This is an excerpt from Handbook of Assessment in Sport Psychology Consulting by Jim Taylor.
A critical first step in concussion management is accurate detection and diagnosis. Among several diagnostic schema for SRCs, the most comprehensive currently accepted diagnostic criteria were formulated in the consensus statement from the 4th International Conference on Concussion in Sport, generally referred to as the Zurich Conference (McCrory et al., 2013). According to this document, "Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces" (p. 250). The statement further elaborates that the force may be from a direct blow to the head or may come from physical forces elsewhere on the body transmitted to the head; that the concussion results in time-limited neurologic impairment (although there may be a longer time course); that the immediate symptoms are due to a functional neurometabolic process rather than a structural injury that can be imaged using traditional neuroimaging techniques; and that concussion symptoms have a typical clinical presentation and should resolve in a typical sequential course. A majority of single, uncomplicated concussions resolve within 7 to 10 days; however, a longer recovery time may be needed in children and adolescents(McCrory et al., 2013).
SRC Symptoms and Course of Recovery
As shown in table 14.1, SRC symptoms are grouped into four clusters: physical, cognitive, emotional, and sleep.
Though a majority of collegiate and professional athletes with single, uncomplicated SRCs recover within 7 to 10 days, emerging data from a multiclinical assessment approach suggest it often takes three to four weeks for a complete recovery, especially for younger athletes (Henry, Elbin, Collins, Marchetti, & Kontos, 2015). This parallels the work of McCrea and colleagues, which supports a longer period of physiologic vulnerability even after traditional post-SRC assessment suggests symptom resolution (Nelson, Janecek, & McCrea, 2013). Growing consensus suggests that SRCs are best managed within a comprehensive education, prevention, and management program based in a clinic, school, or team or league. This program should provide resources and information geared toward all stakeholders involved, including athletes, parents, coaches, teachers, consultants, and sports medicine professionals. As a consultant working with athletes with SRCs, you are likely mandated by your state law and professional organization to know the fundamentals of SRC injury to ensure you can play an active role in helping athletes receive the best possible care.
Concussion Education Resources
Several resources for concussion education are available to consultants. The CDC’s Heads Up Concussion in Youth Sports website (www.cdc.gov/HeadsUp/youthsports) provides free downloadable educational handouts for players, coaches, sport officials, and parents. It is particularly suitable for K - 12 sport programs. Collegiate and professional sport organizations have specific SRC training programs for their health care personnel that are based on material from the Zurich Conference (McCrory et al., 2013). The NCAA program addresses the special needs of the collegiate student-athlete (www.ncaa.org/health-and-safety/concussion-guidelines). The NHL, the NFL, and Major League Soccer (MLS) use a neuropsychological concussion evaluation model (Lovell, 2006). Finally, many professional organizations have developed concussion guidelines for their disciplines, such as the American Medical Society for Sports Medicine (AMSSM), the American Academy of Neurology (AAN), and NATA (Echemendia, Giza, & Kutcher, 2015). Of these guidelines, the NATA position statement is one of the most comprehensive and pragmatic documents available. It is useful for all disciplines (Broglio et al., 2014), and therefore consultants working with concussed athletes should be familiar with it regardless of their discipline.
Components of SRC Assessment
With the preceding SRC education and management guidelines in mind, this section provides an overview of essential components of SRC assessment. Integrating data obtained from each assessment component during the postconcussion period is critical to maximize safe SRC recovery and expedite return to play (RTP) and return to learn (RTL) baseline assessment.
Preseason baseline neurocognitive assessment is essential, providing an individualized reference point for comparison in the event of an SRC, especially if the athlete has a preexisting academic learning disability, ADHD, or chronic medical or psychological condition. No athlete is perfect, and many have preexisting symptoms when not injured that can confound postinjury assessment and symptom management, necessitating the need for baseline assessment. Serial postinjury evaluations can be compared against the baseline to establish that an SRC has occurred, to quantify the initial degree of impairment and graduated improvement with rehabilitation and intervention, and to document final recovery. Some argue that this testing is too expensive to be practical and does not prevent concussions (Randolph, 2011); however, the consensus among sports medicine professionals is that it is essential when used within an integrated management program.
