Crosby and Weber - The most famous and the most recent concussions.

I thought I was pretty clever when I came up with the name for these posts. (“The Quiet Room! I AM HILARIOUS!”) My bubble was unceremoniously burst over the holidays when a hockey-savvy friend of mine pulled me aside at a game (I’d like to think so as not to embarrass himself) and asked me just what the hell the quiet room is. It’s the place an NHL player is taken to be evaluated after anything that may have caused a concussion during a game – it can be the training room, an office, whatever. The point is it’s supposed to be quiet and free of distractions. What goes on in the quiet room? What exactly does it take to get a player in there? There are some very specific criteria, but it doesn’t seem as though teams are consistently following them despite the NHL’s best intentions.

Last March at the GM meeting in Florida, Gary Bettman announced that the league had revised its concussion evaluation protocols. This was in addition to other changes that would affect player safety – the testing of smaller/less rigid pads, rink redesign, holding teams responsible for their repeat offenders, and establishing a safety committee of former players tasked with continued examination of these issues.

The NHL Protocol for Concussion Evaluation and Management was revised in a few important ways – the evaluation has to be done by a physician (not a trainer) in a quiet place (not the bench) using a standardized assessment tool (not random questions). The changes to the protocol also went so far as to specify conditions under which players must be removed from the game and evaluated. The conditions? Any signs or symptoms of concussion. Specifically (per the NHL), any loss of consciousness, coordination or balance problems, being slow to get up after a hit to the head, a blank/vacant look, disorientation, “clutching the head” after a hit, and visible injury to the face in concert with any of the others. Bonus medical nerd aside: A symptom is something the patient complains of (“My head hurts!”), and a sign is something discovered on exam (“This guy’s head has a giant bruise on it!”)


Okay, but seriously. What happens in the quiet room?


The injured player comes off the ice, and the team physician is summoned from wherever team physicians hang out during games. After any first aid concerns are taken care of (letting someone continue to bleed is poor form) the player is supposed to be immediately evaluated with a standardized test. The point is to determine if they’re fit to return to the ice or need to be held out for further evaluation and testing. The obvious problem with this is that these evaluations aren’t always happening right away. Not only that, but we’ve definitely seen players come back after hits only to end up on the IR later on with a concussion (Kris Letang comes to mind). In fairness, concussions don’t always show up right away, and no test is perfect. It’s also difficult to evaluate and treat a player if he’s concealing symptoms (Colby Armstrong, I’m looking at you).

The standardized assessment tool being used is the SCAT 2 (version 2 of the Sport Concussion Assessment Tool). The SCAT 2 was developed by a group of medical and sport professionals at the International Symposium on Concussion in Sport in 2008. It provides a fairly quick and simple means for physicians, trainers, or other medical professionals to assess for a possible concussion. It’s also a great tool for baseline testing at the start of the season. Let’s be honest here – there’s some stuff on that test I’m pretty sure I couldn’t do fully awake, well rested, and for money, so having an idea of someone’s base abilities before assessing them with this test post-hit is a solid idea.


SCAT 2: More than just a funny name.

A very simplified pocket version of the SCAT 2


The SCAT 2 is a multi-step test that should take quite some time to complete – the intermission between periods would probably do it.

1. Symptom evaluation: The player is asked to rate 22 symptoms (on the card above, with a couple of extras) from 0 (none) to 6 (severe). He’s then assigned a symptom severity score.

2. Cognitive and physical evaluation: As the name implies, this is a test of thinking and physical abilities. It’s broken down into several parts:

  • GCS (Glasgow Coma Scale): A simple evaluation of eye opening, speech and movement. This is used by EMS to separate “okay” from “pretty much dead”, in the ICU as a quick description of a patient’s mental status, and in this case establishes baseline post-injury responsiveness so medical staff can make a comparison if there’s any deterioration.
  • Maddock’s Score: An extremely simple set of questions (“What’s the name of this venue? Who scored last?”) previously used on the sideline to evaluate for a concussion. This actually isn’t used in scoring the SCAT 2, but will definitely give the examiner another way to evaluate how well the player is thinking.
  • Cognitive Assessment: This is probably the longest, most involved portion of the test. This tests orientation (does the player know what day it is? What year?), immediate memory (can the player remember a short list of words?), and concentration (can the player say the months of the year backwards? Repeat a number sequence backwards?).
3. Balance exam: The player is timed and watched for stumbles while standing with his eyes closed on both feet, one foot, and then one foot in front of the other.

4. Coordination exam: Finger to nose testing. It’s exactly what it sounds like.

The player is scored on all the various parts of the test, and the doc has to decide if he’s able to go back on the ice. It’s not based solely on test scores, which the SCAT 2 is careful to point out -

“Scoring data from the SCAT 2 should not be used as a stand alone method to diagnose concussion, measure recovery or make decisions about an athlete’s readiness to return to competition after concussion.”

There’s definitely still a very subjective element to concussion management, and it falls on the medical and coaching staff as well as the player to be smart (and honest) about what they can do and how they’re feeling. So do I think the right decisions are always being made? No, obviously not. Do I think it’s getting better? Just when I think I can finally answer this question yes, something happens to put me off again (COLBY FRICKIN’ ARMSTRONG). I suspect the concussion epidemic is in part a result of teams and players starting to wise up to the importance of not pushing a head injured player back on the ice too soon. Where in the past a player might have fought through and never been officially “injured” I believe we’re now seeing a lot more concussions actually being diagnosed and treated in a more appropriate manner. There’s no reason Sidney Crosby has to be the next Eric Lindros – an excellent example of a promising career horribly damaged by poor injury management.

If you’d like your own copy of the SCAT 2 in its entirety, it’s available for download, and the authors encourage its distribution and use at all levels of sport. There’s also an app for that:

SCAT 2 for the iPhone