Baseline Balance and Computerized Neurocognitive Tests Recommended For Sports With High Concussion Risk

William P. Meehan, III, MD, Director of the Sports Concussion Clinic at Boston Children's Hospital, recommends baseline testing, both balance and computerized neurocognitive, for  athletes playing sports that can carry a substantial risk of concussion, not just football, ice hockey, and lacrosse, but even soccer and basketball, sports which also have fairly high rates of concussion. ^[11,12]

"In particular," Dr. Meehan recommends conducting a balance assessment, ideally using the Balance Error Scoring System (BESS), and a form of neurocognitive or neuropsychological testing. "I like the computerized versions," he says, although he admits, "That's a little bit controversial. Some people think that every athlete should see a neuropsychologist and have traditional [i.e. pencil and paper] [neuropsychological] testing. (NP) I actually think that would be ideal, quite frankly it would be great. But there are just not enough neuropsychologists, and the ones that are there certainly don't have enough time to do an individual assessment on every athlete." [For more about the controversial nature of baseline computerized neurocognitive testing, see discussion below]

"And so the choice in reality, is that they get nothing, or they get computerized testing. And the computerized testing gives you information, and it gives you an accurate assessment of their memory. It gives you an accurate assessment of their reaction time, some of them to 1/1000th of a second, so a very high sensitive measure of their reaction time. And it gives you an accurate assessment of their processing speed, how long it takes them to think through information and come to some conclusion. And all those things are affected by concussion, they get worse after a concussion, and so you can use it to monitor their progress."

"The truth is [that] 20 to 30 percent of athletes in sports will report being symptom-free before their brain function as returned to its own personal baseline values. And so if you don't do that testing, you run the risk of returning 20 to 30 percent of concussed athletes back to sports before they're fully recovered."

Comment from MomsTEAM Senior Editor, Lindsey Barton Straus: 

Although Dr. Meehan does not discuss the issue in this video, 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 there at least two studies ^[1,2] that suggests that age-related norms may be adequate to assist with management decisions. 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, with existing recommendations based on experts' opinion. ^[3]

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, ^[3] 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 ^[4] 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 ^[5] 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."
• If NP testing is used, both the Zurich statement and the AMSSM position statement, many recent studies,^[6-10] and Dr. Meehan himself, 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). ^[3,4]

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1. Echemendia R, Bruce J, Bailey C, Sanders J, Arnett P, Vargas G. The Utility of Post-Concussion Neuropsychological Data in Identifying Cognitive Change Following Sports-Related MTBI in the Absence of Baseline Data.  Clin Neuropsy 2012;26(7):1077-1091.

2. Schmidt J, Register-Mihalik J, Mihalik J, Kerr Z, Guskiewicz K. Identifying Impairments after Concussion: Normative Data vesus Individualized Baselines. Med & Sci Sports & Exer. 2012;44(9):1621-1628.

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

4. 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

5. Giza C, Kutcher J, Ashwal S, et. al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2013 (published online ahead of print March 18, 2013): DOI:10.1212/WNL.ob013e31828d57dd (accessed March 23, 2013)

6.Resch J, et al. ImPact Test-Retest Reliability: Reliably Unreliable? J Athl Tr. 2013;48(3):000-000 doi: 10.4085/1062-6050-48.3.09 (ePub in advance of print).

7. Schatz P, et al. Long-term test-retest reliability of baseline cognitive assessments using imPACT. Am J Sports Med. 2009;10:38(1):47-53.

8. Broglio SP, Macciocchi SN, Ferrara MS. Sensitivity of the concussion assessment battery. Neurosurgery. 2007;60(6):1050-
1058.

9. Erlanger D, Feldman D, Kutner K, et al. Development and validation of a web-based neuropsychological test protocol for sports-related
return-to-play decision-making. Arch Clin Neuropsychol. 2003;18(3):293-316.

10. Elbin RJ, Schatz P, Covassin T. One-year test-retest reliability of the online version of ImPACT in high school athletes. Am J Sports Med. 2011;39(11):2319-2324.

11. Meehan WP, d'Hemecourt P, Collins C, Comstock RD, Assessment and Management of Sport-Related Concussions in United States High Schools. Am. J. Sports Med. 2011;20(10)(published online on October 3, 2011 ahead of print) as dol:10.1177/0363546511423503 (accessed October 3, 2011).

12.  Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of Concussions Among United States High School Athletes in 20 Sports.  Am J Sports Med 2012;40(4):747-755.

Posted August 22, 2013