The reliability and validity of video analysis for the assessment of the clinical signs of concussion in Australian football. Evaluation of Neuropsychological Domain Scores and Postural Stability Following Cerebral Concussion in Sports Is neuropsychological testing useful in the management of sport-related concussion? The assessment of orientation following concussion in athletes. Adding Vision to Concussion Testing: A Prospective Study of Sideline Testing in Youth and Collegiate Athletes Sensitivity and specificity of the ImPACT Test Battery for concussion in athletes. Examining Sport Concussion Assessment Tool ratings for male and female youth hockey players with and without a history of concussion Cognition in the days following concussion: comparison of symptomatic versus asymptomatic athletes. Acute Effects and Recovery After Sport‐Related Concussion: A Neurocognitive and Quantitative Brain Electrical Activity Study Predicting and preventing postconcussive problems in paediatrics (5P) study: protocol for a prospective multicentre clinical prediction rule derivation study in children with concussion Evaluation of the King–Devick test as a concussion screening tool in high school football players The “Value Added” of Neurocognitive Testing after Sports-Related Concussion Use of a rapid visual screening tool for the assessment of concussion in amateur rugby league: A pilot study Immediate Neurocognitive Effects of Concussion Use of the King–Devick test for sideline concussion screening in junior rugby league Athletic Trainers' Concussion-Assessment and -Management Practices: An Update. Grade 1 or “Ding” Concussions in High School Athletes
OBJECTIVES The objective of this study was to determine the reliability and validity of identifying clinical signs of concussion using  video analysis in Australian football . DESIGN Prospect i ve cohort study . METHODS All impacts and collisions potentially result ing in a concussion were identified during 2012 and 2013 Australian Football League seasons . Consensus definitions were developed for clinical signs associated with concussion . For intra- and inter-rater reliability analysis , two experienced clinicians independently assessed 102 r and omly selected videos  on two occasions . Sensitivity , specificity , positive and negative predictive values were calculated based on the diagnosis provided by team medical staff . RESULTS 212 incidents result ing in possible concussion were identified in 414 Australian Football League games . The intra-rater reliability of the  video-based identification of signs associated with concussion was good to excellent . Inter-rater reliability was good to excellent for impact seizure , slow to get up , motor incoordination , ragdoll appearance ( 2 of 4 analyses ) , clutching at head and facial injury . Inter-rater reliability for loss of responsiveness and blank and vacant look was only fair and did not reach statistical significance . The feature with the highest sensitivity was slow to get up ( 87 % ) , but this sign had a low specificity ( 19 % ) . Other video signs had a high specificity but low sensitivity . Blank and vacant look ( 100 % ) and motor incoordination ( 81 % ) had the highest positive predictive value . CONCLUSIONS Video analysis may be a useful adjunct to the side-line assessment of a possible concussion . Video analysis however should not replace the need for a thorough multimodal clinical assessment Context With increasing knowledge and research about concussion , there have been few objective studies that have used neuropsychological domain scores and postural stability to assess concussion . Objective To evaluate the recovery curve of athletes who incur sport-related concussion from repeated serial testing of neuropsychological and posturography testing . Design A prospect i ve epidemiological model was used for the course of the study . Setting Division I intercollegiate athletics . Participants Athletes participating in football , soccer , basketball , softball , and cheerleading . Main Outcome Measures  Neuropsychological scores and posturography measures  were obtained preseason and serially at day 1 , day 2 , day 3 , and day 10 postconcussion .  Control participants  were tested at the same intervals .  