title: The “Value Added” of Neurocognitive Testing after Sports-Related Concussion Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA Concussion Study. The Nature and Duration of Acute Concussive Symptoms in Australian Football Adding Vision to Concussion Testing: A Prospective Study of Sideline Testing in Youth and Collegiate Athletes Evaluation of Neuropsychological Domain Scores and Postural Stability Following Cerebral Concussion in Sports Interrater reliability of Glasgow Coma Scale scores in the emergency department. Acute Effects and Recovery After Sport‐Related Concussion: A Neurocognitive and Quantitative Brain Electrical Activity Study Grade 1 or “Ding” Concussions in High School Athletes Reliability of the Glasgow Coma Scale for the emergency department evaluation of poisoned patients Examining Sport Concussion Assessment Tool ratings for male and female youth hockey players with and without a history of concussion Acute effects and recovery time following concussion in collegiate football players: the NCAA Concussion Study. MEASUREMENT OF HEAD IMPACTS IN COLLEGIATE FOOTBALL PLAYERS: RELATIONSHIP BETWEEN HEAD IMPACT BIOMECHANICS AND ACUTE CLINICAL OUTCOME AFTER CONCUSSION Neuropsychological Test Performance Prior To and Following Sports-Related Mild Traumatic Brain Injury Effect of Mild Brain Injury on an Instrumented Agility Task Assessment of mild traumatic brain injury with the King-Devick Test® in an emergency department sample Effect of acute exercise on clinically measured reaction time in collegiate athletes.
abstract: 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 CONTEXT Approximately 300 000 sport-related concussions occur annually in the United States , and the likelihood of serious sequelae may increase with repeated head injury . OBJECTIVE To estimate the incidence of concussion and time to recovery after concussion in collegiate football players . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve cohort study of 2905 football players from 25 US colleges were tested at preseason baseline in 1999 , 2000 , and 2001 on a variety of measures and followed up prospect ively to ascertain concussion occurrence . Players injured with a concussion were monitored until their concussion symptoms resolved and were followed up for repeat concussions until completion of their collegiate football career or until the end of the 2001 football season . MAIN OUTCOME MEASURES Incidence of concussion and repeat concussion ; type and duration of symptoms and course of recovery among players who were injured with a concussion during the seasons . RESULTS During follow-up of 4251 player-seasons , 184 players ( 6.3 % ) had a concussion , and 12 ( 6.5 % ) of these players had a repeat concussion within the same season . There was an association between reported number of previous concussions and likelihood of incident concussion .  Players reporting a history of 3 or more previous concussions were 3.0 ( 95 % confidence interval , 1.6 - 5.6 ) times more likely to have an incident concussion than players with no concussion history . Headache was the most commonly reported symptom at the time of injury ( 85.2 % ) , and mean overall symptom duration was 82 hours . Slowed recovery was associated with a history of multiple previous concussions ( 30.0 % of those with > or =3 previous concussions had symptoms lasting > 1 week compared with 14.6 % of those with 1 previous concussion ) . Of the 12 incident within-season repeat concussions , 11 ( 91.7 % ) occurred within 10 days of the first injury , and 9 ( 75.0 % ) occurred within 7 days of the first injury . CONCLUSIONS Our study suggests that players with a history of previous concussions are more likely to have future concussive injuries than those with no history ; 1 in 15 players with a concussion may have additional concussions in the same playing season ; and previous concussions may be associated with slower recovery of neurological function Objective The purpose of this pilot study was to document the nature and temporal profile of the clinical symptoms of acute sport-related concussion . Design Prospect i ve cohort study Patient Population A total of 303 elite Australian football players participating in a national competition during a single season . Outcome Measures Number and duration of symptoms , digit symbol substitution test ( DSST ) scores , time of return to play post injury . Results A total of 23 concussions were recorded over the course of the 20-week football season . No catastrophic head injuries occurred . Headache was the most common symptom and the most persistent , with 40 % of players reporting headache symptoms lasting more than 15 minutes . Ten of the players ( 43 % ) returned to sport on the day of the injury with the remainder resuming play within 2 weeks . A low likelihood of return to play on the day of injury was found where 3 or