130214 scat3.indd

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1 ™ SCAT3 Sport Concussion Assessment Tool – 3rd edition For use by medical professionals only examiner: Date / Time of Injury: name Date of Assessment: 1 What is the SCAT3? 1 glasgow coma scale (gCS) the SCAt3 is a standardized tool for evaluating injured athletes for concussion and can be used in athletes aged from 13 years and older. it supersedes the orig- Best eye response (e) 2 . For younger inal SCAt and the SCAt2 published in 2005 and 2009, respectively 1 no eye opening persons, ages 12 and under, please use the Child SCAt3. the SCAt3 is designed 2 eye opening in response to pain for use by medical professionals. If you are not qualifi ed, please use the Sport 1 . preseason baseline testing with the SCAt3 can be Concussion recognition tool eye opening to speech 3 helpful for interpreting post-injury test scores. 4 eyes opening spontaneously Best verbal response (v) Specifi c instructions for use of the SCAT3 are provided on page 3. If you are not familiar with the SCAt3, please read through these instructions carefully. this 1 no verbal response tool may be freely copied in its current form for distribution to individuals, teams, 2 incomprehensible sounds groups and organizations. Any revision or any reproduction in a digital form re- inappropriate words 3 quires approval by the Concussion in Sport Group. the diagnosis of a concussion is a clinical judgment, ideally made by a NOTE: Confused 4 medical professional. the SCAt3 should not be used solely to make, or exclude, oriented 5 the diagnosis of concussion in the absence of clinical judgement. An athlete may Best motor response (m) have a concussion even if their SCAt3 is “normal”. 1 no motor response 2 extension to pain What is a concussion? Abnormal fl exion to pain 3 A concussion is a disturbance in brain function caused by a direct or indirect force Flexion / Withdrawal to pain 4 to the head. It results in a variety of non-specifi c signs and / or symptoms (some examples listed below) and most often does not involve loss of consciousness. localizes to pain 5 Concussion should be suspected in the presence of any one or more of the obeys commands 6 following: glasgow Coma score (e + v + m) of 15 Symptoms (e.g., headache), or - - Physical signs (e.g., unsteadiness), or GCS should be recorded for all athletes in case of subsequent deterioration. Impaired brain function (e.g. confusion) or - Abnormal behaviour (e.g., change in personality). - 3 2 maddocks Score “I am going to ask you a few questions, please listen carefully and give your best effort.” Sideline ASSeSSmenT Modifi ed Maddocks questions (1 point for each correct answer) indications for emergency management 1 0 What venue are we at today? noTe: A hit to the head can sometimes be associated with a more serious brain Which half is it now? 0 1 injury. Any of the following warrants consideration of activating emergency pro- Who scored last in this match? 1 0 cedures and urgent transportation to the nearest hospital: 0 1 What team did you play last week / game? - Glasgow Coma score less than 15 - Deteriorating mental status Did your team win the last game? 1 0 - potential spinal injury maddocks score of 5 - progressive, worsening symptoms or new neurologic signs Maddocks score is validated for sideline diagnosis of concussion only and is not used for serial testing. Potential signs of concussion? if any of the following signs are observed after a direct or indirect blow to the head, the athlete should stop participation, be evaluated by a medical profes- mechanism of injury notes: ): (“tell me what happened”? if a should not be permitted to return to sport the same day sional and concussion is suspected. Y n Any loss of consciousness? “if so, how long?“ Y n Balance or motor incoordination (stumbles, slow / laboured movements, etc.) ? Y n Disorientation or confusion (inability to respond appropriately to questions) ? n Y loss of memory: “if so, how long?“ “Before or after the injury?" Any athlete with a suspected concussion should be removed Y n Blank or vacant look: From PlAy, medically assessed, monitored for deterioration (i.e., should not be left alone) and should not drive a motor vehicle Y n Visible facial injury in combination with any of the above: until cleared to do so by a medical professional. no athlete diag- nosed with concussion should be returned to sports participation on the day of injury. © 2013 Concussion in Sport Group PAge 1 | Sport ConCuSSion ASSeSment tool 3 SC AT3

