Concussion App Identifies Red Flag Symptoms and Streamlines Injury Reporting

App aids clinical management and documentation of sport-related concussion injuries

By Jay Alberts, PhD

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The incidence of sports- and recreation-related concussion is estimated at 1.1 million – 1.9 million annually among youth in the United States.1 The identification and management of concussive injuries by athletes, parents, coaches and medical providers is complicated by inconsistent approaches to injury detection, delayed symptom onset, misconceptions related to injury management and the dynamic environment in which injuries occur (practice, competition or recreational settings).2,3

Concussion management is challenging in youth sports

Regardless of injury severity, medical providers from multiple disciplines commonly participate in the care of athletes with concussion along the continuum of care, from detection and diagnosis, to return to school and play. Health care systems often lack continuity of care across providers who may be administratively or physically located in different departments or locations. These logistical challenges coupled with the lack of interoperability within and between traditional electronic health record systems further complicate a team approach to concussion management.  These challenges are often compounded in a youth sport environment.

In youth athletics, coaches, parents and other non-medical personnel often volunteer to provide oversight of all aspects of event safety and injury. The inconsistent or lack of documentation of an injury by those who first encounter the injured athlete creates the initial barrier to effective concussion care as subsequent hand-offs across providers become challenging and time-consuming. Recognizing the diversity of training and expertise, we developed a mobile application to aid in the clinical management of concussion and communication of symptoms and the injury.

App identifies red flags

The iPad-based Cleveland Clinic Concussion Application (C3 app)4-6 was designed as a concussion management platform for use by providers within the Cleveland Clinic Health System.7 While the initial platform only consisted of evaluation modules, an incident report (IR) module was developed based on evaluation of practice patterns.8 The IR module was designed to standardize and systematize the characterization of injury severity through the evaluation of red flags, and to document injury-related demographics and athlete disposition. Red flags were operationally defined as any clinical sign or symptom that may be indicative of a more severe injury warranting medical monitoring, additional diagnostic testing, or a higher level of management.

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The objectives of this study were to characterize the implementation of the technology-enabled incident report and to determine the impact of age and gender on injury presentation and the management of student athletes.8 We hypothesized that youth athletes would be managed differently from high school and collegiate athletes, due in part to lack of formal medical coverage.

A total of 1,421 unique incidences of sport-related concussions were included in this sample for analysis. Age cohorts were categorized to correspond roughly with academic age levels as follows: youth (ages 5-13), high school (ages 14-18) and collegiate (ages 19-24).

Headache and dizziness were the two most commonly reported initial symptoms across all age cohorts and genders. However, the top six initial symptoms differed across age categories. Headaches were more common in youth and high school athletes than in collegiate athletes.8

Red flag symptoms were reported in 114 (8%) of student athletes, including one youth athlete (1%), 95 high school athletes (8%) and 18 collegiate athletes (11%). Incidence of red flag symptoms differed by age cohort.

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Despite the lower number and rate of red flags, youth athletes were more likely to be sent to the emergency department for evaluation than high school or collegiate athletes, likely reflecting the lack of medical triage knowledge of those monitoring youth sport activities.8 The electronic IR within C3 has the potential to address such gaps in medical coverage at youth sports.  The app presents the user with a series of questions that can be asked of the injured athlete to assess the need to utilize the emergency department in the management of youth concussion.


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  3. O’Kane JW, Spieker A, Levy MR, Neradilek M, Polissar NL, Schiff MA. Concussion among female middle-school soccer players. JAMA Pediatr. 2014;168(3):258-64.
  4. Alberts JL, Linder SM. The Utilization of Biomechanics to Understand and Manage the Acute and Long-term Effects of Concussion. Kinesiology Review. 2015;4(1):39-51.
  5. Alberts JL, Thota A, Hirsch J, et al. Quantification of the Balance Error Scoring System with Mobile Technology. Med Science Sports Exerc. 2015;47(10):2233-40.
  6. Alberts JL. A Multidisciplinary Approach to Concussion Management. The Bridge. 2016;46(1):23-25.
  7. Alberts JL, Modic MT, Udeh B, et al. Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion. J Vis Exp. 2019:143:e58962.
  8. Linder SM, Cruickshank J, Zimmerman NM, Figler R, Alberts JL. A technology-enabled electronic incident report to document and facilitate management of sport concussion: A cohort study of youth and young adults. Medicine (Baltimore). 2019;98(14):e14948.