Concussion Management Best Practices: Early Recognition

Concussion recognition is multifaceted, complex and can be challenging, especially when evaluating  adolescents and young children.  Some sports, such as wrestling, even place time limits on head injury evaluation during competition.  How do we conduct a thorough, yet concise concussion evaluation?  Here are some key considerations to help with early recognition for concussion.  For the purposes of this discussion, "sideline evaluation" refers to concussion evaluation during practice or competition for any sport.

       "When In Doubt, Sit 'Em Out":  This is a fail-safe rule all clinicians and coaches should follow.  As clinicians, sideline concussion evaluation is largely an educated attempt to turn subjective information into objective data.  As a result, it remains an imperfect science.  Above all else, remove an athlete from participation if they experience/exhibit signs and symptoms (S/S) of concussion. 

       Determine the Mechanism of Injury (MOI):  Witnessing/establishing the MOI helps the clinician correlate symptoms with cause.  It is important to note that a direct blow to the head is not necessary for an individual to sustain a concussion.  Establishing the MOI is also vital to help eliminate other correlated differential diagnoses such as a cervical spine injury. 

       Utilize Standardized Assessments:  In 2017, the Concussion In Sport Group (CISG) developed the SCAT5 (Sport Concussion Assessment Tool, 5th Edition) following the International Conference on Concussion in Sport in Berlin, Germany in October 2016.  The CISG also developed the Child SCAT5, intended for use with athletes 10 years or younger.  The SCAT5 is widely accepted as an industry standard for sideline concussion evaluation.  The SCAT5 incorporates MOI,  injury history, behavioral and medication history, cervical orthopedic evaluation, orientation, symptom scores, cognitive function and balance tasks.  Using a tool like the SCAT5 allows us to document the evaluation using the current industry standard criteria so that we may interpret that data as objectively as possible.  When performed efficiently, the SCAT5 can be administered and interpreted within a matter of minutes. 

       Conduct Baseline Exams:  Conducting baseline exams prior to the start of a season provides the opportunity to compare a sideline evaluation to an athlete's healthy baseline evaluation.   This is particularly useful with youth and adolescent populations.

       Use Visual/Ocular-Motor Screening (VOMS):  Like the SCAT5, VOMS is an evidence-based concussion evaluation (and rehabilitation) tool.  VOMS is a low-cost technique that can be administered with simply 2 tongue depressors and a pen/permanent marker.  VOMS is used to evaluate smooth pursuits, horizontal and vertical saccades, near point convergence, horizontal and vertical vestibular-ocular reflex (VOR) and visual motion sensitivity (VMS).   The VOMS assessment can also be performed in  a matter of minutes and, when coupled with a symptom checklist or SCAT5, can allow the clinician to make a confident decision that is safe and efficient. 

Monitor The Athlete:  Continue to monitor the athlete regardless of the outcome of the initial evaluation.  Concussion symptoms can continue to worsen and require immediate emergency medical attention.  Similarly, concussion symptoms can present insidiously, so never assume an athlete who presents as asymptomatic during an initial evaluation will remain asymptomatic.

-Greg Shedd, MS, ATC, LAT