Neuropsychological Testing Point/Counterpoint

A 16-year-old female soccer player experienced a head-to-head collision 3 days ago. There was no loss of consciousness and less than 1 minute of posttraumatic amnesia after the collision. She is still symptomatic with headaches, neck pain, photophobia, significant mental fatigue, and “feeling in a fog.” She has returned to school after a 1-day absence and is able to attend full-time but has been provided minimal informal accommodations, including longer time to take tests and decreased homework, and has been removed from physical education class and soccer participation. She is mentally exhausted at the end of her school day. Her school has preseason ImPACT (ImPACT Applications Inc, Pittsburgh, PA) testing scores available from the previous season, but the school has not performed postinjury testing. She has no personal medical, surgical, psychiatric, or psychological history. Her family history is significant for migraines in her mother and attention-deficit/hyperactivity disorder in her older brother. She has never been formally diagnosed with a concussion but “saw stars” briefly after a collision during the last soccer season. A 17-year-old high school junior, football player (running back) presents 3 weeks after his fourth concussion. His at-rest symptoms have completely resolved for 4 days, and he is back to school without accommodations. He has not been cleared for return to play. The first concussion occurred after a helmet-to-helmet collision in the ninth grade, and symptoms resolved after 5 days. The second concussion occurred after a head–to–court-surface impact during his sophomore basketball season (18 months ago), and symptoms resolved after 6 days. His third concussion occurred during a motorbike accident over the summer (4 months ago) and symptoms lasted for 2 weeks. None of his concussions involved loss of consciousness. No preseason testing has been performed. A computed tomography of his brain was normal, and cervical spine radiographs performed after the most recent concussion were normal. He has a negative personal medical and surgical history. He has a history of a mild learning disability that requires minimal accommodations via an individualized education program (IEP). He is allowed 1 hour of language arts tutoring that he uses weekly. He has had several episodes of mild depression, anxiety, and adjustment difficulties, which has required psychological counseling since he entered high school. He currently endorses anhedonia, sadness, and feelings of isolation and loneliness. He denies suicidal or homicidal ideation. He feels that these feelings are worse than his baseline but states that it is because he cannot play sports or see his friends. He has no previous neuropsychological testing available. The premise that underlies the use of “baseline” testing in the management of sport-related concussion is that postinjury testing can be compared with baseline performance to detect evidence of cognitive impairment after a concussion. Such evidence would indicate that recovery was incomplete at the time of testing and that this would be taken into consideration in management decision making. The use of baseline testing is further predicated upon the assumption that baseline testing is capable of detecting the residual effects of a concussion once a player has become symptom-free (or claims to be symptom-free). This assumption, however, remains largely untested. For example, there has never been a prospective controlled study with the ImPACT battery to demonstrate that the test is capable of detecting impairment in a significant percentage of players with concussion compared with controls once the players with concussion have normalized on a symptom checklist. To be useful in this context, it also is imperative that the neurocognitive test battery being used is sensitive to the effects of concussion and that the test psychometrics meet appropriate criteria to be useful in individual decision making. The relevant parameters have been reviewed in detail [1], and it is fairly clear that the ImPACT battery does not meet criteria for this application. The current version of the ImPACT battery (2.0) has never been demonstrated to be sensitive to concussion via a single prospective controlled study, and the test-retest reliability of the constituent subtests is too low to be useful in individual decision making. Because test-retest reliability typically declines over time, it is important to have retest data from clinically relevant intervals. In the only 2 peer-reviewed publications of ImPACT test-retest reliability at clinically relevant intervals (45 days [2] and 1 year [3]), the test-retest stability coefficients of the ImPACT cognitive measures ranged from .15-.61, with a median reliability coefficient of .39 across the 2 studies. Retest confidence intervals based upon reliabilities this low are so large that they are not clinically useful [4]. Finally, the ImPACT test does not have a global score, and there is no clear algorithm for controlling for multiple comparisons when considering change scores for 5 separate subtests (the more tests given, the more likely it is that one will decline below any established cutoff due to random variation), which further limits the utility of the battery in reliably identifying impairment. With that important background information in mind, there is one additional critical point to be made regarding the use of baseline testing: there is absolutely no reason to repeat baseline testing while an athlete is still symptomatic. This was clearly communicated in a consensus statement published several