Current and Potential Practices in Athletic Training

Current Trends in the Assessment and Management of Sport-Related Concussions:
The Result of ImPACT

Chris Parker
California University of Pennsylvania

Abstract

Sport-related concussions are all too common in athletics today. Repeated concussions can lead to more serious injuries such as long-term brain damage. Difficulty in assessment and management of sport-related concussions results in premature return to play decisions by certified athletic trainers and physicians. The purpose of this paper is to outline the methods of diagnosis, the current assessment and management trends in athletic training, and the role of ImPACT concussion testing in the advancement of concussion management.

Concussion Diagnosis

The diagnosis of sport-related concussions can be a difficult process. Sports medicine professionals are equipped with numerous tools to aid in this task; however, no two concussions are alike. The recovery timeframe of a concussion can range from a few days to months, depending on severity. According to Reddy & Collins, the Center for Disease Control (CDC) states that a concussion is a “pathophysiological process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head” (2009). The discussion on diagnosis and management of sports-related concussions has come to the forefront among health care professionals and the media in recent years, because these traumatic brain injuries are becoming all too common in athletics today. Proper diagnosis is crucial in providing proper management and making correct return-to-play decisions. Diagnosis of these injuries is often the responsibility of certified athletic trainers and physicians. According to Guskiewicz et al. (2004), the certified athletic trainer must be able to properly identify the signs and symptoms of a concussion, which might include headache, nausea, vomiting, dizziness, balance problems, fatigue, trouble sleeping, memory problems, blurred vision, LOC, sensitivity to light, and/or difficulty concentrating. The mechanism of injury for sport-related concussions is often an acceleration-deceleration mechanism as seen when an athlete’s head strikes another object.

 Though athletes are often referred for diagnostic imaging to rule out more serious head injuries, concussion remains a clinical diagnosis (Eckner & Kutcher, 2010). As previously stated, this diagnosis is based on symptom scales and a wide variety of available tests such as the Balance Error Scoring System (BESS) and neuropsychological testing. This task is often difficult because some signs and symptoms may not appear immediately. Concussion grading scales that are solely based on the athlete’s initial injury characteristics have been abandoned. More recent recommendations suggest a multi-faceted approach to diagnosing and managing concussions. These recommendations include self- symptom scales, postural analysis, and neurocognitive testing (2010). Following three recent International Conferences on Concussion in Sport, a consensus is building that every concussion is unique and that concussion assessment must be more individualized. To date, there is no single “gold standard” for diagnosing a concussion. For this reason, sports medicine professionals must be proficient in using a wide variety of concussion assessment tools.

Current Trends in Concussion Assessment and Management

The assessment and management of sport-related concussions has become a topic of increasing importance in recent years. This is due in part to recurrent concussions in several high-profile athletes in the NFL and NHL, some of whom were forced into early retirement.  Assessment tools and grading scales, such as the widely used Cantu Concussion Scale, have been abandoned. Scales based mainly on loss of consciousness and amnesia are no longer recommended. No matter the severity, the athlete cannot return to play until all symptoms subside.

Sport-related concussions are extremely complex injuries that require certified athletic trainers and other sports medicine professionals to use a comprehensive approach to assess and manage them. Due to the ability of the athlete to provide false information, one can no longer rely solely on self-symptom checklists. The most recent NATA position statement recommended the use of symptom checklists, neuropsychological testing, and postural stability assessments (Notebaert & Guskiewicz, 2005). It is also recommended by NATA that all athletes undergo baseline testing in order to establish the athletes “normal” pre-injury performance (Guskiewicz et al., 2004).

 The Sport Concussion Assessment Tool 2 (SCAT2) is the only sideline assessment tool developed within the past few years (Eckner & Kutcher, 2010). This assessment tool was recommended with the Consensus Statement on Concussion in Sport from the Third International Conference on Concussion in Sport (Eckner & Kutcher, 2010; McCrory et al., 2009). The SCAT2 combines aspects of several concussion tools into eight component scores:  symptom scores, physical signs score, Glasgow coma scale (GCS), sideline assessment, cognitive assessment, balance examination, coordination examination, and a delayed recall test. Along with these scores, a thorough clinical examination must be performed. The results of this examination cannot be overlooked by sports medicine professionals and should be considered an integral part of the concussion assessment (Guskiewicz et al., 2004). This clinical examination includes a complete history, observation of pupil response, and a cranial nerve assessment. A detailed clinical examination used in conjunction with other assessment tools can better position sports medicine professionals to make a proper return-to-play decision (Notebaert & Guskiewicz, 2005).

