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.
Take Home Message

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.

These findings are similar to other studies (Broglio et al. 2007; Resch et al. 2016) indicating that self-reported symptom checklists are the strongest diagnostic tool, but clinicians should not rely solely on the SCAT symptom checklist as patients may not disclose their signs or symptoms. Using the recommended multidimensional assessment battery consisting of the SAC, SCAT symptom checklist, and BESS can provide the highest level of diagnostic accuracy when compared to a single tool alone and can further help identify impairments that a single tool could not. Clinicians should aim to use these multiple standardized assessment tools together when performing immediate sideline concussion assessments to more accurately rule in or out the pathology. Their findings also suggest baseline assessments may hold limited clinical assessment value due to change scores lacking greater diagnostic accuracy. One important consideration however is diagnostic accuracy was assessed in collegiate athletes and the authors’ findings may not be translatable to high school or youth sports. Clinicians may be able to accurately assess concussions without a baseline, but should still conduct baselines in order to better determine when clinical recovery has occurred.
Questions for Discussion:
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?
Written by: Landon B. Lempke, MEd, LAT, ATC
Reviewed by: Jeffrey Driban
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