2 CogniTive & PhySiCAl ev AluATion BACkground Date: name: 4 Cognitive assessment examiner: 4 Standardized Assessment of Concussion (SAC) Sp o r t / team / s ch o o l: Date / time of injury: (1 point for each correct answer) orientation Gender: Age: F m 0 1 What month is it? Years of education completed: 1 What is the date today? 0 Dominant hand: left right neither 1 0 What is the day of the week? How many concussions do you think you have had in the past? 0 1 What year is it? When was the most recent concussion? (within 1 hour) What time is it right now? 1 0 How long was your recovery from the most recent concussion? Have you ever been hospitalized or had medical imaging done for Y n orientation score of 5 a head injury? Have you ever been diagnosed with headaches or migraines? Y n immediate memory Do you have a learning disability, dyslexia, ADD / ADHD? n Y Trial 2 Trial 1 List Alternative word list Trial 3 Have you ever been diagnosed with depression, anxiety Y n candle baby elbow finger 1 0 1 0 1 0 or other psychiatric disorder? 1 1 penny monkey paper 0 0 1 0 apple Has anyone in your family ever been diagnosed with Y n blanket perfume sugar 1 0 1 0 1 0 carpet any of these problems? 0 lemon sunset sandwich 1 0 1 1 saddle 0 Are you on any medications? i f yes, please list: n Y wagon iron bubble insect 1 0 1 0 1 0 Total SCAT3 to be done in resting state. Best done 10 or more minutes post excercise. of 15 immediate memory score total AluATion SymPTom ev d igits Backward Concentration: Trial 1 List Alternative digit list 6-2-9 5-2-6 4 -1-5 4-9-3 1 0 3 how do you feel? 4-9-6-8 3-8-1-4 0 1 3-2-7-9 1-7-9 -5 “You should score yourself on the following symptoms, based on how you feel now”. 6-1-8-4-3 3-8-5-2-7 1-5-2-8-6 6 -2-9 -7-1 0 1 moderate mild none severe 1 7-1-8-4-6-2 0 5-3-9-1-4-8 8-3-1-9-6-4 7-2-4-8-5-6 Headache 0 3 2 1 4 5 6 of 4 Total “pressure in head” 1 2 3 4 5 6 0 0 1 2 6 5 neck pain 3 4 month in r everse o rder (1 pt. for entire sequence correct) Concentration: 6 nausea or vomiting 1 2 3 4 5 0 1 0 may-Apr- mar-Feb-Jan oct-Sept-Aug-Jul-Jun- nov- Dec- Dizziness 0 5 2 3 6 4 1 Concentration score of 5 Blurred vision 0 2 3 4 5 6 1 0 1 2 3 4 5 6 Balance problems 2 1 0 Sensitivity to light 6 5 4 3 5 6 Sensitivity to noise 0 1 2 3 4 5 neck examination: Feeling slowed down 0 1 2 3 4 5 6 & strength u t pper and lower limb sensation enderness range of motion 6 Feeling like “in a fog“ 0 1 2 3 4 5 Findings: “Don’t feel right” 0 1 2 3 4 5 6 6 3 Difficulty concentrating 0 1 2 4 5 Difficulty remembering 0 1 2 3 4 5 6 6 Balance examination 4 6 5 3 2 1 0 Fatigue or low energy Do one or both of the following tests. 0 1 2 3 4 5 6 Confusion Footwear (shoes, barefoot, braces, tape, etc.) 0 3 4 5 Drowsiness 6 2 1 5 Modified Balance Error Scoring System (BESS) testing 2 5 1 trouble falling asleep 0 6 4 3 foot) non-dominant (i.e. which is the Which foot was tested left right 2 3 4 5 6 more emotional 0 1 Testing surface (hard floor, field, etc.) 0 3 irritability 5 1 2 4 6 Condition 2 Sadness 0 1 3 4 5 6 errors Double leg stance: 4 nervous or Anxious 1 2 3 0 5 6 (non-dominant foot): errors Single leg stance (Maximum possible 22) Total number of symptoms errors (non-dominant foot at back): tandem stance Symptom severity score (Maximum possible 132) And / o r n Y Do the symptoms get worse with physical activity? 6,7 Tandem gait n Y Do the symptoms get worse with mental activity? seconds time (best of 4 trials) : self rated and clinician monitored self rated self rated with parent input clinician interview 7 overall rating: if you know the athlete well prior to the injury, how different is Coordination examination the athlete acting compared to his / her usual self? upper limb coordination Please circle one response: Which arm was tested: right left unsure very different no different N/A Coordination score of 1 Scoring on the SCAT3 should not be used as a stand-alone method 4 8 to diagnose concussion, measure recovery or make decisions about SAC delayed recall an athlete’s readiness to return to competition after concussion. delayed recall score of 5 Since signs and symptoms may evolve over time, it is important to consider repeat evaluation in the acute assessment of concussion. | ge 2 PA © 2013 Concussion in Sport group ool 3 SS eSment t CuSS ion A Sport Con SC AT3

