The director of the Brain Injury Laboratory at the University of Texas at Arlington and lead author on this review, Dr. Jacob Resch, has been able to update information available for computerized neurocognitive testing such that this imaging can be used to support clinical use.
According to Resch, “Limited data has been published since 2005 to assist clinicians in determining the clinical value of this form of testing. While these products are an important component of concussion management, their development, marketing and sales seem to have outpaced the evidence. So, some caution is needed”. Co-authors on this review include Michael McCrea, an author of the 2005 study and director of brain injury research at the Medical College of Wisconsin, and C. Munro Cullum, professor and head of the neuropsychology program at UT Southwestern Medical Center.
According to Cullum, “Given the attention that concussion in sports has gained in recent years, it is surprising there has not been more research into the some of the newer computer-based methods used to evaluate post-concussion symptoms. Since there is no single brain-test or biomarker for concussion at this point, the diagnosis of concussion remains a challenge in many cases, as it relies upon reported and observed symptoms.”
Resch, McCrea and Cullum studied 29 peer-reviewed articles that were published since 2005 that addressed commercially available computerized neurocognitive tests. The results of this study suggests that evidence on reliability and validity of these tests were not consistent. One such article, published in May 2013 by the Journal of Athletic Training, misclassified healthy study participants as impaired as much as 46 percent of the time for some evaluation factors. This was based on the ImPACT test which stands for Immediate Post Concussion Assessment and Cognitive Testing. This is the most used computerized neurocognitive test for concussion management.
According to an Institute of Medicine report, the number of patients 19 and under treated in U.S. Emergency rooms for concussions and other non-fatal, sports and recreation-related traumatic brain injuries increased from 150,000 in 2001 to 250,000 in 2009. With the recent settlement of a landmark lawsuit filed by former NFL players, concussions remain in the headlines and on the minds of athletes, parents, coaches and others in the sports world.
It is common practice for athletic trainers to use computerized neurocognitive tests in response to sports-related concussion. These tests are typically used as pen and paper versions were in the past to establish a baseline to use as a point of comparison after injury. However, concussion symptoms can vary widely amongst patients making clear documentation of mild brain injury difficult. According to the researchers, the new findings should serve as a caution to utilizing and interpreting computerized cognitive tests.
McCrea notes, “Neurocognitive testing is an important component of the concussion assessment, but should not be used as a stand alone method to diagnose injury or determine an athlete’s level of recovery and fitness to return to play. A multi-dimensional approach is supported by the evidence as best practice.”
The article titled “Computerized Neurocognitive Testing in the Management of Sport-Related Concussion: An Update.” is available at http://link.springer.com/article/10.1007%2Fs11065-013-9242-5
Until more research is done, Resch, McCrea and Cullum suggest that healthcare providers follow some precautions when using computerized neurocognitive testing:
- Choose the best test by determining its limitations.
- Use a multi-faceted concussion management approach.
- Bring in a neuropsychologist into the concussion management team to aid in interpreting results.
- Individuals administering tests should be properly trained.
- Conduct quality control reviews of baseline testing.
In addition to the current work, Resch and Cullum are collaborating on a long-term study of concussion management in North Texas middle school and high school students that involves more than 2,000 participants.
Photo from theconcussionblog.com