Resolution of symptoms following concussion is a poor indicator of brain recovery (1). Concussion results in metabolic disturbance, changes in cerebral blood flow and perfusion, and several other pathophysiologic processes known as the Neurometabolic Cascade of concussion (2–4). Numerous studies show that prior to full metabolic recovery from a concussion, the brain is extremely vulnerable, where even smaller impacts can cause secondary concussion injuries and these injuries can result in severe brain injury with potentially permanent or fatal outcomes (5,6). The most important aspect to safe and proper management of concussions is to ensure that complete recovery of the brain has been achieved prior to allowing an athlete to return to a high-risk sport environment; a process which has been shown to take at least 3 to 4 weeks in adults and has an unknown timeline for children and adolescents (7,8).
Relying on the resolution of self-reported symptoms, to make return-to-play decisions puts healthcare practitioners in an extremely precarious position, as symptoms do not reflect true recovery of the brain following concussion. Self-reported symptoms at rest are even more unreliable as ongoing blood flow and cognitive abnormalities may only come to light when challenged by intensive physical exertion tests (9–14).
Pre-season baseline testing involves testing high-risk athletes prior to starting their sporting season to assess numerous physical and cognitive systems that could potentially become affected by a concussion. When properly used and interpreted, baseline testing adds useful information to the management of sport-related concussion by giving clinical insight into pre-injury physical and cognitive functioning, which provides clinicians with objective data to make more informed and safer, return-to-play decisions (15–17). In fact, annual baseline testing is endorsed, recommended, or considered to be helpful for appropriate concussion care by most leading global health and medical groups, and position statements including the International Consensus Statement on Concussion in Sport (16), the Centers for Disease Control (CDC) (https://www.cdc.gov/headsup/basics/baseline_testing.html), the National Athletic Trainers Association (18), The Canadian Olympic and Paralympic Concussion Guidelines (19), Concussion in Sport Australia Position Statement (20), the International Ice Hockey Summit (21), and the Canadian Academy of Sport and Exercise Medicine (22).
It should be noted that baseline testing should involve more than just computerized neurocognitive measures (23–25) due to numerous reliability and validity concerns (26–28, 77). Additionally, neurocognitive tests, in isolation, don’t measure important aspects of concussion injuries such as balance, visual tracking and processing speed, strength & physical performance measures, auditory memory & concentration. A proper baseline assessment should involve all of these areas, including neurocognitive testing parameters for improved diagnostic and management utility (29–31). Baseline testing is a ‘procedure’ not ‘a test’.
This document covers all aspects of the baseline testing protocol used by Complete Concussions and provides supporting evidence for each test included within our testing battery.
Complete Concussions offers a service to physicians by conducting comprehensive preseason testing, as well as return-to-play management, multistage physical exertion tests, and re-testing of injured individuals. All of this information can be provided to the overseeing physician in a detailed report; providing additional insight to make safer return-to-sport clearance decisions.
The Complete Concussions baseline testing battery takes roughly 30 minutes per individual and costs may vary clinic to clinic. In some cases, testing may be covered under health insurance benefits. All test results are stored on a secure electronic health records system that is accessible by any Complete Concussions clinic worldwide.
Our testing protocol consists of the following areas:
NOTE: Re-testing prior to return to play also involves physical exertion testing immediately prior to conducting the baseline re-assessment. This method (testing in a physically exerted state), has been shown to be a more sensitive way of testing, revealing up to 28% more neurocognitive impairment than neurocognitive testing at rest (12,14).
The Post-Concussion Symptom Score (PCSS) is the most widely used concussion symptom inventory worldwide. Adapted by the Concussion in Sport Group as part of the Sideline Concussion Assessment Tool (SCAT), the PCSS is a 22-item measure with each symptom scored on a 7-point Likert scale (16). A study by Barr et al., found that the PCSS demonstrated the most sensitive and specific measure for concussion at the time of injury (when compared to balance and a neurocognitive examination), however, this score tends to normalize prior to full metabolic and functional brain recovery (32),(7). This indicates that the symptom score, while potentially the most useful parameter for making the initial diagnosis, does not coincide with the recovery of the brain following concussion. Therefore, more objective testing parameters are required to inform safer return-to-play decision-making.
Another component of the SCAT, the SAC is a verbal/auditory neurocognitive test, which consists of Orientation, Immediate Memory, Concentration, and Delayed Memory Recall Tests. The SAC has been validated in several studies for use in the assessment of sport-related concussion (33–35). Because the SAC does not yet have established normative data, this test must be administered at baseline to establish individualized scores. Barr & McCrea found that immediate SAC scores decrease in concussion patients by an average of 4 points from baseline. Using multiple regression, the authors found that a 1-point decrease from baseline SAC carried a 94% sensitivity and 76% specificity for the diagnosis of concussion (36). This test has also been found to demonstrate objective impairment in individuals reporting a complete resolution of symptoms (32). Marinides et al., found that the SAC alone was only able to accurately diagnose concussion 52% of the time, however adding in balance assessments and the King-Devick test improved the diagnostic accuracy to 100% (37), demonstrating the importance of a multifaceted approach.
