








































CLINICAL EXPERTISE COMMENTARY 

 

31 
Copyright © Indiana State University   Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 
 

Concussion Profiles: Moving Beyond the Graded Symptom Scale 
Tamara Valovich McLeod, PhD, ATC, FNATA*; Brian Vesci, DAT, ATC† 
*A.T. Still University, Mesa, AZ; † Northwestern University, Evanston, IL 
 

 
Key Phrases 
Diagnostic testing and physical examination: non-
musculoskeletal conditions, patient-reported outcomes, 
patient education 

Correspondence 
Dr. Tamara C. Valovich McLeod, Athletic Training Programs 
and School of Osteopathic Medicine in Arizona, A.T. Still 
University, 5850 E. Still Circle,  Mesa, AZ 85206. 
E-mail: tmcleod@atsu.edu  
Twitter: @TamaraCVMcLeod 
 
 
Full Citation 
Valovich McLeod TC, Vesci B. Concussion profiles: Moving 
beyond the graded symptom scale. Clin Pract Athl Train. 
2022;5(1): 31-35. 
https://doi.org/10.31622/2021/0005.01.5.      
 
 
COMMENTARY 

With the increased focus over the last decade on 
evidence-based practice, the majority of the 
discussion has been on evidence and the need for 
high quality evidence to assist athletic trainers in 
making important clinical decisions. Often left to 
last in the discussion of evidence-based practice, 
is the patient perspective. In the area of concussion 
evaluation and treatment, the patient perspective 
is critical. The assessment of symptoms has always 
been part of the multifactorial assessment 
paradigm for concussion, at baseline and post-
injury. The use of these scales has been criticized 
as subjective in nature, although they are often the 
only aspect of the concussion clinical examination 
that assesses the patient perspective.  As an injury 
that does not demonstrate many outward signs, 
reliance on the patient to provide input regarding 
symptoms is vital for the athletic trainer’s 
concussion evaluation. However, the graded 
symptom scale is often administered independent 
of more detailed outcome measures or with 
limited follow-up questions, which limits its utility. 
In this commentary, we will discuss how to go 
beyond the graded symptom scale, using 
concussion profiles and patient-report outcome  

 

measures (PROs) to better understand the patient 
perspective following concussion. 

While there are many symptom checklists and 
scales available, athletic trainers are probably 
most familiar with the symptom evaluation that is 
part of the Sport Concussion Assessment Tool-
Version 5.1 This symptom scale allows clinicians to 
assess a patient’s symptom status across 22-items 
and allows the patients to express the severity of 
each symptom on a 0-6 scale. These short 
symptom scales allow the clinician to understand 
the number of symptoms a patient has and the 
individual and total symptom severity, resulting in 
the ability to document two scores: symptoms 
endorsed and total symptom severity or classify a 
patient as symptomatic vs. asymptomatic. The 
brevity and non-descript nature of the included 
symptoms can provide a high level symptom 
screen; however it is up to clinicians to take a 
deeper dive in their evaluation process to aid in a 
differential diagnosis and to better understand 
the influence of the patient’s symptoms on their 
functional abilities. 

First, in order to aid in our differential diagnosis 
and determine appropriate treatment strategies, 
we should be asking additional questions 
regarding endorsed symptoms. For example, a 
patient who endorses headache on a graded 
symptom scale should be asked follow-up 
questions regarding the onset, location, duration, 
characterization, aggravating factors, relieving 
factors and treatment. Similarly, an endorsement 
of dizziness can be related to concussion, but also 
a number of other differential diagnoses. As such, 
it is important to ask follow-up questions 
regarding the quality, timing and duration, 
triggers, and other associated symptoms. This 
approach can be taken with most of the symptoms 

mailto:tmcleod@atsu.edu
https://doi.org/10.31622/2021/0005.01.5


Concussion Profiles: Moving Beyond the Graded Symptom Scale 

 

 
32 

Copyright © Indiana State University   Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 

on a graded symptom scale to assist in learning 
more about the reported symptoms. 

The next step in the evaluation process extends 
our interpretation of the graded symptom scale 
by grouping or categorizing the various symptoms 
into concussion profiles or sub-types. Authors have 
published different classifications for assigning 
concussion profiles (Table 1) allowing athletic 
trainers the ability to use the one that fits best with 
their clinical practice and directing physician 
standing orders. Regardless of which classification 
is used, clinicians should classify their patient’s 
symptoms to determine their patient’s primary 
concussion profile or sub-type. Due to the overlap 
of symptoms between profiles, often patients will 
have a secondary profile and in some cases a 
tertiary profile. Once the profiles are determined, 
the next step allows clinicians to learn more about 
how the patient’s symptoms are affecting aspects 
of their lives.  

