Concussion Management, Over 70% of Doctors Got It Wrong – Part 5Written By: Leah Concannon, MD; Stanley Herring, MD
When Should You Consider Neuropsychological Testing?
Jamie’s brother is on the high school football team and underwent computerized neuropsychological testing last fall. Jamie’s parents question whether she should have testing performed before returning to soccer.
Neuropsychological testing can identify subtle cognitive difficulties that cannot be evaluated by general office questions or the SCAT2. In discussing neuropsychological testing, it is important to recognize that differences exist between computerized testing and paper-and-pencil testing.
What Type of Test Is Best?
Computerized testing is less time-intensive and can be performed serially to track an athlete’s progress over time, as well as compare to baseline testing if available. Variability in the administration of the test, including occasional lack of full effort on the part of the athlete during baseline testing, and variability in the interpretation of the results are clear limitations.
Paper-and-pencil tests are performed as part of a comprehensive interview and evaluation and can therefore provide information about not just performance but also confounding factors, such as depression, anxiety, and other biopsychosocial factors, that may be contributing to the results. However, these tests are time-intensive and more expensive and are not designed to be repeated within a short period.
Factors to Consider
Full cognitive recovery can occur before or after full symptom resolution. Therefore, neuropsychological testing cannot be used alone to determine management plans. In addition, regardless of whether neuropsychological testing is computerized or on paper, the results are best interpreted by neuropsychologists or others trained in the interpretation of these tests. Neuropsychologists have unique knowledge and training that enables them to integrate cognitive performance with any accompanying psychological complexities that may be present to give a more complete picture of the athlete.
The timing of neuropsychological testing, when performed, is a subject of continued debate. In general, it is best performed when the information gathered will affect decision-making, often after the patient has returned to baseline status. Testing performed earlier in the recovery process can be helpful to evaluate the impact of confounding factors and coexisting conditions, or to help with school accommodations. Baseline testing before an injury may enhance the usefulness of postinjury testing. Neuropsychological testing is not essential to determine an athlete’s readiness to return to play, but it can be a useful tool as part of a comprehensive evaluation that includes assessments of balance and symptom resolution.
In this case, given Jamie’s history of ADHD and anxiety, neuropsychological testing could be considered to both confirm her cognitive recovery and to act as a baseline if she should experience another concussion in the future.
The long-term effects of concussions have not yet been adequately established, although patients and families often ask about future risks. Previous retrospective studies have linked a history of multiple concussions in US football players to increased risk for depression[17,18] and earlier onset of cognitive impairment. In contrast, a recent study of high school students who played football between 1946 and 1956 found no increase in dementia, Parkinson disease, or amyotrophic lateral sclerosis compared with their non-contact sports counterparts.Clearly, more prospective studies are needed to help answer this question.
Comprehensive Examinations / Baseline Evaluations
At Brain Centers NW a comprehensive functional neurological evaluation or baseline testing evaluates the strength and symmetry of all levels of the nervous system. Examining each level of the neural axis, comparing the symmetry of responses and putting the findings into the context of the whole network allows for pattern appreciation of what areas are weak and how you can be helped.
The following diagnostics are used in addition to the neurological examination to ascertain the level of performance of various aspects of your brain / nervous system:
ImPACT testing measures multiple aspects of cognitive functioning including:
• Attention span
• Working memory
• Sustained and selective attention time
• Response variability
• Non-verbal problem solving
• Reaction time
Posturography is perfect for screening, assessing and diagnosing balance disorder/falls-risk patients. This testing gives us insight into areas of the nervous system associated with balance / vestibular function.
Interactive Metronome (IM) is an assessment and treatment tool used in therapy to improve the neurological functions of motor planning, sequencing and processing.
VNG equipment provides simultaneous subjective observation of the individual’s eye movements and objective collection and analysis of eye movement during both testing and rehabilitation.
David Burns, DC ND DACNB FACFN