Quantifying the Value of Multidimensional Assessment Models for Acute Concussion: An Analysis of Data from the NCAA-DoD Care Consortium
Garcia G, Broglio S, Lavieri M, McCrea M, McAllister T, & CARE Consortium Investigators. Sports Medicine. Epub Ahead of Print. doi: 10.1007/s40279-018-0880-x.
A multidimensional assessment battery provides clinicians with the best concussion diagnostic accuracy. Symptom checklists are the driving force for accurate diagnosis while BESS has limited utility when the Standardized Assessment of Concussion (SAC) and symptom checklists are performed.
Sports medicine bodies recommend clinicians use multiple tests to assess various domains (e.g., balance, symptoms) when evaluating concussions. Furthermore, change scores (the difference between baseline values and post-injury values) can help clinicians interpret test results, but baseline tests are sometimes not utilized. Hence, clinicians are challenged with interpreting the multiple results to provide a diagnosis, especially when baseline test results may be unavailable. Therefore, the authors examined the diagnostic accuracy of standardized concussion assessments tools and the value of using change scores when scores are used individually and in combination. They used data from the Concussion Assessment, Research, and Education (CARE) Consortium between 2014 and 2017 that consisted of 16,142 collegiate athletes’ baseline assessments. Of the large sample, 870 athletes experienced 941 concussions. The authors examined the raw and change scores for the Standardized Assessment of Concussion (SAC), Sport Concussion Assessment Tool (SCAT) symptom checklist, and the Balance Error Scoring System (BESS) at three post-injury timepoints: 0-6 hours, 24-48 hours, and return to play. They examined the utility of each tool individually and when used together as recommended in clinical practice. The authors found that raw scores for SCAT symptom severity (sensitivity = 0.92, specificity =0.97) and total symptom presence (sensitivity = 0.93, specificity = 0.95) had the highest diagnostic accuracy of any individual tool. When assessment tools were combined, they found the multidimensional assessment to be equally sensitive (0.93) and slightly more specific (0.96) to concussion than SCAT symptom presence alone. Interestingly, when BESS was removed from the model, the diagnostic value of the multidimensional assessment was not altered. Change and raw scores differed in their diagnostic value for each individual assessment, suggesting baselines may hold limited clinical utility for assessing concussions.
Do you utilize multiple standardized concussion assessment tools in practice? If not, what are the limiting factors in your decision? Despite the limited utility of BESS in this study, does the BESS test influence your clinical decision?