While there has always been the recommendation 
to assess and manage each patient with an 
individualized approach, this philosophy becomes 
more important in our current era where we are 
moving to an active treatment paradigm. To 
facilitate active treatment of concussion, clinicians 
should be using the graded symptom scale as a 
screen to assign a symptom cluster or profile to 
each patient.2 Once a symptom profile is 
assigned, further assessment using a patient-
report outcome measure is indicated to allow a 
more thorough understanding of the patient’s 
perception of elements of those symptoms on their 
perceived health (Figure 1). This will allow for a 
more thorough understanding of the patient’s 
complaints and direct the clinician to an 
appropriate treatment strategy. While there is 
not one single PRO for sport-related concussion, 
there are many established PROs that could be 
used with the various concussion profiles (Table 2)3 
Clinicians should review the various options, 
understand licensing requirements (if applicable), 
and determine question relevance in their patient 
population. In the following section, we discuss an 
example in practice using the cervical profile. 

EXAMPLE IN PRACTICE  

The 22-item symptom evaluation previously 
mentioned evaluates the symptoms of headache, 
dizziness, cognitive impairment, and neck pain. 
These specific symptoms are important in a clinical 
context because they have been identified as 
common and shared symptoms of both concussion 
and whiplash associated disorder, and they are 
associated with similar mechanisms of injury.4 This 
suggests that a patient history alone, including 
mechanism of injury and symptom profile, is 
unlikely to differentiate these conditions. The Neck 
Disability Index (NDI) is a PRO that, although not 
currently validated for concussion, has been 
validated in a wide variety of patient populations 
and languages for acute and chronic neck pain. 
The NDI is a 10-item scale measured 0 (no 
disability) to 5 (full disability) and the authors of 
a systematic review found that a MDC of 5/50 is 
appropriate and that a score between 0-10 likely 
is approaching a floor effect.5 A study aiming to 
characterize cervical spine impairments in a 
younger population following concussion found 
that 90% of subjects demonstrated impairments in 
at least three out of five assessment categories; 
further, of those subjects for which the NDI was 
administered on initial physician assessment, over 
80% were interpreted as having disability due to 
neck pain. The five assessment categories utilized 
by the authors for their analyses were 
posture/movement quality, muscle strength and 
endurance, myofascial tension to palpation, joint 
mobility, and selective tissue testing for upper 
extremity radicular symptoms.6  

Due to the interrelationship of both mechanism 
and symptoms following trauma between 
concussion and whiplash associated disorder, it is 
of paramount clinical importance to evaluate a 
patient with suspected concussion for a 
cervicogenic origin of these symptoms. The NDI 
can offer a reliable and valid means to determine 
the need to complete a thorough assessment of the 
cervical spine  



Concussion Profiles: Moving Beyond the Graded Symptom Scale 

 

33 
Copyright © Indiana State University   Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 
 

Table 1. Concussion profile or sub-type classifications. 

Author Classifications 

Collins, 20147 Vestibular, ocular, cognitive, migraine, anxiety/mood, cervical 

Craton, 20178 Cognitive, oculomotor, affective, cervical, headache, cardiovascular, vestibular 

Harmon, 20192 Vestibular, cognitive, fatigue, anxiety/mood, headache/migraine, ocular 

Lumba-Brown, 20209 Cognitive, ocular-motor, headache/migraine, vestibular, anxiety/mood 

Associated conditions: sleep disturbance, cervical strain 

Kontos, 202010 Anxiety/mood, cognitive/fatigue, migraine, ocular, vestibular 

Modifying factors: sleep, neck 

Table 2. Possible patient-report outcomes for patients with different concussion symptom profiles. 
Clinical Profile Patient-Report Outcomes 
Anxiety/Mood Beck Depression Inventory 

Generalized Anxiety Disorders-7 
Profile of Mood States 
Patient Health Questionnaire 
Brief Symptom Inventory-18 
NeuroQOL Depression and Anxiety Subscales 

Cognitive/Fatigue Pediatric Quality of Life Inventory - Cognitive Subscale 
Multidimensional Fatigue Scale 
NeuroQOL Cognitive Subscale 

Migraine Headache Impact Test-6 
Migraine Disability Assessment 
Pediatric Migraine Disability Assessment 
Migraine Specific Quality of Life Questionnaire 

Ocular Convergence Insufficiency Symptom Survey 
National Eye Institute Visual Function Questionnaire–25 
Vision-Related Dizziness Questionnaire 

Vestibular Dizziness Handicap Inventory  
UCLA Dizziness Questionnaire 
Vertigo Symptom Scale 

Cervical Neck Disability Index 
Northwick Park Neck Pain Questionnaire. 
Copenhagen Neck Functional Disability Scale 
Whiplash Disability Questionnaire 

Sleep Basic Nordic Sleep Questionnaire  
Leeds Sleep Evaluation Questionnaire 
Medical Outcomes Study - Sleep Problems Measures 
Pittsburgh Sleep Diary 
Pittsburgh Sleep Quality Index 
Self-Rated Sleep Questionnaire  
Sleep Dissatisfaction Questionnaire 



