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ObjectivesThe purpose of this paper is to provide reliable change metrics and assess the test–retest psychometrics of the Sport Concussion Assessment Tool fifth Edition (SCAT5) in a multilingual sample of professional ice hockey players.MethodsThe SCAT5 was administered to National Hockey League and American Hockey League male professional ice hockey players as part of the 2018 and 2019 season medical evaluations. We extracted data from an existing clinical database of players who were administered two consecutive baseline evaluations and had no intervening concussions to assess psychometric properties (eg, test–retest reliability) and develop reliable change metrics.ResultsOverall, 1007 players met inclusion criteria. Players were reassessed on average 344.52 (±62.52) days following their first baseline. Test–retest reliability ranged from r=0.3 to r=0.5. Reliable change metrics for Immediate Memory varied considerably dependent on form order. Significant differences were found between English versus non-English language preference on Immediate Memory and Concentration but not Delayed Memory or the modified Balance Error Scoring System (mBESS). Reliable change indices at the 90% CI were: Symptom Severity (5), Total Symptoms (3), Immediate Memory (3-8), Concentration (2), mBESS (5) and Delayed Memory (2-4).ConclusionsOur findings highlight the importance of considering form differences and language preference when determining reliable change from baseline on the SCAT5 in male professional hockey players. The relatively modest test–retest reliability of the measures leaves room for improved psychometric properties and increased sensitivity to concussion in future iterations of the SCAT.

ObjectivesThis paper provides comprehensive normative data stratified by language preference and age on the components of the National Hockey League (NHL) Sport Concussion Assessment Tool 5 (SCAT5) in a multilingual sample of professional ice hockey players and compares the findings from a paper form of the NHL SCAT5 with an electronic (App) version of the tool.MethodsA total of 1924 male NHL and American Hockey League (AHL) players (ages 17–41) were assessed during preseason medical evaluations (baseline); 1881 were assessed with the NHL SCAT5 App via tablet and 43 received the paper version of the NHL Modified SCAT5.ResultsNo significant differences between the App and paper modes of administration emerged in a subsample of English preference players. Significant SCAT5 differences among language preference groups emerged on measures of cognitive functioning (Immediate Memory,Concentration). No language preference differences emerged on the Delayed Recall component. Using age as a continuous variable, older participants outperformed younger players on Immediate Memory, Delayed Recall and Concentration. Players wearing skates demonstrated significantly more modified Balance Error Scoring System (mBESS) total errors than barefoot players. Normative data tables for language preference groups are presented.ConclusionsSignificant differences were found between English and non-English language preference groups on the components of SCAT5, which suggest that language-specific normative data, rather than aggregated normative data, are preferable when interpreting test scores. Similarly, age-specific normative data tables may provide greater precision in data interpretation. Due to clear ceiling effects on the mBESS single leg and tandem stances, players should not be tested while wearing skates.

BackgroundThe Sport Concussion Assessment Tool (SCAT) and Child SCAT are the ‘gold standard’ assessment tools for a suspected sport-related concussion (SRC). A number of ‘modifiers’ (eg, previous history of concussion) of a SRC have been identified. These may influence how the SCAT/Child SCAT results should be interpreted.ObjectivesTo achieve consensus, via an international panel of SRC experts, on which athlete/player and parent/caregiver demographic variables should be considered for inclusion in future editions of the SCAT/Child SCAT respectively.MethodsA two-round modified Delphi technique, overseen by a steering committee, invited 41 panellists to achieve expert consensus (≥80% agreement). The first round utilised open questions to generate demographic variables; the second round used a five-point ordinal item to rank the importance of including each variable in future editions of the SCAT/Child SCAT.Results15 experts participated in at least one Delphi round. 29 athlete/player and eight parent/caregiver variables reached consensus for inclusion in the SCAT, whereas two parent/caregiver variables reached consensus for exclusion. 28 athlete/player and four parent/caregiver variables reached consensus for the Child SCAT, whereas two parent/caregiver variables reached consensus for exclusion. Key categories of variables included the following: concussion/sport details, personal medical conditions and family medical history.ConclusionThis study provides a list of athlete/player and parent/caregiver demographic variables that should be considered in future revisions of the SCAT/Child SCAT. By considering (and ultimately likely including) a wider and standard set of additional demographic variables, the Concussion in Sport experts will be able to provide clinicians and researchers with data that may enhance interpretation of the individual’s data and the building of larger datasets.

