Still recommended by many
Many concussion clinicians, however, still recommend baseline neurocognitive testing.
One is William P. Meehan, III, MD, Director of the Sports Concussion Clinic at Boston Children's Hospital, who recommends baseline testing, both balance and computerized neurocognitive, for athletes playing sports that can carry a substantial risk of concussion, not just football, ice hockey, and lacrosse, but even soccer and basketball, sports which also have fairly high rates of concussion. [14,15]
"In particular," Dr. Meehan recommends conducting a balance assessment, ideally using the Balance Error Scoring System (BESS), and a form of neurocognitive or neuropsychological testing. "I like the computerized versions," he says, although he admits, "That's a little bit controversial. Some people think that every athlete should see a neuropsychologist and have traditional [i.e. pencil and paper] testing. I actually think that would be ideal, quite frankly it would be great. But there are just not enough neuropsychologists, and the ones that are there certainly don't have enough time to do an individual assessment on every athlete."
"And so the choice in reality, is that they get nothing, or they get computerized testing. And the computerized testing gives you information, and it gives you an accurate assessment of their memory. It gives you an accurate assessment of their reaction time, some of them to 1/1000th of a second, so a very high sensitive measure of their reaction time. And it gives you an accurate assessment of their processing speed, how long it takes them to think through information and come to some conclusion. And all those things are affected by concussion, they get worse after a concussion, and so you can use it to monitor their progress."
"The truth is [that] 20 to 30 percent of athletes in sports will report being symptom-free before their brain function as returned to its own personal baseline values.[16,17] And so if you don't do that testing, you run the risk of returning 20 to 30 percent of concussed athletes back to sports before they're fully recovered."
Is post-exertion neurocognitive testing needed?
In fact, a recent study [18] argues that clinicians should not return athletes to play based solely on the fact that they report being asymptomatic, but also should not view their results on computerized neurocognitive tests taken before they begin a graduated return to sports protocol. Researchers found that, among concussed student-athletes who reported no symptoms and even had returned to baseline on computerized neurocognitive tests taken before beginning the RTP protocol, more than a quarter (27.7%) exhibited declines in verbal and visual memory on the tests after moderate exercise.
Those findings prompted the authors of that study, led by sports concussion neuropsychologist Neal McGrath, Ph.D. of Sports Concussion New England, to recommend that neurocognitive testing become an "integral component of the athletic trainer's post-exertion evaluation protocol and that student-athletes should not be cleared for full contact activity until they are able to demonstrate stability, particularly in memory functioning, on such post-exertion neurocognitive concussion testing."
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3. Giza C, Kutcher J, Ashwal S, et. al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2013 (published online ahead of print March 18, 2013): DOI:10.1212/WNL.ob013e31828d57dd (accessed March 23, 2013)
4. Echemendia R, Bruce J, Bailey C, Sanders J, Arnett P, Vargas G. The Utility of Post-Concussion Neuropsychological Data in Identifying Cognitive Change Following Sports-Related MTBI in the Absence of Baseline Data. Clin Neuropsy 2012;26(7):1077-1091.
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11. Meehan WP, d'Hemecourt P, Collins C, Comstock RD, Assessment and Management of Sport-Related Concussions in United States High Schools. Am. J. Sports Med. 2011;20(10)(published online on October 3, 2011 ahead of print) as dol:10.1177/0363546511423503 (accessed October 3, 2011).
12. Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of Concussions Among United States High School Athletes in 20 Sports. Am J Sports Med 2012;40(4):747-755.
13. Institute of Medicine (IOM) and National Research Council (NRC). 2013. Sports-related concussions in youth: Improving the science, changing the culture. Washington, DC: The National Academies Press.
14. Meehan WP, d'Hemecourt P, Collins C, Comstock RD, Assessment and Management of Sport-Related Concussions in United States High Schools. Am. J. Sports Med. 2011;20(10)(published online on October 3, 2011 ahead of print) as dol:10.1177/0363546511423503 (accessed October 3, 2011).
15. Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of Concussions Among United States High School Athletes in 20 Sports. Am J Sports Med 2012;40(4):747-755.
16. Sandel N, Lovell M, Kegel N, Collins M, Kontos A. The Relationship Of Symptoms and Neurocognitive Performance to Perceived Recovery From Sports-Related Concussion Among Adolescent Athletes. Applied Neuropsychology: Child. 2012; DOI:10.1080/21622965.201 2.670680 (published online ahead of print 22 May 2012)(accessed June 5, 2012)
17. Lovell MR, Solomon GS. Neurocognitive Test Performance and Symptom Reporting in Cheerleaders in Concussions. J Pediatrics 2013. DOI: 10.1016/jpeds.2013.05.061 (epub September 2013).
18. McGrath N, Dinn WM, Collins MW, Lovell MR, Elbin RJ, Kontos AP. Post-exertion neurocognitive test failure among student-athletes following concussion. Brain Injury 2013;27(1):103-113.
Posted November 1, 2013
