Along with studies reporting high concussion rates [1], increased concussion awareness among athletes, parents, coaches and health care providers, and new state concussion safety laws [2] has come rapid growth in the use of computerized neuropsychological testing [3] to evaluate and manage sports concussions, particularly at the college and high school levels.
By establishing an athlete's baseline or "normal" score on tests of cognitive functions that are often affected by concussion, such as memory, processing speed, reaction time, and attention, and on measures of physical/emotional/cognitive symptoms [4], re-testing after a suspected concussion can help determine if and when an athlete's brain has recovered. If the youth feels symptom free, and post-concussion testing is the same or better than baseline (pre-concussion) testing, recovery is imminent.
At least that's the way it's supposed to work.
In practice, however, I have unfortunately found in treating athletes after concussion that too many arrive at my office with invalid baseline test results from their schools: baseline scores that can't be used, because they don't provide an accurate snapshot of a child or teen's pre-concussion or normal cognitive functioning, and so can't be used to measure the degree of post-concussion cognitive impairment and recovery. Two research papers - one on which I am lead author, [1] the other on which I am a co-author, [2] confirm my anecdotal experience as a clinician, suggesting that between 6 and 12% of baseline tests may be invalid. An earlier study of college athletes reported a rate of up to 25% invalid baselines. [3]
Baseline test results can be invalid for a variety of reasons. [7] The most obvious - recently highlighted by the media in professional sports - occurs when athletes intentionally perform poorly on their pre-season tests in order to establish low baselines that increase their chances of "passing" a post-concussion test and being medically cleared to return to play before their brains have actually healed. Given the increased risk of a second concussion or, worse, a catastrophic brain injury from second impact syndrome [5], a youth athlete willing to fake a baseline test in order to return to a contact or collision sport too soon, to borrow a phrase, needs a wake-up call!
Most of the time, however, there tend to be other reasons for "invalids" among the youth athlete population.
Some of these reasons include:
Unfortunately, many baseline testing programs are conducted en masse in schools with limited athletic or school staff to oversee and review test results. As a result, baselines tend to be automatically stored in databases, but may not be looked at again until a concussion occurs. Some computerized neuropsychological tests now in use automatically identify or "flag" test results that may be invalid.
So what should parents, schools and testing centers do to ensure that their child's baseline test is valid?
My advice is to make sure that the people in charge of obtaining a baseline for your child:
The bottom line is, as a recent study emphasized,[9] to remember that "comparisons made between baseline tests and follow-up testing [after concussion] are only valid if baseline testing truly represents normal functioning and extraneous factors influencing the scores are taken into account."
2. Schatz P, Moser RS, Solomon GS, Ott SD, Karpf R. Incidence of invalid computerized baseline neurocognitive test results in high school and college students. J. Ath Tr 2012;47(3):289-286.
3. Broglio SP, Ferrara MS, Macciochi SN, Baumgartner T A, Elliott R. Test-retest reliability of computerized concussion assessment programs. J Ath Tr 2007;42(4):509-541.
4. Consensus Statement on Concussion in Sport: the 4th InternationalConference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2012;47:250-258.
5. Erdal K. Neuropsychological Testing for Sports-related Concussion: How Athletes Can Sandbag Their Baseline Testing Without Detection. Arch Clin Psych 2012;27(5):473-479.
6. Covassin T, Elbin R, Stiller-Ostrowski J. Current sport-related concussion teaching and clinical practices of sports medicine professionals. J Athl Train 2009; 44(4):400-404.
7. Schatz P, Glatts C. "Sandbagging" Baseline Test Performance on ImPACT, Without Detection, Is More Difficult than It Appears. Arch Clin Neuropsychol (published online ahead of print February 11, 2013)
8. McClure DJ, Zuckerman SL, Kutscher SJ, Gregory A, Solomon GS. "Baseline Neurocognitive Test Results in Non-concussed Athletes: Does Sleep Matter?" Presentation paper, AOSSM (June 13, 2013)
9. Mihalik JP, Lengas E, Register-Mihalik J, Oyama S, Begalle R, Guskiewicz KM. The Effects of Sleep Quality and Sleep Quantity on Concussion Baseline Assessment. Clin J Sport Med 2013;23(5):343-348.
Most recently revised September 13, 2014
Links:
[1] https://mail.momsteam.com/node/3283
[2] https://mail.momsteam.com/node/3015
[3] https://mail.momsteam.com/node/3385
[4] https://mail.momsteam.com/node/149
[5] https://mail.momsteam.com/node/208
[6] https://mail.momsteam.com/node/2695
[7] https://mail.momsteam.com/node/6084
[8] https://mail.momsteam.com/node/6315
[9] https://mail.momsteam.com/node/5383
[10] https://mail.momsteam.com/baseline-neurocognitive-concussion-testing-getting-enough-sleep-may-affect-results
[11] https://mail.momsteam.com/health-safety/concussion-safety/recognition-evaluation/neuropsychological-testing-for-concussions
[12] https://mail.momsteam.com/impact/computerized-neuropsychological-testing-has-important-role-in-concussion-evaluation-return-play
[13] https://mail.momsteam.com/team-of-experts/brooke-de-lench/editorials/concussion-bill-of-rights-5-neuropsychological-testing-fo
[14] https://mail.momsteam.com/baseline-neuropsychological-testing/baseline-computerized-concussion-testing-products-caution-urged-before-purchasing
[15] https://mail.momsteam.com/scat2/baseline-scores-vary-by-youth-athletes-gender-concussion-history-says-study
[16] https://mail.momsteam.com/health-safety/sandbagging-baseline-test-much-harder-than-one-might-think