On-field Diagnosis and Management
Athletes should be evaluated if they show any signs or symptoms that are concerning for concussion. They should be evaluated immediately using standard emergency management and first aid and/or cardiopulmonary resuscitation principles including airway, breathing, and circulation, and particular attention should be paid to evaluation for a cervical spine injury. If a cervical spine injury cannot be ruled out, the participant must be immobilized with rigid orthotics, leaving on any sports equipment, such as a helmet and pads if applicable, and transferred to an emergency department capable of trauma evaluation and advanced neurological imaging. Additionally, if there is any sign of more serious brain injury (deteriorating mental status, localizing neurological deficit, abnormal results on pupillary examination, extraocular movement abnormalities, motor or sensory disturbances), the patient should be transferred for evaluation on an emergent basis. Once the appropriate initial disposition of the athlete is made by a health care provider on site, a concussion assessment may be performed on the sideline. However, if no health care provider is present, as is often the case in a practice setting, the participant should be removed from play and urgently referred to a physician.
First, the participant must be removed from play or practice. The assessment includes the use of standardized and validated symptom scoring scales of SRCs. These provide an easy to follow, systematic approach for on-field providers to use to evaluate and manage players, and they also provide a common language that may transfer longitudinally with the patient from various health care providers during future health care appointments following the injury. Commonly used scales include the Pittsburgh Steelers postconcussion scale; the Concussion Resolution Index; the Postconcussion Symptom Scale; the Concussion Symptom Inventory; and the Sport Concussion Assessment Tool (SCAT), third iteration, which is commonly referred to as SCAT3. If used in preseason physical assessments, these scales may also provide a baseline for future comparison should a postinjury evaluation be necessary. The remainder of the sideline evaluation includes a history and physical examination, primarily to rule out more serious neurological injuries.
Vision is an important assessment for concussion, although it is often underutilized during sideline assessment. Although not universally accepted as diagnostic, the King-Devick test is an oculomotor test that can be used for concussion screening in athletes.[61,146] This test provides a rapid assessment of the visual pathways, and the results of numerous trials have shown that concussed athletes have significantly increased cumulative read times when compared with healthy controls, increasing the sensitivity of sideline evaluations.[36,61,130]
Balance and postural stability testing during sideline physical examination, especially when the results can be compared with preseason baselines, is very sensitive for the diagnosis of concussion.[18,32,45,128] Standardized balance assessment tools are available to help diagnose concussions, and they include the Balance Error Scoring System (BESS) and the Sensory Organization Test on the NeuroCom Smart Balance Master System (NeuroCom International, Inc.), which is used to identify musculoskeletal instability that becomes apparent only during balance testing. Studies have reported that acute postural instability deficits last approximately 72 hours following SRCs,[18–20,44,45] suggesting that postural stability is a useful tool for evaluating motor function following an mTBI. Formal testing using sophisticated clinical balance tests should be considered a reliable and valid addition to the assessment of an athlete who is suspected of having a concussion.
Standardized cognitive evaluation of the injured athlete allows trainers and team physicians to quickly assess and identify struggling athletes who have signs that might indicate a concussion. Common mental status questions used in our day-to-day practice, such as "What is your name?" "What is the year?" and "Where are we?" are often not sensitive for evaluation of a concussion.[77,92] Maddocks and colleagues developed a series of questions that are more appropriate and accurate in assessing a possibly concussed athlete. These are integrated into the SCAT3 assessment, and include questions such as "What venue are we at?" "Who scored last?" "What half are we in?" "Did we win our last game?" and "Where did we play last week?"[77,95] Other cognitive assessments that are quickly completed during the sideline evaluation include recalling 5 words, repeating a series of numbers backward, or listing the months of the year in reverse order.
Once a concussed athlete is identified, the athlete should be immediately removed from the field of play or practice and not allowed to return to athletic activities that day. A referral is made for further evaluation by health care providers to assess for a gradual, safe return to play.
Neurosurg Focus. 2016;40(4):e5 © 2016 American Association of Neurological Surgeons