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
Written by: Landon B. Lempke, MEd, LAT, ATC
Reviewed by: Jeffrey