Neuropsychological Testing in the Treatment and Management of Sport-Related Concussion

Melissa A. Lancaster, PhD

Lindsay D. Nelson, PhD

Michael A. McCrea, PhD

None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Lancaster, Dr. McCrea, and Dr. Nelson.

Introduction

After sustaining a sport-related concussion (SRC), the nervous system begins a complex sequence of neurochemical and metabolic processes that result in adverse physical, cognitive, and emotional sequelae.¹ As a result, a multidimensional assessment approach is needed that takes into account an athlete’s past history in addition to current report of symptoms, neurologic status, postural stability, and cognitive functioning in order to make an accurate diagnosis and proper treatment recommendations (Figure 26-1). Regarding cognitive functioning, common symptoms include memory disturbance, impaired vigilance, heightened distractibility, difficulty forming cohesive thoughts, slowed processing speed, and inability to carry out sequences of goal-directed movements.²^,³ Although self-report measures are a simple and convenient way to screen for cognitive symptoms, their reliability and sensitivity may be diminished because athletes sometimes fail to recognize these symptoms or may be motivated to underreport symptoms in order to return to play (RTP).⁴ As a result, objective, standardized measurement of cognitive symptoms by a trained neuropsychologist can be valuable for evaluating concussed athletes and informing RTP because repeat injuries appear most likely while athletes are early in their recovery.⁵

The purpose of this chapter is to describe how the field of neuropsychology contributes to the diagnosis and treatment of SRC. Within the sections below, the following will be discussed: the role of the neuropsychologist and neuropsychological (NP) testing in treatment of SRC, points of NP intervention, issues surrounding interpretation of NP data, and factors to consider when assessing pediatric populations.

Role of the Neuropsychologist in the Assessment of Sport-Related Concussion

Neuropsychologists are the healthcare professionals best trained to assess cognitive and emotional functioning in individuals who have sustained SRCs.⁶ Beginning with the work of Barth and colleagues, who first used NP tests to monitor the acute effects of SRC and recovery in collegiate athletes in the 1980s,⁷ neuropsychologists have been essential to the study of assessment and treatment of SRC.⁸ Neuropsychologists receive doctoral-level training in the field of clinical psychology in addition to
specialized training in brain–behavior relationships and the science of assessment. As described by Barth et al⁹:

FIGURE 26-1 Multidimensional approach to the assessment of sport-related concussion.

Clinical neuropsychologists use this knowledge in the assessment, diagnosis, treatment, and/or rehabilitation of patients across the lifespan with neurological, medical, neurodevelopmental and psychiatric conditions, as well as other cognitive and learning disorders. The clinical neuropsychologist uses psychological, neurological, cognitive, behavioral, and physiological principles, techniques, and tests to evaluate patients’ neurocognitive, behavioral, and emotional strengths and weaknesses and their relationship to normal and abnormal nervous system functioning (p. 16).

Neuropsychologists are also well-qualified to assess for preexisting factors, such as attention deficit hyperactivity disorder (ADHD), learning disability, and other developmental conditions, which may complicate interpretation of cognitive test data.

In addition to cognitive disturbance, individuals with SRC can present with emotional symptoms such as depression, fear, and anxiety.¹⁰ Also, athletes have been documented to respond differently to their injury than would nonathletes and have difficulty coping with restriction in activity after SRC and other lifestyle changes during recovery.¹¹ Furthermore, a positive relationship has been established between the presence of mood symptoms and length of recovery.¹²^,¹³^,¹⁴ Neuropsychologists, who are trained in the fundamentals of clinical psychology, are highly competent in the assessment of emotional factors that may be impacting cognitive functioning and injury recovery, and they are able to make appropriate recommendations for treatment of mood symptoms if deemed necessary.

