While concussions are a “mild” form of traumatic brain injury (TBI) that can heal with adequate recovery, suffering multiple impacts to the head can potentially lead to permanent complications. This is true of both suffering multiple impacts in short succession (e.g., if an athlete is not pulled from play after suffering a concussion) and suffering multiple concussions over time.
This makes a prompt diagnosis of concussions very important – particularly in situations in which there is a risk for a subsequent head injury. One tool that can be used to assess whether an athlete or other individual may be concussed is the Standardized Assessment of Concussion (SAC).
The Standardized Assessment of Concussion (SAC): An Overview
The SAC is a Screening Tool That Should Not Be Used Exclusively
The Standardized Assessment of Concussion is a tool that parents, coaches, trainers, and doctors can use to determine whether a child or adult is exhibiting signs of a concussion. Crucially, the SAC does not provide sufficient information to support diagnosis, but rather is intended to be used as a means of screening an athlete or other individual to determine if a more thorough diagnosis may be necessary. As explained in the American Association of Neurological Surgeons’ (AANS) Journal of Neurosurgery:
“The Standardized Assessment of Concussion (SAC) is a brief cognitive test that specifically evaluates orientation, concentration, and memory. While the test is easy to administer as a sideline screening tool, it suffers from inadequate sensitivity to justify its use as a stand-alone test.”
The authors go on to write that the outcome of a concussion screening performed with the Standardized Assessment of Concussion is susceptible to manipulation by the subject. “[D]etermined athletes can manipulate the outcome, either by memorizing certain portions of the evaluation or by intentionally underperforming in the preseason baseline assessment to which subsequent tests will be compared.”
Even with its limitations, the Standardized Assessment of Concussion is still a useful tool in many circumstances, and individuals who are well trained in administering the SAC can help make important determinations as to whether athletes should be allowed to return to play. At the same time, improper administration of the SAC, ignoring signs of a concussion identified through the SAC, and performing an SAC to the exclusion of a formal diagnosis are all common mistakes that can lead to serious health complications and may support claims for legal liability.
The SAC Screens for Five Signs of Concussion Symptoms
The Standardized Assessment of Concussion is used to screen individuals who have suffered head injuries, and who have been involved in falls and collisions, for signs of concussions. These signs are not strictly “symptoms” themselves – which is why the SAC is not an appropriate diagnostic tool – but rather are indicative of the possibility of symptoms being present.
To this end, the Standardized Assessment of Concussion measures the five cognitive functions that are most likely to be impaired by the effects of a concussion. These are:
- Immediate Memory
- Neurologic Function
- Delayed Recall
The orientation component of the SAC examines subjects’ awareness of basic information – specifically the time and date. To do this, the SAC incorporates the “Maddocks questions,” which are:
- What month is it?
- What is the date?
- What day of the week is it?
- What year is it?
- What time of day is it?
Depending on the subject’s answer, each question is scored as either “0” or “1” for a possible total score of five.
Other tests similar to the SAC incorporate additional questions, such as: Where are we today? How much time is left in the game? Did your team win its last game? If an athlete or other individual is not able to answer the Maddocks questions, then there is not much point in asking these additional questions, and the individual should be seen by a doctor in a medical setting as soon as possible. If the individual is able to answer all or most of the Maddocks questions correctly, then asking these additional questions may help provide further insight into whether he or she is exhibiting signs of cognitive impairment caused by a concussion.
2. Immediate Memory
The immediate memory component of the SAC examines subjects’ ability to remember information they have just heard. This is done by reading the subject a list of five words and then asking the subject to repeat as many of the words as he or she can. This is done three times, and each word is scored as either “0” or “1” for a possible total score of 15.
3. Neurologic Function
The neurologic function component of the SAC focuses on aspects of cognitive ability other than recall. Specifically, the individual performing the screening is tasked with assessing six aspects of neurologic functionality:
- Loss of Consciousness – While the individual performing the SAC screening is tasked with determining both the occurrence and duration of loss of consciousness, any loss of consciousness should lead to the athlete or other subject being formally diagnosed.
- Retrograde Amnesia – Traumatic brain injuries can cause individuals to lose memories of past events. Screening for retrograde amnesia involves asking the subject questions about his or her past to which the subject should know the answer.
