A Review of Sport-related Concussion – Part 2: Detection and Diagnosis

By Dr. Shawn Halvorson, DC, CCSP

Now that we have established the definition of concussion and ways to prevent it in Part 1, the next step is to look at identifying and diagnosing a concussion. I will provide evidence-based resources for identifying and detecting concussions, as well as cover the latest findings for properly diagnosing a concussion. As it was in Part 1, most of the information presented stems from the Concussion In Sports Group Berlin Consensus Paper (2017), unless otherwise noted.1

Detection

Within the Concussion in Sport Group (CISG) definition of concussion is that concussion has a range of signs and symptoms that may or may not involve loss of consciousness. It is important for all involved to have a basic understanding of what these signs and symptoms are, thus the CISG developed the Concussion Recognition Tool 5 (CRT5). It has four important steps that need to be walked through: Red flags→Observable signs→Symptoms→Memory Assessment.

Here is a picture of the CRT5:


I would like to re-state the importance of the last paragraph of the CRT5: Any athlete with a suspected concussion should be immediately removed from practice or play and should not return to activity until assessed medically, even if the symptoms resolve.

Diagnosis of Concussion

Concussion detection and diagnosis has come a long way in the last 15 years, where the standard of care was basically asking “How many fingers am I holding up?”. Having said that, there is still much to research and discover. Two common objective measures that the medical field uses for diagnosing diseases and conditions are labs (blood sugar, strep test, etc.) and imaging (X-rays, MRI, etc.).

There is currently no brain imaging that can diagnose concussion or assess recovery, only rule out a more serious brain injury. A CT scan may be warranted in 1-2% of cases but is unnecessary for 98% of concussions.

There is currently no lab test that can help diagnose concussion or assess recovery.

What we are left with is a diagnosis from the history, physical exam findings, and an assessment tool specific to concussion. The two most common assessment tools for concussion are the SCAT5** and ImPACT. FIFA and the IOC officially support the SCAT5, which means it has widespread international acceptance. To my knowledge, the use of the ImPACT assessment is primarily in the US. With my training underneath members of the USA Olympic Sports Medicine Team I was taught to use the SCAT5. Both are validated as assessment tools for the aid in diagnosing concussion.

**The SCAT5 (Sport Concussion Assessment Tool) is the latest edition developed by the Concussion in Sport Group that meets every 4 years. Their last meeting was in Berlin 2016 and was the 5th time the group had met. They will meet again in 2020 towards the end of the year in Paris, France and release the newest consensus statement in 2021. It is very possible that they will revise the SCAT5 and the new standard will be the SCAT6.

The Controversial Role of Baseline Testing

Baseline testing in sports is having the athlete undergo neuropsychological testing in the pre-season or any point prior to an athlete having a concussion. Baseline testing has become popular with advances in the use of neuropsychological testing to assess cognitive abilities prior to and after a sport-related concussion.

The gold standard for concussion protocol is good acute injury evaluations and robust return to play/return to learn evaluations. There are experts on both sides of the debate for and against baseline testing, but currently there is no consistent widespread evidence that baseline testing is necessary for the evaluation and management of sports concussion. It may be helpful or add useful information to the overall interpretation of concussion tests and provides an additional educative opportunity for the healthcare provider to discuss the significance of this injury with the athlete. On the other hand, if the baseline testing isn’t performed correctly it could lead to ill-informed and possibly dangerous return to play decisions. Like the SCAT5 this will be a major point of review during the 6th meeting of the CISG in the fall of 2020 and we may see a different consensus opinion after that meeting.

Part 3 will cover Team Concepts of the Treatment and Management of Concussion.

References:

1. McCrory P, Meeuwisse W, Aubry M, et al. Consensus statement on concussion in sport—the 5th International Conference on Concussion in Sport Held in Berlin, October 2016. Br J Sports Med 2017; 51: 838–847

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