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Three Part Question

In [children with concussion] can a [pitch-side clinical assessment tool in comparison with clinical judgement] be used [to guide management and improve outcomes]?

Clinical Scenario

A 12 year old boy has sustained a head injury at a school rugby match. The coach takes him off the pitch, but the player is keen to finish the game. He is told he needs an assessment for traumatic head injury before he can continue to play. As the team doctor you perform the head injury assessment but wonder if it is useful for predicting outcome and guiding further management in mild traumatic brain injury (TBI).

Search Strategy

PubMed was searched using the following search strategy: [(((paediatric OR pediatric OR children)) AND concussion) AND mild traumatic brain injury) AND (side-line assessment or tools)]. The search was limited to English publications, in humans in the paediatric population (birth-16 years).
The literature search identified 4 relevant studies: 1 systematic literature review, 1 observational study, and 2 prospective cohort studies. All studies included looked at children under the age of 16 years who were assessed using a version of Sport Concussion Assessment Tool or Children’s Sport Concussion Assessment Tool.

Search Outcome

ChildSCAT5 has taken into consideration differing developmental stages in children but at present there is no published literature on validity. However, it is a useful symptom screen and trigger for further management, especially in relation to return-to-play decisions

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Babl FE et al 2017 Australia	Children with concussion presenting to ED (n=90) versus control (n= 174; 90 upper limb injury and 84 well children)	Prospective observational study	1.Ability to complete ChildSCAT3 (5-12Y) 2.Ability to complete SCAT (13-16Y)	32.2% of 5-8year olds and 5.5% of 9-12year olds were not able to complete ChildSCAT3 13.3% of 13-16year olds were not able to complete SCAT3 Subsets of ChildSCAT3 and SCAT with the highest rate of inability to complete: - symptoms scale (n=17) - BESS (n=9) - coordination (n=9) - digits backwards (n=8) - concentration (n=8)	Single centre, unblinded study
Babl FE et al 2017 Australia	Children with concussion (n=90) versus controls (n=174; 90 upper limb injury (ULI) and 84 well children) Separated across three age groups: • 5 – 8years • 9 – 12years • 13 – 16years	Prospective observational study	Aim to determine if SCAT3 and ChildSCAT3 can differentiate children with and without concussion Outcome measurements: 1. Symptom number and severity score 2. Immediate memory 3. Balance assessment (BESS) 4. Cognitive assessment younger age group	Significant difference between concussed and control groups (ULI and well) in relation to: 1a. Mean (SD) symptom number in <13Y: 9.51 (5.56) vs. 4.07 (3.52) vs. 4.50 (3.84), p < 0.001 1b. Mean (SD) symptom number in >13Y: 11.73 (4.79) vs. 3.73 (3.80) vs. 4.08 (4.26), p < 0.001 1c. Mean (SD) symptom severity score in <13Y: 18.65 (12.42) vs. 6.0 (6.42) vs. 6.80 (6.81), p < 0.001 1d. Mean (SD) symptom severity score in >13Y: 30.77 (18.6) vs. 8.5 (10.13) vs. 7.38 (9.39), p < 0.001 2a. Mean (SD) immediate memory score in <13Y: 11.53 (3.04) vs. 12.4 (2.57) vs. 12.48 (2.14), p = 0.023 2b. Mean (SD) immediate memory score in >13Y: 12.9 (2.87) vs. 14.13 (1.07) vs. 14.04 (0.69), p = 0.038 3a. Mean (SD) balance score in <13Y: 5.05 (3.91) vs. 2.95 (3.02) vs. 2.80 (2.33), p < 0.001 3b. Mean (SD) balance score in >13Y: 6.83 (4.47) vs. 4.0 (2.67) vs. 3.17 (2.97), p = 0.011 4. Mean (SD) cognitive score in <13Y: 21.64 (5.08) vs. 22.6 (4.74) vs. 23.4 (4.31), p = 0.024 No differences noticed when comparing children with upper limb injury and well children	Single centre, unblinded study therefore unable to confirm validity of SCAT and ChildSCAT
Brooks et al 2017 US	Children <13yr who participated in sport (n=478) Separated across three age groups: • 5 – 7years • 8 – 10years • 11 – 13years	Cross-sectional observational study	Primary objective was to obtain baseline normative Child SCAT3 scores and to examine differences based on: 1. Age and symptom severity score 2. Gender any symptom severity score 3. Age and mBESS 4. Gender and mBESS	Higher symptom severity scores in children aged 5-7years compared to those aged 11-13years (18.2 [10.0] vs. 11.3 [9.0]; mean difference, 6.86 [95% CI, 4.22-9.50]; effect size, 0.74) Males had higher symptom severity scores compared to females (15.1 [9.8] vs. 11.8 [9.2]; mean difference, 3.31 [95% CI, 1.60-5.02]; effect size, 0.35) In relation to mBESS: - Younger children scored worse than older children (mean [SD] score, 1.67 [1.8] vs. 0.76 [1.2]; mean difference, 0.91 [95% CI, 0.53-1.29]; effect size, 0.68) - Males scored worse compared to female counterparts (1.21 [1.5] vs. 0.71 [1.0]; mean difference, 0.50 [95% CI, 0.27-0.74]; effect size, 0.38)	Time of assessment was not standardised; therefore fatigability may have affected performance No intra-rater or inter-rater reliability testing performed between investigators
Echemendia RJ et al 2017 US	96 articles: • 21 SCAT • 32 ChildSCAT • 21 sideline • 8 video or observation • 14 oculomotor	Systematic review	Review of the utility of SCAT and ChildSCAT in Sports Relation Concussion in adults and children	No study validated ChildSCAT in its entirety. Components were assessed individually, and no study was able to effectively determine the validity of each component. Poor differentiation between concussed and not concussed children in 8 out of 13 symptoms for younger age group Older age was predictive of better cognitive scores and overall SCAT/ChildSCAT scores Higher symptom burden in females than males SCAT3 and ChildSCAT3 reliability diminishes with time post-injury Inclusion of near point of convergence (NPC) may be of benefit	Most studies involving children were cohort or case-control studies Studies limited to sports related injuries only No reference in the studies to linguistic or cultural factors which may affect test performance

