Acute evaluation of sport-related concussion and implications for the Sport Concussion Assessment Tool (SCAT6) for adults, adolescents and children: a systematic review

OBJECTIVES

To systematically review the scientific literature regarding the acute assessment of sport-related concussion (SRC) and provide recommendations for improving the Sport Concussion Assessment Tool (SCAT6).

DATA SOURCES

Systematic searches of seven databases from 2001 to 2022 using key words and controlled vocabulary relevant to concussion, sports, SCAT, and acute evaluation.

ELIGIBILITY CRITERIA

(1) Original research articles, cohort studies, case-control studies, and case series with a sample of >10; (2) ≥80% SRC; and (3) studies using a screening tool/technology to assess SRC acutely (<7 days), and/or studies containing psychometric/normative data for common tools used to assess SRC.

DATA EXTRACTION

Separate reviews were conducted involving six subdomains: Cognition, Balance/Postural Stability, Oculomotor/Cervical/Vestibular, Emerging Technologies, and Neurological Examination/Autonomic Dysfunction. Paediatric/Child studies were included in each subdomain. Risk of Bias and study quality were rated by coauthors using a modified SIGN (Scottish Intercollegiate Guidelines Network) tool.

RESULTS

Out of 12 192 articles screened, 612 were included (189 normative data and 423 SRC assessment studies). Of these, 183 focused on cognition, 126 balance/postural stability, 76 oculomotor/cervical/vestibular, 142 emerging technologies, 13 neurological examination/autonomic dysfunction, and 23 paediatric/child SCAT. The SCAT discriminates between concussed and non-concussed athletes within 72 hours of injury with diminishing utility up to 7 days post injury. Ceiling effects were apparent on the 5-word list learning and concentration subtests. More challenging tests, including the 10-word list, were recommended. Test-retest data revealed limitations in temporal stability. Studies primarily originated in North America with scant data on children.

CONCLUSION

Support exists for using the SCAT within the acute phase of injury. Maximal utility occurs within the first 72 hours and then diminishes up to 7 days after injury. The SCAT has limited utility as a return to play tool beyond 7 days. Empirical data are limited in pre-adolescents, women, sport type, geographical and culturally diverse populations and para athletes.

PROSPERO REGISTRATION NUMBER

CRD42020154787.

Beyond acute concussion assessment to office management: a systematic review informing the development of a Sport Concussion Office Assessment Tool (SCOAT6) for adults and children

OBJECTIVES

To systematically review the scientific literature regarding the assessment of sport-related concussion (SRC) in the subacute phase (3-30 days) and provide recommendations for developing a Sport Concussion Office Assessment Tool (SCOAT6).

DATA SOURCES

MEDLINE, Embase, PsycINFO, Cochrane CENTRAL, CINAHL, SPORTDiscus and Web of Science searched from 2001 to 2022. Data extracted included study design, population, definition of SRC diagnosis, outcome measure(s) and results.

ELIGIBILITY CRITERIA

(1) Original research, cohort studies, case-control studies, diagnostic accuracy and case series with samples >10; (2) SRC; (3) screening/technology that assessed SRC in the subacute period and (4) low risk of bias (ROB). ROB was performed using adapted Scottish Intercollegiate Guidelines Network criteria. Quality of evidence was evaluated using the Strength of Recommendation Taxonomy classification.

RESULTS

Of 9913 studies screened, 127 met inclusion, assessing 12 overlapping domains. Results were summarised narratively. Studies of acceptable (81) or high (2) quality were used to inform the SCOAT6, finding sufficient evidence for including the assessment of autonomic function, dual gait, vestibular ocular motor screening (VOMS) and mental health screening.

CONCLUSION

Current SRC tools have limited utility beyond 72 hours. Incorporation of a multimodal clinical assessment in the subacute phase of SRC may include symptom evaluation, orthostatic hypotension screen, verbal neurocognitive tests, cervical spine evaluation, neurological screen, Modified Balance Error Scoring System, single/dual task tandem gait, modified VOMS and provocative exercise tests. Screens for sleep disturbance, anxiety and depression are recommended. Studies to evaluate the psychometric properties, clinical feasibility in different environments and time frames are needed.

PROSPERO REGISTRATION NUMBER

CRD42020154787.

Clinician Perspectives on Providing Concussion Assessment and Management via Telehealth: A Mixed-Methods Study

OBJECTIVE

To examine clinician perspectives regarding the use of telehealth for concussion assessment and management.

SETTING

A Pan-Canadian survey.

PARTICIPANTS

Twenty-five purposively sampled multidisciplinary clinician-researchers with concussion expertise (female, n = 21; physician, n = 11; and other health professional, n = 14).

DESIGN

Sequential mixed-method design: (1) electronic survey and (2) semistructured interviews with focus groups via videoconference. Qualitative descriptive design.

MAIN OUTCOME MEASURES

Survey : A 59-item questionnaire regarding the suitability of telehealth to perform recommended best practice components of concussion assessment and management. Focus groups : 10 open-ended questions explored survey results in more detail.

RESULTS

Clinicians strongly agreed that telehealth could be utilized to obtain a clinical history (96%), assess mental status (88%), and convey a diagnosis (83%) on initial assessment; to take a focused clinical history (80%); to monitor functional status (80%) on follow-up; and to manage symptoms using education on rest (92%), planning and pacing (92%), and sleep recommendations (91%); and to refer to a specialist (80%). Conversely, many clinicians believed telehealth was unsuitable to perform a complete neurologic examination (48%), cervical spine (38%) or vestibular assessment (61%), or to provide vestibular therapy (21%) or vision therapy (13%). Key benefits included convenience, provision of care, and patient-centered approach. General and concussion-specific challenges included technology, quality of care, patient and clinician characteristics, and logistics. Strategies to overcome identified challenges are presented.

