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Background and rationale
The recognition, evaluation, diagnosis and management of sport-related concussion (SRC) is complex, dynamic and multidimensional. It is viewed by many as one of the most complex injuries faced in sports medicine.1 Historically, several standardised, empirically derived, brief screening tools were available to acutely evaluate concussion signs and symptoms, cognitive functioning, and postural stability.2 3 Each of these instruments existed in isolation. The Concussion in Sport Group (CISG) integrated these measures into one multimodal tool designed to assist clinicians by standardising an acute assessment across several domains of functioning. The original Sport Concussion Assessment Tool (SCAT) was published in 20054 and contained educational information, a concussion symptoms scale and information on management of concussion.
In the years that followed several iterations of the SCAT have been published, informed by empirical data, systematic reviews and clinical experience. Each iteration of the SCAT evolved along with the scientific literature, with each version increasingly representing the complexity and multimodal nature of SRC assessment.
Development process
The systematic review pertaining to the SCAT65 was asked to: (1) review and evaluate the literature related to the identification and evaluation of sports concussion in the acute phase of injury (<7 days) among children, adults, and adolescents and (2) use this information to provide recommendations for improving the SCAT tools. The volume of research for this search necessitated a priori creation of six overlapping content subdomains: cognition, balance/postural stability, oculomotor/cervical/vestibular, emerging technologies, neurological examination/autonomic dysfunction and paediatric/child.
The results of the search were compiled into a draft paper forwarded to the expert panel for review in advance of the sixth International Conference for Concussion in Sport (27 October 2022–30 October 2022—Amsterdam). The primary outcomes were presented by the lead author at the open meeting. These outcomes were voted on and approved by the expert panel and became the focus of a workshop to discuss the tools on the final day of the conference. The final version of the SCAT66 was created by a group of systematic review coauthors between November 2022 and March 2023.
Content of the SCAT6
Overall, the data in the systematic review supported modifications to the SCAT5 in creating the SCAT6 to further enhance its clinical utility. The SCAT6 contains an enhanced athlete demographic section that includes annotation of language preference and a recognise and remove section that identifies key points for the healthcare professional.
Box 1 presents a summary of changes that were made to the SCAT6. The immediate memory/neurological screening contains six steps to be completed sequentially: (1) enhanced observable signs, (2) Glasgow Coma Scale, (3) cervical spine assessment, (4) revised coordination and ocular/motor screen, (5) memory assessment/Maddocks questions, and (6) an enhanced Red Flags section.
What’s New?
Enhanced athlete demographic section.
The SCAT6 is for use in adolescents (>12 years), and adults. The Child SCAT6 is for use with children 8-12 years.
SCAT6 requires a minimum of 10–15 min to be performed correctly.
SCAT6 is to be used within 72 hours (3 days), and up to 7 days, following injury.
Revised recognise and remove section.
Revised immediate assessment/neurological screen section.
New coordination and ocular/motor screen.
Enhanced Red Flags section.
Removal of the ‘Read Aloud’ instructions of the symptom scale.
Removal of the immediate memory 5-word list option (10-word list included).
Addition of a timed component to the months in reverse subtest.
Revised coordination and balance examination, including an optional dual-task tandem gait.
Revised detailed instruction section.
The off-field assessment contains revised athlete background questions and symptom evaluation, which was revised to remove the requirement for the athlete to read the instructions aloud. The cognitive screening section contains orientation questions and immediate memory,7 which now omits the 5-word option and only contains the 10-word lists. The concentration section contains digit span and months in reverse, now modified to include a timed component.
The coordination and balance examination underwent the most changes. There was sufficient evidence to consider tandem gait measures of dynamic postural control as meaningful additions to the acute assessment paradigm within the SCAT6. The recommended sequencing of measures begins with static balance (eg, mBESS or BESS) and then progresses to single-task and dual-task tandem gait measures. The dual-task tandem gait adds complexity by including a cognitive component that requires the athlete to count backwards by 7 s while walking heel-to-toe.
Lastly, delayed recall requires the athlete to repeat back as many words from the original learning task list as possible.
Clinical considerations
Clinicians using this tool will vary widely in their education and training, experience in evaluating and managing SRC, experience with cognitive assessment, and understanding of the clinical and physiological manifestations of SRC. Because of this variability, it is important for clinicians to familiarise themselves with all aspects of the tool, including the strengths and limitations of the SCAT6. To this end, we offer the following considerations:
The SCAT is most effective in discriminating between concussed and non-concussed athletes up to 7 days postinjury, with diminishing clinical utility after 72 hours. It is suggested that if the time frame is greater than 7 days after injury, the SCOAT6/Child SCOAT6 should be considered.
The SCAT6 is for use with adolescents (>12 years), and adults. The Child SCAT6 is for use with children aged 8-12.
The SCAT6 is intended to be an aide in the standardised evaluation of SRC during the acute phase of injury. It is not intended to be used as a stand-alone diagnostic tool but rather to inform clinical assessment and diagnosis.
