Recognizing Concussions; Assessment

Many concussion experts explain that diagnosing concussions is more art than science. There isn’t a blood test, imaging, or x-ray that can detect a concussion. A physician trained in the identification and management of concussion can diagnose a concussion.

Adults working with youth sports and recreation need to know when and how to suspect that a concussion has occurred. The following is a list of various tools that professionals can use to determine if a concussion may have been sustained.

Baseline Assessments/Cognitive Testing

Pre-season cognitive baseline testing is relatively new to youth sports. It is typically a short computerized test administered prior to the beginning of the season that measures selected brain processes and scores the test for each individual athlete; this establishes the athlete’s baseline. If it is suspected that the athlete may have sustained a concussion during the season, s/he can take a re-test. The computer software will compare the baseline score to the re-test score and alert the clinician that there has been a reliable change in the score. Computerized cognitive testing can also be used during management/treatment even when a baseline has not been established. The changes/improvements in scores over time help to determine progress toward recovery. It is important to remember that computerized cognitive baseline testing is only a tool to be used by a trained clinician. It cannot diagnose a concussion and should always be used as one component of a concussion assessment.

The following is a list of some of the computerized cognitive baseline testing programs available:

The Sports Concussion Assessment Tool (SCAT) and Child-SCAT3

The SCAT has been in use since 2005 as a reliable sideline assessment of concussion. Recently the SCAT 3 was developed at the 2012 International Summit on Concussion in Zurich; the Child-SCAT3 was released at the same time.

The SCAT 3

is a standardized tool for evaluating injured athletes for concussion and can be used in athletes aged from 13 years and older. It measures symptoms, orientation, memory, recall, balance and gait. The SCAT can be administered by a licensed healthcare professional on the sidelines or in the athletic trainers’ office once an athlete has been pulled off the field because a concussion is suspected.

The Child-SCAT3

is a standardized tool for evaluating children ages 5 to 12 for concussion and is designed for use by medical professionals. It is designed for use by medical professionals. The Child-SCAT3 recommends that “any child suspected of having a concussion should be removed from play, and then seek medical evaluation. The child must NO T return to play or sport on the same day as the suspected concussion. The child is not to return to play or sport until he / she has successfully returned to school / learning, without worsening of symptoms. Medical clearance should be given before return to play.”

Balance Error Scoring System (BESS)

The BESS is included in the SCAT as part of a sideline assessment and can be performed on the sideline or in the athletic trainers’ office once an athlete has been pulled off the field because a concussion is suspected.

Neuropsychological Testing

A neuropsychologist is a psychologist with special training in brain-behavior relationships. Historically neuropsychologists are key professionals and an integral part of the multidisciplinary team that treats more severe brain injuries. They have also been key to diagnosis and management of mild traumatic brain injury outside of the sports purview. When symptoms linger it may be advisable meet with a neuropsychologist who can conduct a more in-depth neuro-cognitive evaluation and better determine what additional treatment or intervention may be necessary to facilitate recovery.

Management of Concussion

Concussion management begins the moment a concussion is suspected. The very first decisions made on the playing/practice field when a concussion is suspected can make the difference between a good outcome and a disaster.

Immediate Management: ABCs (Airway, Breathing, Consciousness)

A suspected concussion may sometimes be associated with a more severe injury; therefore, before moving an individual with a suspected concussion the basic first aid assessment of Airway, Breathing, Consciousness (ABCs) should be performed and a decision made to determine if the individual can be moved safely to the sideline or sent to the hospital for further evaluation and assessment.

Interscholastic Sports:

The New Jersey Concussion Law and the New Jersey Department of Education Model Policy for Concussion provides directions for concussion management on school district property. Whenever a concussion is suspected the student playing interscholastic sports in New Jersey must be immediately removed from play and cannot return to play until evaluated by a physician knowledgeable in the identification and management of concussion to determine if a concussion has occurred. If the physician rules out the diagnosis of concussion the student can return to play. If the physician diagnosis a concussion is present then the student must follow the return-to-play protocol established in the Model Policy.

