Sideline evaluation of concussion
- Josh Bloom, MD, MPH
Josh Bloom, MD, MPH
- Clinical Instructor, Department of Family Medicine
- University of North Carolina at Chapel Hill
- Jim G Blount, MD, CAQSM
Jim G Blount, MD, CAQSM
- Adjunct Clinical Professor, Departments of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
- Section Editor
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Sports-Related Injuries; Symptom Assessment and Physical Examination
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Concussions are common, but complex, traumatic brain injuries seen in athletes of all ages and skill levels in a wide variety of athletic settings. Given the variability of the clinical presentation associated with concussion, it is important that team physicians and other clinicians responsible for the care of athletes perform a systematic and comprehensive sideline evaluation of each athlete with a suspected concussion.
This topic reviews the risk factors, clinical presentation, sideline evaluation, and initial management of adolescent and adult athletes with a concussion. More detailed discussions of mild traumatic brain injury and trauma assessment are provided separately. (See "Acute mild traumatic brain injury (concussion) in adults" and "Minor head trauma in infants and children: Evaluation" and "Postconcussion syndrome" and "Initial management of trauma in adults".)
A concussion is a complex, trauma-induced pathophysiological process affecting the brain. The biomechanical forces involved in the trauma (eg, acceleration, deceleration, rotation) can injure the brain via a direct blow to the head, face, or neck, or via a blow to the body that transmits force to the head (eg, whiplash). The ensuing brain disturbance is due to neurometabolic dysfunction, which manifests in a wide variety of symptoms and signs that may or may not include loss of consciousness [1,2]. No gross structural abnormalities are seen with conventional neuroimaging.
It is important to note that while a concussion typically manifests with rapid onset of short-lived neurologic dysfunction, in some cases, development of signs and symptoms of concussion can be delayed minutes to hours . Detailed discussions of the definitions, pathophysiology, and epidemiology of concussion are provided separately. (See "Acute mild traumatic brain injury (concussion) in adults", section on 'Pathophysiology'.)
ACUTE CONCUSSION EVALUATION
Evaluation and diagnosis of concussion remains a clinical exercise. At this point, there is no compelling evidence supporting one specific test, tool, biomarker, imaging study, or protocol to definitively diagnose or exclude a concussion. In the absence of such evidence, use of a consensus-derived, multimodal concussion assessment tool, such as the Sport Concussion Assessment Tool 5th Edition (SCAT5), is recommended as the framework for a sideline concussion evaluation .To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med 2017.
- Steenerson K, Starling AJ. Pathophysiology of Sports-Related Concussion. Neurol Clin 2017; 35:403.
- Patricios J, Fuller GW, Ellenbogen R, et al. What are the critical elements of sideline screening that can be used to establish the diagnosis of concussion? A systematic review. Br J Sports Med 2017; 51:888.
- Guskiewicz KM, McCrea M, Marshall SW, et al. Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA Concussion Study. JAMA 2003; 290:2549.
- Zemper ED. Two-year prospective study of relative risk of a second cerebral concussion. Am J Phys Med Rehabil 2003; 82:653.
- Castile L, Collins CL, McIlvain NM, Comstock RD. The epidemiology of new versus recurrent sports concussions among high school athletes, 2005-2010. Br J Sports Med 2012; 46:603.
- Abrahams S, Fie SM, Patricios J, et al. Risk factors for sports concussion: an evidence-based systematic review. Br J Sports Med 2014; 48:91.
- Guskiewicz KM, Weaver NL, Padua DA, Garrett WE Jr. Epidemiology of concussion in collegiate and high school football players. Am J Sports Med 2000; 28:643.
- Hollis SJ, Stevenson MR, McIntosh AS, et al. Incidence, risk, and protective factors of mild traumatic brain injury in a cohort of Australian nonprofessional male rugby players. Am J Sports Med 2009; 37:2328.
- Delaney JS, Lacroix VJ, Leclerc S, Johnston KM. Concussions among university football and soccer players. Clin J Sport Med 2002; 12:331.
- Emery CA, Kang J, Shrier I, et al. Risk of injury associated with body checking among youth ice hockey players. JAMA 2010; 303:2265.
- Dick R, Hootman JM, Agel J, et al. Descriptive epidemiology of collegiate women's field hockey injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2002-2003. J Athl Train 2007; 42:211.
- Dick R, Lincoln AE, Agel J, et al. Descriptive epidemiology of collegiate women's lacrosse injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2003-2004. J Athl Train 2007; 42:262.