Comment(s)

Over the last number of years, sports related concussions (SRC) and mild traumatic brain injury (TBI) have become of growing interest and concern to sporting communities, medical professionals and the general public. Although often used synonymously there are variations in the definition between concussion and mild TBI. Concussion is a complex pathophysiological process that affects the brain and is influenced by biomechanical forces which in essence involves mild traumatic brain injury as a result of direct or indirect blow to the head.[1] In the US there are approximately 750,000 young people and children presenting to ED with mild TBI each year. However, this is likely not a true representation of the incidence as many cases may go unreported or undiagnosed.[2] The signs and symptoms of a mild TBI are extensive and vary between individuals and may present immediately or over hours to days. They can be categorised into signs and symptoms relating to physical, emotional, cognitive and sleep domains. Symptoms are usually self-limiting, but may continue to have symptoms for over 4 weeks in up to 30% of children and young people with increased school absenteeism.[3] Children with ongoing symptoms at 28 days post-TBI are defined as having post concussive syndrome and have poorer academic performance, low mood, loss of social life and activities and as a result lower quality of life, highlighting the importance of early recognition and management of concussion.[4,5] The early recognition of mild TBI and correct decision-making surrounding return-to-play in sporting injuries is important for limiting potentially worse or prolonged symptoms of mild TBI. There are various concussion tools used at the pitch-side for evaluating mild TBI in adults and children, although there is only limited data on their use in children. Following a review by Davis et al in 2014,[6] an international concussion consensus meeting was held and the Sport Concussion Assessment Tool 3 (SCAT3) and Children’s Sport Concussion Assessment Tool 3 (ChildSCAT3) were developed.[7] The ChildSCAT is used for children between the ages of 5-13years; SCAT is used for children older than 13 years of age and adults. The SCAT and Child SCAT includes five different elements (1) symptom severity, using the Post- Concussion Symptom Score (PCSS) and Health and Behaviour Inventory (HBI); (2) cognitive assessment, through the SAC and SAC-C; (3) examination of the neck; (4) balance assessment, based on the modified balance error scoring system (mBESS); (5) assessment of co-ordination. The ChildSCAT includes reports from both the child and their parent, whilst the SCAT is only a self-reporting questionnaire.[1,6,7] It is performed following the initial stabilisation of the child and completion of a clinical assessment to out rule a more serious brain injury. In a single centre observational study, ChildSCAT3 was shown to reliably predict concussion in those children over 8 years with higher symptom severity scores, however, was less reliable in younger children.[8] In addition, younger children with concussion may have higher symptom severity scores than their older counterparts; this should be interpreted with caution as many of the symptoms reported in the questionnaire may be normal behaviours for this younger age group. [9] Differences have also been noted between symptom severity score and genders, with males more likely to have a higher symptom severity score.10 Regardless of age or gender, it is worth noting that scores were less reliable as the time from initial injury increased.[10] A systematic review in 2017 by Echemendia and colleagues looked at 21 studies involving ChildSCAT3 and concluded that there was only level 3-4 evidence of data for the use of this tool in children with concussion.