Neuropsychological scores were converted to st and ards score and then into domains of attention , learning , speed of information processing , concentration , memory , and verbal fluency . Analysis of covariance with the baseline test as the covariate was used to analyze the data with univariate post hoc tests performed . Results Significant group differences were found for self reported symptoms ( P = 0.001 ) , speed of information processing ( P = 0.005 ) , mean stability ( P = 0.002 ) , and vestibular function ( P = 0.003 ) between injured and control participants . A group , by day , planned comparison found that speed of information processing and composite balance measures demonstrated significant differences through day 10 postinjury , while symptoms and the vestibular ratio remained significant only through day 3 . Conclusions The concussion recovery curve demonstrated short-term neuropsychological and posturography deficits following injury . A comprehensive approach to concussion management should be used to assess the injury and make return-to-play decisions OBJECTIVE Neuropsychological ( NP ) testing has been used for several years as a way of detecting the effects of sport-related concussion in order to aid in return-to-play determinations . In addition to st and ard pencil- and -paper tests , computerized NP tests are being commercially marketed for this purpose to professional , collegiate , high school , and elementary school programs . However , a number of important questions regarding the clinical validity and utility of these tests remain unanswered , and these questions present serious challenges to the applicability of NP testing for the management of sport-related concussion . Our purpose is to outline the criteria that should be met in order to establish the utility of NP instruments as a tool in the management of sport-related concussion and to review the degree to which existing tests have met these criteria . DATA SOURCES A comprehensive literature review of MEDLINE and PsychLit from 1990 to 2004 , including all prospect i ve , controlled studies of NP testing in sport-related concussion . DATA SYNTHESIS The effects of concussion on NP test performance are so subtle even during the acute phase of injury ( 1 - 3 days postinjury ) that they often fail to reach statistical significance in group studies . Thus , this method may lack utility in individual decision making because of a lack of sensitivity . In addition , most of these tests fail to meet other psychometric criteria ( eg , adequate reliability ) necessary for this purpose . Finally , it is unclear that NP testing can detect impairment in players once concussion-related symptoms ( eg , headache ) have resolved . Because no current guideline for the management of sport-related concussion allows a symptomatic player to return to sport , the incremental utility of NP testing remains question able . CONCLUSIONS / RECOMMENDATIONS Despite the theoretic rationale for the use of NP testing in the management of sport-related concussion , no NP tests have met the necessary criteria to support a clinical application at this time . Additional research is necessary to establish the utility of these tests before they can be considered part of a routine st and ard of care , and concussion recovery should be monitored via the st and ard clinical examination and subjective symptom checklists until NP testing or other methods are proven effective for this purpose The purpose of this study was to investigate the sensitivity of  orientation and recent memory questions  in the diagnosis of concussion . In a prospect i ve study over 7 consecutive years ( 1985 - 1991 ) , all players at a professional Australian Rules Football club who sustained a concussive injury ( n = 28 ) were administered a set of questions evaluating orientation and recent memory .  Concussion was diagnosed independently on the basis of loss or disturbance of consciousness and clinical symptoms . A control group of age-matched nonconcussed players was administered the same set of questions . The results showed that items evaluating recently acquired information were more sensitive in the assessment of concussion than st and ard orientation items . The relative sensitivity of orientation questions must be considered when they are used in the clinical diagnosis of concussion in sport Background : Sports-related concussion commonly affects the visual pathways . Current sideline protocol s test cognition and balance but do not include assessment s of visual performance . We investigated how adding a vision-based test of rapid number naming could increase our ability to identify concussed athletes on the sideline at youth and collegiate levels . Methods : Participants in this prospect i ve study included members of a youth ice hockey and lacrosse league and collegiate athletes from New York University and Long Isl and University . Athletes underwent preseason baseline assessment s using : 1 ) the King – Devick ( K-D ) test , a < 2-minute visual performance measure of rapid number naming , 2 ) the St and ardized Assessment of Concussion ( SAC ) , a test of cognition , and 3 ) a timed t and em gait test of balance .  