- Anterograde Amnesia – Anterograde amnesia refers to the loss of the ability to create new memories following a traumatic brain injury. Screening for anterograde amnesia involves asking the subject questions about events occurring subsequent to the impact suspected of causing a possible concussion.
- Strength – Neurologic impairments resulting from concussive brain injuries can cause athletes and other individuals to lose the ability to exert full strength with their muscles. Appropriate screening should be conducted to assess muscle strength without subjecting the individual to the possibility of additional brain trauma.
- Sensation – Neurologic impairments resulting from concussive brain injuries can also cause temporary loss of sensation. Appropriate screening should be conducted to assess whether the subject’s senses (i.e., smell, hearing, sight, taste, or touch) are impaired.
- Coordination – Individuals who are concussed may (but will not necessarily) exhibit a loss of coordination. Following a possible concussive impact, the athlete or other subject should be asked to perform a series of tasks that require a sufficient level of coordination to assess any possible neurologic impairment.
Unlike the other components of the Standardized Assessment of Concussion, the neurologic function component is not judged with a binary score. Instead, the individual performing the screening must be able to assess the subject’s condition based on the information gathered and determine whether this information suggests that a formal medical diagnosis is necessary.
The concentration component of the SAC requires subjects to recite four sets of three to six numbers backward and then recite the months of the year in reverse order. Each task is given a score of either “0” or “1” for a possible total score of five.
5. Delayed Recall
The delayed recall component of the SAC is used to assess anterograde amnesia, but in a slightly more structured format than the neurologic function component of the assessment. In order to test the subject’s delayed recall ability, the individual performing the screening should tell the subject to remember five words and then ask the subject to recite the words five minutes later. The inability to remember any word is given a score of “0” while recall of the word is given a score of “1” for a possible total score of five.
Overall, excluding the neurologic function component of the Standardized Assessment of Concussion (which is not scored), the maximum overall score on the SAC is 30. However, there is not a specific “passing” or “failing” score. Again, it is important to emphasize that the SAC is a screening tool only, and a high score on the SAC is not necessarily indicative of the absence of a concussion.
Alternatives to the Standardized Assessment of Concussion
While the Standardized Assessment of Concussion is commonly used as a screening tool on the sideline of practices, games, and other sporting events, it is not the only screening tool that is used. For example, the Sport Concussion Assessment Tool (SCAT5) has gained fairly widespread use in recent years. The SCAT5 is an expanded version of the SAC, and it uses additional questions and assessments to more thoroughly assess athletes’ possible concussion symptoms. Other screening tools that are used include:
- Symptom checklists
- Balance and gait assessments
- King-Devick Test
- Oculomotor assessments
Importantly, each of these assessment tools has its limitations, and individuals who perform concussion screenings must have sufficient knowledge and training to test and interpret subjects’ performance appropriately. Allowing an athlete to return to play after suffering a concussion can be extremely dangerous, and can significantly increase the athlete’s risk of post-concussion syndrome (PCS) and chronic traumatic encephalopathy (CTE).
Legal Liability for Failing to Perform the SAC or Sideline an Athlete Showing Signs of a Concussion
In terms of legal liability, coaches, teams, leagues, schools, camps, physicians, and other individuals and entities can potentially be held liable when an athlete is allowed (or forced) to return to play despite showing signs of a concussion. These individuals and entities owe a duty of care, and ignoring concussion risks will constitute a breach of this duty in some cases.
Failing to perform a screening assessment, improperly interpreting an athlete’s performance on the SAC, failing to seek a medical diagnosis, and misdiagnosing an athlete’s concussion are all forms of negligence for which athletes and their families can recover financial compensation under Connecticut law. While waivers can limit sports entities’ liability in some cases, they are not effective to insulate these entities from liability for egregious errors and intentional acts that exhibit a disregard for athletes’ safety.
Contact the Sports Concussion Lawyers at Berkowitz Hanna
If you have questions about pursuing a claim for legal liability for a sports-related concussion, we encourage you to get in touch. Our attorneys represent professional athletes, amateur athletes, and parents of youth athletes throughout Connecticut. For a free and confidential consultation, call us directly or request an appointment online today.