Originally developed for the assessment of dyslexia, the King-Devick (K-D) test has emerged as one of the most popular and useful baseline and post-injury tests for concussion. The K-D test is an easily administered test for visual tracking and processing speed. Dhawan et al., found that following a concussion, there is an average drop in total reading time from baseline by 7.3 seconds. These deficits also typically remain beyond the symptomatic period, which makes the K-D test not only a good immediate sideline test, but also a good return-to-play assessment measure (38). Marindes et al., found that the K-D test alone was able to pick up 79% of concussion injuries and when combined with balance and SAC testing, 100% of concussions were accurately diagnosed (37). In ages 8 through to adulthood, the King-Devick test is able to distinguish healthy vs. concussed individuals with high accuracy and moderate test-retest reliability when a baseline test is used as comparison (40–49). As with all concussion tests, the accuracy improves when used as part of a larger testing battery.
Complete Concussions performs a two-part balance assessment, which consists of the Dual-Task Tandem Gait from the SCAT as well as a more objective measure of Postural Sway on the Concussion Tracker app.
Dual-task Tandem Gait combines balance and cognitive tasks. This is important as dual-tasks are a more sensitive measure for detecting ongoing functional impairments after concussion (even following the resolution of symptoms), which is a good indicator in return to play decision-making. One study showed that previously concussed asymptomatic individuals still make significantly more errors on the cognitive portion of a dual task compared to healthy controls after an average of 71 days post-injury (78). Another study focusing on acute concussions looked at both single and dual-task tandem gait and found significant differences in the motor performance of concussed and non-concussed individuals (79). These two studies combined highlight the importance of dual-task testing for both acute concussion and RTP decisions, as well as the importance of analyzing all of the variables (both cognitive and physical). The level of acceptable change however remains undetermined, and the advice is to air on the side of caution while more research is completed. Dual-task measures also demonstrate high test-retest reliability (79).
Postural sway measures utilizing force plate technology demonstrate balance deficits up to 30 days following concussion (beyond resolution of symptoms, SAC scores, BESS, and computerized neurocognitive test scores); demonstrating added sensitivity to the overall concussion test battery (50,57–60). Postural sway measures using force plates also demonstrate high test-retest consistency in adolescent athletes (60). Due to challenges around availability for sideline testing, postural sway measures in smartphone applications have been rigorously compared to force plate technology. Postural Sway testing in the Concussion Tracker app is equivalent to SWAY(80) and has a very stable test-retest reliability. The testing application is FDA-approved, gamified, and has an extremely high correlation to force plate testing. This test can now be applied directly on the sidelines as well as for return-to-sport clearance testing.
NOTE: As an alternative balance assessment for wheelchair users, the WESS test has been included in the Complete Concussions baseline testing battery. This test is similar to a BESS test, utilizing varying postural and visual conditions. A preliminary study in 2013 demonstrated the WESS test to show high inter-rater and test-retest reliability (81,82,83).
Neurocognitive testing has been a cornerstone to concussion evaluation and involves testing various domains such as reaction time, executive function, processing speed, and cognitive efficiency. As mentioned previously, neurocognitive testing is never meant to be used in isolation (27,69), however it is an important tool due to the ability to demonstrate ongoing impairment beyond symptom and other baseline test normalization (70).
Complete Concussions uses the Digital Automated Neurobehavioral Assessment (DANA) which was commissioned and studied by the US military specifically for use in a variety of field conditions. This is a mobile-optimized neurocognitive test that has been made available within our Concussion Tracker application for both pre-and post-injury testing. The included tests were selected by a scientific advisory group comprised of military and civilian neuropsychologists and neurologists. All tests included in the DANA battery were in the public domain and have extensive literature supporting their reliability and validity for traumatic brain injury.
The DANA tool has demonstrated high test-retest reliability across various testing, environmental, and temperature conditions (71–73). DANA has also been validated for the detection of concussion (74) and found in head-to-head studies to be equal to (75), or superior to (71), other neurocognitive tests on the market for the detection of concussion beyond symptom resolution (76).
Two recent studies have also found that high-intensity physical exertion, completed prior to test administration effects neurocognitive function (12,14). As such, the current recommendation is to perform neurocognitive testing following intensive physical exertion when making return-to-play clearance decisions, as this may be a more sensitive measure of ongoing cognitive deficits. In lieu of these studies, Complete Concussions clinics perform our entire testing battery following the completion of the Gapski-Goodman physical exertion test (13) prior to making return-to-play clearance decisions. Athletes must remain symptom free throughout the duration of the Gapski-Goodman Test (GGT) as well as complete ALL physical and cognitive measures to a level at or above their pre-season baseline test results immediately following the GGT.
Complete Concussions was developed out of the necessity to provide high-risk athletes with evidence-based concussion management strategies. The baseline testing protocol was developed through years of research to establish the most comprehensive testing battery to assess both acute injuries and the readiness to return to high-risk sporting activities.
It has been well established through the literature that symptoms alone do not reflect true recovery of the brain, making it imperative that objective measures be incorporated into the decision-making process. In addition to this, healthcare practitioners often face pressure from athletes, parents, and coaches to provide clearance. Having rigorous, objective testing parameters can relieve this pressure and provide the clinician with the needed evidence to hold an athlete back from an early return to competition.
As was demonstrated above, no single concussion test is adequate to be used in isolation for either diagnosis or return-to-play decision-making. The Complete Concussions protocol conducts the most extensive concussion baseline testing available. Clearance of any athlete is not granted until there is a complete return to baseline of ALL measures following the passing of all step-wise return-to-learn and return-to-play stages including a 2-step process of physical exertion testing.
If you would like to learn more about how Complete Concussions baseline testing can help your patients or how we can help with return to school, work, and sport, or rehabilitation for persistent concussion symptoms please visit CompleteConcussions.com.
You can also download our PDF referral form here: https://completeconcussions.com/for-doctors/
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