more symptoms were present or where the symptoms lasted more than 15 minutes . These findings were significantly correlated with poor DSST performance . Conclusions This pilot study suggests that both the number of postconcussive symptoms and their duration may be used as a measure of injury severity and a guide for return to play 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 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 STUDY OBJECTIVE Emergency physicians often use the Glasgow Coma Scale ( GCS ) to help guide decisions in patient care , yet the reliability of the GCS has never been tested in a typical broad sample of emergency department ( ED ) patients . We determined the interrater reliability of the GCS between emergency physicians when adult patients with altered levels of consciousness are assessed . METHODS In this prospect i ve observational study at a university Level I trauma center , we enrolled a convenience sample of ED patients older than 17 years who presented with an altered level of consciousness . Two residency-trained attending emergency physicians independently assessed and recorded the GCS score and its components ( eye , verbal , and motor ) in blinded fashion within a 5-minute period . Data were analyzed for interrater reliability by using st and ard ordinal calculations . We also created scatter plots and Bl and -Altman plots for each GCS component and for the GCS score . RESULTS One hundred thirty-one patients were screened and enrolled in the study , with 15 excluded because of protocol violations . Of the 116 remaining patients , the agreement percentage for exact total GCS was 32 % ( tau-b=0.739 ; Spearman rho=0.864 ; Spearman rho2=75 % ) . Agreement percentage for GCS components were eye 74 % ( tau-b=0.715 ; Spearman rho=0.757 ; Spearman rho2=57 % ) , verbal 55 % ( tau-b=0.587 ; Spearman rho=0.665 ; Spearman rho2=44 % ) , and motor 72 % ( tau-b=0.742 ; Spearman rho=0.808 ; Spearman rho2=65 % ) . Our Spearman 's analyses found that only approximately half ( 44 % to 65 % ) of the observed variance could be explained by the relationship between the paired component measures . For GCS components , only 55 % to 74 % of paired measures were identical , and 6 % to 17 % of them were 2 or more points apart . CONCLUSION We found only moderate degrees of interrater agreement for the GCS and its components 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 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 Glasgow Coma Scale ( GCS ) was developed for monitoring the mental status of head-injured patients in the intensive care unit . The purpose of this study is to determine the inter-rater reliability of the GCS for poisoning patients in the emergency department . Methods : This was a prospect i ve , observational study . Two observers used a st and ard assessment checklist to determine the GCS of suspected poisoning patients . Inter-rater reliability was assessed with a weighted Kappa score . Results : A total of 39 patients were enrolled . Weighted kappa for the total GCS demonstrated excellent agreement . Agreement was also good for each component of the score . Conclusion : The GCS is a reliable tool for the evaluation of mental status of poisoning patients in the emergency department 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 CONTEXT Lack of empirical data on recovery time following sport-related concussion hampers clinical decision making about return to play after injury . OBJECTIVE To prospect ively measure immediate effects and natural recovery course relating to symptoms , cognitive functioning , and postural stability following sport-related concussion . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve cohort study of 1631 football players from 15 US colleges . All players underwent preseason baseline testing on concussion assessment measures in 1999 , 2000 , and 2001 . Ninety-four players with concussion ( based on American Academy of Neurology criteria ) and 56 noninjured controls underwent assessment of symptoms  , cognitive functioning  , and postural stability immediately , 3 hours , and 1 , 2 , 3 , 5 , 7 , and 90 days after injury . MAIN OUTCOME MEASURES Scores on the Grade d Symptom Checklist ( GSC ) , St and ardized Assessment of Concussion ( SAC ) , Balance Error Scoring System ( BESS ) , and a neuropsychological test battery . RESULTS No player with concussion was excluded from participation ; 79 players with concussion ( 84 % ) completed the protocol through day 90 . Players with concussion exhibited more severe symptoms ( mean GSC score 20.93 [ 95 % confidence interval [ CI ] , 15.65 - 26.21 ] points higher than that of controls ) , cognitive impairment ( mean SAC score 2.94 [ 95 % CI , 1.50 - 4.38 ] points lower than that of controls ) , and balance problems ( mean BESS score 5.81 [ 95 % CI , -0.67 to 12.30 ] points higher than that of