The Physical Examination of Concussion: A Paradigm Shift in Diagnosis

Summary and Comment |
May 5, 2016

The Physical Examination of Concussion: A Paradigm Shift in Diagnosis

  1. Jonathan Silver, MD

A focused physical examination is critical for a thorough evaluation.

  1. Jonathan Silver, MD

The assessment of sports concussion is modeled after a system conceptualized by Jeffrey Barth at the University of Virginia more than 20 years ago. The procedure requires first a “preconcussion” evaluation and then postevent assessments of cognition and symptoms. The current authors, from the University of Buffalo, provide an evidence-based review of study findings on using the physical examination (PE) to diagnose concussion.

In addition to assessments of cognition, mood, and anxiety, the PE has several central elements:

  • Examination for autonomic dysfunction, including orthostatic hypotension and exercise intolerance with symptom exacerbation (e.g., the Buffalo Concussion Treadmill Test).

  • Assessment of cranial nerve abnormalities, especially in olfaction.

  • Examination for injuries of the head, neck, and, especially, cervical spine, which can produce dizziness, headaches, and abnormalities in balance. Assessments include cervical proprioception and temporo-manibular joint problems.

  • Balance/coordination examination. Tests include motor coordination and dual tasks (e.g., solving math problems while undergoing the Timed Up and Go test).

  • Vestibulo-ocular and ophthalmologic examinations. Vestibulo-ocular impairments are tested with the Head Thrust Test; dynamic visual acuity is also examined. Also assessed are smooth pursuits, horizontal and vertical saccades, near point of convergence, horizontal vestibulo-ocular reflex, and visual motion sensitivity.


It has been assumed that for the diagnosis of concussion, “baseline testing” is the gold standard. This differs from diagnosis of any other medical or neurological condition. These authors challenge that assumption and provide specific instructions for administering a PE that incorporates findings from tasks that commonly precipitate or exacerbate concussion symptoms. This article changes the paradigm for concussion assessment to one based on a thorough PE, similar to evaluations of other medical conditions. It should be required reading and practice for anyone who assesses patients with concussion.

Editor Disclosures at Time of Publication

  • Disclosures for Jonathan Silver, MD at time of publication Royalties Textbook of Traumatic Brain Injury, 2nd edition (less than $1,000) Editorial boards UpToDate Leadership positions in professional societies North American Brain Injury Association (Board Member); Chair of Data Monitoring Safety Board for National Institute on Disability, Independent Living, and Rehabilitation Research study of donepezil on cognition after traumatic brain injury


Reader Comments (3)

Cara Baxter, DPT Other Healthcare Professional

In response to Dr. Leigh: Physical therapists are doing these evaluations! Certainly not all are educated on concussion rehabilitation (this is not currently in the DPT education), but those who pursue concussion rehabilitation post-graduate are well equipped to deal with vestibular/oculomotor PCS, cervicogenic PCS, and physiologic PCS. And I bet they would welcome the referral!

JONATHAN SILVER Physician, Psychiatry

I appreciate Dr. Leigh's frustration. I think it is necessary to clarify what type of evaluation is necessary in different settings. If an individual comes to the emergency department, the main goal is getting an accurate description of the incident, including reports of amnesia or loss of consciousness, an evidence-based decision on the need for CT scan, and if appropriate, reassurance that the vast majority of patients have significant improvement over several days. I don't see that the evaluation described in this paper pertains to the ED. When symptoms persist for more than a week, a more thorough evaluation is indicated. Whoever does this evaluation, it would seem prudent for them to know the important aspects of the evaluation.

THOMAS LEIGH Physician, Emergency Medicine, Estes Park, CO

Well, that's just super. What are we supposed to do when we see these kids in the Emergency Department? Naturally, we ALL have vestibulo-ocular testing equipment in the ED, and have all been expertly trained examining "dynamic visual acuity". I'm sure we can all do this in the 30 seconds or so that we typically get to spend with patients when we are not fighting for 30 minutes to document in the EMR that information which we spent 30 seconds acquiring. All this in addition to screening for depression, domestic violence, TB exposure, AIDS exposure, EBOLA and every other potential medical condition ever described. And what about the pre-teens, and the other 99.9999% of the population that doesn't happen to have their preconcussion cognitive assessments in their back pockets. No problem. I'm thrilled. And if we can't do these assessments in the ED, (where most people with concussions present), to whom do we refer? The concussion assessment centers (which I am sure are as common as Starbuck's or McDonalds)?? And who is going to pay for these assessments in all the intoxicated homeless people that show up in the ED every other night? Where on earth do these recommendations come from?

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