Concussion Initial Evaluation 13 years and older

Sport Concussion Assessment Tool - 3rd Edition

For use by medical professionals only

What is childSCAT3?

The SCAT3 is a standardized tool for evaluating injured children for concussion and can be used in children aged from 13 years and older. It supersedes the original SCAT and the SCAT2 published in 2005 and 2009, respectively'. For younger persons, ages 12 and under, please use the Child SCAT3. The SCAT3 is designed for use by medical professionals. If you are not qualified, please use the Sports Concussion Recognition Tool'.Preseason baseline testing with the SCAT3 can be helpful for interpreting post-injury test scores.

Specific instructions for use of the SCAT3 are provided on page 3. If you are not familiar with the SCAT3, please read through these instructions carefully. This tool may be freely copied in its current form for distribution to individuals, teams, groups, and organizations. Any revision and any reproduction in a digital form require approval by the Concussion in Sport Group.

NOTE: The diagnosis of a concussion is a clinical judgment, ideally made by a medical professional. The SCAT3 should not be used solely to make, or exclude, the diagnosis of concussion in the ab· sense of clinical judgment. An athlete may have a concussion even if their SCAT3 is "normal".

What is a concussion?

A concussion is a disturbance in brain function caused by a direct or indirect force to the head. It results in a variety of non-specific signs and/or symptoms (like those listed below) and most often does not involve loss of consciousness. Concussion should be suspected in the presence of any one or more of the following:

• Symptoms (e.g., headache), or
• Physical signs (e.g., unsteadiness), or
• Impaired brain function (e.g. confusion) or
• Abnormal behavior (e.g., change in personality).

SIDELINE ASSESSMENT

Indications for Emergency Management

NOTE: A hit to the head can sometimes be associated with a more severe brain injury. If the concussed child displays any of the following, then do not proceed with the ChildSC AT3; instead activate emergency procedures and urgent transportation to the nearest hospital:

• Glasgow Coma score less than 15
• Deteriorating mental status
• Potential spinal injury
• Progressive, worsening symptoms or new neurologic signs

Potential signs of concussion?

If any of the following signs are observed after a direct or indirect blow to the head, the child should stop participation, be evaluated by a medical professional and should not be permitted to return to sport the same day if a concussion is suspected.

1. Glasgow coma scale (GCS)

2. Maddocks Score3

"I am going to ask you a few questions, please listen carefully and give your best effort.·

Modified Maddocks questions (1 point for each correct answer)

Any athlete with a suspected concussion should be REMOVED FROM PLAY, medically assessed, monitored for deterioration (i.e., should not be left alone) and should not drive a motor vehicle until cleared to do so by a medical professional. No athlete diagnosed with a concussion should be returned to sports participation on the day of injury.

BACKGROUND

SCAT3 to be done In resting state. Best done 10 or more minutes post exercise.

3. SYMPTOM EVALUATION

How do you feel?

You should score yourself on the following symptoms. based on how you feel now•.

0 = None | 1 and 2 = Mild | 3 and 4 = Moderate | 5 and 6 = Severe

Overall rating: If you know the athlete well prior to the injury, how different is the athlete acting compared to his/her usual self?

Scoring on the SCAT3 should not be used as a stand-alone method to diagnose concussion, measure recovery or make decisions about an athlete's readiness to return to competition after concussion. Since signs and symptoms may evolve over time, it is important to consider repeat evaluation in the acute assessment of concussion.

