Pillar Three: Early Identification/Immediate Removal from Play

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To minimize the risk of delayed recovery and long-term injury (or, in rare instances, catastrophic injury or death), it is critical that athletes suspected of having sustained a concussion be removed from play as soon as possible, a step now required by law, at least at the high school level, in all 50 states and the District of Columbia.

Because of an athlete’s tendency to under-report or failure to recognize concussion symptoms, and because the vast majority of sport-related concussions occur without loss of consciousness or other obvious neurological signs, and/or may not even be the result of a specific concussive blow, identifying a concussion as early as possible requires a multi-pronged approach utilizing every tool in the concussion toolbox.

That means using the Four “E’s”:

1. Employingcertified athletic trainer with specialized expertise in the identification of concussion on the sideline at every game and practice (a practice recently endorsed by the American Academy of Pediatrics in its 2015 Policy Statement on Tackling in Youth Football)(1)and long advocated by MomsTEAM). 

2. Encouraging honest self-reporting by athletes of concussion symptoms, not just during game or practice action but in the hours and days after play (delayed onset of concussion symptoms is common, particularly among younger athletes), such as by implementing the #TeamUp4ConcussionSafety program featured on this website, and by using a “buddy system” in which players look for – and report – signs of concussion in designated teammates.  

Research in recent years (3-6) has consistently shown that the biggest barriers to honest reporting by athletes of concussion symptoms are not, contrary to conventional wisdom, a lack of concussion knowledge, but the result of a combination of other factors, including:

  • the negative attitudes of coaches, parents, and teammates towards reporting;
  • systemic and deeply entrenched social and competitive pressure on athletes from coaches, parents, teammates, and even fans, to keep playing with concussion symptoms, and to conform to what they perceive to be their expectations (7);
  • a fear by athletes of what will happen to them if they report concussion symptoms (such as a loss of playing time, a regular starting position, or, at the college level, a scholarship); 
  • a belief by athletes that they will be seen as letting their coach, teammates, parents, and fans down if they don’t continue playing with symptoms (4); and
  • an athlete’s tendency to think that their own attitudes towards reporting are safer and more positive than those of their teammates.  

3. Evaluating players on the sideline (or in the locker room) utilizing scientifically-validated and reliable sideline assessment tools capable of detecting and quantifying the acute phase of concussion, including the:

Four notes of caution about sideline assessments: 

a.  A 2013 analysis of the peer-reviewed literature on date of injury assessments (13) found the SAC reliable in detecting and quantifying acute cognitive impairment, and the BESS to be an “important component” of the sideline assessment, but said further research was required to establish the reliability, sensitivity, and clinical utility of the SCAT2/3, and that it was too early to draw any conclusion regarding the eventual usefulness of the K-D Test or others in the development pipeline.  

The American Academy of Neurologists’ updated concussion evaluation and management guidelines (14) likewise states the SAC is “likely” to identify the presence of concussion in the early stages post-injury with a high degree of sensitivity  (the ability of the test to correctly identify those having concussions, also called the “true positive rate”) and specificity, and that the BESS was “likely to identify concussions with low to medium diagnostic accuracy);

b.  The full SCAT3 and Child-SCAT3 sideline assessment “remove from play” screening tools are designed for use on the sports sideline only by trained healthcare professionals, including certified athletic trainers. The SAC can be used by non-physicians. Thus, a coach/parent/volunteer should immediately remove a player from practice or play, arrange for an immediate evaluation by medical professional, and not allow the athlete to return to play that day, if he or she observes any of the following signs observed after a direct or indirect blow to an athlete’s head: (a) loss of consciousness (however brief); (b) balance or coordination problems (unsteady gait, athlete stumbles, walks sideways, is labored in their movements); (c) disorientation or confusion (inability to respond appropriately to questions); (d) blank or vacant look; (e) visible facial injury in combination with any of the above. 

c. A recent research paper  expressed concern about the use of KD as a sideline assessment tool because it demonstrated “relatively poor” specificity (the ability of the test to correctly identify athletes who have not having suffered a concussions, also called the “true negative rate”), finding a substantial percentage (25.6%) of athletes without concussion had slowing on their tests from baseline, which, according to the manufacturer’s current guidelines, would rule them out of further play. (2) Indeed, another recent study, after finding a significant practice effect, and that both age and especially gender skewed the test results, characterized validation of KD for use as a clinical tool as being in its “early stages.”

c.  All four are quick screening tools; none are meant to diagnose concussion, which should only be done by a qualified healthcare professional based on a formal symptom assessment and standardized testing of cognitive ability and balance, and consideration of all clinical factors. Rather, they are only intended for use to guide an initial “remove from play” decision.

4. Ensuring that no player is allowed to return to game or practice play if there is even a slight suspicion, based on the sideline evaluation, self-reported symptoms, or observable signs, to suggest that the athlete may have suffered a concussion (the standard under the law in all states), but is referred for a more formal evaluation by a health care professional with appropriate training and expertise in the diagnosis and management of concussion. If there is any question about whether a player has suffered a concussion, follow the mantra, “When in doubt, sit them out.”

