Abstract
BackgroundOff-field screening tools, such as the Sports Concussion Assessment Tool (SCAT), have been recommended to identify possible concussion following a head impact where the consequences are unclear. However, real-life performance, and diagnostic accuracy of constituent sub-tests, have not been well characterized.MethodsA retrospective cohort study was performed in elite Rugby Union competitions between September 2015 and June 2018. The study population comprised consecutive players identified with a head impact event undergoing off-field assessments with the World Rugby Head Injury Assessment (HIA01) screening tool, an abridged version of the SCAT3. Off-field screening performance was investigated by evaluating real-life removal-from-play outcomes and determining the theoretical diagnostic accuracy of the HIA01 tool, and individual sub-tests, if player-specific baseline or normative sub-test thresholds were strictly applied. The reference standard was clinically diagnosed concussion determined by serial medical assessments.ResultsOne thousand one hundred eighteen head impacts events requiring off-field assessments were identified, resulting in 448 concussions. Real-life removal-from-play decisions demonstrated a sensitivity of 76.8% (95% CI 72.6–80.6) and a specificity of 86.6% (95% CI 83.7–89.1) for concussion (AUROC 0.82, 95% CI 0.79–0.84). Theoretical HIA01 tool performance worsened if pre-season baseline values (sensitivity 89.6%, specificity 33.9%, AUROC 0.62, p < 0.01) or normative thresholds (sensitivity 80.4%, specificity 69.0%, AUROC 0.75, p < 0.01) were strictly applied. Symptoms and clinical signs were the HIA01 screening tool sub-tests most predictive for concussion; with immediate memory and tandem gait providing little additional diagnostic value.ConclusionsThese findings support expert recommendations that clinical judgement should be used in the assessment of athletes following head impact events. Substitution of the tandem gait and 5-word immediate memory sub-tests with alternative modes could potentially improve screening tool performance.
Highlights
Off-field screening tools, such as the Sports Concussion Assessment Tool (SCAT), have been recommended to identify possible concussion following a head impact where the consequences are unclear
Clinical judgement was commonly used to interpret off-field concussion screening tool results, resulting in improved performance compared to the strict application of baseline or normative test thresholds
Symptoms and clinical signs were the HIA01 screening tool sub-tests most predictive for concussion; substitution of the tandem gait and 5-word immediate memory sub-tests with alternative modes could potentially improve screening tool performance
Summary
Off-field screening tools, such as the Sports Concussion Assessment Tool (SCAT), have been recommended to identify possible concussion following a head impact where the consequences are unclear. Elite sports have introduced processes to identify and manage head impact events during matches [2]. These procedures typically involve immediate removal of players with clearly apparent signs of concussion (e.g. loss of consciousness). Where the circumstances or consequences of a head impact are unclear (e.g. dangerous mechanism), brief off-field screening tests are commonly used to identify possible concussion, with the diagnosis subsequently confirmed or refuted by detailed clinical assessments conducted in the hours and days following the head impact event [2,3,4]. World Rugby’s concussion management system is the Head Injury Assessment (HIA) process
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