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Paper and Pencil Neuropsychological Testing for Concussions: Valuable But Come with Limitations

The most recent international consensus of concussion experts (1), views neuropsychological or neurocognitive (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 computerized neurocognitive testing is now commonplace at the professional and collegiate level, and is increasingly used at the high school level as well. (2)

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 years.

The tests 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 results of which can assist clinicians in quantifying the severity of the brain injury and eliminate some of the guesswork.  They have the advantage of testing additional cognitive functions not tested by the computerized NP tests, but are more expensive and require significantly more time to administer. (5)

The key to a successful testing program is to have results from pre-season baseline testing for comparison to post-injury results, both to determine extent and duration of impaired cognitive function and make the all-important decision about when it is safe for a young athlete to begin a graduated exercise program eventually leading to a return to play.

 

Common Neuropsychological Tests Used in Sport Concussion Assessment (3)

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 paper-and-pencil NP tests, and they are copyright protected, most concusson experts recommend 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 most recent international consensus of concussion experts (1) echoes that position ("Neuropsychologists are in the best position to interpret NP tests by virtue of their background and training.").  

The Centers for Disease Control agrees. In its recently issued "FAQs about Baseline Testing among Young Athletes (4), the CDC makes two important points: first, that baseline tests should only be administered by a trained health care professional; and, second, that "only a trained health care professional with experience in concussion management should interpret the results of [a] baseline exam," and, "when possible, ideally a neuropsychologist should interpret the computerized or paper-pencil neuropsychological test components of a baseline exam. 

The American Medical Society for Sports Medicine position statement on concussion in sport (5) concurs, saying NP testing "does require health professionals who are competent in test interpretation."


1. McCrory P, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-258. 

2. Meehan W, d'Hemecourt P, ComstockD, High School Concussions in the 2008-2009 Academic Year: Mechanism, Symptoms, and Management. Am J Sports Med 2010; 38(12): 2405-2409 (accessed December 2, 2010 at http://ajs.sagepub.com/content/38/12/2405.abstract?etoc).

3. McCory P, et al. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008.  Phys. Sportsmed 2009;37:141-159.

4. Centers for Disease Control and Prevention. FAQs about Baseline Testing among Young Athletes (http://www.cdc.gov/concussion/pdf/baseline_testing_FAQs-a.pdf)(accessed April 16, 2012) 

5. Harmon K, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med 2013;47:15-26. 

Most recently updated May 28, 2013 

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