controls ) immediately after concussion . On average , symptoms gradually resolved by day 7 ( GSC mean difference , 0.33 ; 95 % CI , -1.41 to 2.06 ) , cognitive functioning improved to baseline levels within 5 to 7 days ( day 7 SAC mean difference , -0.03 ; 95 % CI , -1.33 to 1.26 ) , and balance deficits dissipated within 3 to 5 days after injury ( day 5 BESS mean difference , -0.31 ; 95 % CI , -3.02 to 2.40 ) . Mild impairments in cognitive processing and verbal memory evident on neuropsychological testing 2 days after concussion resolved by day 7 . There were no significant differences in symptoms or functional impairments in the concussion and control groups 90 days after concussion . CONCLUSIONS Collegiate football players may require several days for recovery of symptoms , cognitive dysfunction , and postural instability after concussion . Further research is required to determine factors that predict variability in recovery time after concussion . St and ardized measurement of postconcussive symptoms , cognitive functioning , and postural stability may enhance clinical management of athletes recovering from concussion OBJECTIVE To determine the relationship between recorded head accelerations and impact locations and acute clinical outcome of symptomatology , neuropsychological , and postural stability tests after cerebral concussion in Division I collegiate football players . METHODS A prospect i ve field study was used in which accelerometers were embedded in the football helmets of 88 collegiate football players .  Linear and rotational accelerations of all head impacts sustained over the course of 2004 to 2006 National Collegiate Athletic Association football seasons were collected in real-time . Change scores were calculated on clinical measures from the players ' preseason baseline to postinjury ( within 48 h ) and regressed against the recorded linear and rotational accelerations of the head at the time of the concussion . RESULTS Thirteen concussions were recorded ranging in impact magnitudes of 60.51 to 168.71 g. Linear regression showed no significant relationships between impact magnitude ( linear or rotational acceleration ) or impact location and change scores for symptom severity , postural stability , or neurocognitive function ( P > 0.05 ) . CONCLUSION Our findings suggest that football players are concussed by impacts to the head that occur at a wide range of magnitudes and that clinical measures of acute symptom severity , postural stability , and neuropsychological function all appear to be largely independent of impact magnitude and location . Because of the varying magnitudes and locations of impacts result ing in concussion as well as other factors such as the frequency of subconcussive impacts and number of previous concussions , it may be difficult to establish a threshold for concussive injury that can be applied to all football players Objective To examine the utility of neuropsychological tests in assessing college athletes prior to and following a sports-related mild Traumatic Brain Injury ( mTBI ) . Design A prospect i ve study of college athletes who sustained mTBI while engaged in sport . Preinjury baseline neuropsychological test data were obtained for athletes at risk for mTBI . Following an mTBI , the athlete and his or her matched noninjured control were evaluated at 2 hours , 48 hours , 1 week , and 1 month postinjury . Setting Male and female athletes from a Division I college . Participants Male and female athletes from the football , men 's ice hockey , men 's and women 's soccer , and men 's and women 's basketball teams at Penn State University . A total of 29 injured and 20 noninjured athletes participated in the study . Interventions Neuropsychological test batteries were administered at baseline and serially following mTBI . Main Outcome Measures Post-Concussion Symptom Checklist , Hopkins Verbal Learning Test , Symbol Digit Modalities Test , Stroop Color-Word Test , Trail Making Test , VIGIL/W , List Learning , Digit Span , Penn State Cancellation Test , and Controlled Oral Word Association . Results Neuropsychological test data yielded significant differences between injured athletes and controls at 2 hours and 48 hours following cerebral concussion ; injured athletes performing significantly worse than controls . Injured athletes reported a significantly greater number of postconcussion symptoms 2 hours following injury but not at the 48-hour assessment . No multivariate group differences were found at 1 week , but univariate analyses suggested significant differences on a few measures . At 1 month postinjury , a statistically significant difference was found on one measure with injured athletes marginally outperforming controls . Conclusions Neuropsychological tests are useful in the detection of cognitive impairment following mTBI . The test data appear to be more