9.2.1 Description

Functional versus structural injury: In SRC, neurological impairment is short-lived and resolves spontaneously. Clinical signs and symptoms largely reflect the result of direct impact resulting in acute acceleration or deceleration of the body with the brain moving within the cranium, which leads to injury. Cumulative exposures can have clinical consequence, and some studies report cognitive deterioration is directly related to exposure burden, whereas other studies have failed to reproduce this result [5].

9.3 Concussion Evaluation

SRC is an evolving injury in the acute phase and there are quickly changing clinical signs and symptoms. SRC is considered one of the most complex injuries in sports medicine to diagnose, assess, and manage. Complicating this, often there is no loss of consciousness or delineating neurologic signs. There is also no perfect diagnostic test. So, SRC cannot be ruled out when injury occurs. If SRC is suspected, the individual should be removed from the playing field and assessed by a physician.

Sideline evaluation of cognitive function is essential in the assessment of injury. Neuropsychological (NP) test batteries assessing attention and memory function are effective. Included in this is the SCAT5, which contains Maddocks questions (Maddocks) and standardized assessment of concussion (SAC) [6]. Orientation questions like person, place, and time are unreliable compared to memory assessment. These sideline screening tests are not meant to replace neurological evaluation or as an ongoing management tool for SRC.

The purpose of the rapid screening for SRC is not to make a definitive diagnosis of head injury. If clear on-field signs of SRC (e.g., loss of consciousness, tonic posturing, balance disturbance) are apparent, the individual should be immediately suspended from play. Sideline (SCAT5) and a more thorough diagnostic evaluation should be performed in a distraction-free environment. Sideline assessment, including information from the athlete and assessment or inspection of videotape of the incident, can be used to determine if concussion is no longer suspected. The physician determines the timing of return to play.

Contact sports have a tendency to be fast-paced, in disorganized environments, and field of play is often obscured. Therefore, these present challenges in diagnosing SRC. Because of this, suspected SRC should be approached with multidimensional testing and well-established instruments for sideline assessment. Both the SCAT5 and Child SCAT5 are suggested in the evaluation of SRC. These sideline assessments help in distinguishing if an athlete is concussed or non-concussed, but the tests’ usefulness decreases significantly after 3–5 days of the injury. The symptom checklist has more utility in tracking recovery. Replicating baseline testing conditions should be similar. Additional areas that may be assessed are clinical reaction time, gait/balance assessment, video observation, and oculomotor screening. Video review appears to be a promising mode of identifying and evaluating SRC.

9.3.1 Signs and Symptoms: Physical, Cognitive, Emotional, Sleep [4]

These signs and symptoms may be present with non-brain-related injury. Therefore, concussion is added to the differential diagnosis for further investigation, but concussion cannot be diagnosed based on the symptoms present. The majority of athletes (80–90%) have symptom resolution after a week, but younger children under age 12 may take a month before fewer symptoms are present. Symptom resolution does not guarantee complete cognitive recovery [4].

9.3.1.1 Concussion Evaluation Tools

When an athlete aged 13 and older is suspected of having sustained an SRC, the SCAT5 is a tool used by sideline physicians to assess for the presence of concussion and initiate management based on clinical findings. If the athlete falls into the ages of 5–12 years old, the Child SCAT5 will be utilized. The athlete with a possible concussion should be immediately removed from play and evaluated by medical personnel for any red flag signs.

Observable signs including lack of movement, disorientation, vacant stare, and orofacial injury after head trauma should be assessed. The Glasgow Coma Scale (GCS) can be performed serially to assess for changes in eye, verbal, and motor response. Maddocks questions for memory assessment and cervical spine examination are critical in the initial assessment. A cervical injury should be assumed until proven otherwise [7, 8]. Decision to transport an athlete should be made in a timely fashion. The athlete background and symptom evaluation should be performed in a distraction-free environment. The cognitive screening includes the following: orientation, immediate memory from lists of words, and concentration assessed by digits backwards and months in reverse order. Neurological screening includes the ability to read without difficulties, full pain-free active neck movements, movement of the head or neck without double vision, coordination, and tandem gait testing. Delayed recall should include words from the list read earlier. When differentiating concussed from non-concussed athletes, the graded symptom checklist, Standardized Assessment of Concussion (SAC), and Balance Error Scoring System (BESS)/modified Balance Error Scoring System (mBESS) were found to be the most useful post-injury [9]. When assessing for concussion, a single scoring system should not determine the diagnosis. Although tools such as the SCAT5 are utilized, more research is required to determine the efficacy of these tools in improving SRC identification and management.

9.3.2 Neuropsychology Evaluation

Most concussion symptoms will resolve within 7–10 days. Neuropsychological (NP) testing can be useful for those athletes with prolonged symptoms and recovery. This testing can be used as part of a comprehensive investigation and should not be used alone to guide management. “Both paper and pencil and computerized testing have significant individual variability with regard to domains measured and performance measures such as validity, sensitivity, specificity, reliable change index and baseline variability” [4]. Computerized NP baseline testing can be useful in comparing post-injury results, but this can result in expenses that may not be affordable for many school systems. NP testing performed when the athlete is asymptomatic may be useful when considering return-to-school and return-to-play decisions. Although neuropsychologists have the background to administer and interpret test results, the ultimate return-to-play decision should remain with the medical team [10].