The SAC and timed t and em gait are components of the currently used Sport Concussion Assessment Tool , 3rd Edition ( SCAT3 and Child-SCAT3 ) . In the event of a concussion during the athletic season , injured athletes were retested on the sideline/rink-side . Nonconcussed athletes were also assessed as control participants under the same testing conditions . Results : Among 243 youth ( mean age 11 ± 3 years , range 5–17 ) and 89 collegiate athletes ( age 20 ± 1 years , range 18–23 )  , baseline time scores for the K-D test were lower ( better ) with increasing participant age ( P < 0.001 , linear regression models ) . Among 12 athletes who sustained concussions during their athletic season , K-D scores worsened from baseline by an average of 5.2 seconds ; improvement by 6.4 seconds was noted for the nonconcussed controls ( n = 14 ) . The  vision-based K-D test  showed the greatest capacity to distinguish concussed vs control athletes based on changes from preseason baseline to postinjury ( receiver operating characteristic [ ROC ] curve areas from logistic regression models , accounting for age = 0.92 for K-D , 0.87 for timed t and em gait , and 0.68 for SAC ; P = 0.0004 for comparison of ROC curve areas ) . Conclusions : Adding a vision-based performance measure to cognitive and balance testing enhances the detection capabilities of current sideline concussion assessment . This observation in patients with mild traumatic brain injury reflects the common involvement and widespread distribution of brain pathways dedicated to vision This study explored the diagnostic utility of the composite scores of Immediate Post-Concussion Assessment and Cognitive Testing ( ImPACT ) and Post Concussion Symptom Scale scores ( PCSS ) . Recently concussed high school athletes ( N=72 ) were tested within 72 h of sustaining a concussion , and data were compared to non-concussed high school athletes with no history of concussion ( N=66 ) . Between-groups MANOVA revealed a significant multivariate effect of concussion on test performance ( p<.001 ) ; univariate ANOVAS revealed all six measures contributed to the between-groups differences . A discriminant function analyses was conducted to measure the ability of the five ImPACT composite scores , as well as the PCSS to classify concussion status . One discriminant function was identified that consisted of the Visual Memory , Processing Speed , and Impulse Control composite scores PCSS , which correctly classified 85.5 % of the cases . Approximately 82 % of participants in the concussion group and 89 % of participants in the control group were correctly classified . Using these data , the sensitivity of ImPACT was 81.9 % , and the specificity was 89.4 % . As part of a formal concussion management program , ImPACT is a useful tool for the assessment of the neurocognitive and neurobehavioral sequelae of concussion , and can also provide post-injury cognitive and symptom data that can assist a practitioner in making safer return to play decisions Background Concussion is one of the most commonly occurring injuries in sport today . The Sport Concussion Assessment Tool ( SCAT ) is a commonly used paper neurocognitive tool . To date , little is known about SCAT baseline normative values in youth athletes . Objective The purpose of this study was to determine normative values on the SCAT for male and female youth hockey players . Methods This is a secondary data analysis of pooled data from three prospect i ve cohort studies examining the risk of injury in paediatric ice hockey players aged 9–17 years . A preseason baseline demographic and injury history question naire was completed by each player . Results A total of 4193 players completed SCATs at baseline and were included in the analysis . 781 players ( 18.6 % ) reported a previous history of concussion . Fatigue and low energy followed by headache were the most commonly reported symptoms in all players . The majority of youth players could recite all five words immediately but only three words when delayed . A smaller proportion of the males were able to report the months of the year in reverse order compared with females of a similar age . The median number of digits recited in reverse order was 4 . Conclusions Youth ratings varied between age groups , gender and from previously reported ratings of varsity athletes , possibly reflecting developmental and gender differences . An underst and ing of these differences in youth athletes is important to ensure appropriate performance expectations on the SCAT and when making clinical decisions following a concussion BACKGROUND Concussion is a common neurological injury occurring during contact sport . Current guidelines recommend that no athlete should return to play while symptomatic or displaying cognitive dysfunction . This study compared post-concussion cognitive function in recently concussed athletes who were symptomatic/asymptomatic at the time of assessment with that of non-injured ( control ) athletes . METHODS Prospect i ve study of 615 male Australian Rules footballers . Before the season , all participants ( while healthy ) completed a battery of baseline computerised ( CogSport ) and paper and pencil cognitive tasks .  