, age-related differences in test performance, and uncertain retesting intervals are factors that affect its utility.
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As additional diagnostic tools become available and are supported by evidence, published guidelines for SRC care should take into consideration time and resource constraints of clinicians who perform clinical assessments of athletes with SRC.
Introduction
Expert opinion and limited evidence suggest that sports-related concussion (SRC) is a self-limited condition with expected symptom duration less than 2 weeks in adults, and less than 4 weeks in children and adolescents. , However, 10% to 30% of adult athletes experience symptoms beyond 10 to 14 days, and when comprehensive assessment approaches (eg, postconcussion symptom scales, cognitive, vestibular-oculomotor) are used, concussion recovery may extend up to 21 to 28 days in high school and collegiate athletes. , Recent literature suggests that adolescent and young adult patients who receive clinical care within 7 days of SRC recover faster and are less likely to have prolonged (≥30-day) recoveries compared with those initiating care between 1 and 3 weeks after their SRC. Given this information, a clinician who is well-versed in contemporary SRC management strategies has the potential to expedite the recovery and return to academics and sports for patients who report their symptoms and are evaluated in a timely fashion.
Outpatient management of SRC has evolved significantly over the past few decades, as evidence emerges supporting a multidisciplinary approach to the clinical assessment of SRC , , and an adoption of active rehabilitation rather than strict, sustained cognitive and physical rest, otherwise known as “cocoon therapy.” , With this paradigm shift in SRC management, pragmatic approaches are highly sought after by clinicians in busy outpatient settings who may not have the same spectrum of resources available to manage SRC as a provider practicing in a tertiary or quaternary care facility.
In this article, we review the office-based approach to SRC management, including the recommended tools for clinical evaluation, prescribed cognitive and physical activity, adjunctive therapies, and future directions of outpatient SRC management.
Office-based evaluation: recommended tools for clinical assessment
Overview
SRC is a challenging diagnosis to make and relies to a great degree on history, physical examination, and clinical judgment. Because there does not currently exist an accurate, objective diagnostic measure for SRC, the treating clinician typically supports their judgment with a variety of assessment tools. The more common tools used when evaluating SRC are discussed, but the reader should note that all current tools have less than optimal reliability. The development of more reliable clinical tools and a gold standard diagnostic measure are among the more active issues in SRC research.
History
As with any clinical scenario, obtaining a detailed history is vitally important when assessing an individual for a possible SRC. Defined by the 2016 Consensus Statement on Concussion in Sport drafted by the Concussion in Sport Group (CISG), SRC is an injury that can result from either a direct blow to the head or an impulsive force delivered elsewhere to the body and transmitted to the head, resulting in transient neurologic deficits. Therefore, the treating clinician should assess whether the presenting individual had a plausible mechanism of injury either by direct query of the patient and/or of witnesses. The latter group of potential historians is especially important when assessing pediatric patients or in an instance where the individual themselves has had either loss of consciousness (LOC) or amnesia around the time of the injury. The assessment of the transient neurologic deficits expected with this injury includes assessing for expected signs and symptoms (discussed later).
The past medical history is of importance primarily for two reasons. First, a history of any previous concussion is needed. A recent concussion temporally close to the current injury, or a litany of having had multiple previous concussions, might alert the treating clinician to the possibilities of a prolonged recovery or a need to discuss the possibility of an extended break from the sport of concern. Second, comorbidities must be assessed because they can affect the expected progression of concussion. It is important to inquire specifically about preexisting neurologic (history of migraines), psychological (anxiety, depression), or cognitive (attention-deficit/hyperactivity disorder, other learning disorders) conditions because these can affect the longitudinal evaluation of recovery and modify prognosis.
Regarding the social history, it is important to ask about other sports or activities where the individual participates, including work and school. Driving status should be obtained when relevant, bearing in mind that even preadolescents may in some circumstances be operating motor vehicles (eg, a farming child using a tractor). Finally, when relevant an alcohol/substance use history should be obtained.
Symptom Evaluation
SRC is a challenging diagnosis because the clinical evaluation relies heavily on self-reported symptoms, many of which are nonspecific to concussion. Moreover, these same symptoms may evolve over time and the diagnosis may only become clear sometime after the injury itself (hours to days postinjury).
