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From the Institute of Medicine and National Research Council

'Culture of Resistance' for Self-Reporting Concussions, Study Finds

Questions use of baseline testing, graduated return to play protocol

Neurocognitive testing: role in tracking recovery

The committee noted that "the persistence of cognitive declines following symptom resolution in some individuals suggests there may be a role for neuropsychological testing in concussion management, for example, to help inform return-to-play decisions in these cases."

It recognized, however, that "such a role for computerized neuropsychological testing has been criticized ... on the grounds that there currently is no evidence to show that delaying an individual's return to full physical activity on the basis of residual neurocognitive deficits actually improves recovery outcomes or reduces the risk of subsequent injury."

Baseline neurocognitive testing: unnecessary?

While acknowleding that baseline neurocogntive testing had been called for and recommended for many years, the committee noted that very few studies had specifically examined the value of baseline testing, and that "establishing the validity of baseline testing is difficult."

The committee also noted that, while baseline testing was a common practice in schools and programs and has a theoretical foundation, it was expensive and time consuming and group testing had disadvantages. 

In fact, it pointed to the trend in recent years away from recommending baseline neurocognitive testing, at least for athletes not playing contact or collision sports with a high risk of concussion such as football, hockey, or lacrosse, citing as examples the fact that the consensus statement from the 4th International Conference on Concussion in Sport held in Zurich[2] took the lack of evidence for baseline testing "as an indication that baseline testing should not be required," while the 2013 position statement of the American Medical Society for Sports Medicine[3] stated that most concussions could be managed appropriately without neuropsychological testing, also noting the lack of evidence that use of baseline testing in the clinical management of concussions improves short- or long-term outcomes.

"The universal 'screening' approach of using baseline tests may be a significant improvement, but there are very few data on that issue, and it is not clear how one could determine if one approach is 'better' than another (i.e., comparing post injury to one's own baseline or to normative standards[4,5])," the reports states.

Gradual return to play protocol: little scientific basis 

The report also challenges as lacking in scientific basis the almost universal recommendation by concussion experts that, once individuals are symptom-free,  they follow a graded return-to-play protocol.[2]  "Aside from evidence supporting refraining from activities that risk additional injury or re-injury during the temporally undefined 'window of cerebral vulnerability' following a concussion," the committee noted that there was "little empirical evidence to support the timing of return to physical activity or to the use of graded approaches to do so."

It said that "randomized controlled trials or other appropriately designed studies on the management of concussion youth are needed in order to develop empirically based clinical guidelines, including studies to determine the efficacy of physical and cognitive rest following concussion, the optimal period of rest, and the best protocol for returning individuals to full physical activity as well as to inform the development of evidence-based protocols and appropriate accommodations for students returning to school."