Concussion

On-Field Assessment

In the acute setting for athletes who are evaluated on the field, the initial evaluation should be for consciousness, as the unconscious athlete must be assumed to have a cervical spine injury and appropriate management must be initiated. If an athlete is conscious, assessment of his or her cognition, including details of the current game, amnesia before or after the injury, and confusion must be assessed. The athlete should be asked about the symptoms related to his or her concussion.

The physical exam should be focused on neurologic assessment, including evaluations of short-term memory and observation of balance ability, changes in personality, ability to follow instructions or answer questions, vomiting, or emotions inappropriate to the situation or the athlete, such as laughing or crying.

A useful sideline assessment tool is the Sport Concussion Assessment Tool (SCAT), which was developed during the 2004 Second International Conference on Concussion in Sport. The SCAT is a combination of various previous sideline evaluation tools, which used the most evidence-based assessments of each of these tools.

In-Office Assessment

If the first assessment is in an office-based setting, history of the concussion and any prior concussions must be obtained. A thorough neurological assessment should be undertaken, as well as evaluation of cognitive function. A postconcussion symptom checklist with grading of the common symptoms related to concussions can be useful to assess the present condition of the athlete and to follow up his or her improvement over time.

Neuroimaging

In the vast majority of sports-related concussions, results of neuroimaging studies such as CT and MRI scans are normal. Indications for considering further neuroimaging would include worsening neurological status, recurrent vomiting, focal neurologic findings on physical exam, and loss of consciousness. Further imaging may also be warranted in a person with symptoms that are not improving over a 10-day period, as most concussions will see improvement of symptoms over that time. There is no consensus as to how long an athlete should have been unconscious to require neuroimaging. Various sources suggest loss of consciousness for at least 30 to 60 seconds before one may consider further neuroimaging.

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