Posted August 1, 2016
By Nicole T. Wasylyk, MSEd, LAT, ATC
Traumatic brain injuries (TBIs) are an ever-prevalent topic in our society today, in part due to their high incidence rate. It’s estimated that 1.7 million Americans sustain a TBI each year.1 Diagnosing and managing TBIs can be a complex pathway. Clinical assessment of patients is key to diagnosis since there is currently no objective diagnostic tool to identify whether a patient has sustained a TBI. Assessing a patient’s baseline is also key in the post-injury assessment and management process.
In order to craft the best clinical assessment to identify TBIs, we need to understand the key components that make up the assessment toolkit. A baseline assessment should consist of the following key components.2
Clinical History and Self-Reported Symptom Assessment
There are many useful tools clinicians can use to assess symptom number and severity. The most frequently used and researched tools include the Standardized Assessment of Concussion (SAC), Head Injury Scale, Graded Symptom Checklist, Brief Symptom Inventory 18 (BSI-18), Sport Concussion Assessment Tool Version 3 (SCAT3)3 and the Concussion Symptom Inventory. The SCAT, now in its 3rd version, is a useful tool that incorporates more than just a self-reported symptom scale. In 2012, a consensus statement was released by the International Conference on Concussion in Sport4 supporting the use of the SCAT3 and the Child SCAT3 (ages 5-12). 5
Assessing motor control can include any number of functional tests to assess gait, postural control, fine motor control or hand control and proprioception. Most commonly utilized tests include simple heel-toe gait observation and the Balance Error Scoring System (BESS). The BESS is a quick, portable and cost effective way to evaluate motor control. Although there is variability, the BESS has been found to be both a valid and reliable tool to assess motor control.6
A neurologic exam should certainly be completed post injury. Baseline assessments most often do not demonstrate deficits but are helpful to perform for completion and practice’s sake.
Computerized testing is the most frequently utilized form of neurocognitive testing. This type of testing is a comprehensive evaluation of specific domains such as memory, attention, problem solving, language, visuospatial and motor processing speed. Commonly used tests include the ImPACT test, Wisconsin Card Sort and King-Devick. There are numerous computerized tests to assess patients; it’s important to review and understand each of the domains the test seeks to evaluate and ensure it meets your patient population needs.
This leads us to the following question: What makes up the best baseline concussion assessment?
We do not yet have strong evidence to suggest the gold standard for clinical assessments. However, we do know that a combination of assessment tools, such as the SCAT3, which incorporates both a clinical history and self-reported symptom assessment and physical motor control testing, along with ImPACT testing is a robust way to evaluate patients. Almost all of the tests, aside from the computerized ones, are low cost, reliable, valid and easily implemented. They also carry little burden on both the clinician and the patient.
Recently the National Collegiate Athletic Association (NCAA) and the Department of Defensehave partnered together on a comprehensive study of concussions. This multi-center center study titled Concussion Research Initiative of the Grand Alliance7 will seek to answer questions on the etiology, evaluation, diagnosis and prevention of concussions. The study has 3 aims: to create a sustainable framework to achieve clinical and scientific research, to investigate the natural history of concussions, and to conduct advanced research that will integrate biomechanical, clinical, neuroimaging and genetic markers of injury to advance our understanding of TBIs.8
Hopefully there will be more information in the coming years regarding evidence based management of concussions. Currently, best practice is to utilize a multimodal approach to assess and manage concussions. This includes symptom assessment, physical motor control testing, neurologic exam and neurocognitive testing if available.
1. Daneshvar DH, Nowinski CJ, McKee AC, Cantu RC. The epidemiology of sport-related concussion. Clin Sports Med. 2011 Jan;30(1):1-17, vii.
3. 4. SCAT3: http://bjsm.bmj.com/content/47/5/259.full.pdf
5. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013 Apr;47(5):250-8.
6. Child SCAT3: http://bjsm.bmj.com/content/47/5/263.full.pdf
7. Bell DR, Guskiewicz KM, Clark MA, Padua DA. Systematic review of the balance error scoring system. Sports Health. 2011 May;3(3):287-95. PubMed PMID: 23016020;
About the Author
Nicole Wasylyk works as an Athletic Trainer in a physician practice at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, New Hampshire. Prior to DHMC she resided in Madison, Wisconsin and was an Athletic Trainer in a physician practice at Meriter-Unity Point Health. Wasylyk obtained her Bachelor of Science in Athletic Training from Boston University and Masters of Science in Education from Old Dominion University. She has completed a residency program for healthcare providers who extend the services of a physician at UW Health. Wasylyk also obtained her orthopedic technician certification. Her professional interests include injury surveillance and prevention, standardization of best practices and patient reported outcomes collection.