The Grey Area of Concussion Diagnosis

Athletes often deny symptoms and a concussion diagnosis may depend on others noticing that a player is "off."
Athletes often deny symptoms and a concussion diagnosis may depend on others noticing that a player is "off."

The diagnosis and management of concussion is still a grey area for sports medicine specialists, according to a review published in Clinics in Sports Medicine.1

Despite the plethora of guidelines and consensus statements from medical societies and professional sports,2 decisions regarding the diagnosis and management of concussion remain relatively subjective and largely based on clinical judgment, write Michael McNamee, PhD, from the College of Engineering at Swansea University in Singleton Park, United Kingdom, and colleagues.

"The discussions relating to diagnosis and management of sports-related concussion are often clouded between what is supported by data, and what is supported by clinical experience or expert opinion," said Christopher Giza, MD.

Issues in diagnosis are often compounded by dishonesty from athletes, who may lie about their symptoms to remain in the game. The consequences can be significant, Dr Giza pointed out.

"If concussions are missed, then the risk for repeat injuries is greater and there is likely greater risk for long-term cumulative impairments," Dr Giza said.

Dr. Giza is director of the Steve Tisch BrainSPORT Program at the University of California at Los Angeles, and a lead author of the American Academy of Neurology (AAN)'s concussion guidelines.

Barriers to Concussion Diagnosis

In the review, the authors addressed barriers to concussion diagnosis in athletes, including lack of a diagnostic standard, return-to-play regulations, conflicts of interest with coaches and stakeholders, and confidentiality issues. Failure to directly observe the circumstances of injury can be compounded by dishonesty in symptom reporting, lack of trained medical personnel, and inadequate tools for assessment.2

"There is no gold standard or simple test to definitively diagnose concussion — diagnosis is complex and based upon clinical assessment," Dr. Giza pointed out. Moreover, most diagnostic tests used on the sidelines rely on patient honesty and are therefore not psychometrically reliable.

"The SCAT-3, for instance, relies primarily on a player reporting their symptoms. If a player has obvious memory or balance issues, the diagnosis is easy. If not, the best — and sometimes the only way — to diagnose a concussion is for the player to report their symptoms," Kimberly G. Harmon, MD, professor and head team physician for Husky football at the University of Washington in Seattle, told Clinical Pain Advisor.

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