years ago by a group of experts that included Dr Lovell: “Neuropsychological testing should not be performed when the athlete is symptomatic because it adds nothing to return to play decisions, and it may contaminate the testing process by allowing practice effects to confound the results” [5]. Baseline tests, for example, ImPACT, are not intended to substitute for more comprehensive neuropsychological assessments, which can be useful in quantifying impairments and psychological symptomatology relative to the normal population and in arriving at a differential diagnostic decision regarding the etiology of cognitive complaints. Therefore, I see absolutely no reason to repeat the ImPACT testing at any of the time points listed here, because such testing cannot add anything to treatment planning. In terms of her general management, I would recommend a common-sense approach. There is evidence from the clinical mild traumatic brain injury literature that psychoeducational interventions can be helpful in diminishing symptom duration [6], and, therefore, it would be appropriate to provide her with information and reassurance about the natural history of recovery from this type of injury. Good sleep hygiene and appropriate short-term accommodations at school are sensible recommendations. There is absolutely no basis for the “complete brain rest” approach advocated by some for these injuries, and, in my opinion, this type of intervention carries the risk of both putting students too far behind their peers in academic progress and increasing the potential for iatrogenic prolongation of symptomatology due to psychological factors [7]. An unusually prolonged or atypical recovery should prompt a referral to an appropriate specialist for a more in-depth diagnostic evaluation. In most cases, involvement of a board-certified clinical neuropsychologist would be appropriate, because “postconcussive” symptoms are highly nonspecific and can be due to a variety of factors. Parenthetically, I would exercise some additional vigilance in the management of concussion in an athlete with a family history of migraine. There is some suggestion that the rare phenomenon of diffuse cerebral swelling after minor brain trauma (also known within the American sports literature as “second impact syndrome”) may be related to the same calcium-channel subunit gene mutation that underlies familial hemiplegic migraine [8]. This scenario is a fairly common one. This athlete is injured and has (appropriately) been removed from sports and physical education. However, the fact that she is exhausted at the end of the school day raises the question of whether she initially should have taken several more days off from school. She is likely to be quite symptomatic at school, and her ability to learn and participate in class is likely to be limited. It has been my group's experience that early physical and cognitive rest can result in a more rapid recovery. It is helpful that the school is accommodating her with regard to time to complete tests and decreased homework. However, the overstimulation of the classroom environment is likely to be leading to an exacerbation of her symptoms and could delay her recovery. Regarding the role of neuropsychological testing in this case, our philosophy in conducting postinjury neuropsychological testing is not based on a specific timeline but rather on how the test results might help clarify her treatment needs and condition, and provide information to the athlete, her parents, coaches, and school officials with regard to her prognosis. In this specific case, I would most likely wait a few more days until her symptoms have decreased before administering another ImPACT test (or any other cognitive test). However, there are several factors that might change this decision. First, if the school was not providing accommodations because “she looks normal” or her teachers (or parents) are underestimating the aftereffects of the injury, then the testing would be very helpful to validate her injury. Second, the timing of when to conduct testing would be when there are specific questions regarding what she can and cannot do in the classroom (eg, does she have specific difficulties with reading or attentional focus problems that will interfere with her ability to complete her calculus assignments). A third consideration might be circumstances in which a coach or parent is insisting on a time frame for return to play. In such circumstances, I would test her immediately because results of a recent study have indicated that the combination of symptom assessment and neurocognitive testing yields the best prediction for whether the course will be “short” or “protracted” [1]. When assuming that her symptoms were resolving relatively quickly (ie, better on a day-to-day basis) and her school accommodation situation is adequate, I would not necessarily repeat her ImPACT test during the first week. However, I would certainly want to repeat her neurocognitive evaluation and compare this with her baseline before her return to sports or to gym class. Students often deny or hide symptoms, and I would use the comparison of her postinjury ImPACT test to her baseline test. In addition to neurocognitive testing, our protocol also emphasizes the implementation of a graduated exercise (exertion) program to assure that her symptoms are actually resolved. It has been our experience that, even when athletes may be endeavoring to hide their symptoms, both cognitive exertion (ImPACT) and aerobic exertion will likely bring these symptoms to the surface if, in fact, the symptoms persist. The ImPACT Best Practice model recommends the