4. COGNITIVE & PHYSICAL EVALUATION

Cognitive assessment

Standardized Assessment of Concussion- Child Version {SAC-C)4

Orientation (1 point for each correct answer)

Immediate memory

Elbow | Alternative word list: Candle Baby Finger

Apple | Alternative word list: Paper Monkey Penny

Carpet | Alternative word list: Sugar Perfume Blanket

Saddle | Alternative word list: Sandwich Sunset Lemon

Bubble | Alternative word list: Wagon Iron Insect

Concentration: Digits Backward

4-9-3 | Alternative digit list: [ 6-2-9 ] [ 5-2-6 ] [ 4-1-5 ]

3-8-1-4 | Alternative digit list: [ 3-2-7-9 ] [ 1-7-9-5 ] [ 4-9-6-8 ]

6-2-9-7-1 | Alternative digit list [ 1-5-2-8-6 ] [ 3-8-5-2-7 ] [ 6-1-8-4-3 ]

7-1-8·4·6-2 | Alternative digit list: [ 5-3-9-1-4-8 ] [ 8-3-1-9-6-4 ] [ 7-2-4-8-5-6 ]

Concentration: Days in Reverse Order (1 pt. for entire sequence correct)

5. Neck Examination:

Range of motion | Tenderness | Upper and lower limb sensation & strength

6. Balance Examination

Done one or both of the following tests.

Modified Balance Error Scoring System {BESS) testing

Condition

And /OR
Tandem Gait

7. Coordination Examination

Upper limb coordination

8. SAC Delayed Recall 4

INSTRUCTIONS

Words in quotations throughout the SCAT3 are the instructions given to the athlete by the tester.

Symptom Scale

"You should score yourself on the following symptoms. based on how you feel now"

To be completed by the athlete. In situations where the symptom scale is being completed after exercise, it should still be done in a resting state, at least 1 0 minutes post-exercise.

For a total number of symptoms, the maximum possible is 22. For Symptom severity score, add all scores in the table, the maximum possible is 22 x6 = 132.

SAC4

Immediate Memory
"I am going to test your memory. I will read you a list of words and when I am done. repeat back as many words as you can remember, in any Order"

Trials 2&3:
"I am going to repeat the same list again. Repeat back as many words as you can remember in any order, even if you u said the word before."

Complete all 3 trials regardless of score on trial 1 &2. Read the words at a rate of one per second. Score 1 pt. for each correct response. Total score equals sum across all 3 trials. Do not inform the athlete that delayed recall will be tested.


Concentration
Digits backward
"I am going to read you a string of numbers and when I am done, you repeat them back to me backward, in reverse order of how I read them to you. For example, if I say 7-1-9, you would say 9-1-7"

If correct, go to next string length. If incorrect, read trial 2. One point is possible for each string length. Stop after Incorrect on both trials. The digits should be read at the rate of one per second.

Months In reverse order
"Now tell me the months of the year in reverse order. Start with the last month and go backward. So you'll say December, November... Go Ahead"
1pt. for entire sequence correct


Delayed Recall
The delayed recall should be performed after completion of the Balance and Coordination
Examination.

"Do you remember that list of words read an fl!w times earlier? Tell me as many ones from the lists you can member in any order."

Score 1 pt. for each correct response

Balance examination

Modified Balance Error Scoring System (BESS) testing'

This balance testing is based on a modified version of the Balance Error Scoring System (BESS)5. A stopwatch or watch with a second hand is required for this testing.

"I am now going to test your balancr!. Please take your shoes off, roll up your pant legs above ankle (if applicable), and remove any ankle taping (if applicable). This test will consist of three twenty second 1ests with different stances."


"I am now going to test your balance. Please, take your shoes off, roll up your pant legs above the ankle (if applicable), and remove any ankle taping (if applicable). This test will consist of two different parts"

(a) Double leg stance:
"The first stance is standing wM the reet together with hands on hips and with eyes closed. The child should try to maintain stability in that position for 20 seconds. I will be counting the number of times you move out of this pasition. I will start timing when you are set and have dosed your eyes."

(b) Tandem stance:
"If you were to kick a bail, which would you use? This will be dominant foot. Now stand on your non-dominant foot. the dominant leg should be held in apprximately 30 degress of hip flexion and 45 degrees of knee flexion. Again, you should try to maintain stability for 20 seconds with your hands on your hips and your eyes closed. I will be counting the number of times you move out of this position. If you stumble out of this position, open your eyes and retum to the start position and continue balancing. I will start timing when you are set and hall!! dosed your eyes."

