One way for athletes, coaches, parents, officials, support staff and medical personnel to become educated about concussions is by downloading concussion "apps" on their mobile devices. Because of their widespread use, portability and wireless connectivity, mobile phones are, in the words of a 2013 study (1), "uniquely placed," to address the "significant" gap in concussion education.
While there are, as of yet, no studies investigating the use of mobile devices for sports concussion education, diagnosis or management, the authors of the 2013 study identified two key advantages of a mobile phone app as an educational tool: first, that they give the user the opportunity to download educational materials quickly, and, second, they possess operating systems that support engaging and interactive solutions to learning.
While the study identifies a need for smartphone apps to organize information on injury demographics, symptom timing, recovery milestones, and medical appointments, to provide licensed health care professionals diagnostic screening tools, such as the Sport Concussion Assessment Tool (SCAT2/3), easily accessible across computing platforms, the authors noted that, of the eleven applications they identified as being assessment tools, only four described the intended audience as health care professionals. Concerned that use by parents and other non-medical personnel might carry significant legal liability, the authors of the study say "care should be taken to ensure that assessment tools are used exclusively by licensed health care providers."
There are currently 18 smartphone applications on sports concussions (including apps from the maker of the Shockbox helmet sensor, and the mobile version of the King-Devick test). Six, according to a 2013 study, were found to provide educational materials for public consumption, one of which was created specifically for educating children (Hockey Canada Concussion Awareness for Kids). Most, however, are designed for use by medical professionals, such as athletic trainers or team doctors, not by parents or coaches. A seventh, issued in conjunction with the American Academy of Neurology's updated guidelines for the management of concussion in sport (2) in March 2013, after the 2013 study was issued, is also designed for parents, coaches and other non-medical personnel and reviewed below.
1. Concussion Recognition and Response (CRR) ($.99).
An excellent smart phone application developed by two top concussion experts, Gerard A. Gioia, PhD, a pediatric neuropsychologist and the Chief of the Division of Pediatric Neuropsychology at Children's National Medical Center, where he directs the Safe Concussion Outcome, Recovery & Education (SCORE) program, and Jason Mihalik, PhD, CAT(C), ATC, Assistant Professor in the Department of Exercise and Sports Science at the University of North Carolina, and co-director of the Matthew A. Gfeller Sport-Related Traumatic Brain Injury Research Center.
The app allows parents and coaches to capture and retain data on concussion incidents for a particular athlete and determining whether concussion is suspected by responding to a series of screen prompts:
- asking whether there was a blow to the head or body, the cause of injury, and how powerful the blow was;
- marking yes or no on a list of concussion signs (observed by parent or coach), including whether any seizures immediately following injury;
- instructing user to call 911 (with link) or go to nearest emergency room right away if athlete displays any of the warning signs of a more serious brain injury; and
- interviewing athlete and marking yes or no on list of concussion symptoms (experienced by athlete).
In case of suspected concussion, the app prompts parents and coaches to remove the athlete from the game or practice right away and provides recommendations for follow-up care and management, including:
- informing parent/guardian of suspected concussion
- recommending further medical evaluation
- giving parent ACE Post-Concussion Home/School instructions (while the instructions are provided, they are so small as to be essentially unreadable as formatted unless enlarged).
- observing athlete over next 24 hours, including not leaving him or her alone (the app includes a helpful checklist for use in home monitoring to record observations)
- instructing parents to review and record symptoms every 1-2 hours and observe for danger signs
- no return to play until athlete symptom free and been cleared by health professional for gradual return.
The app also includes helpful answers to concussions FAQs, with separate general FAQs and ones geared to coaches and parents.
This is an excellent and helpful concussion app, easy to navigate, and it puts at the fingertips of a coach, or parent or parent-coach most of the essential information they need for identifying a possible sports concussion and what parents need to do - and not do - in the first, critical 24 to 72 hours after suspected concussion. It is, in the view of MomsTEAM editors, the best concussion application for parents currently on the market.
Note: Before this application loads, the following box appears on the screen: "This application is not intended to replace seeking help from a trained medical professional. If the youth has lost consciousness, even briefly, call 911 immediately. Refer to the FAQs section for the complete disclaimer related to the application." The FAQs contain the standard legal disclaimer that the app is for "information and educational purposes only." Highly recommended.
2. Concussion App from Sports Safety Labs LLC (free/$4.99),
The free version of this application:
- provides basic information on concussion signs and symptoms;
- allows a user to call an ambulance via 911,
- helps a user locate the nearest hospital and provides driving directions, and
- allows the user to send location coordinates via email to emergency contacts and rescue personnel.