Concussion Profiles: Moving Beyond the Graded Symptom Scale 

 

34 
Copyright © Indiana State University   Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 

 

as well as benchmarking to track progress. A 
cervical spine exam would be indicated for any 
patient reporting at least mild disability on the 
NDI. This exam should begin with an assessment of 
ligamentous and vascular integrity in the upper 
cervical spine. At minimum, screening for the 
atlanto-occipital (sharp-purser test) and atlanto-
axial (alar ligament test) joints in combination with 
a screen for vertebral basilar insufficiency is 
indicated. The clinical exam is then recommended 
to consist of the previously identified categories of 
assessment found in these patients.6 Utilizing the 
graded symptom scale as an initial screen, 
followed by a PRO specific to patient’s clinical 
profile can allow clinicians to further investigate 
the impact of the concussion in a more thorough 
manner and develop an appropriate treatment 
plan. 

REFERENCES 

1. Echemendia RJ, Meeuwisse W, McCrory P, et 
al. The sport concussion assessment tool 5th 
edition (SCAT5). Br J Sports Med. 2017. 
https://doi.org/10.1136/bjsports-2017-
097506.  

2. Harmon KG, Clugston JR, Dec K, et al. 
American Medical Society for Sports 
Medicine position statement on concussion in 
sport. Br J Sports Med. 2019;53(4):213-225. 
https://doi.org/10.1136/bjsports-2018-
100338.  

3. Valovich McLeod TC, Register-Mihalik JK. 
Clinical outcomes assessment for the 
management of sport-related concussion. J 
Sport Rehabil. 2011;20(1):46-60. 
https://doi.org/10.1123/jsr.20.1.46.  

4. Rebbeck T, Evans K, Elliott JM. Concussion in 
combination with whiplash-associated 
disorder may be missed in primary care: Key 
recommendations for assessment and 
management. J Orthop Sports Phys Ther. 
2019;49(11):819-828. 
https://doi.org/10.2519/jospt.2019.8946.  

5. MacDermid JC, Walton DM, Avery S, et al. 
Measurement properties of the neck disability 
index: a systematic review. J Orthop Sports 

Phys Ther. 2009;39(5):400-417. 
https://doi.org/10.2519/jospt.2009.2930.  

6. Tiwari D, Goldberg A, Yorke A, Marchetti GF, 
Alsalaheen B. Characterization of Cervical 
Spine Impairments in Children and 
Adolescents Post-Concussion. Int J Sports Phys 
Ther. 2019;14(2):282-295. 

7. Collins MW, Kontos AP, Reynolds E, Murawski 
CD, Fu FH. A comprehensive, targeted 
approach to the clinical care of athletes 
following sport-related concussion. Knee Surg 
Sports Traumatol Arthrosc. 2014;22(2):235-
246. https://doi.org/10.1007/s00167-013-
2791-6.  

8. Craton N, Ali H, Lenoski S. Coach cv: The seven 
clinical phenotypes of concussion. Brain Sci. 
2017;7(9). 
https://dx.doi.org/10.3390%2Fbrainsci709
0119.  

9. Lumba-Brown A, Teramoto M, Bloom OJ, et al. 
Concussion Guidelines Step 2: Evidence for 
Subtype Classification. Neurosurgery. 
2020;86(1):2-13. 
https://doi.org/10.1093/neuros/nyz332.  

10. Kontos AP, Elbin RJ, Trbovich A, et al. 
Concussion Clinical Profiles Screening (CP 
Screen) Tool: Preliminary Evidence to Inform a 
Multidisciplinary Approach. Neurosurgery. 
2020;87(2):348-356. 
https://doi.org/10.1093/neuros/nyz545.  

  

https://doi.org/10.1136/bjsports-2017-097506
https://doi.org/10.1136/bjsports-2017-097506
https://doi.org/10.1136/bjsports-2018-100338
https://doi.org/10.1136/bjsports-2018-100338
https://doi.org/10.1123/jsr.20.1.46
https://doi.org/10.2519/jospt.2019.8946
https://doi.org/10.2519/jospt.2009.2930
https://doi.org/10.1007/s00167-013-2791-6
https://doi.org/10.1007/s00167-013-2791-6
https://dx.doi.org/10.3390%2Fbrainsci7090119
https://dx.doi.org/10.3390%2Fbrainsci7090119
https://doi.org/10.1093/neuros/nyz332
https://doi.org/10.1093/neuros/nyz545


Concussion Profiles: Moving Beyond the Graded Symptom Scale 

 

35 
Copyright © Indiana State University   Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 

 

Figure 2. Example Using the Symptom Scale to Identify a Patient Profile 

 Anxiety/Mood 

Migraine 

Sleep Cervical 

Cognitive Fatigue  

Vestibular Ocular 

• Dizziness Handicap Inventory 
• Vertigo Symptom Scale 
• UCLA Dizziness Questionnaire 


