Original research
Use of video to facilitate sideline concussion diagnosis and management decision-making

https://doi.org/10.1016/j.jsams.2016.02.005Get rights and content

Abstract

Objectives

Video analysis can provide critical information to improve diagnostic accuracy and speed of clinical decision-making in potential cases of concussion. The objective of this study was to validate a hierarchical flowchart for the assessment of video signs of concussion, and to determine whether its implementation could improve the process of game day video assessment.

Methods

All impacts and collisions potentially resulting in a concussion were identified during 2012 and 2013 Australian Football League (AFL) seasons. Consensus definitions were developed for clinical signs associated with concussion. A hierarchical flowchart was developed based on the reliability and validity of the video signs of concussion. Ninety videos were assessed, with 45 incidents of clinically confirmed concussion, and 45 cases where no concussion was sustained. Each video was examined using the hierarchical flowchart, and a single response was given for each video based on the highest-ranking element in the flowchart.

Results

No protective action, impact seizure, motor incoordination or blank/vacant look were the highest ranked video signs in almost half of the clinically confirmed concussions, but in only 8.8% of non-concussed individuals. The presence of facial injury, clutching at the head and slow to get up were the highest ranked sign in 77.7% of non-concussed individuals.

Conclusions

This study suggests that the implementation of a flowchart model could improve timely assessment of concussion, and it identifies the video signs that should trigger automatic removal from play.

Introduction

The use of video assessment on the sideline in sport is assuming an important role in concussion management.1, 2, 3, 4, 5, 6, 7, 8, 9 To date, video analysis has largely been used in concussion research to investigate the biomechanics, mechanism of injury and situational factors surrounding the injury. More recently, there has been an increased focus on the use of video assessment in the clinical setting to identify signs of concussion, particularly in professional sports such as ice hockey, American football, rugby union, rugby league and Australian football.3, 4, 10

In no other medical endeavour is it usual for the treating medical practitioner to have access to video footage that includes the mechanism of injury and the clinical signs that occur immediately upon impact, and in the subsequent seconds and minutes. Interpretation of video in sports requires the treating doctor to understand the video findings in the context of the game, and to appreciate which validated clinical signs are usefully extracted from review of the video footage. When studying the video criteria for concussion in sport, assessment of each video sign must be analysed for reliability and validity. This process must be performed separately for each sport because of the peculiarities within and between sports, including the nature of the field, use of protective equipment (e.g., helmets), video camera angles/distance and number of players on the field/arena.

For video analysis to be useful as a sideline-screening tool for concussion video footage must be readily available and easy to review (including slow motion replays with multiple camera angles). Moreover, whilst reliability and validity data can be generated for each clinical sign, the pressures of time on the sideline require a rapid review of the video, to allow the doctor to make a rapid assessment and decide whether or not there are sufficient signs to justify immediate removal of the athlete from the field of play.

Whilst concussion is usually a diagnosis made by a doctor based on the assessment of symptoms and signs following trauma, the video analysis can provide critical information that may improve diagnostic accuracy and speed. Video review however can take considerable time to complete thoroughly, especially if examining multiple video angles and replays for each clinical sign. A hierarchical flowchart may simplify this process, particularly when a diagnostic sign is present. When such a video sign is identified quickly on the sideline, the clinician can confidently remove the athlete from the field of play, and proceed to more detailed management as per the associated clinical protocol.11

This study continues the work from earlier investigations in which video signs of concussion were studied in Australian football and reliability and validity data presented.12, 13 A hierarchical order for video sign assessment was subsequently developed, with the intention of simplifying the process of game day video assessment for concussion. The aim of this study was to validate this flowchart model, and to determine whether its implementation could potentially improve sideline assessment of concussion.

Section snippets

Methods

This prospective cohort study was conducted in professional Australian football during over two seasons (2012 and 2013). Approval for the study was obtained from the Cabrini Human Research Ethics Committee (CHREC 09-09-11-15). The methods have previously been described in detail.13 In brief, an experienced clinician (MM) reviewed the video of each of the 414 AFL games played during the 2012 and 2013 seasons. Games were typically viewed within a week of being played. All impacts and collisions

Results

The highest ranked sign observed in the concussed and non-concussed groups are summarised in Fig. 2.

For concussed individuals, almost one in four videos demonstrated no protective action, and no further video assessment was required. Working through the flowchart down to the level of blank/vacant look demonstrated that at least one positive video sign was present in 48.9% of the concussed players. By comparison, the flow chart demonstrated a positive response by the level of blank/vacant look

Discussion

This study presents the results of applying a hierarchical flowchart to the assessment of video signs of concussion in Australian football. The results demonstrated that nearly half of videos with a clinical diagnosis of concussion had evidence of at least one of four video signs considered to be consistent with a diagnosis of concussion and warrant immediate and permanent removal from the game. Conversely, video signs suggesting “further assessment” were the highest ranked video signs in the

Conclusion

The use of video on the sideline in Australian football is an essential tool that has been used in the AFL in the sideline diagnosis of concussion. By utilising validated video definitions in a hierarchical flowchart, the team doctor has access to a wealth of information that may allow rapid diagnosis of concussion, and provide sufficient information to enable the team doctor to confidently remove the player from the field for clinical assessment. The video often informs the team doctor of

Practical implications

  • The introduction of a hierarchical flowchart model for video assessment of concussion on the sideline using validated video signs of concussion in Australian football may improve timely sideline concussion diagnosis.

  • The use of such a flowchart model may assist with rapid review of video on the sideline, and provides the team doctor with sufficient information regarding the key video signs that should automatically trigger removal of a player from the field.

  • The use of video assessment in

Acknowledgements

The authors are honorary members of the AFL concussion working group.

No external financial support was received for this study.

The authors wish to thank: Dr Hugh Seward (CEO, AFL Doctors Association (AFLDA)), Dr Andrew Potter (President, AFLDA), members of the AFLDA, Dr Patrick Clifton (AFL Football Research Analyst) and Dr Peter Harcourt (AFL Medical Director) for their support of the project; and the AFL for supplying the video clips for the research.

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