An optional concussion diagnostic module, available via in-app purchase for $4.99, allows the user to capture and store for individual athletes the results of 11 tests based on the SCAT2 test to assist in the evaluation of the physiological and neurocognitive status of pre-concussion (baseline) and post-concussion (injured) athletes. The standardized presentation of the report and its data can be emailed from the user's smartphone to a physician to support their diagnostic interpretation of the athlete's condition. Physician's post-injury reports may be forwarded via email from the smartphone to a child's club or league if the user chooses to do so for rapid documentation and approval for return-to-play status.
The application provides a personal baseline testing program which compares the athlete's own post-injury results versus their own pre-injury results rather than to "norms" or population samples of other athletes who have also taken the test, and is designed to help the athlete and their doctor make accurate, personalized comparisons for return-to-play decision.
Pop-up prompts at various points during the testing indicate that the app is designed for use by medical professionals, not by parents.
In the opinion of the MomsTEAM editors, the free version might be worth a download for parents, if for no other reason than to utilize the Call 911 and Locating the Nearest Hospital features, but the one for $4.99 is really not designed for parents, so there is no point in shelling out five bucks for a test that isn't meant for a parent to use, and, as the 2013 study reviewing smartphone apps pointed out, shouldn't be used except by qualified health care professionals. Free version: recommended. $4.99 version: not recommended.
3. Play It Safe (free)
This free smartphone application from Concussion Health, LLC includes a 22-part test, including:
- a simplified symptom checklist
- the so-called "Maddocks" questions used to determine if the athlete is oriented to time and space;
- a word recall test to test memory
- a number reversal test;
- some simple balance tests; and
- a vision test.
Once the test is completed, the app provides a result summary (red flag,yellow flag, green flag).
The application is unwieldy, as it doesn't include an explanation of why the 22 items are tested with the individual test modules, requiring the user to access the application's "Help" section to obtain such explanations. While the app says the tests can be performed by coaches, parents or other individuals involved in the athlete's care, it doesn't seem designed with any particular type of user in mind; the test modules are only loosely based on the SCAT2 test, and hence of questionable utility by a clinician in diagnosing a suspected concussion. Not recommended.
4. Pocket SCAT2 (free)
A smartphone version which purports to replicate the SCAT2 test, but which doesn't even come close to doing anything of the sort. A total waste and completely useless, either as a diagnostic tool for suspected concussion or as providing basic concussion information. In any event, the SCAT2 (now updated to the SCAT3) is designed for use by clinicians, not parents or coaches. Not recommended.
5. SCAT2 (free)
A smartphone version of the SCAT2 test intended for use only by qualified medical professionals, thus of no use for parents and coaches. With the March 2013 release of the SCAT3, expect this app to be updated soon. Not recommended.
6. ImPACT Concussion Awareness Tool (ImCAT)(free).
As the application's name suggests, this app, from the folks who make the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT), the most widely used computerized neurocognitive test for concussion management, provides information about concussions, but, unlike the others apps, is not a concussion testing tool.
The app includes:
- a helpful 10-question concussion quiz to test the user's knowledge of concussions (and debunk common concussion myths; for an article discussing concussion myths in detail, click here)
- A concussion overview, including a list of common signs and symptoms of concussion, information about post-concussion syndrome, what a concussion assessment involves, a discussion of current concussion management guidelines (correctly pointing out that there is no evidence to support the "grading" of concussions,, an approach that has now, as Dr. Joseph Congeni of Akron Children's Hospital points out in The Smartest Team, has been completely abandoned), a brief summary of the step-wise process experts recommend prior to return to play, concussion treatment (rest, no sports, no return while symptomatic), and concussion recovery.
- Information about Mild Traumatic Brain Injury (mTBI)
- Advice on preventing mTBI (not just in sports but in everyday life).
While all the information on this app can be found in the MomsTEAM concussion center and elsewhere on the Internet, it might not be a bad idea for parents and coaches, especially of teams without trained healthcare professionals, such as certified athletic trainers, on the sidelines to download so it is available for quick reference, just in case Internet access isn't possible. Recommended.
7. Return2Play (University of Michigan Neurosport)(free)
Developed by the Pediatric Trauma Program at C.S. Mott Children's Hospital in partnership with Michigan Neurosport, this app is Intended tor use primarily as a management utility for concussion patients to track their recovery from concussion and doctor's appointments. The app also contains some brief - too brief, in the view of MomsTEAM editors, sections on:
- some common concussion myths and facts;
- an abbreviated signs and symptom checklist;
- a list of signs which may indicate a more serious brain injury ;
- a short list of things to do during concussion recovery;
- a return to play protocol developed by Michigan Neurosport using the acronym BRAIN, which stands for : Bike, Run, Agility, In Red, No Restrictions;
- a list of factors that may increase an athlete's risk of concussion
- a list of three ways (technology, education, and enforcement) to reduce concussion risk.
