Article Text

other Versions

What are the critical elements of sideline screening that can be used to establish the diagnosis of concussion? A systematic review
  1. Jon Patricios1,2,
  2. Gordon Ward Fuller3,
  3. Richard Ellenbogen4,
  4. Stanley Herring4,5,6,
  5. Jeffrey S Kutcher7,
  6. Mike Loosemore8,
  7. Michael Makdissi9,10,
  8. Michael McCrea11,
  9. Margot Putukian12,
  10. Kathryn J Schneider13
  1. 1 Section Sports Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria South Africa
  2. 2 Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg South Africa
  3. 3 Centre for Urgent and Emergency Care Research, School of Health and Related Research, University of Sheffield, Sheffield UK
  4. 4 Department of Neurological Surgery, University of Washington, Seattle, Washington USA
  5. 5 Departments of Rehabilitation Medicine, University of Washington, Seattle, Washington USA
  6. 6 Orthopedics and Sports Medicine, University of Washington, Seattle, Washington USA
  7. 7 The Sports Neurology Clinic at the CORE Institute, Brighton, Michigan USA
  8. 8 Institute of Sport Exercise and Health, University College London, London UK
  9. 9 Florey Institute of Neuroscience and Mental Health, Austin Campus, Melbourne Brain Centre, Heidelberg, Victoria Australia
  10. 10 Olympic Park Sports Medicine Centre, Melbourne, Victoria Australia
  11. 11 Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin USA
  12. 12 Director of Athletic Medicine, Princeton University, Princeton, New Jersey USA
  13. 13 Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Alberta Canada
  1. Correspondence to Dr Jon Patricios, Morningside Sports Medicine, PO Box 1267, Parklands, Cape Town 2121, South Africa; jpat{at}


Background Sideline detection is the first and most significant step in recognising a potential concussion and removing an athlete from harm. This systematic review aims to evaluate the critical elements aiding sideline recognition of potential concussions including screening tools, technologies and integrated assessment protocols.

Data sources Bibliographic databases, grey literature repositories and relevant websites were searched from 1 January 2000 to 30 September 2016. A total of 3562 articles were identified.

Study selection Original research studies evaluating a sideline tool, technology or protocol for sports-related concussion were eligible, of which 27 studies were included.

Data extraction A standardised form was used to record information. The QUADAS-2 and Newcastle-Ottawa tools were used to rate risk of bias. Strength of evidence was assessed using the Grades of Recommendation, Assessment, Development and Evaluation Working Group system.

Data synthesis Studies assessing symptoms, the King-Devick test and multimodal assessments reported high sensitivity and specificity. Evaluations of balance and cognitive tests described lower sensitivity but higher specificity. However, these studies were at high risk of bias and the overall strength of evidence examining sideline screening tools was very low. A strong body of evidence demonstrated that head impact sensors did not provide useful sideline concussion information. Low-strength evidence suggested a multimodal, multitime-based concussion evaluation process incorporating video review was important in the recognition of significant head impact events and delayed onset concussion.

Conclusion In the absence of definitive evidence confirming the diagnostic accuracy of sideline screening tests, consensus-derived multimodal assessment tools, such as the Sports Concussion Assessment Tool, are recommended. Sideline video review may improve recognition and removal from play of athletes who have sustained significant head impact events. Current evidence does not support the use of impact sensor systems for real-time concussion identification.

  • sports related concussion
  • sideline
  • screening
  • diagnostic accuracy

Statistics from


  • Competing interests JP received travel subsidies for conferences from South African Rugby and World Rugby. GWF is funded by the National Institute for Health Research and received travel funding from World Rugby. RE, SH, JSK, ML, MM, MP have no competing interests to declare. MM received travel and accommodation costs. KJS has received speaking honoraria for presentations at scientific meetings.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.