- Dick R, Romani WA, Agel J, et al. Descriptive epidemiology of collegiate men's lacrosse injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2003-2004. J Athl Train 2007; 42:255.
- Collins MW, Lovell MR, Iverson GL, et al. Cumulative effects of concussion in high school athletes. Neurosurgery 2002; 51:1175.
- Field M, Collins MW, Lovell MR, Maroon J. Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. J Pediatr 2003; 142:546.
- Moser RS, Schatz P, Jordan BD. Prolonged effects of concussion in high school athletes. Neurosurgery 2005; 57:300.
- Guskiewicz KM, Valovich McLeod TC. Pediatric sports-related concussion. PM R 2011; 3:353.
- Meehan WP 3rd, d'Hemecourt P, Comstock RD. High school concussions in the 2008-2009 academic year: mechanism, symptoms, and management. Am J Sports Med 2010; 38:2405.
- Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med 2012; 40:747.
- Meehan WP 3rd, d'Hemecourt P, Collins CL, Comstock RD. Assessment and management of sport-related concussions in United States high schools. Am J Sports Med 2011; 39:2304.
- Daneshvar DH, Nowinski CJ, McKee AC, Cantu RC. The epidemiology of sport-related concussion. Clin Sports Med 2011; 30:1.
- Mueller FO, Cantu RC. Twenty-ninth annual report: Fall 1982 - Spring 2011. National Center for Catastrophic Sports Injury Research. University of North Carolina, Chapel Hill, NC www.unc.edu/depts/nccsi (Accessed on March 21, 2013).
- Gessel LM, Fields SK, Collins CL, et al. Concussions among United States high school and collegiate athletes. J Athl Train 2007; 42:495.
- Lincoln AE, Caswell SV, Almquist JL, et al. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med 2011; 39:958.
- Covassin T, Swanik CB, Sachs ML. Sex Differences and the Incidence of Concussions Among Collegiate Athletes. J Athl Train 2003; 38:238.
- Dick RW. Is there a gender difference in concussion incidence and outcomes? Br J Sports Med 2009; 43 Suppl 1:i46.
- Collins MW, Iverson GL, Lovell MR, et al. On-field predictors of neuropsychological and symptom deficit following sports-related concussion. Clin J Sport Med 2003; 13:222.
- Erlanger D, Kaushik T, Cantu R, et al. Symptom-based assessment of the severity of a concussion. J Neurosurg 2003; 98:477.
- Asplund CA, McKeag DB, Olsen CH. Sport-related concussion: factors associated with prolonged return to play. Clin J Sport Med 2004; 14:339.
- McCrea M, Guskiewicz K, Randolph C, et al. Incidence, clinical course, and predictors of prolonged recovery time following sport-related concussion in high school and college athletes. J Int Neuropsychol Soc 2013; 19:22.
- Mihalik JP, Guskiewicz KM, Marshall SW, et al. Head impact biomechanics in youth hockey: comparisons across playing position, event types, and impact locations. Ann Biomed Eng 2012; 40:141.
- Darling SR, Schaubel DE, Baker JG, et al. Intentional versus unintentional contact as a mechanism of injury in youth ice hockey. Br J Sports Med 2011; 45:492.
- Broglio SP, Eckner JT, Kutcher JS. Field-based measures of head impacts in high school football athletes. Curr Opin Pediatr 2012; 24:702.
- Broglio SP, Schnebel B, Sosnoff JJ, et al. Biomechanical properties of concussions in high school football. Med Sci Sports Exerc 2010; 42:2064.
- Greenwald RM, Gwin JT, Chu JJ, Crisco JJ. Head impact severity measures for evaluating mild traumatic brain injury risk exposure. Neurosurgery 2008; 62:789.
- Fuller CW, Fuller GW, Kemp SP, Raftery M. Evaluation of World Rugby's concussion management process: results from Rugby World Cup 2015. Br J Sports Med 2017; 51:64.
- Eckner JT, Kutcher JS. Concussion symptom scales and sideline assessment tools: a critical literature update. Curr Sports Med Rep 2010; 9:8.
- Alla S, Sullivan SJ, Hale L, McCrory P. Self-report scales/checklists for the measurement of concussion symptoms: a systematic review. Br J Sports Med 2009; 43 Suppl 1:i3.
- Gioia G, Collins M. Acute Concussion Evaluation: Physician/Clinician Office Version CDC. 2006. http://www.cdc.gov/concussion/headsup/pdf/ace-a.pdf (Accessed on May 16, 2013).