Sixty one injured athletes ( symptomatic = 25 and asymptomatic = 36 ) were reassessed within 11 days of being concussed ; 84 controls were also reassessed . The serial cognitive function of the three groups was compared using analysis of variance . RESULTS The performance of the symptomatic group declined at the post-concussion assessment on computerised tests of simple , choice , and complex reaction times compared with the asymptomatic and control groups . The magnitude of changes was large according to conventional statistical criteria . On paper and pencil tests , the symptomatic group displayed no change at re assessment , whereas large improvements were seen in the other two groups . CONCLUSION Injured athletes experiencing symptoms of concussion displayed impaired motor function and attention , although their learning and memory were preserved . These athletes displayed no change in performance on paper and pencil tests in contrast with the improvement observed in asymptomatic and non-injured athletes . Athletes experiencing symptoms of concussion should be withheld from training and competition until both symptoms and cognitive dysfunction have resolved Objective To investigate the clinical utility and sensitivity of a portable , automatic , frontal quantitative electroencephalographic ( QEEG ) acquisition device currently in development in detecting abnormal brain electrical activity after sport-related concussion . Design This was a prospect i ve , non-r and omized study of 396 high school and college football players , including cohorts of 28 athletes with concussion and 28 matched controls . All subjects underwent preseason baseline testing on measures of postconcussive symptoms , postural stability , and cognitive functioning , as well as QEEG . Clinical testing and QEEG were repeated on day of injury and days 8 and 45 postinjury for the concussion and control groups . Main Outcomes and Results The injured group reported more significant postconcussive symptoms during the first 3 days postinjury , which resolved by days 5 and 8 . Injured subjects also performed poorer than controls on neurocognitive testing on the day of injury , but no differences were evident on day 8 or day 45 . QEEG studies revealed significant abnormalities in electrical brain activity in the injured group on day of injury and day 8 postinjury , but not on day 45 . Conclusions Results from the current study on clinical recovery after sport-related concussion are consistent with early reports indicating a typical course of full recovery in symptoms and cognitive dysfunction within the first week of injury . QEEG results , however , suggest that the duration of physiological recovery after concussion may extend longer than observed clinical recovery . Further study is required to replicate and extend these findings in a larger clinical sample , and further demonstrate the utility of QEEG as a marker of recovery after sport-related concussion Introduction Persistent postconcussive symptoms ( PCSs ) is the persistence of somatic , cognitive , physical , psychological and /or behavioural changes lasting more than 1 month following concussion . Persistent concussion impacts the quality of life through impaired cognition , memory and attention affecting school performance , mood and social engagement . No large epidemiological studies have determined the true prevalence of persistent concussion symptoms . Vali date d , easy-to-use prognosticators do not exist for clinicians to identify children at highest risk . The goal of Predicting and Preventing Postconcussive Problems in Pediatrics study is to derive a clinical prediction rule for the development of persistent postconcussion symptoms in children and adolescents presenting to emergency department following acute head injury . Methods and analysis This study is a prospect i ve , multicentre cohort study across nine academic Canadian paediatric emergency departments . We will recruit the largest prospect i ve epidemiological cohort of children with concussion . Eligible children will be followed using  Post-Concussion Symptom Inventory , a vali date d tool in children as young as 5 years . Patients will follow-up at 1 , 2 , 4 , 8 and 12 weeks postinjury . The main outcome will be the presence/absence of PCSs defined as three or more persistent concussion symptoms 1 month following the injury .  