  1. Meehan WP, Landry GL. Council on Sports Medicine and Fitness Pediatrics. Tackling in Youth Football. Pediatrics 2015;136(5). doi: 10.1542/peds.2015-3282 (accessed at http://pediatrics.aappublications.org/content/early/2015/10/20/peds.2015…)
  2. MacDonald J, Kyroac D, Peterson I. Reliability and Specificity of the King-Devick Test in Baseline Concussion Evaluations of High School Athletes. Research Paper presented at 2016 American College of Sports Medicine Annual Meeting, Boston, MA, June 2016.
  3. Chrisman SP, Quitiquit C, Rivara FP. Qualitative study of barriers to concussive symptom reporting in high school athletics. J Adolesc Health 2013;52:330-5 e3.
  4. Register-Mihalik JK, Guskiewicz KM, Valovich McLeod TC, Linnan LA, Meuller FO, Marshall SW.  Knowledge, Attitude, and Concussion-Reporting Behaviors Among High School Athletes: A Preliminary Study.  J Ath Tr. 2013;48(3):000-000. DOI:10.4085/1062-6050-48.3.20 (published online ahead of print
  5. Kroshus E, Daneshvar DH, Baugh CM, Nowinski CJ, Cantu RC. NCAA concussion education in ice hockey: an ineffective mandate. Br J Sports Med. 2013;doi:10.1136/bjsports-2013-092498 (epub. August 16, 2013)
  6. Register-Mihalik JK, Linnan LA, Marshall SW, Valovich McLeod TC, Mueller FO, Guskiewicz KM.  Using theory to understand high school aged athletes’ intentions to report sport-related concussion: Implications for concussion education initiatives.  Brain Injury2013;27(7-8):878-886.
  7. Kroshus E, Garnett B, Hawrilenko M, Baugh C. Concussion under-reporting and pressure from coaches, teammates, fans, and parents.  Soc Sci & Med. 2015; 134:66-75.
  8. Kutcher J, McCrory P, Davis G, et al. What evidence exists for new strategies or technologies in the diagnosis of sports concussion and assessment of recovery? Br J Sports Med 2013;47:299-303. (accessed March 21, 2013)
  9. Broglio SP, Martini D, Kasper L, Eckner JT, Kutcher JS.  Estimation of Head Impact Exposure in High School Football: Implications for Regulating Contact Practices.  Am J Sports Med 2013;20(10). DOI:10.1177/036354651302458 (epub September 3, 2013).
  10. SCAT3. Br J Sports Med 2013;47:259 (full pdf can be accessed without charge at http://bjsm.bmj.com/content/47/5/259.full.pdf )
  11. Child-SCAT3. Br J Sports Med 2013;47:263 (full pdf can be accessed without charge athttp://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/JSM/A/JSM_23_2_2013_02_14_MCCRORYY_200872_SDC3.pdf)
  12. McCrea M. Standardized mental status testing on the sideline after sport-related concussion. J Athl Train. 2001;36:274-279.
  13. McCrea M, Iverson, Echemendia R, Makdissi M, Raftery M.  Day of injury assessment of sport-related concussion. Br J Sports Med 2013;47:272-284.
  14. Giza C, Kutcher J, Ashwal S, et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology2013;DOI:10.1212/WNL.0b013e31828d57dd (published online before print March 18, 2013)

Important note from SmartTeams

At the time The Smartest Team was filmed in 2012 and for a time after its August 2013 release, SmartTEAMS was recommending an additional “E”: Equipping players with impact sensors (eg. accelerometers) – whether in their helmets, mouth guards,  chin straps, or headbands or behind their ear – to alert coaches, athletic trainers, team doctors, other sideline personnel and/or parents to impacts of sufficient force to possibly cause concussion, thus triggering either closer observation of the athlete for signs of concussion or a quick “remove from play” concussion sideline assessment.

While there were, at the time, no published studies validating the use of impact sensor systems in this manner, and a precise “concussion threshold” remains unknown, SmartTeams, as did the authors of a 2013 study (8), believed that the potential clinical utility of impact sensors was worthy of careful consideration.

A subsequent study by researchers at the University of Michigan (9) noted that, while sensors were then beyond the reach of most football programs, a “number of companies [were] developing innovative, low-cost technologies that [would likely] make instrumentation both practical and feasible” in the future.

Based, however, on MomsTEAM’s extensive experience working with a host of sensor companies, high school football programs (2012 and 2013 seasons), and youth football programs (2014 and 2015 seasons), it now appears that the day when affordable and reliable impact sensors become available for widespread use in contact and collision sports is further off than we, and other concussion experts and observers, first believed.  As a result, SmartTEAMS is not currently recommending the use of impact sensors as a best practice in aiding the identification of athletes with possible concussion on the sports sideline.

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