A Bump On The Head: Concussion Testing Revisited

Sometime today, League officials will announce a new standardized sideline testing protocol for diagnosing concussions in NFL players. This will put all 32 teams in compliance with procedures designed to protect the athletes from post-career mental health problems. The reason this is significant is that there are a few different kinds of tests for checking concussions and not all teams are using the same methods or being as diligent as they could be. And with the suicides of Andre Waters, Shane Dronett and more recently, Dave Duerson, it's really about time the NFL has moved forward in this area.

I really wanted to address this issue during the Bye week last season, but I couldn't find a standard procedure for Post-Concussion testing. I found out that there are more than a couple assessment tools that the trainer would use to see if a player could re-enter a game after being knocked unconscious. As I chased the White Rabbit down the hole, I unfurled enough to raise more questions and amass enough data on the subject of concussions to fill many many posts, so I will try to be as concise as I can. Hopefully I can bring you up to speed and prepared to understand the new policy as it is unfolded later today.

On Dec. 3, 2009, the NFL updated their rules on managing concussions, requiring players who showed any significant sign of concussion be removed from a game or practice and be barred from returning on the same day. Previous to that, players were only not allowed to return if they lost consciousness. The memo stated that a player who gets a concussion should not return to action on the same day if he shows certain signs or symptoms. Those symptoms included the inability to remember assignments or plays, a gap in memory, persistent dizziness, and persistent headaches.

Symptoms that require immediate removal include amnesia, poor balance and an abnormal neurological examination, whether or not those symptoms quickly subside. For symptoms like dizziness and headache, however, a player can return to the field unless they are "persistent." 

The new policy also stated:

"Once removed for the duration of a practice or game, the player should not be considered for return-to-football activities until he is fully asymptotic, both at rest and after exertion, has a normal neurological examination, normal neuropsychological testing, and has been cleared to return by both his team physician(s) and the independent neurological consultant."

Teams were also told that they must find an outside neurologist who can be consulted on concussions.

So at this point, it went from counting the fingers a trainer was holding up, to a few days of complete rest, then a re-testing of the symptoms. If nausea, dizziness or any other symptom persisted, more rest was required. If the symptoms were gone, the next step was walking around with no physical exertion. If problems arose, a return to rest. If not, the next step was to begin light physical activity. Then running, going through drills, then physical contact. Each step followed by tests to progress to the next.

The new standardized exam will have three components: cognitive, with questions for the player; neurological, with the athletic trainer or doctor examining the player's eye movement and doing hands-on physical checks; and the balance test.

Twenty-four symptoms will be listed, including confusion, headaches and trouble sleeping.

Later today we will find out more about the new changes, but here I will list some of the tests that are already in use, including one that should be part of the new standard.

    The SCAT Card

Many athletic trainers use a Sport Concussion Assessment Tool (SCAT), or a variation of it, to check for concussions during games. This laminated sheet or card lists a procedure to follow after a player concussion. The first one is a version supplied by a doctor with the NFL's Head, Neck, and Spine Committee. The second, as you will see, is adopted by other sports organizations and is not much different from the first.

SCAT
SCAT 2

The second one has a test called the Maddocks questions and is also part of the Standardized Assessment of Concussion (SAC).

The guidelines are intended for implementation by Athletic Trainers, Athletic Directors and Coaches and actual diagnosis of concussions and return to play decisions should be made by licensed physicians only.

Once the patient has been removed from the field and been stabilized, a full medical and neurological assessment exam should be undertaken. This assessment should include:

   1. Evaluation of potential signs and symptoms of concussion;
   2. Evaluation/diagnosis of concussion using a sideline mental status examination;
   3. Consideration for urgent hospital referral.

There is also a Post-Concussion Symptom Scale.

Rivermead Post Concussion Symptoms Questionnaire

The Rivermead Post Concussion Symptoms Questionnaire, abbreviated RPQ, is a questionnaire that can be administered to someone who sustains a concussion or other form of traumatic brain injury to measure the severity of symptoms. Used to determine the presence and severity of post-concussion syndrome (PCS), the measure has been cited in over 40 papers. The test, which can be self-administered or given by an interviewer, asks patients to rate the severity of 16 different symptoms commonly found after a mild traumatic brain injury (MTBI). Patients are asked to rate how severe each of the 16 symptoms has been over the past 24 hours on a scale from 0 to 4: absent, mild, moderate, or severe. In each case, the symptom is compared with how severe it was before the injury occurred.

Stroop Test

The Stroop effect has been used to investigate the psychological capacities of a person since its discovery while during the twentieth century it also became a popular neuropsychological test. This test is considered to measure selective attention, cognitive flexibility and processing speed, and it is used as a tool in the evaluation of executive functions.

The Stroop Task is a psychological test of our mental (attentional) vitality and flexibility. The task takes advantage of our ability to read words more quickly and automatically than we can name colors. If a word is printed or displayed in a color different from the color it actually names; for example, if the word "green" is written in blue ink (as shown in the figure to the left) we will say the word "green" more readily than we can name the color in which it is displayed, which in this case is "blue." 

Try your hand at the test.

Balance Equilibrium Scoring System

An athlete's balance and equilibrium can be tested through use of the Balance Error Scoring System (BESS). The BESS consists of 3 tests lasting 20 seconds each, performed on two different surfaces, firm and foam:
The athlete first stands with the feet narrowly together, the hands on the hips, and the eyes closed (double leg stance). The athlete holds this stance for 20 seconds while the number of balance errors (opening the eyes, hands coming off hips, a step, stumble or fall, moving the hips more than 30 degrees, lifting the forefoot or heel, or remaining out of testing position for more than 5 seconds) are recorded.
The test is then repeated with a single-leg stance using the non-dominant foot, and
A third time using a heel-toe stance with the non-dominant foot in the rear (tandem stance).
All three tests are performed on a firm surface (grass, turf, court), and again on a piece of medium-density foam (a piece of foam can easily be carried in a travel trunk or equipment bag for road games).


My best guess is that this will be part of the new guidelines announced later today. That brings us to the last and probably most important part of Post Concussion Testing:

The ImPACT™ Test

In early 2010, NFL commissioner Roger Goodell ordered all teams to implement baseline neuropsychological tests. ImPACT is one of a handful of computerized neuropsychological systems available (Axon Sports, the Concussion Resolution Index, and the Automated Neuropsychological Assessment Metrics are among the others) It has literally become the league's standard testing system. Thirty of the NFL's 32 teams now use ImPACT, according to the company's Web site.

The ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) test gauges things like memory and focus, to see whether a player is still affected by a concussion.

The test is administered during Mini Camps before contact drills, when players are healthy. Each player takes a 20-minute test to establish his baseline score of cognitive functions. Words, numbers and drawings flash on a computer screen and the athlete must at varying intervals recall those which did appear. If an athlete suffers a concussion, they retake the test and must achieve their baseline score before being allowed to return to the field. The software costs $500 a year and is used by several NFL and NHL teams.

This should give you a taste of what is and what shall come to pass and hopefully it helps players take something away from the game, especially their memories.

Go Broncos!