(c) Tandem stance:
Now stand heel-to-toe with your non-dominant foot in back. Your weight should be evenly distributed aaoss both feet. Again, you should try to maintain stability for 20 seconds with your hands on your hips and your eyes closed. I will be counting the number of times you move out of this position. If you stumble out of this position. open your eyes and retum to the start position and continue balandng. I will start timing when you are set and have closed your eyes.

Balance testing- types of errors

1. Hands lifted off iliac crest
2. Opening eyes
3. Step, stumble, or fall
4. Moving hip into> 30 degrees abduction
5. Lifting forefoot or heel
6. Remaining out of test position > 5 sec

Each of the 20-second trials is scored by counting the errors, or deviations from the proper stance, accumulated by the child. The examiner will begin counting errors only after the child has assumed the proper start position. The modified BESS is calculated by adding one error point for each error during the two 20-second tests. The maximum total number of errors for any single condition Is 10. If a child commits multiple errors simultaneously, only one error is recorded but the child should quickly return to the testing position, and counting should resume once the subject is set. Children who are unable to maintain the testing procedure for a minimum of five seconds at the start are assigned the highest possible score, ten, for that testing condition.

OPTION: For further assessment, the same 3 stances can be performed on a surface of medium density foam (e.g., approximately 50cm x 40cm x 6cm).

Tandem Gait
Participants are instructed to stand with their feet together behind a starting line (the test is best done with footwear removed). Then, they walk in a forward direction as quickly and as accurately as possible along with a 38mm wide (sports tape), 3-meter line with an alternate foot heel-to-toe gait ensuring that they approximate their heel and toe on each step. Once they cross the end of the 3m line, they turn 180 degrees and return to the starting point using the same gait A total of 4 trials are done and the best time is retained. Athletes should complete the test in 14 seconds. Athletes fail the test if they step off the line, have a separation between their heel and toe, or if they touch or grab the examiner or an object. In this case, the time is not recorded and the trial repeated, if appropriate.

Coordination examination

Upper limb coordination
Finger-to-nose (FTN) task:
The tester should demonstrate It to the child.

"I am going to test your coordination now. Please sit comfortably on the chair with your eyes open and your arm (either right or left) outstretched (shoulder flexed to 90 degrees and elbow and fingers extended). When I give a start signal I would like you to perform five successive fingers to nose repetition using your index finger to touch the tip of the nose as quickly and as accurately as possible."

Scoring: 5 correct repetitions in < 4 seconds = 1
Note for testers: Children fail the test if they do not touch their nose, do not fully extend their elbow or do not perform five repetitions. Failure should be scored as 0.

References & Footnotes

1. This tool has been developed by a group of international experts at the 4th International Consensus meeting on Concussion in Sport held in Zurich, Switzerland in November 2012. The full details of the conference outcomes and the authors of the tool are published in The BJSM Injury Prevention and Health Protection, 2013, Volume 47, Issue 5. The outcome paper will also be simultaneously co-published in other leading biomedical journals with the copyright held by the Concussion in Sport Group, to allow unrestricted distribution, providing no alterations are made.
2. McCrory P et al., Consensus Statement on Concussion in Sport - the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. British Journal of Sports Medicine 2009; 43: i76-89.
3. Maddocks, DL; Dicker, GD; Saling, MM. The assessment of orientation following concussion in athletes. Clinical Journal of Sport Medicine. 1995; 5(1): 32-3.
4. McCrea M. Standardized mental status testing of acute concussion. Clinical Journal of Sport Medicine. 2001; 11: 176-181.
5. Guskiewicz KM. Assessment of postural stability following sport-related concussion. Current Sports Medicine Reports. 2003; 2: 24-30.
6. Schneiders, A.G., Sullivan, S.J., Gray, A., Hammond-Tooke, G.&McCrory, P. Normative values for 16-37 year old subjects for three clinical measures of motor performance used in the assessment of sports concussions. Journal of Science and Medicine in Sport. 2010; 13(2): 196-201.
7. Schneiders, A.G., Sullivan, S.J., Kvarnstrom. J.K., Olsson, M., Yden. T.&Marshall, S.W. The effect of footwear and sports-surface on dynamic neurological screening in sport-related concussion. Journal of Science and Medicine in Sport. 2010; 13(4): 382-386
8. Ayr, L.K., Yeates, K.O., Taylor, H.G.,&Brown, M. Dimensions of post-concussive symptoms in children with mild traumatic brain injuries. Journal of the International Neuropsychological Society. 2009; 15:19-30.