Given this, the serial evaluation of symptoms is a cornerstone of the diagnosis and management of SRC. The potential symptoms are various and cluster into five specific domains:
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Somatic (headache, neck pain, nausea/vomiting, photophobia, phonophobia)
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Cognitive (confusion, amnesia, difficulty concentrating)
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Affective (emotional, irritable, sad, anxious/depressed)
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Vestibular (balance problems, dizziness, blurred vision)
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Sleep/wake disturbance (drowsiness, fatigue/low energy, difficulty falling asleep)
The most universally used tools for clinical evaluation in SRC are an adult and pediatric version of the Sport Concussion Assessment Tool (SCAT), 5th edition (SCAT5) and the Child SCAT5. These are iterative versions released in 2017 by the CISG and represent an evolution from previous tools known as the SCAT3 and Child SCAT3. The Child SCAT5 is designed for use in children aged 5 to 12 and the SCAT5 for individuals 13 and older. The two tools are used for sideline evaluation and serial, postinjury assessments in the training room or clinic; are widely available; free of cost; and provide a standardized approach to the care of SRC.
These two tools include a standardized symptom checklist in addition to a guided physical examination (discussed next). The SCAT5 includes a 22-item, seven-point Likert scale (0–6) symptom checklist incorporating the five domains in which SRC symptoms cluster. The Child SCAT5 is modified to address the unique concerns associated with pediatric patients ages 5 to 12. In these individuals, the symptom checklist is filled out by parent and patient. The wording for the 21-item symptom checklist is different and more child-friendly than the wording used in the SCAT5 checklist. A four-point Likert scale (0–3) is used in the Child SCAT5.
Physical Examination
An SRC is a traumatic brain injury (TBI). A brief period of LOC is associated with many SRCs, but it is unlikely to last longer than 30 to 60 seconds and once resolved the patient’s LOC should be full. Once possible LOC has resolved, the clinician should expect the 15-point Glasgow Coma Scale to be greater than 13 at all times in the acute and subacute settings of this injury. If the GCS is 13 or lower, a more severe TBI is present and emergency medical care should be initiated, the details of which are beyond the scope of this article.
In the setting of a TBI, the evaluating clinician must be aware of the possibility of associated trauma to the body and perform a pertinent secondary survey of the patient as one would do with all trauma patients. Given the mechanism of injury and presenting symptoms, this is a limited, focused examination to assess for possible injury sustained concurrent with the concussion itself and typically constitutes a thorough HEENT and cervical spine examination. The cranium must be examined for possible soft tissue injury (lacerations) or bony injury (eg, fractures of the basilar skull, frontal bone and sinus, orbit, and maxillae). The ear and nasal canals should be examined to rule out tympanic membrane or auricular injury or a nasal septal hematoma. It may be necessary to evaluate the oropharynx, dentition, and temporomandibular joint based on presenting complaints and do a thorough ophthalmologic examination if a primary eye injury is suspected. Finally, the cervical spine must not be overlooked because cervical sprains and vertebral fracture/dislocations are frequently seen in conjunction with concussions. The specifics of evaluation and treatment of these comorbidities are beyond the scope of this article, but each of these injuries may require evaluation (eg, imaging) and treatment separate from concussion care.
The core of the neurologic assessment of the SRC patient includes:
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A mental status assessment
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Oculomotor function
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Gross sensorimotor function
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Coordination, gait, balance, and vestibular assessment
These components are part of the previously referenced SCAT5 and Child SCAT5 tools, which in addition to a symptom checklist include a brief cognitive assessment (the Standardized Assessment of Concussion), a brief neurologic examination checklist, and a balance assessment (the modified Balance Error Scoring System [mBESS]).
Assessment of Vestibuloocular, Vestibulospinal Pathways
Vestibular and oculomotor impairments have been increasingly recognized as common following SRC. Vestibular symptoms include dizziness, nausea, vertigo, blurred or unstable vision, and discomfort in busy environments. , Oculomotor symptoms include headaches, dizziness, nausea, eye strain, difficulty reading or tracking moving targets, blurred vision, convergence insufficiency, diplopia, and problems scanning for visual information. , Dizziness is reported by 50% of concussed athletes and is associated with a greater than six-fold increased risk of protracted (>21 days) recovery compared with any other on-field symptom. Delayed recognition of these symptoms can lead to a protracted recovery. ,
The vestibular system is a complex network connecting the inner ear to the brainstem, cerebellum, cerebral cortex, ocular system, and muscles responsible for postural stability. Functionally, it is divided into two pathways: the vestibuloocular pathway and the vestibulospinal pathway ( Fig. 1 ). These pathways do not share identical circuitry. The vestibuloocular pathway is responsible for maintaining visual stability during head movements. Vestibular/Ocular Motor Screening (VOMS) and King-Devick Test are screening tools that assess components of the vestibuloocular pathway; King-Devick Test is primarily used as a sideline screen and is discussed in detail in Andrew Gregory and Sourav Poddar’s article, “ Diagnosis and Sideline Management of Sport Related Concussion ,” elsewhere in this issue. The vestibulospinal pathway is responsible for postural control. Disrupted balance is the primary symptom associated with vestibulospinal pathway impairment. Until recently, standard assessments of SRC only assessed the vestibulospinal pathway. Balance Error Scoring System (BESS), mBESS, and tandem gait testing are tests designed to assess postural stability and the vestibulospinal pathway. Because most balance impairments in SRC patients recover within 3 to 5 days of injury, , using postural stability tests alone as a measure of a vestibular system injury inadequately assesses vestibuloocular impairment. It is critical for clinicians to use tools that assess for vestibuloocular and vestibulospinal impairment to identify vestibular system involvement related to SRC.