1792 patients provide adequate power to derive a clinical decision rule using multivariate analyses to find predictor variables sensitive for detecting cases of persistent postconcussion symptoms . Ethics and dissemination Results of this large prospect i ve study will enable clinicians to identify children at highest risk , optimise treatment and provide families with realistic and appropriate anticipatory guidance . Ethics has been obtained through the Children 's Hospital of Eastern Ontario Research Ethics Board . Results will be disseminated at international conferences and in four manuscripts to peer- review ed journals . Trial registration This study is registered at Clinical trials.gov through the US National Institute of Health/National Library of Medicine ( NCT01873287 ; http:// clinical trials.gov/ct2/show/NCT01873287 ) OBJECTIVE Concussion is the most common type of traumatic brain injury , and results from impact or impulsive forces to the head , neck or face . Due to the variability and subtlety of symptoms , concussions may go unrecognized or be ignored , especially with the pressure placed on athletes to return to competition . The King-Devick ( KD ) test , an oculomotor test originally design ed for reading evaluation , was recently vali date d as a concussion screening tool in collegiate athletes . A prospect i ve study was performed using high school football players in an attempt to study the KD as a concussion screening tool in this younger population . METHODS 343 athletes from four local high school football teams were recruited to participate . These athletes were given baseline KD tests prior to competition . Individual demographic information was collected on the subjects . St and ard team protocol was employed to determine if a concussion had occurred during competition . Immediately after diagnosis , the KD test was re-administered to the concussed athlete for comparison to baseline . Post-season testing was also performed in non-concussed individuals . RESULTS Of the 343 athletes , nine were diagnosed with concussions . In all concussed players , cumulative read times for the KD test were significantly increased ( p<0.001 ) . Post-season testing of non-concussed athletes revealed minimal change in read times relative to baseline . Univariate analysis revealed that history of concussion was the only demographic factor predictive of concussion in this cohort . CONCLUSION The KD test is an accurate and easily administered sideline screening tool for concussion in adolescent football players Background Neurocognitive testing has been endorsed as a “ cornerstone ’ of concussion management by recent Vienna and Prague meetings of the Concussion in Sport Group . Neurocognitive testing is important given the potential unreliability of athlete self-report after injury . Relying only on athletes'ormalities after injury . Study Design Case control study ; Level of evidence , 3 . Methods High school and college athletes with a diagnosed concussion were tested 2 days after injury . Postinjury neurocognitive performance ( Immediate Postconcussion Assessment and Cognitive Testing ) and symptom ( postconcussion symptom ) scores were compared with preinjury ( baseline ) scores and with those of an agex and education-matched noninjured athlete control group . “ Abnormal ” test performance was determined statistically with Reliable Change Index scores . Results Sixty-four percent of concussed athletes reported a significant increase in symptoms , as judged by postconcussion symptom scores , compared with preinjury baseline at 2 days after injury . Eighty-three percent of the concussed sample demonstrated significantly poorer neurocognitive test results relative to their own baseline performance . The addition of neurocognitive testing result ed in a net increase in sensitivity of 19 % . Ninety-three percent of the sample had either abnormal neurocognitive test results or a significant increase in symptoms , relative to their own baseline ; 30 % of a control group demonstrated either abnormalities in neurocognitive testing or elevated symptoms , as judged by postconcussion symptom scores . For the concussed group , use of symptom and neurocognitive test results result ed in an increased yield of 29 % overreliance on symptoms alone . In contrast , 0 % of the control group had both symptoms and abnormal neurocognitive testing . Conclusion Reliance on patients ’ self-reported symptoms after concussion is likely to result in underdiagnosis of concussion and may result in premature return to play . Neurocognitive testing increases diagnostic accuracy when used in conjunction with self-reported symptoms AIM This study undertook to use the K-D sideline test with the SCAT2 to see if concussions could be identified in amateur rugby league players over a representative competition period . METHOD A prospect i ve cohort study was conducted on two teams participating in an amateur rugby league . All players were tested for signs of concussion utilising the K-D test and players with longer times than their baseline scores undertook a further concussion assessment with the SCAT2 . RESULTS Five athletes with suspected concussion were evaluated by K-D testing .  