evaluation of the athlete by an individual who has specific training in the management of concussion [2]. Under the best of circumstances, this would include a neuropsychologist who has training in concussion management. Our model allows certified athletic trainers to administer the neurocognitive assessment at the school as part of a multidisciplinary team. Our model further promotes the interpretation of the test results by a doctoral-level individual who has training in concussion management. In other words, all return-to-play decisions should be made by a doctoral-level or appropriately licensed individual, in accordance with the state law, if applicable. These laws differ somewhat from state to state, but all emphasize the involvement of a professional with specific training in the management of concussion. This model also emphasizes that the athlete should be evaluated by the professional in a face-to-face appointment before returning to play. In other words, this evaluation should not be conducted electronically. I would expect that she would still be symptomatic at 1 week, because we have found the average time line for the complete resolution of symptoms to be closer to 3 weeks in high school athletes [3]. If she continued to have ongoing symptoms, then I would have her evaluated at a maximum of 1 testing session per week. If she were still clearly symptomatic after 2 weeks' time, I would reevaluate whether she is overexerting cognitively or physically, or whether there are other factors that might be maintaining her symptoms (eg, disruption of her sleep cycle, evolving symptoms of depression). If she continued to remain symptomatic, I would refer to our physical medicine and rehabilitation (or other for an evaluation of the for treatment with In her family history of migraine with a personal or family history of migraine may have longer recovery after I would want to the potential of a migraine with the to the [4]. This might a approach to symptom management. The management with to this athlete would be the risk of another because concussion risk to in a somewhat with concussion he has an risk of his from a concussion would not be to be his recovery might be [1]. There currently is no evidence that multiple concussions result in any cognitive a there is no reason to from returning to I would not baseline testing for this athlete, for the in the reliability of these tests, it is that they have a high they are likely to a significant percentage of players as when in fact they are not [3]. These could result in a of confidence and a return to play. the of a symptom-free before return to play remains this remains the single common across all of the for management of sport-related concussion. on results from cognitive testing in this could actually result in an return to play for to the that any risk of return to play actually such could be by the use of these a clinical I would be of the fact that this athlete has a medical history that (eg, depression, learning that are likely to symptoms that with concussion [5]. He does currently have a history and a of symptoms that would a clinical neuropsychological evaluation. This type of evaluation can cognitive and to accommodations, and psychological symptomatology to decisions about or and will include measures of that could be after a if which is in to “baseline” testing and tests of and and cannot be used for any other than for change the low they are not even useful for that of this history of injury, I would take a very approach to management of his injury. This is an important in decisions regarding whether or not an athlete should return to a of have demonstrated that multiple concussions are often with longer recovery and a for injury this athlete had not baseline testing, it would still be useful to complete postinjury testing. For an approach such as ImPACT, there are available for with learning or attention-deficit/hyperactivity disorder and neurocognitive evaluation may be helpful both currently and in the if he to participate in sports [3]. his of a learning it also is that there might be other psychological or neuropsychological test results that could be used as the basis for comparison with his baseline of This could be With regard to a time I would conduct neuropsychological testing within 1 of injury and 2 weeks during the recovery The results of these would provide information regarding his recovery (or and may also provide information that would be helpful with regard to the potential for his with depression, I would neurocognitive testing with a checklist. this history of difficulties and his current of symptoms of depression, I would his or in his management. This would be important if the athlete were (eg, for attention-deficit/hyperactivity for it is that his may be to some a result of his from that he this consideration should not the to from further injury and to a for his in sports In other words, I would not want to the athlete to play football because it provided a for if I that this would at risk for additional injury. This is a and relatively common for who with concussion. The question When does the potential for short-term and cognitive impairment as a result of multiple concussions the to an athlete involved in a that is a of and In this case, I would most likely that the athlete to another that carries less risk of injury (eg, or Finally, I would certainly recommend baseline testing and or for this if he were to return to The fact that he has a learning disability and a history of adjustment and symptoms could his management in the and baseline testing results could clarify the management of a injury. If