Vestibular/Ocular Motor Screening
The VOMS is a valid clinical tool that is used in patients older than 10 years of age. VOMS measures symptom provocation in SRC patients after assessment of each of the following domains: (1) smooth pursuit, (2) horizontal and vertical saccades, (3) near point convergence (NPC), (4) horizontal vestibuloocular reflex, and (5) visual motion sensitivity. Convergence is evaluated based on the average measurement of three trials of NPC distance in centimeters. Patients are asked to rate symptoms of headache, dizziness, nausea, and fogginess (scale 0–10, with 0 representing no symptoms present) before and after provocative testing. An NPC distance greater than or equal to 5 cm and any VOMS item symptom score greater than two higher than baseline constitutes a positive screen. The VOMS tool has strong internal consistency and significant correlation with the Post-Concussion Symptom Scale. It has also demonstrated the ability to differentiate between concussed individuals and healthy control subjects. VOMS typically takes 10 minutes to administer. Clinicians need to decide whether to perform universal or targeted screening of SRC patients. Given the time constraints placed on busy clinicians and the pressures of productivity, universal screening of SRC patients may be challenging for health care providers outside of a tertiary center to perform, and a targeted screen based on presence or absence of vestibuloocular symptoms on Post-Concussion Symptom Scale may be more pragmatic. Additionally, the optimal timing of VOMS screening (eg, initial evaluation, 2-week follow-up) has yet to be determined.
Current consensus statements on SRC recognize that although oculomotor assessment may be indicated in SRC assessment, the most valid method for assessing oculomotor function is not clear. Therefore, oculomotor screening has not been incorporated into the SCAT5.
Modified Balance Error Scoring System
The mBESS, developed by Guskiewicz, provides a rapid assessment of postural stability in an outpatient clinic setting. The athlete stands on a firm surface and performs double leg, single leg, and tandem stances. Each trial/stance is 20 seconds in duration. Errors (eg, hands lifted off iliac crest, opening eyes, stumbling, hip movement, foot/heel lift, remaining out of test position >5 seconds) are counted, one point for each error, during the six 20-second tests.
Tandem Gait
Timed tandem gait is an alternative test of postural stability in patients with SRC. Athletes are instructed to stand with their feet together, and then walk in a forward direction as quickly and accurately as possible, preferably along a 3-m long piece of athletic tape on the floor, using a heel-to-toe gait. Once they reach the end of the tape, the athlete turns 180° and returns to the starting point along the tape. Time is recorded, and a total of four trials are performed. Tandem gait should be completed in 14 seconds or less. , Howell and colleagues recently showed that tandem gait testing demonstrates high test-retest reliability in a cohort of healthy, uninjured pediatric and adolescent patients, although a moderate practice effect was noted.
Neurocognitive Testing
Neuropsychological (NP) assessment is recommended as a cornerstone of a multidisciplinary approach to the management of SRC by the CISG. The CISG also notes the significant limitation that NP is in many cases not readily accessible to clinicians and patients.
In lieu of formal NP assessment, computerized neurocognitive testing (CNT) is frequently used in the clinic. The CISG notes that CNT is not a substitute for complete NP assessment, but in practice CNT is frequently more accessible and can be rapidly administered in the clinic, schools, and training rooms. The different CNTs are proprietary products ( Table 1 ), which have variable psychometric properties. ,
| Trade Name Product | Manufacturer |
|---|---|
| ANAM a | Vista LifeSciences, Parker, CO |
| Axon Sports CogState | CogState Ltd, Melbourne, Australia |
| Concussion Vital Signs (CNS-VS) | CNS Vital Signs, LLC, Morrisville, NC |
| Headminder Concussion Resolution Index | Headminder Inc, New York, NY |
| ImPACT b | ImPACT Applications, Inc, Pittsburgh, PA |
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