It is important to underscore that ‘concussed’ athletes may perform within normal ranges on the SCAT6 (false negative) just as ‘normal’ individuals may perform poorly (false positive).
Interpretation of SCAT6 data is a clinical endeavour that includes examining the athlete in the context of personal, psychological, social, cultural, athletic, medical, injury characteristics/mechanism and educational history/factors.
Clinicians must familiarise themselves with best practices in the administration of standardised tests, use of appropriate normative data, interpretation of postinjury scores, psychometric test properties and the proper analysis of multiple tests used simultaneously (eg, population base rates) when using the SCAT6.
Clinicians who choose to use baseline data must familiarise themselves with reliable change metrics and base rates of reliable change scores.
Baseline testing may be useful when resources (eg, financial, personnel, time) permit, such as at the professional or elite level, but the evidence does not support compulsory use at other levels of sport, such as at the child and adolescent level.
When a baseline assessment is given, test users should be familiar with identification of performance invalidity on the SCAT6.
Performance well below emerging normative standards should trigger repeat and/or additional cognitive evaluation to establish an accurate baseline and/or rule out true cognitive impairment.
The SCAT6 is not intended to be used in isolation for making return-to-sport decisions.
Skates should not be worn during the mBESS.
The mBESS is most accurate if administered by the same person at baseline and postinjury.
Differences have been found on SCAT performance due to demographic variables (eg, age, sex, education), as well as cultural and linguistic differences.
The cultural/linguistic differences underscore the need to create approved, well-developed and validated approaches to different language versions of the SCAT6.
Simple literal translation of the SCAT6 is neither adequate nor valid. Translation coupled with cultural/linguistic adaptation of the tools, particularly immediate memory, is imperative.
There was insufficient evidence to guide modifications of the SCAT6 for para athletes. Modifications may be needed for both content and modes of administration.8
In closing, the development and promotion of the SCAT tools by the CISG has led to worldwide dissemination over many years and have been useful in the evaluation and management of acute SRC. We are committed to the free and broad distribution of the SCAT6 in its present form. Minor modifications of the tool for research purposes are permissible, as are minor formatting changes for internal non-commercial organisation use. However, any modification to the tools including translations and other alterations of the SCAT6 are not permitted without the approval of BMJ and the CISG.
The SCAT6 is an easily deployable multimodal tool to be used in the acute evaluation of SRC by healthcare professionals. Importantly, the diagnosis of concussion remains a clinical endeavour, of which information from the SCAT6 is only one part of the overall diagnostic process.
Supplemental material
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Acknowledgments
The authors gratefully acknowledge the work of the coauthors of the systematic review that served as a foundation for the SCAT6: Juan Carlos Arango-Lasprilla, Christopher M. Bailey, Neil Bhathela, Amanda M. Black, Nyaz Didehbani, Gerard A. Gioia, James Kissick, Simon Kemp, Michael Makdissi, William P. Meehan III, Jamie Pardini, Zahra Premji, Danielle Salmon, Jacqueline Josee van Ierssel and Roger Zemek. We also want to recognise the assistance of librarians Alix Hayden and Heather Ganshorn, and Corson Johnson, Candice Goerger, Shauna Rutherford, Kenzie Vaandering, Stacy Sick, and Kirsten Holte for their help with various aspects of the systematic review.
Footnotes
Twitter @BenjaminBrett1, @griz1, @DrKimHarmon, @HowellDR, @drtinamaster, @TamaraCVMcLeod, @jonpatricios, @Mputukian, @SammoWalton, @Kat_Schneider7
Contributors RJE served as the primary author and responsible for all aspects of the project, including initial preparation, coordination, review, editing and final preparation of the manuscript and SCAT6 tool. All coauthors contributed to the development and critical review of the manuscript and SCAT6 tool, and approved the final version of the manuscript and tool.
Funding Education grant from the Concussion in Sport International Consensus Conference Organising Committee through Publi Creations for partial administrative and operational costs associated with the writing of the systematic reviews and tool design.
