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3 Year Appraisal of SCAT5 (where to go from here?)

There are several tools used on the field when a player sustains a blow to the head or starts acting differently, including the most widely used sideline tool, the Sports Concussion Assessment Tool - 5th Edition (SCAT5). 

The SCAT5 sideline tool was updated in 2017 by the Concussion in Sport Group (CISG) during the 5th International Consensus Conference on Concussion in Sport in Berlin. It is intended for use by medical practitioners and gives guidance on how to approach and monitor suspected concussions. However, it does have its limitations, notably that a player may have a concussion despite having a normal SCAT5 score, and, therefore, clinical judgement should take precedence. The adult SCAT5 has on-field and off-field assessments to categorize severity and follow-up evaluation. It is broken down into subscales, or categories of observable signs and examinations, some of which can be scored individually. The composite scoring system was removed during the update of SCAT2 to SCAT3 in 2012 based on limited evidence supporting its use.

• Step 1 includes easily identifiable red flags: loss of consciousness, severe and increasing headache, seizures, tonic posturing, vomiting, deteriorating alertness, severe neck pain, or weakness. These players should be removed from play and immediately transported to an emergency room.

• Step 2 is to recognize other observable signs including motionlessness, facial injuries, blank stares, disorientation or confusion, and balance or gait difficulties. Most items on this list seem obvious. However, the balance or gait issues occur on a spectrum, and many highly coordinated athletes will have a better ability to compensate for balance loss than other less seasoned athletes. There are several other behaviors that are subtler and may not be recognized without retrospective video analysis, if at all. Research is underway to develop better recognition skills for medical providers, trainers, and other non-medical providers.

• Step 3 is a memory test to evaluate the mental status of an athlete. The Child SCAT5 skips this step, presumably because children may not be able to answer these types of questions in a normal state. Questionnaires, in general, are fraught with subjectivity and inaccuracies that make interpretation difficult. However, these are relatively straight-forward and give an idea of whether amnesia is a component of the head injury. Amnesia alone is a less sensitive than specific associated symptom of concussions.

• Step 4 is a basic Glascow Coma Scale (GCS) examination, which evaluates the visual, verbal, and motor responses on a scale of 0-15. This is a crucial component of any trauma assessment, especially in the acute emergency setting, and is intended to be performed serially when monitoring a suspected concussed athlete. This is the only scored section of the on-field assessment process of the SCAT5.

• Lastly, a cervical spine exam is required for all on-field concussion subjects. This exam focuses on neck pain at rest, which is an important distinction from pain with activity for vertebral injuries. Once determining a pain-free state at rest (again, a subjective finding athletes could lie about), range of motion, limb strength, and sensation is evaluated. This is a one-time assessment and a trained medical professional can rule out significant cervical dangers.

Off-site or in-office assessment should be performed on all athletes in the concussion protocol. This secondary assessment should be done in a distraction-free environment because it is long and requires full attention to get an accurate score. This assessment is especially important in distinguishing non-concussed from mild- or moderately-concussed athletes. Ideally, each player would complete this entire assessment in a non-concussed state before play to know their baseline. This would be helpful for higher level athletes that may display better balance or for those with lower cognitive baseline during the Standardized Assessment of Concussion (SAC) (step 3 of the SCAT5).



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