3 Balance testing – types of errors inSTruCTionS 1. Hands lifted off iliac crest pening eyes 2. o in t3 are the instructions given to the athlete by throughout the SCA Italics Words 3. Step, stumble, or fall the tester. 4. m oving hip into > 30 degrees abduction 5. l ifting forefoot or heel emaining out of test position > 5 sec 6. r Symptom Scale “You should score yourself on the following symptoms, based on how you feel now”. each of the 20-second trials is scored by counting the errors, or deviations from he examiner will begin counting the proper stance, accumulated by the athlete. t to be completed by the athlete. i n situations where the symptom scale is being The modified errors only after the individual has assumed the proper start position. completed after exercise, it should still be done in a resting state, at least 10 minutes BeSS is calculated by adding one error point for each error during the three post exercise. For total number of symptoms, maximum possible is 22. - 20-second tests. The maximum total number of errors for any single con x 6 = 132. For Symptom severity score, add all scores in table, maximum possible is 22 i dition is 10. f a athlete commits multiple errors simultaneously, only one error is recorded but the athlete should quickly return to the testing position, and counting should resume once subject is set. Subjects that are unable to maintain the testing 4 SAC at the start are assigned the highest procedure for a minimum of five seconds immediate m emory possible score, ten, for that testing condition. “I am going to test your memory. I will read you a list of words and when I am done, repeat back as many words as you can remember, in any order.” oPT ion : For further assessment, the same 3 stances can be performed on a surface of medium density foam (e.g., approximately 50 cm x 40 cm x 6 cm). Trials 2 & 3: “I am going to repeat the same list again. Repeat back as many words as you can remember in 6,7 ait Tandem g any order, even if you said the word before.“ Participants are instructed to stand with their feet together behind a starting line (the test is & 2. Read the words at a rate of one per second. Complete all 3 trials regardless of score on trial 1 best done with footwear removed). Then, they walk in a forward direction as quickly and as . Total score equals sum across all 3 trials. Do not inform Score 1 pt. for each correct response accurately as possible along a 38mm wide (sports tape), 3 meter line with an alternate foot the athlete that delayed recall will be tested. heel-to-toe gait ensuring that they approximate their heel and toe on each step. Once they cross the end of the 3m line, they turn 180 degrees and return to the starting point using the Concentration same gait. A total of 4 trials are done and the best time is retained. Athletes should complete digits backward the test in 14 seconds. Athletes fail the test if they step off the line, have a separation between their heel and toe, or if they touch or grab the examiner or an object. In this case, the time is “I am going to read you a string of numbers and when I am done, you repeat them back to not recorded and the trial repeated, if appropriate. me backwards, in reverse order of how I read them to you. For example, if I say 7-1-9, you would say 9-1-7.” One point possible for each string If correct, go to next string length. If incorrect, read trial 2. Coordination examination length . Stop after incorrect on both trials. The digits should be read at the rate of one per second. upper limb coordination months in reverse order Finger-to-nose (FTN) task: “Now tell me the months of the year in reverse order. Start with the last month and go “I am going to test your coordination now. Please sit comfortably on the chair with your eyes backward. So you’ll say December, November ... Go ahead” open and your arm (either right or left) outstretched (shoulder flexed