1. Vanderbilt Sports Medicine Sports Concussion Assessment Tool An Update and Systematic Review David G. Liddle, MD Assistant Professor of Orthopedics Assistant Professor of Internal Medicine Vanderbilt University Medical Center Nashville, TN

2. Vanderbilt Sports Medicine Disclosures None

3. Vanderbilt Sports Medicine Objectives Discuss the history and development of tools that quantitatively evaluate athletes for concussion Review the ability of these tests to diagnose concussions and follow them clinically Review the affect of age, gender, and prior history of concussion on the results of these tests Discuss the ability of the SCAT to predict clinical outcomes Discuss other testing considerations when using SCAT

4. Vanderbilt Sports Medicine Systematic Review Design – Searched across PubMed, PsychInfo, CINAHL, & Embase – Utilized Preferred Reporting Items for Systematic Reviews & Meta-Analyses (PRISMA) guidelines to evaluate studies – Included Studies with: Quantitative Data on Standardized Assessment of Concussion (SAC), Balances Error Scoring System (mBESS), & Sport Concussion Assessment Tool (SCAT) Athletes ≥13 y/o only; Baseline and post-concussion – Excluded Studies with: Only symptoms, only BESS data, or Non-SCAT-related assessments Non-Athletes, <13 y/o

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7. History Standardized Assessment of Concussion (SAC) – Developed in 1997 – Objective and standardized assessment – Screened neurocognitive & neurologic function + symptoms

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9. History Standardized Assessment of Concussion (SAC) – Developed in 1997 – Objective and standardized assessment – Screened neurocognitive & neurologic function + symptoms SCAT (2004) – Created at 2 nd Concussion In Sport conference – SAC + Post-Concussion Symptom Scale (PCSS) + Sports Specific orientation questions (mod. Maddock’s) + On-field markers (amnesia, LOC, etc. ) + systematic, step-wise RTP guideline

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20. History SCAT 2 (2008) – SCAT + GCS + new word list for recall items + mBESS – More Labor Intensive – Designed for sideline and subsequent serial clinical use – Widely used by MDs and ATCs; Smartphone App

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22. SCAT 2

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31. History SCAT 2 (2008) – SCAT + GCS + new word list for recall items + mBESS – More Labor Intensive – Designed for sideline and subsequent serial clinical use – Widely used by MDs and ATCs; Smartphone App SCAT 3 (2013) – Adds blank/vacant stare and cervical stability assessment to objective signs – Adds Concussion-related Past Medical History – Option for either foam stances or timed tandem gait tasks to eval postural stability – Child-SCAT 3 now available

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36. Systematic Review Design – Included Studies with: Quantitative Data on Standardized Assessment of Concussion (SAC), Balances Error Scoring System (mBESS), & Sport Concussion Assessment Tool (SCAT) Athletes ≥13 y/o only; Baseline and post-concussion – Evaluated SAC, BESS, and SCAT tests for: Affect of Age, Gender, and h/o Previous Concussion Diagnostic Value Predicting Recovery Times Affect of Dehydration, Mental Health, and Athlete Effort on Baseline Testing

37. Vanderbilt Sports Medicine Affect of Age SAC (19 Studies) – No diff except in a single study with 332 pts, 5-23 y/o mBESS (1 Study) – Fewer errors w/ increased age/higher grade levels SCAT (16 Total, 2-SCAT, 11-SCAT 2, 3-SCAT 3) – SCAT Older females have higher sympt scores than younger females – SCAT 2 Younger pts (13-15) reported fewer sympt. & better at delayed recall Improved overall SCAT2 scores were 2/2 incr. mBESS component Younger pts. worse in balance and cognition; concentration worse in 12 y/o vs. 15 & 18 y/o

38. Vanderbilt Sports Medicine Affect of Gender SAC (19 Studies) – Mixed results; Trend for females to do better in concentration and memory mBESS – Females had fewer errors than males in 3/4 studies SCAT (16 Total, 11 SCAT 2, 3 SCAT 3, 2 SCAT) – SCAT Females reported more sympt. & higher cognitive performance but Stats Sig. not evaluated – SCAT 2 Females report more sympt. (P=0.38) & higher overall performance (P<0.01); 2 studies 3 other studies found no diff in performance; confirmed females reporting more symptoms & with greater severity

39. Vanderbilt Sports Medicine Affect of Prior Concussion SCAT – Previously concussed athletes: Perform better on the SCAT in all areas except delayed recall Report more symptoms; headache most common SCAT 2 – High school athletes with the h/o concussion do worse on SCAT 2 because they report more severe symptoms (P <0.001) Affect did not transfer to college or professional athletes (4 studies) – Previously Dx athletes do better on cognitive testing Exposure Effect – Learning how to take the test

40. Vanderbilt Sports Medicine Diagnostic Value SAC (19 Studies) – 94% Sensitive (Sn) (Rule Out) & 76% Specific (Sp) (Rule Out) 2 studies in HS/Col FB (? Generalizability) – Less Sn & Sp in mixed sport cohorts mBESS – Better with accelerometers & gyroscope (Sn 81% vs. 64%) SCAT (16 Total, 11 SCAT 2, 3 SCAT 3, 2 SCAT) – SCAT 2 Prospective cohort 263 college athletes, 32 of whom had concussions, found that a 3.5 point drop from baseline SCAT2 scores was 96% Sensitive and 81% Specific for Dx Using an absolute cut off of 74.5 on the SCAT 2 to Dx concussion was 83% sensitive and 93% specific No published data yet on SCAT 3 Sn & Sp

41. Vanderbilt Sports Medicine Sideline SCAT & Predicting Recovery Times SCAT – No published data showing ability of SCAT to predict Return To Play or Return To Learn SCAT 2 – Lower SCAT 2 Scores at the time of injury as well as Higher Total Symptoms scores are associated with: More days needed to become symptom-free (P<0.05)(P<0.01) More days to return to graduated activity (P<0.05)(P<0.01) More days to return to play (P<0.05) – SAC & mBESS we're not predictive of return to play – High school athletes had longer times & more difficulty returning to learn with worse total SCAT 2 scores

42. Vanderbilt Sports Medicine Testing Considerations Dehydration – SCAT 2 performance in college wrestlers declined from baseline to post- practice testing (P<0.05) Increased mBESS errors (P<0.05) accounted for 50% of the increased score – Correlated with increased urine specific gravity Depression and anxiety both decreased performance on SCAT 2 – Associated with increased symptoms reporting No difference in the SAC or mBESS components Sandbagging – Suboptimal performance on baseline testing has been studied on ImPACT tests, but no studies address this for the SCAT

43. Vanderbilt Sports Medicine Summary Older athletes have better balance and cognitive scores but report more symptoms Females report more symptoms but may perform better on SCAT 2 Diagnosis of Concussion and SCAT 2 – A 3.5 point drop from baseline = 96% Sen./81% Spec. – Using an absolute cut off of 74.5 = 83% Sens./93% Spec. History of prior concussions is associated with reporting more symptoms and better performance on cognitive testing parts of SCAT 2 (HS athletes only) Lower SCAT 2 scores & Higher Total Symptoms scores at the time of injury predict longer recovery times Dehydration, Depression, Anxiety will affect performance on SCAT 2

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