[10] No study investigated SCAT or ChildSCAT in its entirety but individual aspects of the tool have been investigated and can be used with variable accuracy in assessing children for concussion. Modified balance error score system (mBESS) is clinical assessment tool which can be used on its own or as part of SCAT. mBESS is reported to be able to differentiate between college athletes who had, and had not, sustained mild TBI.[11] However, the sensitivity and specificity of this test lessened as the time from injury increased.[12] It is less reliable in younger children.[9] Another element of SCAT is the Standardised Assessment of Concussion (SAC). It evaluates concentration, orientation, immediate and delayed amnesia. In adults it has shown to have a sensitivity and specificity of 80-95% and 76-91% respectively.[2] There is no data on the value of the paediatric modified version, SAC-C, in the assessment of concussion. In a cross-sectional study of high school students Glaviano et al found that children under the age of 12 had significantly lower concentration scores in all tasks in the SAC tool than those over 12year of age.[13] The symptom score, the balance assessment for double and tandem stance, and immediate memory scores differentiated well from concussed children but orientation and digit backward count did not.[6] At the Berlin International Consensus Meeting in Concussion in Sport in 2017 there were modifications made to the child orientated SCAT and an updated SCAT5/ChildSCAT5 was implemented.[6,7,14,15] In ChildSCAT5 the symptom evaluation, rather than the post-concussive symptom scale, contains a health and behaviour inventory with a validated list for children and parents. It included red flag signs and symptoms for early detection of mild TBI. There are no validation or reliability studies performed of this latest version of ChildSCAT. The use of a baseline SCAT in the general population is not supported by the literature.[10] Although, there are limited studies in children with concussion who have complex medical needs, significant neurological disorders or mood disorders, and the impact it may have in interpretation of SCAT or Child SCAT.[16] A case control study by Cook et al concluded that children with ADHD performed worse on balance scores and reported more post concussive symptoms than their control counterparts, [17] and may benefit from a baseline pre-concussion assessment for comparison. SCAT5 and ChildSCAT5 may potentially assist medical health care professionals in the diagnosis of mild TBI especially in conjunction with clinical judgement. In addition, initial and repeated assessments with SCAT5/ChildSCAT5 may guide clinician advice about return to school or sports. It should be performed by a trained medical health professional, under no specific time limit.

Clinical Bottom Line

ChildSCAT5 has taken into consideration differing developmental stages in children but at present there is no published literature on validity. However, it is a useful symptom screen and trigger for further management, especially in relation to return-to-play decisions.

References

1. Babl FE et al Ability of Scat3 and Childscat3 to discriminate children with concussion from children with upper limb injuries and uninjured children in the emergency department British Journal of Sports Medicine 2017;51(11):A73
2. Babl FE et al Accuracy of Components of SCAT to Identify Children With Concussion Pediatrics 2017;140(2)
3. Brooks et al Establishing Baseline Normative Values for the Child Sport Concussion Assessment Tool JAMA Pediatrics 2017;171(7):670-677
4. Echemendia RJ et al What tests and measures should be added to the SCAT3 and related tests to improve their reliability, sensitivity and/or specificity in sideline concussion diagnosis? A systematic review British Journal of Sports Medicine 2017;51:895–901