Three concussions were associated with witnessed events during the matches and two athletes were identified by the team medic as having longer K-D time scores incidentally post-match compared to baseline . Post-match K-D scores for all concussed athletes were worse than baseline for those with reported or witnessed concussion events ( 7s ; 5.0 - 7.1 ; p=0.025 ) and for those identified incidentally ( > 5s ; 8.9 - 9.1s ) . Both groups also reported more symptoms on the PCSS ( a part of the SCAT2 ) post-match . DISCUSSION In this rugby cohort , the K-D test was not only useful in identifying changes in players with witnessed head trauma , but in identifying changes in players with an un-witnessed suspected concussion OBJECTIVE To prospect ively measure the immediate neurocognitive effects and early course of recovery from concussion and to examine the effects of loss of consciousness ( LOC ) and posttraumatic amnesia ( PTA ) on the severity of neurocognitive impairment immediately after concussion . METHODS A sports-related concussion research model was used to allow prospect i ve immediate evaluation of concussion . A total of 2385 high school and college football players were studied . Ninety-one players ( 3.8 % ) sustained concussions during the study . A brief neurocognitive and neurological screening measure , the St and ardized Assessment of Concussion  , was used to assess cognitive functioning before the football season , immediately after injury , and 15 minutes , 48 hours , and 90 days after injury . RESULTS St and ardized Assessment of Concussion scores immediately after concussion were significantly lower than the preseason baseline score and the noninjured population baseline mean , even for injured subjects without LOC or PTA . Subjects with LOC were most severely impaired immediately after injury , whereas those without LOC or PTA were least impaired . Significant impairment was also detected 15 minutes after injury , but all three groups returned to baseline levels of cognitive functioning within 48 hours . CONCLUSION These findings are the first to demonstrate not only that a gradient of increasing concussion severity is represented by PTA and LOC but also that measurable neurocognitive abnormalities are evident immediately after injury without PTA or LOC AIM To determine whether the King-Devick ( K-D ) test used as a sideline test in junior rugby league players over 12 matches in a domestic competition season could identify witnessed and incidentally identified episodes of concussion . METHODS A prospect i ve observational cohort study of a club level junior rugby league team ( n=19 ) during the 2014 New Zeal and competition season involved every player completing two pre-competition season baseline trials of the K-D test .  Players removed from match participation , or who reported any signs or symptoms of concussion were assessed on the sideline with the K-D test and referred for further medical assessment . Players with a pre- to post-match K-D test difference > 3s were referred for physician evaluation . RESULTS The baseline test-retest reliability of the K-D test was high ( rs=0.86 ; p<0.0001 ) . Seven concussions were medically identified in six players who recorded pre- to post-match K-D test times greater than 3s ( mean change of 7.4s ) . Post-season testing of players demonstrated improvement of K-D time scores consistent with learning effects of using the K-D test ( 67.7s vs. 62.2s ) . DISCUSSION Although no witnessed concussions occurred during rugby play , six players recorded pre- to post-match changes with a mean delay of 4s result ing in seven concussions being subsequently confirmed post-match by health practitioners . All players were medically managed for a return to sports participation . CONCLUSION The K-D test was quickly and easily administered making it a practical sideline tool as part of the continuum of concussion assessment tools for junior rugby league players CONTEXT Athletic trainers ( ATs ) are often the first health care providers to conduct concussion assessment s and carry out postinjury management . Best practice s for concussion evaluation and management have changed rapidly in recent years , outdating previous reports of ATs ' concussion practice s. OBJECTIVE To examine ATs ' current concussion- assessment and -management techniques . DESIGN Cross-sectional study . SETTING Web-based survey . PATIENTS OR OTHER PARTICIPANTS A r and om convenience sample of 8777 ATs ( response rate = 15.0 % [ n = 1307 ] ; years certified = 15.0 ± 10.6 ) from the National Athletic Trainers ' Association membership . MAIN OUTCOME MEASURE(S ) Survey Web links were e-mailed to prospect i ve participants , with 2 follow-up e-mails sent by the