n OVER 20 SIDELINE TOOLS n USE OF SMART PHONES n SOME ARE PAIDS APPS n FOLLOWING 10 SAMPLES n NOT ENDORSING ANY PARTICULAR ONE

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Sideline Concussion Assessment Tools Aaron Galpert, AT, ATC Akron Children s Hospital SIDELINE TOOLS OVER 20 SIDELINE TOOLS USE OF SMART PHONES SOME ARE PAIDS APPS FOLLOWING 10 SAMPLES NOT ENDORSING

1 Sideline Concussion Assessment Tools Aaron Galpert, AT, ATC Akron Children s Hospital SIDELINE TOOLS OVER 20 SIDELINE TOOLS USE OF SMART PHONES SOME ARE PAIDS APPS FOLLOWING 10 SAMPLES NOT ENDORSING ANY PARTICULAR ONE Standardized Assessment of Concussion SAC only takes approximately 5 to 7 minutes to administer and was designed for use by clinicians with no neurocognitive testing experience, it is considered a "practical sideline assessment tool"(2) which can "detect changes across multiple domains of cognitive functioning that are susceptible to the acute effects of concussion." (3) Standardized Assessment of Concussion Orientation (month, date, day of week, year, time) Immediate memory (recall of 5 words in 3 separate trials) Neurologic: Loss of consciousness (occurrence, duration) Amnesia (either retrograde or anterograde) Sensation Coordination Strength Concentration Exertional maneuvers (jumping jacks, sit-ups) Delayed recall (5 words) SAC SAC cannot identify athletes who may suffer measurable impairment of neurocognitive function (primarily visual working memory) on neurocognitive tests, as well as altered activation in neurophysiologic function on sophisticated brain imaging tests (fmri), resulting from repeated sub concussive blows to the head Sport Concussion Assessment Tool-2 (SCAT2) Recommended as a sideline test by a consensus of sport concussion experts at the Third International Conference on Concussion in Sport in Zurich in 2008, 3 It is comprised of a: 22-item graded symptom scale (22 points); 2-item sign score determining loss of consciousness and balance difficulties (2 points); 1

2 Glasgow Coma Scale (GCS) evaluating eye response, verbal response, and motor response (15 points); Modified Balance Error Scoring System (BESS) (30 points); ). SCAT2 SCAT2 Coordination examination (1 point); and Maddocks' questions for sideline assessment (asking the athlete if he/she knows where he is, what half/period it is, who scored last, what team they played last, did their team win; not included in SCAT2 summary score and only used for sideline diagnosis of concussion SCAT2 The SCAT2 total score is calculated by summing each component score, and has a maximum of 100 points. Since the purpose of the Arizona study involved (healthy) baseline scores, the Maddocks' questions were not administered and the sign score and GCS score were automatically assigned with the correct response point values of 2 and 15, respectively. Studies after the SCAT2 was issued document other drawbacks: The balance test component can be significantly affected by high intensity exercise and muscle fatigue for up to 20 minutes following exercise (8,9,10) as a result, perceived deficits in balance following head injury may be the result of muscle fatigue, not concussion. The American Academy of Pediatrics' 2010 statement on concussions (6)thus recommends that post-concussion balance testing be performed more than 15 minutes after cessation of exercise, and in a setting in which follow-up assessments can be performed, not on a noisy sports sideline. As with all concussion assessment tools that rely, at least in part, on self-reporting by athletes of symptoms, a potential consideration in the use of the SCAT2/3 symptom checklist is the fact that some athletes (as many as 26% in one study (11), may underreport symptoms or claim to be "symptom free" even though they are still experiencing symptoms such as cognitive changes in order to avoid removal from the game or to expedite return to play. Scores are weighted to reflect the number of questions asked in each subsection, rather than the importance of each symptom. For instance, the Glasgow Coma Scale has not been demonstrated to be effective in differentiating between concussed and nonconcussed athletes (largely for the reason that even concussed athletes have a score at or near the maximum on the GCS 15-point scale), yet it accounts for a large number of the total points. 2

The Consensus Statement on Concussion in Sport of the 3rd International Conference on Concussion in Sport in 2008 [1] included a Sport Concussion Assessment Tool 2 (SCAT2) [2] for standardized

When an athlete shows any signs of a concussion, he or she should be medically evaluated on the field or sideline using standard emergency management principles, with particular attention given to