he is symptom-free after then I would to return to However, his I would baseline testing before Dr with ImPACT, this athlete before symptom recovery and then before return to play. He at a of once per as as she is symptomatic, and he a that that resolution of symptoms is typically closer to 3 weeks in high school athletes [1]. He that initially she should have taken several days off from school, and that the of the classroom environment is likely to be leading to an exacerbation of her symptoms and could delay her Finally, he an that that athletes with a family history of migraine may have a longer recovery time and that he want to the potential of a migraine with a to the [2]. None of Dr are in any and his interpretation of the is He no for his testing or for his suggestion of more time off from school based upon his that being in a classroom was her I have the ImPACT tests have such low reliability that they are as a of on an individual also are no substitute for clinical neuropsychological Therefore, it is how ImPACT testing on a basis could in the clinical management of this his that typically to 3 weeks to from a concussion also to the No prospective controlled study has group on any or symptom measures days, which that symptom duration of 3 weeks would be clearly The he not have any and in that study was as to meet all 3 of the criteria after a an ImPACT symptom less than no more than 1 ImPACT below an confidence on and no ImPACT below the of normal. the for these criteria are likely to be very For example, in that same the that of the had a symptom of or at a the is Finally, Dr [2] as providing evidence that with a family history of migraine have longer recovery not on with a family history of migraines at It was a of ImPACT data in athletes with concussion. in this study were as if, after a they a and or These athletes were compared with players with concussion who had and players with concussion and with no The group had symptom scores and neurocognitive test scores than the with the group in the other A more interpretation of these data would be that worse concussions to more symptoms and cognitive I to see how this study posttraumatic migraine in any and he would that this athlete would be at risk for posttraumatic migraines because she has a family history of migraine Dr recommends testing with ImPACT, within a after injury and 2 weeks He to on how this could or other than to state, could be He then on to that the testing could provide information that would be helpful with regard to treatment with There is no information that could be from ImPACT testing that I of that would decision with regard to is it clear what class of would be in the management of concussion. Dr then the of impairment as a result of multiple but does not any data that would this as a He then recommends baseline testing before the return to without a he does not in case, is any clear risk that could be by ImPACT testing or clarify how ImPACT testing might in any more tests is not the to medical condition, as as it is to the American of This is even when there is no as to how the test could clinical and the test reliability to provide In to Dr I will first what to be a of his that neuropsychological tests such as ImPACT are not to their clinical his only of for this opinion, he an by and does not additional published For the of who have not this the has due to some in the of the of the study not use athletes but students who were for class The that a of were removed from the study due to because of the This raises regarding that it to the data that However, the of the study is that the were required to take 3 neuropsychological tests an back to back on 3 which to 2 of cognitive testing and the likely scenario of effects from relatively tests within a single test Because of the tests were to be used in this and were not these the results of the study, therefore, are one cannot administer a neuropsychological test the of intended use and that the test does not In a study that [2] found that athletes who had preseason baseline testing 2 years highly scores and than the another group conducted ImPACT in a of football athletes without concussion and In the group of athletes who had not experienced a concussion during the season, they found no significant across these 3 evaluation If the ImPACT test was so as to these results clinically as by Dr then one were scores so in a group over multiple of Dr of the 2 is that there is no evidence of cognitive impairment from multiple There are multiple published that have demonstrated more cognitive in athletes a of this literature is the of this There also is evidence that cognitive difficulties often the resolution of symptoms I was by Dr regarding the of evidence of cognitive impairment in athletes in that he a study that to cognitive impairment in a group of and he has been in the that there is an risk of in athletes to the for conducting neurocognitive assessment early on in the recovery this is important in and athletes and teachers regarding return to the have found that these data is useful in the school accommodations for a (eg, for a time due to For a of this see Finally, I have a with Dr regarding the clinical management of concussion. First, I take with his of symptoms being and often related to difficulties is of a of have the symptoms cognitive to last for weeks and even months in some In fact, our average time at the of has been weeks in high school and these are highly who want to be back in school and return to in sports rather than have found that return to the classroom while still highly symptomatic most often results in symptomatology and a recovery.