ObjectivesTo examine the relationships among self-reported sport-related concussion (SRC) history and current health-promoting behaviours (exercise frequency, diet quality and sleep duration) with self-reported measures of brain health (cognitive function, symptoms of depression and anxiety and emotional–behavioural dyscontrol) in former NFL players.MethodsIn this cross-sectional study, a questionnaire was sent to former NFL players. Respondents reported SRC history (categorical: 0; 1–2; 3–5; 6–9; 10+ concussions), number of moderate-to-vigorous aerobic and resistance exercise sessions per week, diet quality (Rapid Eating Assessment for Participants—Shortened) and average nightly sleep duration. Outcomes were Patient-Reported Outcomes Measurement Information System Cognitive Function, Depression, and Anxiety, and Neuro-QoL Emotional-Behavioral Dyscontrol domain T-scores. Multivariable linear regression models were fit for each outcome with SRC history, exercise frequency, diet quality and sleep duration as explanatory variables alongside select covariates.ResultsMultivariable regression models (n=1784) explained approximately 33%–38% of the variance in each outcome. For all outcomes, SRC history (0.144≤|β|≤0.217) was associated with poorer functioning, while exercise frequency (0.064≤|β|≤0.088) and diet quality (0.057≤|β|≤0.086) were associated with better functioning. Sleeping under 6 hours per night (0.061≤|β|≤0.093) was associated with worse depressive symptoms, anxiety and emotional–behavioural dyscontrol.ConclusionSeveral variables appear to be associated with mood and perceived cognitive function in former NFL players. SRC history is non-modifiable in former athletes; however, the effects of increasing postplaying career exercise frequency, making dietary improvements, and obtaining adequate sleep represent important potential opportunities for preventative and therapeutic interventions.

ObjectivesTo examine the utility of Sport Concussion Assessment Tool (SCAT5) subcomponents in differentiating physician diagnosed concussed players from controls.MethodsWe evaluated 1924 professional hockey players at training camp using the National Hockey League (NHL) Modified SCAT5 prior to the 2018–2019 season. Over the course of the season, 314 English-speaking players received SCAT5 evaluations within 1 day of a suspected concussive event. Of these players, 140 (45%) were subsequently diagnosed with concussion by their team physicians.ResultsConcussed players reported more symptoms (Concussed M=8.52, SD=4.78; Control M=3.32, SD=3.97), and recalled fewer words than Controls on both the Immediate Memory (Concussed M=19.34, SD=4.06; Control M=21.53, SD=2.94) and Delayed Recall (Concussed z=−0.91; Control z=−0.09) tasks during the acute evaluation. Concussed players also made more errors than Controls on the mBESS and were more likely to report double vision and exhibit clinician-observed balance problems than controls. There were no between-group differences on the Concentration component of the SCAT5. Stepwise regression revealed that symptom report and list learning tasks both accounted for independent variance in identifying players diagnosed with concussion.ConclusionsThese findings provide support for use of the SCAT5 to assist in identifying concussed professional hockey players. When examining SCAT5 subtests, both symptom report and the 10-item word list accounted for independent variance in identifying concussion status in this sample of professional hockey players. The mBESS also differentiated Concussed players and Controls. The Concentration component of the SCAT5 did not significantly differentiate Concussed players and Controls.

The 2017 Berlin Concussion in Sport Group Consensus Statement provides a global summary of best practice in concussion prevention, diagnosis and management, underpinned by systematic reviews and expert consensus. Due to their different settings and rules, individual sports need to adapt concussion guidelines according to their specific regulatory environment. At the same time, consistent application of the Berlin Consensus Statement’s themes across sporting codes is likely to facilitate superior and uniform diagnosis and management, improve concussion education and highlight collaborative research opportunities. This document summarises the approaches discussed by medical representatives from the governing bodies of 10 different contact and collision sports in Dublin, Ireland in July 2017. Those sports are: American football, Australian football, basketball, cricket, equestrian sports, football/soccer, ice hockey, rugby league, rugby union and skiing. This document had been endorsed by 11 sport governing bodies/national federations at the time of being published.