CONCLUSIONS

From the perspective of experienced clinicians, telehealth is suited to manage symptomatic concussion patients presenting without red flags or following an initial in-person assessment, but may have limitations in ruling out serious pathology or providing return-to-sport clearance without an in-person physical examination.

Which psychosocial factors are associated with return to sport following concussion? A systematic review

BACKGROUND

Psychosocial factors predict recurrent injury and return to preinjury level of performance following orthopedic injury but are poorly understood following concussion. Current management protocols prioritize physical measures of recovery. Therefore, the objective of this study was to describe the psychosocial factors associated with return to sport (RTS) and how they are measured in athletes who sustained a concussion.

METHODS

MEDLINE, Embase, APA PsycINFO, CINAHL, and SPORTDiscus were searched through February 2, 2021. Eligible studies included original peer-reviewed publications describing psychosocial factors associated with RTS following a diagnosed concussion. The primary outcome was scales or measures employed and/or key thematic concepts.

RESULTS

Of the 3615 studies identified, 10 quantitative cohort studies (Oxford Centre for Evidence-Based Medicine Level-3) representing 2032 athletes (85% male; high-school and collegiate collision/contact athletes) and 4 qualitative studies representing 66 athletes (74% male; 70% American football; aged 9-28 years) were included. We identified 3 overarching themes and 10 outcome measures related to psychosocial factors associated with RTS following concussion: (a) fear (e.g, of recurrent concussion, of RTS, of losing playing status); (b) emotional factors (e.g, depression, anxiety, perceived stress, mental health, disturbance mood); and (c) contextual factors (e.g, social support, pressure, sense of identity).

CONCLUSION

Although current medical clearance decisions prioritize physical measures of recovery, evidence suggests diverse psychosocial factors influence RTS following concussion. It remains unclear which psychosocial factors contribute to a successful RTS, including the influence of sex/gender and age. Future studies should evaluate the association of psychological readiness with physical measures of recovery at medical clearance, preinjury level of performance, and risk of recurrent concussion to support RTS clinical decision-making.

What is the risk of recurrent concussion in children and adolescents aged 5-18 years? A systematic review and meta-analysis

OBJECTIVE

We aimed to examine the risk of concussion in children with a previous history of concussion.

DESIGN

Systematic review and meta-analysis. The primary outcome was number of children with and without a previous lifetime history of concussion who sustained a diagnosed concussion within each study period. Risk of bias was assessed using the Newcastle-Ottawa Scale. A random effects model was used to estimate a pooled risk ratio (RR) with corresponding 95% CIs; results were summarised in forest plots.

DATA SOURCES

Four electronic databases (MEDLINE, Embase, CINAHL, SPORTDiscus) and selected reference lists were searched (PROSPERO registration No CRD42019135462).

ELIGIBILITY CRITERIA

Original English language peer-reviewed publications that compared concussion risk in children aged 5-18 years with and without a previous concussion history in which risk estimates were reported or able to be calculated.

RESULTS

Of 732 identified studies, 7 studies representing 23 411 children (risk of bias range, 7-9; maximum possible score=9) were included for meta-analysis. Pooled risk of sustaining a concussion was more than three times greater in children with a previous concussion compared with those with no previous concussion (RR=3.64; 95% CI: 2.68 to 4.96; p<0.0001; I ²=90.55%). Unreported sex-stratified data precluded direct comparison of concussion risk in male versus female athletes.

CONCLUSION

Previously concussed children have four times the risk of sustaining a concussion compared with those with no previous concussion history. This should be a consideration for clinicians in return to sport decision-making. Future studies examining subsequent recurrent concussion in youth sports must consider sex differences.

Protocol for the mixed-methods development of a concussion-specific health-related quality of life outcome measure based on the international classification of functioning, disability and health

INTRODUCTION

Recovery from concussion has traditionally been evaluated by patient-reported symptoms, objective measures such as loss of consciousness, specific dimensions such as depression or fatigue, cognitive status, employment status, level of physical activity and the more complex construct of disability. Increasingly, patient-reported outcome measures of health-related quality of life (HRQOL) are being emphasised as an important end point in patient care, clinical trial and health policy decisions. Currently, no standardised concussion-specific HRQOL outcome measure exists. The process for developing a concussion-specific HRQOL outcome measure based on the international classification of functioning, disability and health is outlined.

METHODS AND ANALYSIS

A multistage, patient-centred approach to developing the outcome measure will integrate evidence from systematic reviews, qualitative research and cognitive interviewing into a self-report questionnaire to guide clinical decision-making. The psychometric properties of the questionnaire will be evaluated to assess the inter-rater reliability and construct validity of the measure in individuals with persistent post-concussion symptoms. To date, the systematic review and the clinical expert interviews within the preparatory phase have been completed and work is progressing on the subsequent phases. It is anticipated that the outcome measure will be ready for psychometric testing in September 2018.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Ottawa Health Science Network Research Ethics Board (Protocol #20170720-01H) on 31 October 2017 to conduct the patient and clinical expert interviews. Ethical approval for psychometric testing of the outcome measure will be sought by the Ottawa Health Science Network Research Ethics Board in Phase II, after the development of the final HRQOL questionnaire. Results will be disseminated through peer-reviewed journals and professional conferences.

PROSPERO REGISTRATION

Phase I systematic review registration number CRD42017075588 (15 June 2017). Phase II systematic review registration number CRD42017075588 (27 September 2017).