Student athletes in Grades K-8: When a concussion is suspected the child should be removed from the activity and the remainder of the day. When a concussion is diagnosed the Law and Model Policy cover younger student-athletes (grades K-8) only to suggest that a seven-day rest period is required prior to initiating the graduated return-to-play protocol. In the absence of verifiable information about younger children and concussion it is best to take a more conservative approach to management.

Note: School districts can choose to provide guidelines for elementary and middle schools to follow in the event that a concussion occurs to a student outside of interscholastic sports.

Community Youth Sports:

Children and adolescents in New Jersey who play recreational sports outside of school are covered under the Law and Model Policy if they play/practice on school grounds. Youth sports organizations are mandated to sign a statement of compliance with the school district’s concussion policy in order to waive liability for injuries that occur while present on school grounds. It is important for parents/guardians to check with their child’s youth sports organization to be certain that the organization is in compliance with the Law.

Practice or competition in community youth sports is typically managed by volunteer coaches and managers. New Jersey volunteer coaches are exempt from liability if they participate in a training provided by the Rutgers Youth Development Council to meet the “Minimum Standards for Volunteer Coaches Safety Orientation and Training Skills Programs” (N.J.A.C. 5:52). This course began to include the most current information about concussion several years ago; therefore, new coaches may have received a information on concussion, while coaches who took the course many years ago may not have received any information or very outdated information.

Inevitably it becomes important for parents/guardians whose children play sports to become familiar with the signs and symptoms of concussion and understand what to do if their child is suspected of having sustained a concussion.

Concussion Management: Ongoing

Anyone who sustains a concussion, regardless of age or how the concussion was sustained, should be managed by a medical professional who is knowledgeable in the identification and management of concussion; this could be a the family physician, pediatrician or sports medicine physician. According to the Law, only a physician can clear an athlete for return-to-play.

The Importance of Rest:

Rest is the cornerstone of concussion management. While any individual with a concussion is symptomatic, physical, cognitive, and social rest is recommended.

Physical activities can stimulate the heart rate and increase blood flow to the brain which can exacerbate concussion symptoms or cause them to re-occur. Some examples of physical activity are: doing household chores, walking the dog, traveling, driving, trips outside of home, playing a musical instrument, aerobic exercise, lifting weights, playing sports

Cognitive or thinking activities use energy in the brain and can slow recovery from concussion, exacerbate symptoms, or cause them to re-occur. Some examples of cognitive activities are: playing video games, computer use, phone use, texting, reading, doing puzzles, attending school, taking tests, taking notes, doing homework, watching TV, watching movies, drawing/artwork, etc.

Any social interaction like going to the mall, attending sporting events, hanging out with friends, or having visitors at home may exacerbate symptoms.

When Symptoms Linger:

About 10% of concussions take more than ten days to heal. In these cases the treating physician may choose to refer to another clinical professional to manage all or part of the treatment plan. This may be a neuropsychologist, neurologist, or physical therapist who will address specific symptoms. A neurologist may be suggested to address headaches; a physical therapist to address balance; a neuropsychologist may be suggested to address cognitive/thinking/learning issues. In these cases school accommodations will most likely be necessary. Experts agree that a multidisciplinary approach is best for managing concussions when symptoms linger.

School/Academic Accommodations:

Each student and each concussion is unique. The Model Policy provides a list of academic accommodations that may or may not be sufficient to facilitate recovery for a student with a concussion and lingering symptoms. When school professionals are developing the individualized accommodations for a student with a concussion it is important for them to gather information from the physician and, when appropriate, the multidisciplinary team managing the concussion. It is important that the academic staff working with the student is knowledgeable about concussion and how to facilitate recovery with academic accommodations. Teachers may perceive cognitive symptoms as malingering; for example when a student recovering from a concussion repeatedly forget his homework.