Good information, but incomplete. Perhaps valuable for athletes who want to track their concussion recovery, but for parents, the CRR (#1 above) contains more complete information. Not recommended.
8. Hockey Canada Concussion Awareness (free)
Developed as part of a larger initiative between Hockey Canada and three other not-for-profit organizations) and as part of the Canadian government's Active and Safe Injury Prevention Initiative, this app, while designed for hockey players, has some valuable information on concussions, even for parents who don't have kids playing hockey, including:
- simple animations of the different ways concussions can occur (direct impact to head, impact to head from body blow, direct impact due to fall, and indirect impact);
- short articles dispelling the myths that helmets and mouth guards prevent concussions;
- signs and symptoms of concussion (emphasizing the important point about the need for parents to watch for delayed onset)
- instructions for follow-up care during the first 24-48 hours after injury, and the need for physical and cognitive rest.
- the pocket Concussion Recognition Tool issued as part of the 4th International Consensus Statement on Concussions in Sport (too small to be readable, however, on a smartphone; probably legible on an iPad or other tablet)
- a discussion of the 6-step return to play protocol.
- an explanation of baseline and post-concussion neurocognitive testing, including the important message that baseline tests should be administered and the results interpreted by a trained health care professional and explaining the advantages and disadvantages of such testing and how often a baseline test should be performed.
- 19 concussion videos on You Tube (some in French)
9. Hockey Canada Concussion Awareness for Kids (free)
The only concussion app designed specifically for kids, the app uses a character named "Puckster" to get information about concussions across to younger kids. It includes a simple video game kids can play in which Puckster skates over - or into - various obstacles on the ice with concussion tips on the board in the background, and easy-to-understand versions of the concussion recognition, treatment and return to play information in the regular app. Recommended for young hockey players; not recommended for football players. Hopefully, an app will come out soon for young football players!
10. USA Football Heads Up Football (free)
Speaking of football, as the name suggests, this app explains all of the elements of USA Football's Heads Up Football program, which the organization touts as a comprehensive approach to player safety for leagues, parents, and coaches run in partnership with the NFL.
11. American Academy of Neurology's Concussion Quick Check (free)
Issued in conjunction with the AAN's updated concussion guidelines (2), this is a useful and concise app true to its name, and is designed help parents, coaches, and other non-medical personnel determine if an athlete has a concussion and needs to see a licensed health care provider.
Like many of the other apps, the Concussion Quick Check includes:
- lists of common signs and symptoms of concussion;
- a checklist of things to do if an athlete is knocked unconscious during a game (e.g. check his ABC's: airway, breathing, and circulation);
- a list of things to do if a concussion is suspected: remove from play and not allow return that day, monitor for next three or four hours or longer (although the app doesn't say for what or why this important); notify a licensed health care provider (LHCP) trained in diagnosing and managing concussion, and not allow the athlete to return to play until evaluated and cleared by such a provider; and
- a brief discussion of things a healthcare provider may say to an athlete about return to play, including returning to physical activity slowly and increase activity levels carefully, step by step. (Consistent with the AAN's guidelines, which only go so far as to say that a LHCP "might develop individualized graded plans for return to physical and cognitive activity," the app does not endorse the graduated return to play protocol recommended in the last three international consensus statements on concussion in sport (3,4,5), saying only that the LHCP "may" tell an athlete to increase activity levels carefully.)
Brooke de Lench is the Founder and Publisher of MomsTEAM.com and the author of Home Team Advantage: The Critical Role of Mothers in Youth Sports and Producer and Director of MomsTEAM's new high school football documentary, "The Smartest Team."
1. Kutcher J, McCrory P, Davis G, et al. What evidence exists for new strategies or technologies in the diagnosis of sports concussion and assessment of recovery? Br J Sports Med 2013;47:299-303. (accessed March 21, 2013)
2. Giza C, Kutcher J, Ashwal S, et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2013; published online before print March 18, 2013; DOI:10.1212/WNL.0b013e31828d57dd.
3. McCrory P, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med 2005;39:196-204.
4. McCory P, et al. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Br J Sports Med 2009: 43:i76-i84
5. McCrory P, et al. Consensus Statement on concussion in Sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013:47:250-258.
6. Meehan WP, III. Kids, Sports, and Concussions (Praeger 2011), p. 4.
Posted August 12, 2012; substantially revised and updated April 25, 2013