The Post-Concussion Symptom Scale (PCSS) is an established self-report tool for assessing preinjury baseline symptoms and for assessing and monitoring postinjury concussion symptoms (Pardini et al., 2004). When administered soon after SRC injury, PCSS scores can measure the extent of the injury compared with baseline functioning and may help predict which athletes may have a longer or more complicated recovery (Meehan, Mannix, Straccioloni, Elbin, & Collins, 2013). As with any psychometric instrument, education and training for using the PCSS instrument is necessary. The PCSS is widely used by both athletic trainers and consultants alike, provided that they have the education required to assess and monitor SRC injuries.
The Sport Concussion Assessment Tool-3 (SCAT3; McCrory et al., 2013) is another useful comprehensive instrument that can be administered both at baseline and field-side after a suspected SRC injury by the sports medicine professional responsible for immediate postinjury care. It assesses levels of consciousness, learning and memory, orientation, balance, range of motion, and coordination. A child version of the SCAT3 is available for athletes aged 5 to 12 years. The NHL has used the X2 iPad app version of the SCAT3 for baseline assessment. Due to the complexity of this instrument, advanced training in assessment and interpretation may be needed. However, athletic trainers, physicians, and psychologists with appropriate training can administer the SCAT3. If the consultant responsible for immediate care does not have such training, it is recommended that you use the Sport Concussion Recognition Tool, which relies more on observation of the athlete and a brief game-specific memory questionnaire (McCrory et al., 2013).
Administration of computerized neurocognitive assessment at preinjury baseline is a well-established protocol for assessing large numbers of athletes at one time (e.g., team level). However, although computerized assessment offers ease of administration, concerns remain about reliable and valid psychometrics and valid data interpretation. Appropriate personnel can supervise administration of computerized testing, but test results must be interpreted by consultants with appropriate training in psychometric theory and concussion management. It is recommended that neuropsychologists provide such test interpretation or be available for consultation (Echemendia et al., 2013). Two commonly used computerized instruments for SRC assessment include ImPACT(ImPACT Applications, 2015) and Cogstate CCAT. Core neurocognitive functions assessed by computer programs include attention, reaction time and processing speed, and memory. Scores are compared against general athletic groups. Postinjury reevaluation with the computerized instrument used at baseline can identify specific neurocognitive concussion sequelae and help track the course of recovery from the SRC. The computer program chosen should provide statistics indicating if the change in performance is truly significant and greater than changes due to practice effects, and it should have sound psychometrics that support the statistical reliability and validity of the instrument. Otherwise, the obtained results could be inaccurate (Alsalaheen, Stockdale, Pechumer, & Broglio, 2015; Nelson et al., 2016).
In summary, assessment tools used at baseline assist in establishing critical preinjury baseline functioning and preexisting symptoms necessary for comparison when assessing the presence and extent of postinjury concussion. Assessing a concussed athlete without an appropriate preinjury baseline can be done, but results must be interpreted with greater caution.
Assessment in Action
Using the PCSS in a Guided Interview Format
Consultants should complete this assessment tool in an interview format with concussed clients to better understand their SRC experience. The athlete rates each current SRC symptom on a scale from 0 to 6, and the consultant’s interview elucidates activity and setting triggers and patterns in symptom clusters while encouraging the athlete to identify coping behaviors that reduce symptoms. Though only the PCSS total symptom score reliably predicts symptoms lasting longer than 28 days postinjury (Meehan et al., 2013), this recommended approach provides the consultant with valuable information for tailoring interventions and making appropriate, timely referrals to speed up SRC recovery.
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