3 The Consensus Statement on Concussion in Sport of the 3rd International Conference on Concussion in Sport in 2008 [1] included a Sport Concussion Assessment Tool 2 (SCAT2) [2] for standardized assessment by medical and health professionals (team physicians, certified athletic trainers, neuropsychologists) of sports concussion in athletes ages 10 years and older. When an athlete shows any signs of a concussion, he or she should be medically evaluated on the field or sideline using standard emergency management principles, with particular attention given to ruling out a cervical spine injury (1). In March 2013, the SCAT2 was replaced by the SCAT3 [3] for athletes 13 years and old issued coincident with the Consensus Statement issued after the 4th International Conference on Concussion in Sport held in Zurich in November 2012 ("Zurich statement"), [4] and a modified version (Child SCAT3) was issued for children aged 5 to 12 years. [5] Sideline Evaluation Standardized tools available SCAT 3 SAC Signs & symptoms Evaluation of cognition is an essential component Standard orientation questions are unreliable Postural stability testing is a valid addition to assessment Serial testing recommended WARNING LABEL But, the authors note, of the following applications they identified as being assessment tools, only four described the intended audience as health care professionals. Concerned that use by parents and other nonmedical personnel might carry significant legal liability, the authors of the study say "care should be taken to ensure that assessment tools are used exclusively by licensed health care providers. 3

4 SIDELINE PHONE APPS 1. Concussion Recognition and Response (CRR) ($.99). The CRR app allows parents and coaches to capture and retain data on concussion incidents for a particular athlete and determining whether concussion is suspected by responding to a series of screen prompts: asking whether there was a blow to the head or body, the cause of injury, and how powerful the blow was; marking yes or no on a list of concussion signs (observed by parent or coach), including whether any seizures immediately following injury; instructing user to call 911 (with link) or go to nearest emergency room right away if athlete displays any of the warning signs of a more serious brain injury; and interviewing athlete and marking yes or no on list of concussion symptoms felt by athlete Concussion App from Sports Safety Labs LLC (free/$4.99) The free version of this application: provides basic information on concussion signs and symptoms; allows a user to call an ambulance via 911, helps a user locate the nearest hospital and provides driving directions, and allows the user to send location coordinates via to emergency contacts and rescue personnel. 2. Concussion App LLC /$4.99 An optional concussion diagnostic module, available via in-app purchase for $4.99, allows the user to capture and store for individual athletes the results of 11 tests based on the SCAT2 test to assist in the evaluation of the physiological and neurocognitive status of preconcussion (baseline) and post-concussion (injured) athletes. The standardized presentation of the report and its data can be ed from the user's smartphone to a physician to support their diagnostic interpretation of the athlete's condition. Physician's post-injury reports may be forwarded via from the smartphone to a child's club or league if the user chooses to do so for rapid documentation and approval for return-to-play status. 2. Concussion App from Sports Safety Labs LLC The application provides a personal baseline testing program which compares the athlete's own post-injury results versus their own pre-injury results rather than to "norms" or population samples of other athletes who have also taken the test, and is designed to help the athlete and their doctor make accurate, personalized comparisons for return-to-play decision. Pop-up prompts at various points during the testing indicate that the app is designed for use by medical professionals, not by parents Play It Safe (free) This free smartphone application from Concussion Health, LLC includes a 22-part test, including: a simplified symptom checklist the so-called "Maddocks" questions used to determine if the athlete is oriented to time and space; a word recall test to test memory a number reversal test; some simple balance tests and a vision test. Once the test is completed, the app provides a result summary (red flag, yellow flag, green flag). 4

