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Baseline Neurocognitive Testing: Is It Really Necessary?

Trend among concussion experts appears to be away from routine baseline testing

The most recent concussion consensus statements [1,2,3] recommend neuropsychological (NP) testing in making return to play decisions after concussion, and 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. [1,2]Student in front of computer

While NP testing has become increasingly popular in concussion management, its use remains controversial. As a result, there are no universally agreed-upon recommendations for use of NP testing,[13] with existing recommendations based on experts' opinion. [2]

Open to debate

Whether baseline testing is necessary is open to debate: it appears to have advantages over comparative normal values, but no studies have looked at this issue with regards to outcomes, and at least two recent studies [4,5] suggest that age-related norms may be adequate to assist with management decisions. 

If anything, while the trend in recent years has been for more athletes, especially at the high school level, to undergo baseline NP testing, there appears to be some slight movement away from recommending routine testing of all athletes, or even all athletes in contact or collision sports with a high risk of concussion:

  • The American Medical Society for Sports Medicine's 2013 position statement, [2] for example, says that concussions can be managed appropriately in a majority of cases without the use of NP testing, although it recognizes that it may have "added value in some settings, especially high-risk athletes."
  • The 2013 Zurich consensus statement on concussions [1] pours cold water on the increasingly widespread conventional wisdom that every athlete in contact or collision sports needs a baseline NP test, stating flatly that "[f]ormal NP testing is not required for all athletes," and that there is "insufficient evidence to recommend the widespread routine [or mandatory] use of baseline neuropsychological testing."
  • The American Academy of Neurology's 2013 concussion guidelines [3] states that it is "likely" that NP testing, whether paper-and-pencil or computerized, "is useful in identifying the presence of concussion." The AAN's language on baseline NP testing is equally equivocal, saying only that concussion management "might utilize individual baseline scores on concussion assessment tools, especially in younger athletes, those with prior concussions, or those with preexisting learning disabilities/attention-deficit/hyperactivity disorder, as doing so fosters better interpretation of postinjury scores."
  • The new Institute of Medicine/National Research Council report on concussions in youth sports[13] cites both the Zurich statement[2] and the 2013 position statement of the American Medical Society for Sports Medicine[2] as supporting the view that most concussions may be managed appropriately without neuropsychological testing.  Noting the lack of evidence that use of baseline testing in the clinical management of concussions improves short- or long-term outcomes, the report observes that, while "the universal 'screening' approach of using baseline tests may be a significant improvement, ... 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."
  • If NP testing is used, the Zurich statement,[1] AMSSM position statement,[2]  and Institute of Medicine and National Research report, as well as numerous recent studies,[6-10]  agree that it should not be the sole basis of management decisions, but should only be seen as an aid to the clinical decisionmaking process in conjunction with a range of other assessments (e.g. concussion symptom scales, balance, clinical exam).

 

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