to 90 degrees and elbow 1 pt. for entire sequence correct and fingers extended), pointing in front of you. When I give a start signal, I would like you to perform five successive finger to nose repetitions using your index finger to touch the tip of the nose, and then return to the starting position, as quickly and as accurately as possible.” delayed r ecall the delayed recall should be performed after completion of the Balance and Coor - Scoring: 5 correct repetitions in < 4 seconds = 1 dination e xamination. Athletes fail the test if they do not touch their nose, do not fully extend their elbow Note for testers: “Do you remember that list of words I read a few times earlier? Tell me as many words from the Failure should be scored as 0. or do not perform five repetitions. list as you can remember in any order.“ Score 1 pt. for each correct response references & Footnotes n- his tool has been developed by a group of international experts at the 4th i 1. t Balance examination ternational Consensus meeting on Concussion in Sport held in Zurich, Switzerland 5 Modified Balance Error Scoring System (BESS) testing ovember 2012. t he full details of the conference outcomes and the authors of in n m i rotection, 2013, revention and Health p njury p he BJS the tool are published in t This balance Scoring Error version on a modified of the Balance is based testing 5 he outcome paper will also be simultaneously co-published in ssue 5. t Volume 47, i . A stopwatch or watch with a second hand is required for this testing. System (BESS) other leading biomedical journals with the copyright held by the Concussion in Sport “I am now going to test your balance. Please take your shoes off, roll up your pant legs above Group, to allow unrestricted distribution, providing no alterations are made. ankle (if applicable), and remove any ankle taping (if applicable). This test will consist of three twenty second tests with different stances.“ cCrory p et al., Consensus Statement on Concussion in Sport – the 3rd i - 2. m nter national Conference on Concussion in Sport held in Zurich, n ovember 2008. British (a) d ouble leg stance: Journal of Sports m edicine 2009; 43: i76-89. “The first stance is standing with your feet together with your hands on your hips and with . the assessment of orientation following l; Dicker, GD; Saling, mm maddocks, D 3. your eyes closed. You should try to maintain stability in that position for 20 seconds. I will be concussion in athletes. Clinical Journal of Sport Medicine. 1995; 5(1): 32 – 3. counting the number of times you move out of this position. I will start timing when you are set and have closed your eyes.“ - cCrea m 4. m . Standardized mental status testing of acute concussion. Clinical Jour – 181. nal of Sport m edicine. 2001; 11: 176 (b) Single leg stance: - m. Assessment of postural stability following sport-related concus 5. Guskiewicz K “If you were to kick a ball, which foot would you use? [This will be the dominant foot] Now eports. 2003; 2: 24 sion. Current Sports m edicine r – 30. - stand on your non-dominant foot. The dominant leg should be held in approximately 30 de p. & m tooke, G. 6. Schneiders, A.G., Sullivan, S.J., Gray, A., Hammond- cCrory, grees of hip flexion and 45 degrees of knee flexion. Again, you should try to maintain stability normative values for 16-37 year old subjects for three clinical measures of motor for 20 seconds with your hands on your hips and your eyes closed. I will be counting the number of times you move out of this position. If you stumble out of this position, open your performance used in the assessment of sports concussions. Journal of Science and eyes and return to the start position and continue balancing. I will start timing when you are Medicine in Sport. 2010; 13(2): 196 – 201. set and have closed your eyes.“ 7. Schneiders, A.G., Sullivan, S.J., Kvarnstrom. J.K., o arshall, . & m ., Yden. t lsson, m neurological The effect - and sports-surface S.W. of footwear on dynamic screen (c) Tandem stance: ing in sport-related concussion. Journal of Science and m edicine in Sport. 2010; “Now stand heel-to-toe with your non-dominant foot in back. Your weight should be evenly 13(4): 382 – 386 distributed across both feet. Again, you should try to maintain stability for 20 seconds with your hands on your hips and your eyes closed. I will be counting the number of times you move out of this position. If you stumble out of this position, open your eyes and return to the start position and continue balancing. I will start timing when you are set and have closed your eyes.” ge 3 © 2013 Concussion in Sport group PA | ool 3 SS eSment t CuSS ion A Sport Con SC AT3