Objectives Several iterations of the Sport Concussion Assessment Tool (SCAT) have been published over the past 16 years. Our goal was to systematically review the literature related to the SCAT and provide recommendations for improving the tool. To achieve this goal, five separate but related searches were conducted and presented herein. Design Systematic literature review. Data sources Medline, Embase, PsycINFO, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials, SPORTDiscus and PubMed. Eligibility criteria Original, empirical, peer-reviewed findings published in English and included sports-related concussion (SRC). Review papers, case studies, editorials and conference proceedings/abstracts were excluded. The age range for the ChildSCAT was 5–12 years and for the Adult SCAT was 13 years and above. Results Out of 2961 articles screened, a total of 96 articles were included across the five searches. Searches were not mutually exclusive. The final number of articles included in the qualitative synthesis for each search was 21 on Adult SCAT, 32 on ChildSCAT, 21 on sideline, 8 on video/observation and 14 on oculomotor. Summary/conclusions The SCAT is the most widely accepted and deployable sport concussion assessment and screening tool currently available. There is some degree of support for using the SCAT2/SCAT3 and ChildSCAT3 in the evaluation of SRC, with and without baseline data. The addition of an oculomotor examination seems indicated, although the most valid method for assessing oculomotor function is not clear. Video-observable signs of concussion show promise, but there is insufficient evidence to warrant widespread use at this time.

BackgroundEarly identification and evaluation of concussions is critical. We examined the utility of using visible signs (VS) of concussion in predicting subsequent diagnosis of concussion in NHL players.MethodsVS of concussion were identified through video review. Coders were trained to detect and record specific visual signs while viewing videos of NHL regular season games. 2460 games were reviewed by at least two independent coders across two seasons. The reliability, sensitivity and specificity of these VS were examined.ResultsVS were reliably coded with inter-rater agreement rates ranging from 73% to 98.9%. 1215 VS were identified in 861 events that occurred in 735 games. 47% of diagnosed concussions were associated with a VS but 53% of diagnosed concussions had no VS. Of the VS, only loss of consciousness, motor incoordination, and blank/vacant look had positive likelihood ratios greater than 1, indicating a positive association with concussion diagnoses. Slow to get up and clutching of the head were observed frequently but had low positive predictive values. Sensitivity decreased and specificity increased when multiple VS occurred together.ConclusionsNon-medical personnel can be trained to reliably identify events in which VS occur and to reliably identify specific VS within each of those events. VS can be useful to detect concussion early but they are not enough since more than half of physician diagnosed concussions occurred without the presence of a visual sign. The results underscore the complexity of this injury and highlight the need for comprehensive approaches to injury detection.

BackgroundLittle research examines how to best identify concussed athletes. The purpose of the present study was to develop a preliminary risk decision model that uses visible signs (VS) and mechanisms of injury (MOI) to predict the likelihood of subsequent concussion diagnosis.MethodsCoders viewed and documented VS and associated MOI for all NHL games over the course of the 2013–2014 and 2014–2015 regular seasons. After coding was completed, player concussions were identified from the NHL injury surveillance system and it was determined whether players exhibiting VS were subsequently diagnosed with concussions by club medical staff as a result of the coded event.ResultsAmong athletes exhibiting VS, suspected loss of consciousness, motor incoordination or balance problems, being in a fight, having an initial hit from another player’s shoulder and having a secondary hit on the ice were all associated with increased risk of subsequent concussion diagnosis. In contrast, having an initial hit with a stick was associated with decreased risk of subsequent concussion diagnosis. A risk prediction model using a combination of the above VS and MOI was superior to approaches that relied on individual VS and associated MOI (sensitivity=81%, specificity=72%, positive predictive value=26%).ConclusionsCombined use of VS and MOI significantly improves a clinician’s ability to identify players who need to be evaluated for possible concussion. A preliminary concussion prediction log has been developed from these data. Pending prospective validation, the use of these methods may improve early concussion detection and evaluation.

