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Baseline Neurocognitive Testing: Is It Really Necessary?

Neuropsychological (NP) testing in athletes began in the 1980's and its use has expanded in the last decade with the availability of computerized testing in addition to traditional paper-and-pencil NP tests.

  • data suggests that cognitive impairment after concussion may last longer than subjective symptoms. [2]
  • NP testing is a tool that can identify cognitive impairment and may also aid in documenting an athlete's recovery from concussion, [1-3] although whether the use of NP testing reduces the short-term risks (recurrent or catastrophic injury) or potential long-term complications is currently not known. [2]
  • Paper-and-pencil NP testing has the advantage of testing additional cognitive domains,[19] which may identify other conditions masquerading as concussion or post-concussion syndrome or identify continued cognitive deficits, such as the ability for high level thinking (so-called 'executive function'),[19] which a recent study shows may be impaired in concussed adolescents for as long as 2 months after injury. The disadvantage of paper-and-pencil NP testing, of course, is that it is more expensive than computerized NP and require significantly more time to administer and requires a licensed neuropsycholgist to intepret the results. [2]
  • Computerized NP has advantages in the athletic setting in that it is less expensive, takes less time to administer, may be administered to groups of athletes, provide instant information to the provider, has more precise measures of reaction time, has multiple forms and may be used for serial assessment. [2]
  • Both types of NP tests have significant individual variability with regard to the cognitive domains measured and performance measures. [2]
  • NP testing has not been validated as a tool to diagnose concussion; rather, it is a tool to use in monitoring recovery from concussion [1,2] and making the all-important return-to-play decision.
  • 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 are, as noted, some studies [12,13] that suggests that age-related norms may be adequate to assist with management decisions. [2]
  • If testing is used, care should be taken to make the baseline and postinjury physiological variables (ie, fatigue) and environmental variables (ie. distractions) as similar as possible. [2]
  • No optimum postconcussion monitoring interval has been established and reported intervals vary from every few days to only testing asymptomatic athletes prior to return to play. [2]
  • 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. [2]
  • 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] 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] states that "[f]ormal NP testing is not required for all athletes," and that there was "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."
  • If NP testing is used, both the Zurich statement and the AMSSM position statement 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) [1,2]