Often, when people think about "research," it brings to mind
sterilized labs where closely controlled tests are conducted by scientists
in white coats on various subjects. Although lab research is fundamental
to the progress of science and medicine, it isn't the only way scientific
research studies are performed. Recently, I was involved in a type of
research called the Modified Delphi Technique, aimed at achieving expert
consensus on the assessment of on-field and sideline sports concussion
in collision sports.
The Modified Delphi Technique is a formalized process for achieving consensus
among participants. This scientific study method systematically and quantitatively
blends clinical evidence and clinical expert opinions, in this case from
medical providers and other neurologic experts on a panel, by asking them
to rate the items in question, discuss those items and then re-rate them
according to their importance in assessing the subject at hand.
You see, expert recommendations for anything – from health care to
auto repair must first be determined by evaluating the evidence about
the topic and then asking the experts involved for their opinions. For
this study, the matter at hand was the evaluation of symptoms involved in
sports concussion in collision sports. This critical and weighty topic has significant health
implications for athletes.
Using the Modified Delphi Technique, I and a panel of more than a dozen
other neurologic experts participated first in two rounds of open-ended
question answering. The results from the first two rounds of questions
were used to develop a questionnaire for round three utilizing the Likert
Scale. Likert-style questions use a five or 7-point scale that ranges
from one extreme to another and asks the person answering the question
to "rate" their response. Though this might seem highly technical,
you have likely answered Likert-type questions anytime you have completed
a satisfaction survey for a brand you use. These are questions like: "I
would recommend BRAND to people I know," or "I am deeply satisfied
with BRAND's solution to X problem." The "scale" of
answer prompts ranges from Strongly Agree to Strongly Disagree, with three
to five other options in between.
At the end of round three, if less than 80 percent of the panel agreed
on an item, if the panel members were not in consensus, or if greater
than 30 percent of the panel neither agreed nor disagreed, then the process
moved into round four until the desired level of consensus was achieved.
As a result, the panel achieved a consensus for 85 percent of the clinical
signs indicating concussion. With this in mind, the panel concluded that
on-field and sideline concussion should include observing the mechanism
that resulted in suspected concussion, a clinical exam, and a cervical
spine (neck) assessment.
Our team also reached a consensus that 74 percent of the concussion signs
or red flags should result in removal from play. These include:
- Loss of consciousness
- Motor incoordination/ataxia
- Balance disturbance
- Confusion/disorientation
- Memory disturbance/amnesia
- Blurred vision/light sensitivity
- Irritability
- Slurred speech
- Slow reaction time
- Lying motionless
- Dizziness
- Headaches/pressure in the head
- Falling to the ground with no protective action
- Slow to get up after a hit
- Dazed look
- Posturing/seizures
The team also agreed that a normal on-field or sideline clinical examination
and Health Impact Assessment with no signs of concussion are indicators
of the safest return to play for athletes. In addition, a video assessment
should be a mandatory part of the clinical decision-making process for
professional athletes but should not replace clinical decision-making.
Though arriving at a clinical consensus may be boring for some, it illustrates
neurologic and other health experts' commitment to protecting and
caring for our patients. Sports concussion is a serious topic with myriad
health implications for those who sustain them. Education is critical
and a significant part of ensuring suspected concussions are evaluated
by an expert as soon as possible. Our patients deserve to receive care
from experts who are at the top of their game, and I am proud of the work
this distinguished panel has done to keep us there.
Sources:
https://files.eric.ed.gov/fulltext/EJ590767.pdf
https://pubmed.ncbi.nlm.nih.gov/37391103/#:~:text=On%2Dfield%20and%20pitch%2Dside%20assessment%20should%20include%20the%20observation,concussion%20allow%20return%20to%20play.