Standardized methods of concussion assessment, also known as SMCA, are assessment tools that are objective in nature and use a standard scoring system. SMCA includes assessment tools such as the Standardized Assessment of Concussion (SAC), the Balance Error Scoring System (BESS), and neuropsychological testing (Notebaert Guskiewicz, 2005). Though these forms of concussion assessment may be too lengthy to perform on the sideline, they are widely used by certified athletic trainers during the clinical examination.

One of the most widely used assessment tools is a subjective symptom scale. These self-reported symptoms are an obvious way to assess the effects of a concussion. These checklists include but are not limited to headache, dizziness, nausea, “feeling in a fog,” sensitivity to light, and difficulty remembering. These symptom checklists allow athletes to answer with a yes or no for each symptom. The checklists then allow the athlete to rate the severity or frequency of these symptoms using a Likert Scale (Eckner & Kutcher, 2010; Guskiewicz et al., 2004). It is recommended that the practitioner use a serial administration for tracking of the athlete’s performance (Guskiewicz et al., 2004).

In recent years, neuropsychological testing has become increasingly popular. Neuropsychological testing differs from the tests discussed previously, because it is not used as a diagnostic tool but rather as a way to track recovery following a concussion. This form of testing can be used to evaluate the effects of a concussion across various cognitive domains (Guskiewicz et al., 2004). These tests can now be paper-and-pencil form or computerized. Computerized neuropsychological testing has gained popularity due to decreased test time and the ability to test multiple athletes simultaneously. As with other concussion assessment tools, baseline testing should be performed with neuropsychological testing. Though neuropsychological testing can be a powerful tool used to track recovery following a concussion, there are some issues that must be considered. This form of testing is relatively complex and requires a trained professional to interpret its results. It is suggested that a licensed neuropsychologist interpret the results of neuropsychological testing (Guskiewicz et al., 2004).

The Role of ImPACT

Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) was developed at the University of Pittsburgh Medical Center in an attempt to increase the availability of neuropsychological testing to the athletic community (Randolph, McCrea, & Barr, 2005; Schatz et al., 2005). ImPACT consists of three main sections: demographic information, neuropsychological tests, and a Post-Concussion Symptom Scale (PCSS). The newest version of ImPACT consists of six NP tests that target attention, memory, processing speed, and reaction time (Fazio et al., 2007; Schatz et al., 2005). The tests include: word memory, design memory, X’s and O’s, symbol match, color match, and three letter memory. The results of these tests create composite scores in the areas of verbal memory, visual memory, visualmotor speed, and reaction time (Fazio et al., 2007; Schatz et al., 2005).

The PCSS is used by many sports medicine professionals in the tracking of concussion symptoms and recovery. This checklist, which consists of 21 symptoms, asks the athlete to rate the symptoms on a seven-point scale. The PCSS is useful because it uses common terms that are easily understandable. This eliminates invalid answers caused by confusion. ImPACT is thought to be better than standard pencil-and-paper neuropsychological tests due to the multiple test forms available. The test is slightly different each time. This eliminates any practice effect caused by the repeated use of the same test (Schatz et al., 2005).

The introduction of ImPACT has provided sports medicine professionals with the ability to perform neuropsychological testing without the presence of a neuropsychologist. Traditional paper-and-pencil tests required a licensed professional to score and interpret the results of these tests. The ImPACT program is designed to compute four composite scores that can then be compared to the results of the baseline test. This eliminates the need to have a neuropsychologist present and decreases the cost of performing these tests (Schatz et al., 2005).

Summary

As sports medicine professionals, we must be proficient in the diagnosis and management of these traumatic brain injuries. NATA recommends a multi-faceted approach to concussion management. Current trends in the athletic training community appear to be a thorough clinical examination along with subjective symptom checklists. The ImPACT neuropsychological test battery is just one of the commercially available computerized testing programs. The use of ImPACT in conjunction with a thorough clinical examination will enable athletic trainers to make proper return to play decisions and decrease the risk of long-term brain injuries due to repeated concussions.

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