ATHLETE INFORMATION

Any athlete suspected of having a concussion should be removed from play, and then seek medical evaluation.

Signs to watch for

Problems could arise over the first 24-48 hours. The athlete should not be left alone and must go to a hospital at once if they:

• Have a headache that gets worse
• Are very drowsy or can't be awakened
• Can't recognize people or places
• Have repeated vomiting
• Behave unusually or seem confused; are very irritable
• Have seizures (arms and legs jerk uncontrollably)
• Have weak or numb arms or legs
• Are unsteady on their feet; have slurred speech

Remember, it is better to be safe.
Always consult your doctor after a suspected concussion.

Return to play

Athletes should not be returned to play the same day of injury. When returning athletes to play, they should be medically cleared and then follow a stepwise supervised program, with stages of progression.

Rehabilitation Stage - No Activity
Functional exercise at each stage of rehabilitation - Physical and cognitive rest
The objective of each stage - Recovery

Rehabilitation Stage - Lightaerobic Exercise
Functional exercise at each stage of rehabilitation - Walking, swimming or stationary cycling keeping the intensity, 70% maximum heart rate. No resistance training
The objective of each stage - Increase heart rate

Rehabilitation Stage - Sport-specific exercise
Functional exercise at each stage of rehabilitation - Skating drills in ice hockey. running drills in soccer. No head impact activities
The objective of each stage - Add movement

Rehabilitation Stage - Non-contact training drills
Functional exercise at each stage of rehabilitation - Progression to more complex training drills, eg passing drills in football and May start progressive resistance training
The objective of each stage - Exercise, coordination, and cognitive load

Rehabilitation Stage - Full contact practice
Functional exercise at each stage of rehabilitation - Following medical clearance participate in normal training activities
The objective of each stage - Restore confidence and assess functional skills by coaching staff

Rehabilitation Stage - Return to play
Functional exercise at each stage of rehabilitation - Normal gameplay
The objective of each stage -

There should be at least 24 hours (or longer) for each stage and if symptoms recur the athlete should rest until they resolve once again and then resume the program at the previous asymptomatic stage. Resistance training should only be added in the later stages.

If the athlete is symptomatic for more than 10 days, then consultation by a medical practitioner who is an expert in the management of concussion is recommended.

Medical clearance should be given before return to play.

Scoring Summary:

CONCUSSION INJURY ADVICE

(To be given to the person monitoring the concussed athlete)

This patient has received an injury to the head. A careful medical examination has been carried out and no sign of any serious complications has been found. Recovery time is variable across individuals and the patient will need monitoring for a further period by a responsible adult. Your treating physician will provide guidance as to this timeframe.

If you notice any change in behavior, vomiting, dizziness, worsening headache, double vision or excessive drowsiness, please call an ambulance to transport the child to hospital immediately.

Other important points:

- Rest (physically and mentally), including training or playing sports
until symptoms resolve and you are medically cleared
- No alcohol
- No prescription or non-prescription drugs without medical supervision.
Specifically:
· No sleeping tablets
· Do not use aspirin, anti-inflammatory medication or sedating pain killers
- Do not drive until medically cleared
- Do not train or play sport until medically cleared

SCAT3

Br J Sports Med 2013 47: 259

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