5 3. Play It Safe (free) The application is unwieldy, as it doesn't include an explanation of why the 22 items are tested with the individual test modules, requiring the user to access the application's "Help" section to obtain such explanations. While the app says the tests can be performed by coaches, parents or other individuals involved in the athlete's care, it doesn't seem designed with any particular type of user in mind; the test modules are only loosely based on the SCAT2 test, and hence of questionable utility by a clinician in diagnosing a suspected concussion Pocket SCAT2 (free) A smartphone version which purports to replicate the SCAT2 test, but which doesn't even come close to doing anything of the sort. A total waste and completely useless, either as a diagnostic tool for suspected concussion or as providing basic concussion information. In any event, the SCAT2 (now updated to the SCAT3) is designed for use by clinicians, not parents or coaches. page=0%2c1#ixzz37olxyuiy 5. SCAT2 (free) A smartphone version of the SCAT2 test intended for use only by qualified medical professionals, thus of no use for parents and coaches. With the March 2013 release of the SCAT3, expect this app to be updated soon ImPACT Concussion Awareness Tool (ImCAT)(free) From the folks who make the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) others apps, is not a concussion testing tool. The app includes: a helpful 10-question concussion quiz to test the user's knowledge of concussions (and debunk common concussion myths; for an article discussing concussion myths in detail A concussion overview, including a list of common signs and symptoms of concussion, Information about Mild Traumatic Brain Injury (mtbi) Advice on preventing mtbi (not just in sports but in everyday life) and correctly pointing out there is no evidence of grading of concussions Return2Play (University of Michigan Neurosport)(free) Developed by the Pediatric Trauma Program at C.S. Mott Children's Hospital in partnership with Michigan Neurosport, this app is Intended tor use primarily as a management utility for concussion patients to track their recovery from concussion and doctor's appointments. The app also contains some brief - too brief, in the view of MomsTEAM editors, sections on: some common concussion myths and facts; an abbreviated signs and symptom checklist; a list of signs which may indicate a more serious brain injury: a short list of things to do during concussion recovery; a return to play protocol developed by Michigan Neurosport using the acronym BRAIN, which stands for : Bike, Run, Agility, In Red, No Restrictions; a list of factors that may increase an athlete's risk of concussion a list of three ways (technology, education, and enforcement) to reduce concussion risk. Good information, but incomplete. Perhaps valuable for athletes who want to track their concussion recovery, but for parents, the CRR (#1 above) contains more complete information. 8. Hockey Canada Concussion Awareness (free) Developed as part of a larger initiative between Hockey Canada and three other not-for-profit organizations and as part of the Canadian government's Active and Safe Injury Prevention Initiative, this app, while designed for hockey players, has some valuable information on concussions, even for parents who don't have kids playing hockey, including: simple animations of the different ways concussions can occur (direct impact to head, impact to head from body blow, direct impact due to fall, and indirect impact); short articles dispelling the myths that helmets and mouth guards prevent concussions; signs and symptoms of concussion (emphasizing the important point about the need for parents to watch for delayed onset) instructions for follow-up care during the first hours after injury, and the need for physical and cognitive rest. the pocket Concussion Recognition Tool issued as part of the 4th International Consensus Statement on Concussions in Sport (too small to be readable, however, on a smartphone; probably legible on an ipad or other tablet) a discussion of the 6-step return to play protocol. page=0%2c1#ixzz37onnzf6d 5

9. Hockey Canada Concussion Awareness for Kids (free) The first concussion app designed specifically for kids, the app uses a character named "Puckster" to get information about concussions across to

It includes a simple video game kids can play in which Puckster skates over - or into - various obstacles on the ice with concussion tips on the board in the background, and easy-to-understand

com/smartphone-applications-provideconcussion-information-for-parents? page=0%2c1#ixzz37opubs1g 10.

6 9. Hockey Canada Concussion Awareness for Kids (free) The first concussion app designed specifically for kids, the app uses a character named "Puckster" to get information about concussions across to younger kids. It includes a simple video game kids can play in which Puckster skates over - or into - various obstacles on the ice with concussion tips on the board in the background, and easy-to-understand versions of the concussion recognition, treatment and return to play information in the regular app. Recommended for young hockey players; not recommended for football players. page=0%2c1#ixzz37opubs1g 10. American Academy of Neurology's Concussion Quick Check (free) Issued in conjunction with the AAN's updated concussion guidelines, [2] this is a useful and concise app true to its name, and is designed to help parents, coaches, and other non-medical personnel determine if an athlete has a concussion and needs to see a licensed health care provider. Like many of the other apps, the Concussion Quick Check includes: lists of common signs and symptoms of concussion; a checklist of things to do if an athlete is knocked unconscious during a game (e.g. check his ABC's: airway, breathing, and circulation); a list of things to do if a concussion is suspected: remove from play and not allow return that day, monitor for next three or four hours or longer (although the app doesn't say for what or why this important); notify a licensed health care provider (LHCP) trained in diagnosing and managing concussion, and not allow the athlete to return to play until evaluated and cleared by such a provider; and a brief discussion of things a healthcare provider may say to an athlete about return to play, including returning to physical activity slowly and increase activity levels carefully, step by step. On-field or Sideline Evaluation of Acute Concussion Assessment of concussive injury with SCAT2 or similar tool Player should not be left alone following injury Serial monitoring for deterioration over several hours Concussed player should not be allowed to return to play on the day of injury Sideline Cognitive Function Maddock s questions: At what venue are we? Who scored last? Which half/period is it? Opposing team name? Did we win last game? Sideline Cognitive Function SCAT 3 & Child-SCAT3 Standard orientation questions (time, place, person) unreliable! Concussive symptoms might be delayed several hours! 6