As the consequences of improper treatment of SRC gain more attention, several states have enacted legislation mandating that student athletes with SRC be removed from play until cleared by a healthcare provider. It is the official position of the main governing bodies in neuropsychology, the American Academy of Clinical Neuropsychology (AACN), the American Board of Neuropsychology (ABN), the Society for Clinical Neuropsychology (SCN) of the American Psychological Association (APA), and the National Academy of Neuropsychology (NAN), that neuropsychologists be included among the healthcare professionals authorized to participate in SRC evaluation and management.⁶

The American Academy of Neurology (AAN) also cites that NP testing is likely useful in identifying the presence of concussion,¹⁵ and the American Medical Society for Sports Medicine (AMSSM)¹⁶ has concluded that NP testing may be especially helpful in informing RTP decisions in high-risk athletes with prior concussion. In line with these views, professional organizations such as the National Football League (NFL), Major League Baseball, National Hockey League, and Major League Soccer all include NP assessment in their concussion management protocols. As evidenced by these endorsements, neuropsychologists have played an important role in the development of current guidelines for assessment of SRC.¹⁷

Approaches to Neuropsychological Assessment of Sport-Related Concussion

Neuropsychologists assess cognitive functioning with standardized measures of a range of abilities (e.g., memory, attention, reasoning, visuospatial ability). Patients’ abilities are examined compared with demographically adjusted normative data or patients’ individual premorbid baselines (frequently available in the context of SRC). Taken with other relevant information such as patient history, neuroimaging, and laboratory findings, neuropsychologists make inferences about the presence of dysfunction in certain cognitive domains and sometimes specific neuroanatomical regions and brain circuits. Depending on a patient’s presenting condition, clinical profile, and goals for assessment, NP testing may facilitate differential diagnosis, inform prognosis, and guide appropriate treatment planning.

Traditional Pencil-and-Paper Neuropsychological Testing

Traditionally, the field of neuropsychology has used pencil-and-paper testing methods that have since been borrowed or adapted for assessment of athletes with SRC, especially instruments that measure functions affected by acute head injury (e.g., new learning and memory, attention, processing speed, and executive functioning). Most of these measures have demonstrated acceptable psychometric properties and are at least moderately sensitive to SRC early after injury (see Randolph et al¹⁸ for an overview of these measures). Although several athletic organizations have used fixed batteries composed of such tests,¹⁹ neuropsychologists may modify fixed batteries depending on each patient’s individual cognitive symptoms and other relevant factors (e.g., learning disability, physical limitations). This testing format has a number of advantages over computerized testing in that the one-on-one testing format may maximize participant performance (e.g., clinicians can respond to
participants’ needs for breaks between subtests), allows for clinicians to obtain valuable behavioral observations, allows more flexibility for examiners to test cognitive domains relevant to each patient, and tends to allow for the assessment of a wider range of neurocognitive domains. A negative attribute of traditional NP testing, however, is the amount of time and expertise needed to test athletes.¹⁶^,²⁰

Computerized Neurocognitive Testing

Because traditional NP assessment is not feasible to perform on large groups of athletes or by sports medicine practitioners, several companies have devised computerized neurocognitive tests (CNTs) for SRC assessment. Currently, the most widely used CNTs in the United States include ANAM (Automated Neuropsychological Assessment Metrics), Axon Sports, and ImPACT (Immediate Postconcussion and Cognitive Testing Test Battery), with ImPACT the most widely used.²¹^,²² Since their appearance in the 1990s, CNTs have become considerably more popular with sports medicine professionals (e.g., athletic trainers) because of their ease of administration (especially to large groups of athletes preseason), transportability (with easy access through the internet or computer hard drive), and availability of alternate forms to reduce practice effects. Although strongly discouraged, CNTs can be interpreted more readily than paper-and-pencil measures by non-neuropsychologists, making them more accessible in many sports medicine settings.²²

However, several disadvantages to cognitive assessment via CNT have been noted. For example, environmental distractions (especially when testing several athletes at once in a room), difficulty understanding test instructions, and computer issues may introduce errors into the measurement of cognitive functioning and result in a higher number of invalid test results.²³ Another criticism of CNTs is the fact that studies of reliability and validity of these measures have been highly variable, with all CNTs containing some subtest and summary scores that do not meet acceptable levels of psychometric quality.²² However, it should be noted that some traditional NP measures also have psychometric limitations, especially in the context of SRC assessment.¹⁸^,²⁰ Other limitations of CNTs include a lack of norms corresponding to specific age groups and poor indices of inadequate effort. Finally, there has been concern about non-neuropsychologists such as athletic trainers, who are not trained in psychometrics and test interpretation, interpreting CNT test data.¹⁶

Neurocognitive Recovery From Sport-Related Concussion

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