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From Dr. Rober Cantu, Co-Author of 3rd International Consensus Statement on Sport Concussions

Neuropsychological Testing Helpful in Concussion Management

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The current international consensus of experts (Zurich consensus statement)1 views neuropsychological (NP) testing as an "important component"  in determining when it is safe for an athlete to return to play after a concussion, and recommends formal baseline NP screening of athletes in all organized sports in which there is a high risk of concussion (e.g. football, hockey, lacrosse, soccer, basketball), regardless of the age or level of performance.
Baseline pre-injury and post-injury neuropsychological testing is now commonplace at the professional and collegiate level and has become more and more common at the high school level as well (although the cost, either conventional or computerized, is a factor in how widely such testing can be implemented at the high school level).  In the absence of NP and other (e.g. formal balance assessment), testing, the Zurich consensus statement recommends a more conservative approach to return to play approach, especially for children and adolescents.

Pen-and-paper tests

Standard pencil and paper neuropsychological tests (see box) have proven useful for identifying cognitive deficits resulting from concussions, and have been available to sports medicine clinicians for several years. These tests are designed to assess various domains of cognitive functioning such as short-term memory, working memory, attention, concentration, visual spatial capacity, information processing speed, and reaction time. The tests assist clinicians in quantifying the severity of the injury and eliminating some of the guesswork. The key to a successful testing program is having results from pre-season baseline testing for comparison to post-injury results.

Common Neuropsychological Tests Used in Sport Concussion Assessment1

Neuropsychological Test

Cognitive Domain

Controlled Oral Word Association

Verbal Fluency

Hopkins Verbal Learning Test

Verbal learning, immediate and delayed memory

Trail Making: Parts A and B

Visual scanning, attention, information processing speed, psychomotor speed

Wechsler Letter Number Sequencing Test

Verbal working memory

Wechsler Digit Span: Digits Forward and Digits Backward

Attention, concentration

Symbol Digit Modalities Test

Psychomotor speed, attention, concentration

Paced Auditory Serial Addition Test

Attention, concentration

Stroop Color Word Test

Attention, information processing speed

 

Because most states require advance training and licensing to purchase and use neuropsychological tests, and they are copyright protected, the NATA's 2004 Position Statement recommends that a licensed psychologist, preferably board-certified in clinical neuropsychology or with clinical experience in evaluating sport-related concussions, oversee and supervise the testing. These requirements are, unfortunately, likely to restrict how widely testing can be implemented at the high school level and in rural areas where access to neuropsychologists for consultation is likely to be limited.


Computerized Neuropsychological Tests

More recently, computer generated neuropsychological test programs have been developed and are currently being validated in the sports setting. They include the:

  1. Automated Neuropsychological Assessment Metrics (ANAM) system: a PC Windows-based test protocol developed by the National Rehabilitation Hospital Assistive Technology and Neuroscience Center in Washington, DC;
  2. CogState developed by CogState Ltd of Victoria, Australia; and
  3. Concussion Resolution Index (CRI) developed by HeadMinder, Inc. of New York, NY; and
  4. Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) developed at the University of Pittsburgh Medical Center.

Computerized tests have three significant advantages over more traditional pen and paper neuropsychological tests:

  • They take less time (more traditional pen and paper neuropsychological tests usually take an hour or more to administer)
  • They are easier to administer, as they do not need to be administered by a neuropsychologist.
  • They allow for infinite variety in the test questions that alleviate the practice or learning effects seen with more traditional neuropsychological test batteries.

Widespread use of such tests faces many of the same challenges as with use of pen-and-paper tests, including:

  • Questions regarding test reliability;
  • Validity, sensitivity, and specificity in peer-reviewed literature;
  • Required user training and qualifications;
  • The necessary role of the licensed psychologist for clinical interpretation of test results;
  • Hardware and software issues inherent to computerized testing; and
  • User costs.

Children and adolescents: different rules

The Zurich consensus statement recognizes that in the "majority of cases, NP testing will be used to assist return to play decisions and will not be done until [the] patient is symptom free." 

For children and adolescents, however, different testing rules may apply:

  • Testing while symptomatic.  In contrast to adults and athletes in their late teens, NP testing may be performed while the young athlete is still symptomatic in order to assist in school and home management:  young athletes need to limit exertion in day-to-day activities and scholastic and other cognitive stressors (e.g. text messaging, videogames, etc.) while symptomatic, which in some cases may require restricting school attendance and extracurricular activities to avoid making symptoms worse. Clinical evaluation of such athletes for concussion may also need to include both patient and parent input, as well as teacher and school input, where appropriate.

  • Adjusted for age and maturity level. Whatever cognitive testing is performed, it must be sensitive to the fact that athletes younger than their late teens are not only growing physically, but cognitively at a rapid rate, which may limit the value of  test results when comparing them to either the athlete's own, earlier baseline performance or to what is considered "normal" among his peer population. Note: different rules will apply for children below age 10, because such children report different symptoms - thus requiring a different, age-appropriate symptom checklist as an assessment component.

1. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008.  Br. J. Sports Med. 20090: 43:i76-i84.

2.  National Athletic Trainers’ Association Position Statement: Management of Sport-Related Concussion, Journal of Athletic Training 2004;39(3):280–297

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