**3. Acute screening and detection methods**

Since detecting early signs of sports-related concussion and timely removal from play may reduce the occurrence of second concussions and continued repetitive injury, there is an essential need for understanding and implementing practical sideline tests to aid in diagnosis. Next, we discuss current acute screening and detection methods for sports-related concussion.

#### **3.1 Standardized assessment of concussion**

The Standardized Assessment of Concussion (SAC) is used as a brief cognitive assessment by measuring orientation, immediate memory, concentration and delayed recall. An orientation score out of 5 points possible is determined from five questions: (1) What month is it?, (2) What is the date?, (3) What day of the week is it?, (4) What year is it?, and (5) What time of day is it? (within 1 hour). The number of orientation questions answered correctly determines the orientation score. The immediate memory score captures the athlete's ability to recall five words that are read to them on three separate trials. For example, the athlete is asked to repeat the words: elbow, apple, carpet, saddle, and bubble. The number of words recalled correctly for each trial is then added with a maximum score of 15. Concentration is tested in two parts. Initially, the concussed athlete is read a string of numbers, and then the individual must repeat them in reverse order. For example, the administrator will say: 7-1-9, and the athlete should respond with: 9-1-7. Four trials are completed with number strings of three to six digits long. The second part of concentration testing requires the athlete to recall the months of the year in reverse order. The sum of the correct digits backwards trials and one point for an entirely correct recall of the months in reverse order constitutes the concentration score out of 5.

The SAC can be administered in 5–7 minutes making it a practical sideline assessment tool and athletes suffering from concussion have been shown to have worse scores than baseline and control athletes. However, the SAC presents some shortcomings. First, it only tests a narrow range of neurocognitive functions. It also has a low correlation with other neuropsychological tests, indicating that it is not a comprehensive test [21]. The SAC does not assess brainstem or cerebellar function [9, 22, 23]. Furthermore, athletes are able to memorize sections of the tool via baseline testing or through the experiences of other teammates.

**7**

*Sports-Related Traumatic Brain Injury: Screening and Management*

as an important component of evaluation after concussion [25–28].

Balance is a complex task that requires intact information from the somatosensory, visual, and vestibular systems as well as an intact central nervous system to maintain a balanced, upright stance [24]. Concussions have been shown to inhibit an individual's ability to appropriately use feedback from the vestibular system when visual and somatosensory inputs are disrupted as a result of traumatic brain injury [25–28]. Therefore, postural stability assessments have also been recognized

The balance error scoring system (BESS) was initially developed as a 3–5 minutes

Studies have explored the repeatability and reliability of the BESS. The reliability of this test ranges from poor to good while some studies report reliability coefficients that are below clinically acceptable levels [25, 26, 30]. This wide range of reliability may be due to variability and subjectivity resulting from multiple administrators, therefore, it has been recommended that the same individual administer the BESS for serial testing [25, 26, 30]. Furthermore, studies have recommended that an average of three BESS test administrations be used to improve reliability [25, 26, 30]. Although originally developed as an objective tool, the reliability of BESS can be significantly influenced by the subjective nature of the administrator scoring that athlete. Additionally, further variation is seen among different administrators of the BESS. Likewise, the reliability of the modified BESS is not optimal due to the subjective nature of the scoring system in which the test administrator is required to count errors that include subjective components such as trying to estimate an abduction of the hip by more than 30° or timing a subject out of the testing position by more than 5 seconds. Additionally, low levels of reliability have been reported to be due to subtle changes in balance not detectable by the administrator [25, 26, 30]. Furthermore, stances included in the BESS have been criticized for being either too difficult or too easy for normal healthy controls making it difficult to detect change in performance. In an evaluation of the BESS in a healthy collegiate football cohort at pre-season baseline, the single leg stance accounted for nearly three-quarters of the total errors committed by the study sample. Additionally, over one-fifth of the study participants also demonstrated the maximum error score of 10 errors on the single leg stance. This high variability and large number of errors in the single leg stance leads to concerns over the practical utility of the single leg stance in identifying performance change as

Several other factors are known to influence balance. These include dehydration, ankle bracing, and a prior leg injury [25, 26]. Balance differences have been demonstrated between various training backgrounds and sports played as a result

assessment tool used by clinicians for the evaluation of postural stability after a concussion [29]. The BESS consists of 3 three stances: double-leg stance (hands on the hips and feet together), single-leg stance (standing on the non-dominant leg with hands on hips), and a tandem stance (the non-dominant foot is placed behind the dominant foot in a heel-to-toe fashion). The stances are performed on both a firm and foam surface with the eyes closed for 20-second trials. Testers observe the patient or athlete for errors in performance during the balance assessment trials with a maximum of 10 errors for each stance. Types of errors are defined as (1) lifting hands off the iliac crest, (2) opening eyes, (3) stepping, stumbling or falling out of position, (4) abducting the hip by more than 30°, (5) lifting the forefoot or heel, (6) remaining out of the test position in more than 5 seconds [29]. A modified version of the BESS (modified BESS, mBESS) that consists of testing the 3 stances on only a firm surface has even been incorporated into the Sport Concussion

*DOI: http://dx.doi.org/10.5772/intechopen.88442*

**3.2 Balance error scoring system (BESS)**

Assessment Tool 5 (SCAT 5).

a result of suspected concussion [31].