Promising sideline assessment tool Sideline-Dropstick Test A Simple Measure of Reaction Time To Help Identify Athletes With Possible Concussion?

com/health-safety/ sideline-dropstick-test-simple-measurereaction-time-use-in-identifying-possiblesport-related-concussion#ixzz37mehkvbv Balance

errors in 3 20-sec tests Maximum of 10 King-Devick Test King-Devick Test The study provides more evidence that the King-Devick test, a

7 Promising sideline assessment tool Sideline-Dropstick Test A Simple Measure of Reaction Time To Help Identify Athletes With Possible Concussion? sideline-dropstick-test-simple-measurereaction-time-use-in-identifying-possiblesport-related-concussion#ixzz37mehkvbv Balance Assessment Office assessment of gait and balance Modified BESS balance testing Double leg stance Single leg stance Tandem stance Number of errors in 3 20-sec tests Maximum of 10 King-Devick Test King-Devick Test The study provides more evidence that the King-Devick test, a one-minute test in which athletes are timed reading single-digit numbers on index cards (see photo at right from MomsTEAM's PBS documentary, more-evidence-that-king-devick-test-mayhelp-identify-concussed-athletes-on-sportssideline#ixzz37modlccc 7

8 King-Devick Test cont., King-Devick Test A simple vision test performed on the sports sidelines was able to identify nearly 8 out of 10 athletes later found to have suffered a concussion, and when combined with screens for cognition and balance, allowed identification of concussed athletes with 100% accuracy, according to an abstract of a research paper to be presented at the American Academy of Neurology Annual Meeting in Philadelphia in late April (1) King Devick Test cont., King-Devick Test Screens For: Saccades (eye movements) Attention Concentration Speech/Language Other correlates of sub-optimal brain function Balance Error Scoring System The new American Academy of Neurology concussion guidelines [5] view the BESS assessment tool as likely to identify concussion with only low to moderate diagnostic accuracy with a low specificity of 34 to 64% (meaning a false positive rate for concussion of 34 to 64%), but a high degree of specificity of 91% (meaning that the test will only miss one out of ten concussions). BESS BESS cont., The athlete first stands with the feet narrowly together, the hands on the hips, and the eyes closed (double leg stance). The athlete holds this stance for 20 seconds while the number of balance errors (opening the eyes, hands coming off hips, a step, stumble or fall, moving the hips more than 30 degrees, lifting the forefoot or heel, or remaining out of testing position for more than 5 seconds) are recorded as errors. The test is then repeated with a single-leg stance using the non-dominant foot, and A third time using a heel-toe stance with the non-dominant foot in the rear (tandem stance). (A 2013 study [15] found that these stances were best at separating the healthy participants from the concussed patients.) 8

Other technology in the works Helmet Inserts On-field or Sideline

on site with attention to C-spine injury Appropriate disposition of

healthcare provider available, player should be safely removed from

Same-Day Return to Play Evidence that NFL football players RTP more

collegiate and high school athletes allowed to RTP same day may

9 Other technology in the works Helmet Inserts On-field or Sideline Evaluation of Acute Concussion Player should be medically evaluated on site with attention to C-spine injury Appropriate disposition of player must be determined by treating healthcare provider If no healthcare provider available, player should be safely removed from practice or play and urgent referral to a physician arranged Same-Day Return to Play Evidence that NFL football players RTP more quickly without risk of recurrence or sequelae Evidence shows collegiate and high school athletes allowed to RTP same day may demonstrate NP deficits post injury that may not be evident on sidelines. If in doubt, sit them out. Children should not be returned to practice or play until completely symptom-free, which may require a longer time frame than adults 9

Paramus Athletics. Paramus High School Athletic Department Protocol and Procedures for Management of Sports - Related Concussion

Paramus Athletics. Paramus High School Athletic Department Protocol and Procedures for Management of Sports - Related Concussion Paramus Athletics Paramus High School Athletic Department Protocol and Procedures for Management Medical management of sports-related concussions is evolving. In recent years, there has been significant