9.3.2.1 Pencil and Paper

Neuropsychological testing is a tool used to assess cognitive impairment after an athlete sustains a concussion and to document an athlete’s recovery. Testing is administered and interpreted by a neuropsychologist; therefore, this method is expensive and more time-consuming. The testing typically focuses on memory, cognitive processing speed, and reaction time [4].

9.3.2.2 Computer-Based Testing

Computerized neuropsychological testing has not been validated as a diagnostic tool [29]. Advantages of computerized testing include less time to administer, more cost-effectiveness, and more precision reporting on reaction time.

9.3.3 Vestibular/Ocular-Motor System (VOMS) Evaluation

Vestibular/ocular-motor screening can assist with proper assessment and subsequent referral placement. Prolonged symptoms along with vestibular and oculomotor impairment may be associated with delayed recovery after SRC. Examples of vestibular symptoms may include the following: blurry vision, dizziness, nausea, and vertigo. Oculomotor symptoms may include blurry vision, nausea, difficulty scanning, convergence insufficiency, and difficulty reading [25, 26]. These symptoms can impact academic performance, reading, and ultimately overall performance.

9.3.3.1 King-Devick Test

The King-Devick (KD) test is a vision-based test consisting of numbers that the athlete must track with her eyes and read aloud. This test captures the saccadic eye movements and periods of fixation, and results may vary with changes in cognition [24, 32]. The administrator of the test tracks the testing time and errors, while the athlete performs the test. After the athlete performs a strenuous workout, the test times are not prolonged. However, if the athlete is concussed, the time to completion is prolonged. The mechanisms by which the KD test results are prolonged are postulated to be related to saccadic slowing, pauses between saccades, inaccurate saccades, and abnormal eye movements [11]. The KD test demonstrates promise as a sideline concussion screening tool, but further studies are needed [12] (◘ Fig. 9.2).

9.3.4 Balance Assessment

Following SRC, acute postural instability may persist for up to 72 h [5]. Studies report that changes in balance and postural stability, when compared with preseason baselines, are sensitive for the diagnosis of concussion. The Balance Error Scoring System (BESS) is a standardized sideline assessment tool. This test can be administered in 5–7 min and is cost-effective. Three stances (double-leg stance, single-leg stance, and tandem stance) are performed on two surfaces (firm surface/floor or medium density foam). The athlete stands during each stance with hands on hips and eyes closed for 20 s. Points are deducted from a maximum of 60 when using two surfaces, if the athlete lifts her hands off the hips, stumbles, steps away, opens her eyes, or falls. BESS performance returns to preseason baseline levels by 3–7 days post-injury for most athletes. Balance testing is limited by fatigue, exercise, serial assessments, and reliability. According to McCrea, sensitivity of balance testing is best within 24 h of injury (0.34), and specificity was 0.91 and 0.96 between days 1 and 7 post-injury. Completing the BESS on the sideline can be challenging, so the modified BESS is often used at halftime or in the locker room after practice or game. The high specificity combined with other assessment tools reinforces the use in the sideline evaluation.

9.3.5 No RTS Same Day

There is a no return to sport on same-day policy for those diagnosed with concussion. In 2009, legislation began in Washington state with the Lystedt law. The legislation mandates any athlete younger than 18 must be removed from play and is unable to return on the day of injury. Many states have concussion laws that oppose a same-day return. Signs and symptoms may evolve over time; therefore, reassessment of the athlete’s condition and erring on the side of caution are reasonable actions.

9.4 Concussion Management

If the athlete demonstrates signs and symptoms of cervical spine injury, intracranial bleeding, or skull fracture, the emergency action plan should be activated, and the athlete will be transported to an appropriate medical facility [13]. The sideline examination should include documentation of the injured athlete’s symptoms and neurologic examination including cognition, cranial nerve function, and balance. Visual tracking can provide further information. Symptom scores and cognitive assessment are the most sensitive and specific within 48 h of injury. Comparing post-injury scores to the athlete’s baseline is also useful. This does not replace the benefits of knowing the athlete prior to injury and using clinical judgment despite the athlete passing a sideline screening. All athletes, regardless of level of competition, should be managed using the same principles.

9.4.1 Management Strategies

9.4.1.1 Stepwise RTS Progression (◘ Table 9.1 [10])

After an initial rest period, if deemed necessary, activity can begin if it stays below a threshold that will exacerbate physical and cognitive symptoms. Once the athlete’s concussion symptoms have resolved, the stepwise RTS progression begins. The athlete should be asymptomatic at each level. The RTS progression will take roughly a week to complete. If the athlete is symptomatic, the athlete should return to the previous asymptomatic level. The athlete is able to advance to the next level if the athlete meets all criteria without having symptoms reoccur. The time to RTS may vary due to a myriad of factors including the athlete’s age, level of sport, and history. The table from the Berlin Consensus Statement demonstrates the stepwise process to RTS after sustaining a SRC. RTS must be individualized, and further evaluation is required for those athletes, who have a prolonged recovery course.

Table 9.1

Graduated return-to-sport (RTS) strategy

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