Neuropsychological Testing For Concussions

Different rules for children, adolescents

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 Assessment2

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 NP tests, and they are copyright protected, the National Athletic Training Association's 2004 Position Statement2 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. The Zurich consensus statement echoes that position ("Neuropsychologists are in the best position to interpret NP tests by virtue of their background and training.").

1. Concussion Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008, P. McCrory et. al, Br. J. Sports Med. 2009; 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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