Competing interests BLB reports grants from the National Institute on Aging and National Institute of Neurological Disorders and Stroke and travel support for professional conferences. SB reports current or past research funding from the National Institutes of Health; Centers for Disease Control and Prevention; Department of Defense—USA Medical Research Acquisition Activity, National Collegiate Athletic Association; National Athletic Trainers’ Association Foundation; National Football League/Under Armour/GE; Simbex; and ElmindA. He has consulted for US Soccer (paid), US Cycling (unpaid), University of Calgary SHRed Concussions external advisory board (unpaid), medicolegal litigation, and received speaker honorarium and travel reimbursements for talks given. He is coauthor of 'Biomechanics of Injury (3rd edition)' and has a patent on 'Brain Metabolism Monitoring Through CCO Measurements Using All-Fiber-Integrated Super-Continuum Source' (US 11529091 B2). He is on the and is/was on the editorial boards (all unpaid) for Journal of Athletic Training (2015 to present), Concussion (2014 to present), Athletic Training & Sports Health Care (2008 to present), British Journal of Sports Medicine (2008 to 2019). JMB reports being a part-time employee of the National Hockey League and a member of the NHL/NHLPA Concussion Subcommittee. JMB’s institution has received funding from Genzyme, and EyeGuide supporting his work, and he has served as a paid consultant to Med-IQ, EyeGuide, and Sporting KC. JSB reports receiving methods author funding for this review and Alexander Graham Bell Canada Graduate Scholarships-Doctoral Program. GAD s a member of the Scientific Committee of the 6th International Conference on Concussion in Sport; an honorary member of the AFL Concussion Scientific Committee; Section Editor, Sport and Rehabilitation, NEUROSURGERY; and has attended meetings organised by sporting organisations including the NFL, NRL, IIHF, IOC and FIFA; however has not received any payment, research funding or other monies from these groups other than for travel costs. RJE is a paid consultant for the National Hockey League and co-chair of the National Hockey League /National Hockey League Players Association Concussion Subcommittee, Major League Soccer’s Concussion Committee and the US Soccer Federation, provides testimony in matters related to mTBI and reports a grant from Boston Children’s Hospital (sub-award from the National Football League) and travel support for the CIS conference and other professional conferences, an unpaid board member of CISG and leadership roles (unpaid) in professional organisations. GG reports grant funding from CDC TEAM and OnTRACK grants, NIMH APNA grant, royalties from PAR, consulting fees from NFL Baltimore Ravens, Zogenix International, and Global Pharma Consultancy, and travel support for professional meetings. He is a member of USA Football Medical Advisory Panel. KMG reports compensation from National Collegiate Athletic Association for other services and grants from Boston Children’s Hospital (subaward from the National Football League). KGH reports research grants from AMSSM and Football Research. She is the Research Development Director of the PAC-12 and a member of the NFL Head, Neck And Spine committee and PAC-112 Brain Trauma Task Force. SAH reports occasional payment for expert testimony, travel support for professional meetings, member of Concussion in Sport Group, member of Centers for Disease Control and Prevention and National Center for Injury Prevention and Control Board Pediatric Mild Traumatic Brain injury Guideline Work Group, member of NCAA Concussion Safety Advisory Group, Team Physician Seattle Mariners, Former Team Physician Seattle Seahawks, and Co-founder and Senior Medical Advisor The Sports Institute at University of Washington Medicine. DH reports research support from the Eunice Kennedy Shriver National Institute of Child Health & Human Development, the National Institute of Neurological Disorders And Stroke, the National Institute of Arthritis and Musculoskeletal and Skin Diseases, 59th Medical Wing Department of the Air Force, MINDSOURCE Brain Injury Network, the Tai Foundation, and the Colorado Clinical and Translational Sciences Institute (UL1 TR002535‐05) and he serves on the Scientific/Medical Advisory Board of Synaptek. CLM reports no financial COI. She holds leadership positions with several organisations American College of Sports Medicine, American Medical Society for Sports Medicine, Pediatric Research in Sports Medicine, Council on Sports Medicine and Fitness, American Academy of Pediatrics, Untold Foundation, Pink Concussions, Headway Foundation and the editorial boards of Journal of Adolescent Health, Frontiers in Neuroergonomics, Exercise, Sport, and Movement. MM reports grants from NIH, Veterans Affairs, Centers for Disease Control and Prevention (CDC), Abbott Laboratories, Department of Defense (DoD), and NCAA outside the submitted work. DN receives consulting fees from the CFL and travel support for professional conferences. He is a team physician for the NHL and CFL. He is CMO for the CFL and a member of NHL and CFL committees. JP reports travel support for the CIS conference and other professional meetings, consulting fees and grant funding from World Rugby, and an unpaid board member of CISG and EyeGuide. MP reports receiving a travel stipend for attending CIS meeting and other professional conferences, grant funds from NCAA-CARE 2.0, royalties from Netters’ Sports Medicine, consulting fees from Major League Soccer as CMO, and occasional expert testimony/serves. She is a member of several professional boards advisory panels. KJS reported receiving an educational grant for assisting with the administrative and operational costs associated with the writing of the reviews and a travel grant from Publi Creations, grant funding from Canadian Institutes of Health Research, Public Health Agency of Canada (through Parachute Canada), National Football League Scientific Advisory Board, International Olympic Committee Medical and Scientific Research Fund, World Rugby, Mitacs Accelerate, University of Calgary; leadership roles in AFL, Federal Provincial Territorial Work Group on Concussion, Canada. JVL reports CIHR Postdoctoral Fellowship Award, UOMBRI Grant, travel stipend from CTRC and Founder of R2P Concussion Management. TCVM is a paid member of the NFL Head, Neck, and Spine Committee and an unpaid member of the USA Swimming Concussion Task Force. SRW reports honoraria and travel support for professional meetings and leadership positions in World Federation of Athletic Training and Therapy and Outcomes, International Traumatic Brain Injury Research Initiative.
Provenance and peer review Not commissioned; externally peer reviewed.
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