- Lau BC, Kontos AP, Collins MW, et al. Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players? Am J Sports Med 2011; 39:2311.
- McCrea M, Kelly JP, Kluge J, et al. Standardized assessment of concussion in football players. Neurology 1997; 48:586.
- Maddocks DL, Dicker GD, Saling MM. The assessment of orientation following concussion in athletes. Clin J Sport Med 1995; 5:32.
- McCrea M, Kelly JP, Randolph C, et al. Standardized assessment of concussion (SAC): on-site mental status evaluation of the athlete. J Head Trauma Rehabil 1998; 13:27.
- McCrea M. Standardized Mental Status Testing on the Sideline After Sport-Related Concussion. J Athl Train 2001; 36:274.
- Guskiewicz KM, Riemann BL, Perrin DH, Nashner LM. Alternative approaches to the assessment of mild head injury in athletes. Med Sci Sports Exerc 1997; 29:S213.
- Alsalaheen BA, Mucha A, Morris LO, et al. Vestibular rehabilitation for dizziness and balance disorders after concussion. J Neurol Phys Ther 2010; 34:87.
- Gottshall K, Drake A, Gray N, et al. Objective vestibular tests as outcome measures in head injury patients. Laryngoscope 2003; 113:1746.
- Bell DR, Guskiewicz KM, Clark MA, Padua DA. Systematic review of the balance error scoring system. Sports Health 2011; 3:287.
- Peterson CL, Ferrara MS, Mrazik M, et al. Evaluation of neuropsychological domain scores and postural stability following cerebral concussion in sports. Clin J Sport Med 2003; 13:230.
- McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013; 47:250.
- Sasser SM, Hunt RC, Faul M, et al. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage, 2011. MMWR Recomm Rep 2012; 61:1.
- O'Connor FG, Deuster P, Thompson A. Sickle cell trait: what's a sports medicine clinician to think? Br J Sports Med 2013; 47:667.
- Giza CC, Kutcher JS, Ashwal S, et al. Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2013; 80:2250.
- Harmon KG, Drezner J, Gammons M, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Clin J Sport Med 2013; 23:1.
- National Hockey League. On-ice Concussion management protocol. 2012
- Echemendia RJ, Meeuwisse W, McCrory P, et al. The Sport Concussion Assessment Tool 5th Edition (SCAT5): Background and rationale. Br J Sports Med 2017; 51:848.
- Davis GA, Purcell L, Schneider KJ, et al. The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5): Background and rationale. Br J Sports Med 2017; 51:859.
- Standardized Assessment of Concussion (SAC). From: J Athl Train 2001; 36:274. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC155418/table/T2/ (Accessed on January 11, 2013).
- Lee H, Sullivan SJ, Schneiders AG, et al. Smartphone and tablet apps for concussion road warriors (team clinicians): a systematic review for practical users. Br J Sports Med 2015; 49:499.
- Gioia GA, Mihalik J. Concussion Recognition and Response: Coach and Parent Version. iTunes Application. https://itunes.apple.com/us/app/concussion-recognition-response/id436009132?mt=8 (Accessed on January 11, 2013).
- Galetta KM, Barrett J, Allen M, et al. The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters. Neurology 2011; 76:1456.
- Galetta KM, Brandes LE, Maki K, et al. The King-Devick test and sports-related concussion: study of a rapid visual screening tool in a collegiate cohort. J Neurol Sci 2011; 309:34.
- Curaudeau GA, Sharma N, Rovin RA. Development of an iPhone application for sideline concussion testing. Neurosurg Focus 2011; 31:E4.
- Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med 2017; 51:930.
- ACUTE CONCUSSION EVALUATION
- RISK FACTORS
- CLINICAL PRESENTATION
- Mechanism of injury
- - Location and magnitude of impact
- - High risk mechanisms
- Immediate clinical response after trauma
- Symptoms of concussion
- PERFORMANCE OF THE PHYSICAL EXAMINATION
- INDICATIONS FOR EMERGENCY DEPARTMENT EVALUATION
- DIFFERENTIAL DIAGNOSIS: CONCUSSION MIMICS
- Initial patient evaluation
- Concussion assessment
- Assessment instruments
- Additional tools for assessment
- Initial treatment
- - Remove from play; no return to play
- - Relative rest
- - Management of somatic symptoms
- - Observation after injury and during sleep
- SUMMARY AND RECOMMENDATIONS