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Concussion Identification and Removal from Play: It's All About the "Five E's"

Identifying athletes for removal-from-play sideline screening critical element of Six Pillars approach to concussion risk management

To minimize the risk of delayed recovery from concussion, long-term injury, or, in rare instances, catastrophic injury or death, it is critical that athletes suspected of having sustained a concussion are removed from play as quickly as possible. Removal from play in case of a suspected concussion and no same day return are now required by law, at least at the high school level, in almost all states. Damon Glass giving King Devick test

​​Identification of concussion on the sports sideline, however, is difficult for three main reasons:

  1. athletes are often unwilling to report concussions or fail to recognize that they have suffered a head injury;
  2. a significant percentage of diagnosed concussions are not the result of a specific blow observable on the sideline, and the force required to cause a concussion varies widely from athlete to athlete; ​and
  3. even trained sideline observers have a hard time spotting the often subtle signs of concussion.

Five E's

Experts believe, however, that the chances that a concussion will be identified early on the sports sideline can be maximized by following a multi-pronged approach:​

1.  Employing a certified athletic trainer with specialized expertise in the rapid screening of athletes for possible concussion on the sideline at every game and practice [note: making the clinical diagnosis of concussion should always be left to a doctor);

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, especially by:

a. creating a safe reporting environment, such as by having the athletic director at the school bring in medical providers from the community to talk about concussion during the pre-season concussion safety meeting, and the coach being understanding and supportive of the decision by an athlete to report experiencing concussive symptoms and remove themselves from the game in order to avoid risking further injury by continuing to play, especially in front of other athletes; and 

b. employing a "buddy system" in which players look for and report signs of concussion in designated teammates. 

It is important also to emphasize that, despite ongoing concerns about chronic under-reporting by athletes of concussion symptoms, symptom assessment (via the use of a symptom scale) remains a critical component of concussion evaluation;

3. Equipping players with impact sensors (eg. accelerometers) - whether in their helmets, mouth guards, chin straps, skull caps, or head bands - to alert coaches, athletic trainers, team doctors, other sideline personnel and/or parents to impacts of sufficient force to possibly cause concussion. While a growing number of concussion experts see benefits in real-time monitoring,[1,2,3] and sensors currently on the market are probably beyond the reach of most football programs, a recent study in the prestigious American Journal of Sports Medicine also notes on a positive note that a "number of companies are developing innovative, low-cost technologies that will make instrumentation both practical and feasible." [3]  Shockbox sensor readout

There are, however, a number of important caveats to the use of impact sensors for real-time monitoring:

  • Not diagnostic of concussions. Some in the media and even some concussion researchers are laboring under the misconception that impact sensors are intended to diagnose concussions. They are not. Nor are they intended to replace athletic trainers and other sideline observers trained to spot signs of concussions and evaluate athletes using rapid remove-from-play screening tools.  As Danny Crossman, CEO of Impakt Protective, the Canadian company that manufactures Shockbox sensors featured in the new PBS documentary, "The Smartest Team," "The main point of the helmet sensors wasn't to say, 'You got a concussion.' The point was to say, 'That head took a hit.'"  In talking about the Shockbox sensor system, Crossman noted that "the alerts, the signals from the sensors, [are sent wirelessly to an iPad or iPhone] on the sideline where they] stack up one behind each other like text messages, so [that] the athletic trainer or whoever's got the phone, they would just see five, six, however many impacts there were, alerts one after the other, and they would pop up, and they would see on their roster of players which ones had the impacts. [The athletic trainer] can then use his training, intuition, and his eyes, number one tool is his eyes, to say ‘what just happened there?'"
  • Impact data is just that: data.  Concussion researchers have not yet found the so-called "concussion holy grail": an impact threshold above which concussion is statistically likely. Indeed, because the impact forces that cause concusison are unique for individual athletes, are likely affected by numerous variables, and indeed may change from moment to moment, game to game, and over time, it may be that such an impact threshold will never be found. Thus, the team using sensors must be careful not to rely on the data transmitted by the sensors, whether it triggers a warning or alarm, as in any way determinative of whether an athlete has or has not suffered a concussion.
  • Not intended to replace trained observers on sports sideline. Nor are impact sensors intended as a substitute for athletic trainers, team doctors and other personnel on the sports sideline looking for signs of concussion in athletes.  While the use of impact sensors has not yet been shown in any controlled restrospective or prospective studies pubished in a peer-reviewed journal to lead to statistically significant improvement in the rate at which concussions are identified, the lack of such evidence should not be an obstacle to employing sensors, especially when the anecdotal evidence thus far, not to mention the opinion of respected concussion experts, including Jeffrey Kutcher[2] and Steven Broglio, [3] supports their use.  

4. Evaluating players on the sideline (or in the locker room) utilizing sideline assessment tools capable of detecting and quantifying the acute phase of concussion, including one or more of the following:​

a. Sports Concussion Assessment Test version 3 (SCAT3), or for athletes under age 13, the Child SCAT3 (for use by athletic trainers and other health care professionals); 

b. Standardized Assessment of Concussion (SAC)(intended for use by athletic trainers and other health care professionals, but may be used by coaches with training);

c. Balance Error Scoring System (BESS) or Modified BESS (M-BESS)(for use by trained health care professionals, preferably on both a hard surface and foam pad)​;

d. King-Devick (K-D) Test (best used by trained health care professionals, but designed to be a simple, quick and easy "remove from play" screening tool for use by volunteers with little or no training);

e. Maddocks questions (a series of five questions designed to test an athlete's orientation to time and place; while just one part of the SAC and SCAT3, the Maddocks questions are particularly valuable as a quick, remove-from-play screen because the questions can be asked by anyone, such as a coach, parent, or volunteer).

Notes of caution about sideline assessments

  • Not foolproof: A 2013 analysis of the peer-reviewed literature on date of injury assessments [4] 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 SCAT3, and that it was too early to draw any conclusion regarding the eventual usefulness of the K-D Test, or others still in the development pipeline.
  • Most require training: With the exception of the K-D test and the Maddocks questons, the other three remove-from-play sideline assessment "remove from play" screening tools are designed for use on the sports sideline by trained health care professionals.  In the absence of trained personnel, a coach/parent/volunteer should immediately remove a player from practice or play, arrange for a prompt evaluation by medical professional, and not allow the athlete to return to play that day, if they observe any of the following signs after a direct or indirect blow to an athlete's head:
    • loss of consciousness (however brief)
    • balance or coordination problems (unsteady gait, athlete stumbles, walks sideways, is labored in their movements)
    • disorientation or confusion (inability to respond appropriately to questions, such as the Maddocks questions)
    • blank or vacant look
    • visible facial injury in combination with any of the above. 
  • ​​Intended only as remove-from-play screening tools, not to diagnose concussions:  All five are quick screening tools intended only to guide an initial "remove from play" decision. None are meant to diagnose ​concussion, which should be the exclusive domain of a qualified health care professional after a formal symptom assessment, testing of cognition, balance, and other relevant clinical factors, away from the sports sideline.

5. 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 (as required by law in nearly every state), 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, the mantra that should continued to be followed is, "When in doubt, sit them out."

1.Greenwald R, Chu J, Beckwith J, Crisco J.  A Proposed Method to Reduce Underreporting of Brain Injury in Sports.  Clin J Sport Med 2012; 22(2):83-85.

2. Kutcher J, McCrory, 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.

3.  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)

4. McCrea M, Iverson G, Echemendia R, et. al. Day of injury assessment of sport-related concussion.  Br J Sports Med 2013;47:272-284. (accessed March 23, 2013)

Posted October 6, 2013