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Sideline assessment strategies for sport concussion

By Gary S. Solomon, Karen M. Johnston, and Mark R. Lovell


The sideline assessment of concussion can be approached either qualitatively or quantitatively. A frequently used qualitative measure is Maddocks’ Questions. A recommended quantitative measure is the Standardized Assessment of Concussion (SAC). A third measure is the McGill Abbreviated Concussion Evaluation (McGill ACE), which is a hybrid of the two approaches.

In the past, amateur sports teams typically didn’t have physicians, athletic trainers, and neuropsychologists available on the sidelines. In most cases (especially in high school), the team coach also served as physician and trainer. Teams were considered especially fortunate if a player’s parent was a physician and happened to be a spectator at the game. The typical scenario that occurred when an athlete sustained a concussion was for the coach to place his fist with three fingers extended in front of the athlete’s face and ask, "How many fingers?" If the athlete answered correctly, then he was deemed to be okay ("He just got his bell rung") and was allowed to return to play. A more sophisticated approach involved asking the player her name, the date, and where she was. These are basic orientation questions taken from the mental-status examination used in clinical neurology and psychiatry. If the player was able to answer most of these questions correctly, he was assessed as having a "ding" and usually allowed to return to play. Retired NFL players tell stories of passing these screening tests for concussion, returning to play for the rest of the game, and then having no memory whatsoever of what happened in the game.

We now know that such simplistic tasks are inadequate screening measures for assessing sport concussion. The application of traditional clinical mental-status questions and tasks to the evaluation of sport concussion has been woefully inadequate. It is now known that basic orientation questions (such as "What’s your name? Where are we? What day is it?") are insensitive to the task of screening for sport concussion. Loss of ability to recall one’s name is an extremely rare phenomenon, occurring for example in certain types of psychologically based memory loss (a condition known as "psychogenic amnesia") and in brain diseases such as advanced Alzheimer’s disease. Asking a professional athlete for the specific date is usually of little diagnostic value, as athletes are notoriously poor in keeping up with the date. Asking a football player the day of the week also is of little use because high school athletes typically play on Friday nights, collegiate athletes play on Saturdays, and professional athletes typically have games on Sunday.

Maddocks’ Questions

To screen players for sport concussion more adequately, a set of orientation questions that reliably differentiated concussed from nonconcussed athletes was needed. Dr. D.L. Maddocks and colleagues provided a solution in 1995 by developing a set of standardized questions that have become known as "Maddocks’ Questions":

Which ground (field) are we at?

Which team are we playing today?

Who is your opponent at present?

Which quarter (period) is it?

How far into the quarter (period) is it?

Which side scored the last goal (points)?

Which team did we play last week?

Did we win last week?

Questions should be adapted of course for the specific sport. Maddocks’ Questions are a qualitative measure for the screening of mental-status abnormalities and are a useful starting point in the initial screening for sport concussion. An athlete’s inability to answer Maddocks’ Questions correctly should raise suspicion for the presence of a concussive injury and indicates the need for a more thorough assessment.


This is an excerpt from The Heads-Up on Sport Concussion.


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