title: What are the critical elements of sideline screening that can be used to establish the diagnosis of concussion? A systematic review.
abstract: 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.
  
  
  METHODS
  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.
  
  
  METHODS
  Original research studies evaluating a sideline tool, technology or protocol for sports-related concussion were eligible, of which 27 studies were included.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Section Sports Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.|Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Jon
authors.initials: J
authors.lastname: Patricios
authors.affiliation: Centre for Urgent and Emergency Care Research, School of Health and Related Research, University of Sheffield, Sheffield, UK.
authors.forename: Gordon Ward
authors.initials: GW
authors.lastname: Fuller
authors.affiliation: Department of Neurological Surgery, University of Washington, Seattle, Washington, USA.
authors.forename: Richard
authors.initials: R
authors.lastname: Ellenbogen
authors.affiliation: Department of Neurological Surgery, University of Washington, Seattle, Washington, USA.|Departments of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA.|Orthopedics and Sports Medicine, University of Washington, Seattle, Washington, USA.
authors.forename: Stanley
authors.initials: S
authors.lastname: Herring
authors.affiliation: The Sports Neurology Clinic at the CORE Institute, Brighton, Michigan, USA.
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Kutcher
authors.affiliation: Institute of Sport Exercise and Health, University College London, London, UK.
authors.forename: Mike
authors.initials: M
authors.lastname: Loosemore
authors.affiliation: Florey Institute of Neuroscience and Mental Health, Austin Campus, Melbourne Brain Centre, Heidelberg, Victoria, Australia.|Olympic Park Sports Medicine Centre, Melbourne, Victoria, Australia.
authors.forename: Michael
authors.initials: M
authors.lastname: Makdissi
authors.affiliation: Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: McCrea
authors.affiliation: Director of Athletic Medicine, Princeton University, Princeton, New Jersey, USA.
authors.forename: Margot
authors.initials: M
authors.lastname: Putukian
authors.affiliation: Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Alberta, Canada.
authors.forename: Kathryn J
authors.initials: KJ
authors.lastname: Schneider
mesh_terms: D056352:Athletes; D001265:Athletic Injuries / Q000175:diagnosis*; D001924:Brain Concussion / Q000175:diagnosis*; D006801:Humans; D013178:Sports Medicine / Q000379:methods*
keywords: diagnostic accuracy; screening; sideline; sports related concussion