When college athletes are evaluated for a possible concussion, the diagnosis is based on an athletic trainer or team doctor’s evaluation of three things: the player’s symptoms, physical balance, and cognitive abilities.
Research published today suggests that nearly half of athletes who are ultimately diagnosed with a concussion will test normally on the recommended cognitive skills test.
“If you don’t do well on the cognitive test, it suggests you have a concussion. But many people who have a concussion do well on the test,” said Dr. Kimberly Harmon, lead author of the study. She is a professor of family medicine and section chief of sports medicine at the University of Washington School of Medicine.
The study findings appear in JAMA Network open.
Harmon said her experiences as a team physician for the UW Huskies made her wonder how to accurately interpret the cognitive assessment portion of the Sports Concussion Assessment Tool (SCAT). Introduced in 2004 by the Concussion in Sport Group, the SCAT (now in its fifth version, SCAT5) aimed to standardize the collection of information from athletes with a possible head injury.
The SCAT first asks the athlete if they are experiencing any of 22 symptoms, such as headache, nausea or blurred vision, and the severity of the symptoms. The tool then tests the athlete’s cognition in several ways.
First come the questions of orientation. (What day is it? What month is it?) An immediate memory test is then performed, in which a list of 10 words is read aloud to the athlete, who is asked to repeat the list. This sequence is repeated three times. The athlete’s concentration is then tested by repeating short sequences of numbers in reverse order. Next comes a prescribed assessment of the athlete’s balance, after which he is again asked to remember the 10 words from the first list.
In Harmon’s experience as a team doctor, he saw that “some people had concussions and did well on recall tests. Some people didn’t have concussions and didn’t do well. So I thought we should look into it,” he said. .
The study involved 92 NCAA Division I athletes who suffered a concussion between July 13, 2020 and December 31, 2022, and who had a concussion evaluation within 48 hours. The researchers also recruited 92 of the concussed players’ teammates as matched control subjects, each of whom received the SCAT5 test within two weeks of the concussion incident.
All athletes in the study had previously completed NCAA-required concussion screening. The researchers found no significant differences in baseline scores between athletes with and without concussion.
Harmon and colleagues analyzed the SCAT5 responses of study participants and found that word recall tests had little predictive value for concussion. In fact, nearly half (45%) of athletes who suffered a concussion scored at or above their baseline scores on cognitive tests, the researchers reported.
Instead, the study showed that the most accurate predictor of concussion was athletes’ responses to questions about their symptoms.
“If you get hit in the head and you go to the sideline and say, ‘My head hurts. I’m dizzy. I don’t feel good,’ I can pretty confidently say you have a concussion,” Harmon said. “I don’t need to do any testing. The problem is that some athletes don’t want to go out. They don’t report their symptoms or they may not recognize them. So, you need an objective and accurate test to know. “We don’t know if we can put the athlete back in the field safely. “We don’t have it now.”
During in-game concussion evaluations, team coaches and physicians must quickly synthesize the available evidence and make their best clinical judgment about a player’s health. However, the responsibility to make a decision that prioritizes safety also falls partly on athletes, the study authors wrote:
“Although an increase in symptoms is highly suggestive of concussion, this depends on accurate reporting by the athlete, who may not report symptoms due to a desire to return to play, fear of disappointing teammates, minimizing the severity of concussion, difficulty discerning symptoms, a delay in the development of symptoms, or other reasons.
“We’re still missing the holy grail, which is objective concussion testing,” Harmon said. “For now, this study shows how important it is for athletes to disclose their symptoms.”
The study was funded in part by Jack and Luellen Cherneski and the Chisholm Foundation.