National Athletic Trainers ' Association . The survey collected demographic information , the number of concussions assessed , the concussion-recovery patterns , and the assessment and return-to-participation ( RTP ) decision-making methods used . RESULTS The ATs reported assessing a median of 12.0 ( range = 0 - 218 ) concussions per year . A total of 95.3 % ( 953/1000 ) ATs cited clinical examination as the most frequently used concussion- assessment tool , followed by symptom assessment ( 86.7 % ; 867/1000 ) . A total of 52.7 % ( 527/1000 ) ATs described a 3-domain minimum multidimensional concussion- assessment battery . Published RTP guidelines were the most common RTP decision-making tool ( 91.0 % ; 864/949 ) , followed by clinical examination ( 88.2 % ; 837/949 ) . The ATs with master 's degrees were 1.36 times ( 95 % confidence interval [ CI ] = 1.02 , 1.81 ) more likely to use a 3-domain concussion- assessment battery than ATs with only bachelor 's degrees ( χ2 = 4.44 , P = .05 ) . Collegiate ATs were 2.12 ( 95 % CI = 1.59 , 2.84 ) and 1.63 ( 95 % CI = 1.03 , 2.59 ) times more likely to use a 3-domain concussion- assessment battery than high school and clinic-based ATs , respectively ( χ2 = 26.29 , P < .001 ) . CONCLUSIONS Athletic trainers were using the clinical examination , st and ardized assessment tools , and a 3-domain concussion- assessment -battery approach more frequently in clinical practice than previously reported . However , despite practice improvements , nearly half of ATs were not using a 3-domain minimum concussion- assessment battery . Clinicians should strive to implement multidimensional concussion assessment s in their practice s to ensure optimal diagnosis and management Background Recent concussion management guidelines have suggested that athletes with mild ( grade 1 ) concussions may be returned to play if asymptomatic for 15 minutes . The purpose of this study was to assess the utility of a current concussion management guideline in classifying and managing mild concussion . Hypothesis High school athletes diagnosed with a grade 1 concussion will demonstrate measurable decline in neuropsychological functioning that persists during the 1st week of recovery . Study Design Prospect i ve study design ed to evaluate neuropsychological functioning both prior to and following concussion . Methods Forty-three high school athletes completed  neuropsychological test performance  and  symptom ratings  prior to the season and at two times during the 1st week following  mild concussion . Results Thirty-six hours after injury , mildly concussed high school athletes demonstrated a decline in memory ( P < 0.003 ) and a dramatic increase in self-reported symptoms ( P < 0.00001 ) compared to baseline performance . Conclusions Athletes with grade 1 concussion demonstrated memory deficits and symptoms that persisted beyond the context in which they were injured . These data suggest that current grade 1 return-to-play recommendations that allow for immediate return to play may be too liberal . Clinical Relevance A reconsideration of current concussion grading systems appears to be warranted
The sensitivity and specificity of commonly implemented sideline assessment tools are generally good to very good , especially for symptom scores and cognitive evaluations performed within 48 hours of injury , and they are improved when a baseline evaluation is available for comparison .
CONTEXT The sideline assessment of concussion is challenging , given its variable presentations , the limited sensitivity and specificity of sideline assessment tools , and how the presentation of the injury evolves over time .
In addition , the diagnostic process , as well as the tools used to assess and manage concussion , continue to progress as research and what we know about concussion advance .
This paper focuses on the initial assessment on the sideline by review ing the concussion-evaluation literature , drawing from clinical experience to emphasize a st and ardized approach , and underscoring the importance of both familiarity with the athlete and clinical judgment .
OBJECTIVE To review the evidence regarding the clinical assessment of sport-related concussion on the sideline .
Additional considerations included making same-day return-to-play decisions , the sensitivity and specificity of sideline testing , and the importance of ongoing assessment and follow-up of injured athletes .
CONCLUSIONS The sideline assessment of sport-related concussion is challenging given the elusiveness and variability of presentation , reliance on athlete-reported symptoms , and the varying specificity and sensitivity values of sideline assessment tools .
In addition , the recognition of injury and assessment often occur in a time-pressured environment , requiring rapid disposition and decision making .