BackgroundThe use of video to assist professional sporting bodies with the diagnosis of sport-related concussion (SRC) has been well established; however, there has been little consistency across sporting codes with regards to which video signs should be used, and the definitions of each of these signs.AimThe aims of this study were to develop a consensus for the video signs considered to be most useful in the identification of a possible SRC and to develop a consensus definition for each of these video signs across the sporting codes.MethodsA brief questionnaire was used to assess which video signs were considered to be most useful in the identification of a possible concussion. Consensus was defined as >90% agreement by respondents. Existing definitions of these video signs from individual sports were collated, and individual components of the definitions were assessed and ranked. A modified Delphi approach was then used to create a consensus definition for each of the video signs.ResultsRespondents representing seven sporting bodies (Australian Football League, Cricket Australia, Major League Baseball, NFL, NHL, National Rugby League, World Rugby) reached consensus on eight video signs of concussion. Thirteen representatives from the seven professional sports ranked the definition components. Consolidation and refinement of the video signs and their definitions resulted in consensus definitions for six video signs of possible concussion: lying motionless, motor incoordination, impact seizure, tonic posturing, no protective action—floppy and blank/vacant look.ConclusionsThese video signs and definitions have reached international consensus, are indicated for use by professional sporting bodies and will form the basis for further collaborative research.

BackgroundVideo review has become an important tool in professional sporting codes to help sideline identification and management of players with a potential concussion.AimTo assess current practices related to video review of concussion in professional sports internationally, and compare protocols and diagnostic criteria used to identify and manage potential concussions.MethodsCurrent concussion management guidelines from professional national and international sporting codes were reviewed. Specific criteria and definitions of video signs associated with concussion were compared between codes. Rules and regulations adopted across the codes for processes around video review were also assessed.ResultsSix sports with specific diagnostic criteria and definitions for signs of concussion identified on video review participated in this study (Australian football, American football, world rugby, cricket, rugby league and ice hockey). Video signs common to all sports include lying motionless/loss of responsiveness and motor incoordination. The video signs considered by the majority of sports as most predictive of a diagnosis of concussion include motor incoordination, impact seizure, tonic posturing and lying motionless. Regulatory requirements, sideline availability of video, medical expertise of video reviewers and use of spotters differ across sports and geographical boundaries. By and large, these differences reflect a pragmatic approach from each sport, with limited underlying research and development of the video review process in some instances.ConclusionsThe use of video analysis in assisting medical staff with the diagnosis or identification of potential concussion is well established across different sports internationally. The diagnostic criteria used and the expertise of the video review personnel are not clearly established, and research efforts would benefit from a collaborative harmonisation across sporting codes.

OBJECTIVES: Various definitions for concussion have been proposed, each having its strengths and weaknesses. We reviewed and compared current definitions and identified criteria necessary for an operational definition of sports-related concussion (SRC) in preparation of the 5th Concussion Consensus Conference (Berlin, Germany). We also assessed the role of biomechanical studies in informing an operational definition of SRC.DESIGN: This is a systematic literature review.DATA SOURCES: Data sources include MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Clinical Trials and SPORT Discus (accessed 14 September 2016).ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Eligibility criteria were studies reporting (clinical) criteria for diagnosing SRC and studies containing SRC impact data.RESULTS: Out of 1601 articles screened, 36 studies were included (2.2%), 14 reported on criteria for SRC definitions and 22 on biomechanical aspects of concussions. Six different operational definitions focusing on clinical findings and their dynamics were identified. Biomechanical studies were obtained almost exclusively on American football players. Angular and linear head accelerations linked to clinically confirmed concussions demonstrated considerable individual variation.SUMMARY/CONCLUSIONS: SRC is a traumatic brain injury that is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces with several common features that help define its nature. Limitations identified include that the current criteria for diagnosing SRC are clinically oriented and that there is no gold/standard to assess their diagnostic properties. A future, more valid definition of SRC would better identify concussed players by demonstrating high predictive positive/negative values. Currently, the use of helmet-based systems to study the biomechanics of SRC is limited to few collision sports. New approaches need to be developed to provide objective markers for SRC.

This paper presents the Sport Concussion Assessment Tool 5th Edition (SCAT5), which is the most recent revision of a sport concussion evaluation tool for use by healthcare professionals in the acute evaluation of suspected concussion. The revision of the SCAT3 (first published in 2013) culminated in the SCAT5. The revision was based on a systematic review and synthesis of current research, public input and expert panel review as part of the 5th International Consensus Conference on Concussion in Sport held in Berlin in 2016. The SCAT5 is intended for use in those who are 13 years of age or older. The Child SCAT5 is a tool for those aged 5-12 years, which is discussed elsewhere.