4 AThleTe inFormATion Scoring Summary: Any athlete suspected of having a concussion should be removed Score test Domain from play, and then seek medical evaluation. Date: Date: Date: Signs to watch for number of Symptoms of 22 over the first 24 – 48 hours. The athlete should not be left alone Problems could arise Symptom Severity Score of 132 and must go to a hospital at once if they: orientation of 5 - Have a headache that gets worse immediate m emory of 15 - Are very drowsy or can’t be awakened Concentration of 5 - Can’t recognize people or places Delayed r ecall of 5 - Have repeated vomiting SAC Total - Behave unusually or seem confused; are very irritable Have seizures (arms and legs jerk uncontrollably) - BESS (total errors) - Have weak or numb arms or legs Tandem Gait (seconds) - Are un steady on their feet; have slurred speech Coordination of 1 remember, it is better to be safe. Consult your doctor after a suspected concussion. return to play notes: Athletes should not be returned to play the same day of injury. medically cleared and then follow When returning athletes to play, they should be a stepwise supervised program, with stages of progression. For example: objective of each stage rehabilitation stage Functional exercise at each stage of rehabilitation recovery no activity physical and cognitive rest increase heart rate Walking, swimming or stationary cycling light aerobic exercise % maximum predicted keeping intensity, 70 heart rate. n o resistance training exercise Skating drills in ice hockey, running drills in Sport-specific Add movement soccer. n o head impact activities progression to more complex training drills, non-contact exercise, coordination, and training drills eg passing drills in football and ice hockey. cognitive load may start progressive resistance training Following medical clearance participate in Full contact practice Restore confidence and assess functional skills by coaching staff normal training activities return to play normal game play recur 24 hours should for each stage and if symptoms (or longer) be at least There the athlete should rest until they resolve once again and then resume the program at the previous asymptomatic stage. r esistance training should only be added in the later stages. if the athlete is symptomatic for more than 10 days, then consultation by a medical practitioner who is expert in the management of concussion, is recommended. medical clearance should be given before return to play. ConCuSSion injury AdviCe patient’s name the concussed athlete) person monitoring (To be given to the of injury Date / time this patient has received an injury to the head. A careful medical examination has review of medical Date / time been carried out and no sign of any serious complications has been found. r ecovery time is variable across individuals and the patient will need monitoring for a further treating physician period by a responsible adult. Your treating physician will provide guidance as to this timeframe. if you notice any change in behaviour, vomiting, dizziness, worsening head - ache, double vision or excessive drowsiness, please contact your doctor or the nearest hospital emergency department immediately. other important points: - Rest (physically and mentally), including training or playing sports until symptoms resolve and you are medically cleared - no alcohol - no prescription or non-prescription drugs without medical supervision. Specifically: · no sleeping tablets · Do not use aspirin, anti-inflammatory medication or sedating pain killers - Do not drive until medically cleared - Do not train or play sport until medically cleared Contact details or stamp Clinic phone number © 2013 Concussion in Sport group ge 4 SC AT3 | ool 3 SS eSment t CuSS ion A Sport Con PA

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