Alphabet Soup: Concussion Assessment in Youth

August 25, 2015 by sportingjim

SCAT2, SCAT3, Child-SCAT 3, SAC, BESS…….as those of us in sports medicine know, concussion assessments have become an alphabet soup!

Our July 2015 edition of CJSM contains an interesting study looking at baseline SCAT2 assessments of healthy youth student-athletes; it also included some preliminary evidence for the use of the Child-SCAT3 in children younger than 13.

The 4th International Consensus Statement on Concussion in Sport introduced the SCAT3 and Child-SCAT3 instruments. The Child-SCAT3, in particular, was a significant advancement as there had been no pre-existing instrument for pediatric concussion assessments prior to the 2012 Zurich conference. If you have not ever looked the Child-SCAT3 over, take the chance now by going to the freely available consensus statement–the Child-SCAT3 PDF is readily downloadable. Among the differences between the SCAT3 and Child-SCAT3: a different set of Maddocks questions (is it before or after lunch?); days of the week (as opposed to months of the year) in reverse order; a parent- as well as a self-assessment of symptoms (and the self-assessment is written in more age appropriate language).

Throughout the year, but especially at this time of year (late summer–football has begun) we do assessments like this for the large number of kids we see with concussions or suspected concussions. Over the years, my colleagues and I have wondered over issues such as kids’ seeming inability to get months of the year in reverse order–hence, the perceived improvement of the Child-SCAT3 [as an aside, is it the digital world we live in, the absence of wall calendars–does this generation have some different ‘relationship’ with the months of the year?] I have also wondered about the notion of normative values for instruments like the SCAT2 and SCAT3–this gets into the discussion of our clinical goals: are we returning children to ‘symptom free’ states before return to sport, or are we returning them to baseline? This was the basis for one of our rousing pieces, ‘Is it time to re-think the Zurich guidelines?’

Hence, I read the new study by Glaviano, Benson, Goodkin et al. with great interest. The group comes from the University of Virginia, and they studied 361 athletes grades 7 to 12 [mean age = 14.6 +/- 1.8 years] playing a combination of contact and non-contact sports. These individuals were given the SCAT2 pre-season–in other words, these were uninjured athletes, with the assessments of the subjective and objective components of the SCAT2 measuring their baseline performance. As the authors write, ‘To our knowledge, this is the first study that examined baseline SCAT2 scores in middle school and high school student-athletes when compared by sex and single-year age group comparison.’

The SCAT2 is scored from 0 to 100 [higher # is ‘better,’ reflective of an uninjured state]. Aside from 10 outliers, the SCAT2 scores were normally distributed; mean SCAT2 = 92.0 +/- 3.8. Interestingly, there were no differences between age groups for total SCAT2 score at baseline. There were some statistically significant differences in the concentration subsection of the SCAT2, with increasing age associated with better performance.

The authors also did group comparisons based on gender. Here, too, they found no statistically significant differences between boys and girls in total SCAT2 scores; there were, however, differences in multiple subsections, with females reporting more symptoms, higher BESS and higher immediate memory scores. The statistically significant difference in symptomatology was associated as well with a significant albeit small effect size [Cohen d = -0.29; 95% CI, -0.50 to -0.07]. I think this corresponds to what is seen elsewhere in the literature, and what I could corroborate in my own clinics.

With regards to evidence-based medicine, what I especially like about this study is that it provides some muscle to the consensus statement (and associated SCAT2 instrument) that has been the standard of care for 3+ years. As clinicians, we have to start ‘somewhere’–which is to say, a consensus statement is an important starting point. But I far prefer to hang my hat on evidence, as I am sure we all do. And it gives me real-time clinically relevant evidence to apply to patients of mine who may have no baseline assessments but need me to make return to play decisions. Having some SCAT2 normative data on pediatric and adolescent athletes will help me this fall, I am sure.

An excellent example of the potential disconnect between ‘consensus statement’ and evidence was brought home to me recently at a Grand Rounds at my home institution, Nationwide Children’s Hospital, in a talk on allergies given by David Stukus, MD. As some of you may know, the American Academy of Pediatrics (AAP), recommends that peanuts be withheld from children at risk of developing allergies until they are 3 years old; this recommendation has been in AAP guidelines since 2000 and is still adhered to by many if not most pediatricians here in the USA. However, a New England Journal of Medicine study published in February 2015 turned those guidelines on its proverbial head, finding that introducing peanut in a controlled way at 4 – 11 months to those at risk of atopy was a powerful way of preventing allergies. Already, the needle is swinging toward introducing peanuts earlier rather than holding off.

And so too in our world of clinical sports medicine. Stay in touch with us at CJSM to catch the studies which in our world will be moving the needle too.