Management of Sports-Related Concussions: Staying Ahead of the Game, 2nd Edition: Summary 22
Comprehensive Assessment A thorough clinical evaluation should include: • Detailed symptom assessment • Neurological examination • Balance testing : ○ Balance Error Scoring System (BESS): ■ Balance with eyes closed: double leg, single leg, and tandem stance on a stable surface and foam over 20 seconds • Vestibular Ocular Motor Screening (VOMS) : ○ Assess for headache, dizziness, nausea, and fogginess in response to smooth pursuits, saccades, near point convergence, VOR, and visual motion sensitivity It is crucial to understand that psychological factors play a significant role in symptom recovery and can contribute to persistent symptoms. NEUROPSYCHOLOGICAL TESTING LEARNING TIP! • Cognitive testing • Consideration of psychological factors
Step 4: Coordination and Oculomotor Screen • Finger to nose test • Eye movements in all directions without double vision Step 5: Memory and Maddocks Questions • What venue are we at today? • Which half is it now? • Who scored last in this match? • What team did you play last week/game? • Did your team win the last game? Step 6: Progress to Off-field Assessment • Athlete background/risk factors • Symptom evaluation • Standardized Assessment of Concussion (SAC) King-Devick Test The King-Devick Test is a rapid sideline screening tool that assesses saccadic eye movements (not convergence or pursuits). While useful, it should not be used as a standalone diagnostic tool. CLINICAL EVALUATION Clinical evaluation builds upon the sideline assessment and aims to determine the specific clinical trajectory of the concussion. This approach recognizes that not all concussions are the same and may require different management strategies. Clinical Trajectories Research has identified several common trajectories: • Vestibular —may take longer to recover: ○ Risk factors: history of motion sensitivity ○ Signs: abnormal VOR and visual motion sensitivity • Cervical : ○ Risk factors: whiplash injury ○ Signs: VOMS, VOR, near point convergence, headaches, nausea, dizziness, fatigue, numbness/ tingling • Cognitive/fatigue : ○ Risks: history of learning disability ○ Signs: fatigue, concentration/memory problems, foggy, feeling slowed down, normal VOMS • Post-traumatic migraine • Anxiety/mood : ○ Risks: history of anxiety ○ Symptoms: increased symptoms when inactive, normal VOMS • Ocular : ○ Signs: rarely wake with a headache, abnormal pursuits, saccades, and near point convergence. Each trajectory has characteristic symptoms, risk factors, and findings on specialized tests like the Vestibular/ Ocular Motor Screening (VOMS). Psychological factors and severity of initial symptoms play a significant role in the recovery time.
Neuropsychological testing can provide valuable information about cognitive function following a concussion. Baseline and post tests are not required. However, it should not be used as a standalone diagnostic or return-to-play tool.
Common Tests • Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) : ○ Assess: memory composite (verbal and visual), visual motor speed composite, reaction time composite, impulse control composite ○ C3 Logix These tests assess various cognitive domains including verbal memory, visual memory, processing speed, and reaction time. Interpretation: Results should be interpreted in the context of clinical findings, baseline scores (if available), and the overall clinical picture. Neuropsychological testing has clinical value and contributes significant information but should not be used as an independent return-to-play tool.
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