effective than subjective report of symptoms in differentiating between injured and noninjured athletes at 48 hours postinjury . Although significant individual variability existed , most injured athletes recovered within 1 week of injury . A battery of tests , rather than any single test , is necessary to capture the variability that exists among injured athletes Objective To identify an objective evaluation technique to guide return-to-play decisions following mild brain injury ( MBI ) using an agility task that incorporates cognitive and motor performance . Design Prospect i ve , controlled , repeated measures study . Setting Collegiate athletic training facility . Participants 84 athletes ( 25 male rugby players , 34 female rugby players , 25 male ice hockey players ) from 3 intercollegiate club teams participated . 9 athletes who suffered MBI during their competitive seasons and 9 matched controls completed the entire study protocol . Main Outcome Measures Time to complete an agility task on the Cybex Reactor and a postconcussive symptoms scale score were assessed in all subjects during the preseason . Injured subjects and matched controls were also assessed 1 , 3 , 5 , and 10 days postinjury . Results Repeated measures analyses of variance revealed significant differences between injured subjects and controls in postconcussion symptoms , but not agility performance . Post hoc testing revealed that injured subjects reported significantly more postconcussion symptoms on Day 1 after injury . Conclusion The methods of agility assessment used in this study appear to not be sensitive enough to detect functional impairment following MBI Abstract Objective : The King-Devick Test ® ( K-D ) is a brief measure of cognitive processing speed and rapid gaze shifting that appears sensitive to the effects of sport-related concussion . This study evaluated its diagnostic and incremental validity in civilian patients with mild traumatic brain injury ( MTBI ) . Methods : Participants with MTBI ( n = 26 ) and controls with non-head injuries ( n = 33 ) were prospect ively recruited from an Emergency Department ( ED ) . They underwent a clinical evaluation including the  K-D test and the Sport Concussion Assessment Tool 2 ( SCAT2 ) . Magnetic resonance imaging ( MRI ) was conducted within 10 days post-injury . Results : The patients with MTBI differed from those without MTBI on components of the SCAT2 , including the Symptom Scale ( Cohen ’s d = 1.02–1.15 , p < 0.001 ) and St and ardized Assessment of Concussion ( d = 0.81 , p = 0.004 ) , but not the K-D test ( d = 0.40 , p = 0.148 ) . In a logistic regression analysis , the K-D Test did not contribute over and above these two measures in predicting group membership ( MTBI vs. control ) , p = 0.191 . Low K-D Test scores in the MTBI group ( < 1 SD below controls ) were not associated with poor SCAT2 performance , loss of consciousness or traumatic abnormalities on MRI , suggesting these cases may have been false positives . Conclusions : The present findings do not support the K-D Test for the assessment of civilian MTBI in an ED setting PURPOSE We have developed a reliable and valid clinical test of reaction time ( RTclin ) that is sensitive to the acute effects of concussion . If RTclin is to be used as a sideline concussion assessment tool then the acute effects of exercise on RTclin may need to be controlled for . The purpose of this study was therefore to determine the effect of exercise on RTclin . METHODS A gender-balanced group of 42 collegiate athletes were assigned to an  exercise ( n = 28 ) and a  control ( n = 14 ) group using 2:1 block r and omization . The exercise group completed a grade d four-stage exercise protocol on a stationary bicycle ( 100 W × 5 min ; 150 W × 5 min ; 200 W × 5 min ; sprint × 2 min ) , whereas the control group was tested at identical periods without exercising .  Mean RTclin was calculated for eight trials as the fall time of a vertically suspended rigid shaft after its release by the examiner before being caught by the athlete . RTclin was measured at baseline and after each of the four stages . RESULTS As both HR and RPE significantly increased for the four stages in the exercise group ( P < 0.001 ) , mean RTclin showed a significant overall decline during repeated test administration ( P < 0.008 ) . However , there were no significant group ( exercise vs control , P = 0.822 ) or group-by-stage interaction ( P = 0.169 ) effects on RTclin as assessed by repeated- measures analysis of variance . CONCLUSIONS Exercise did not appear to affect RTclin performance in this study . This suggests that RTclin measured during a sideline concussion assessment does not need to be adjusted to account for the acute effects of exercise
target: 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 .
background: 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 .