Neuropsychological tests in sport-related concussion – are they worthwhile?

The article by Shrier in the current edition of CJSM revisits the issue of neuropsychological testing in the setting of sport-related concussion, and poses some searching questions in relation to the use of these tools in the diagnosis and management of sport-related concussion. In particular, he asks ‘…do the results of neuropsychological testing change patient management or provide other clinical benefit to the patient?’ and ‘Is there sufficient evidence to mandate it (neuropsychological testing) as standard of medical care?’ (Shrier, 2012).

Whilst it is clear that sport-related concussion is a hot topic in Sports Medicine, with an ever-increasing literature on the subject, and following three expert consensus panellist group meetings since 2001, controversy surrounding the diagnosis, management, and return to play protocols continues to rage amongst academics and clinicians alike.

In his article, Shrier concentrates on the application of neuropsychological tests to the sport-related concussion setting. Whilst it is accepted that neuropsychological tests alone are not adequate to confirm the diagnosis and dictate the ongoing management of concussion, they are currently widely used in the rehabilitation and return-to-play setting as a part of an overall neuropsychological assessment for players in elite sport suffering from a concussion – especially in hockey, and college football.

Shrier points out that neuropsychological tests are designed to give an objective assessment of brain function, but that ‘the objective in concussion management is to measure brain injury’ and points out that ‘brain injury is only one cause of decreased brain function,’ mentioning that there are several other factors that may affect brain function such as the presence or absence of other injuries or mood disorders (Shrier, 2012). The author does not point out exactly when he means by ‘brain function,’ however, nor discusses in detail any of the other multidimensional tools that may be used to assess this such as EEG and fMRI.

There are clearly limitations in using neuropsychological tests in the setting of sports-related concussion related to the issues Shrier points out in his article. However, it is important to remember that it is the application of these tests in the overall clinical context that perhaps assists the practitioner in making an informed and reasoned judgement as to whether impairment in brain function is likely to be secondary to concussion.

Further on in the article, Shrier goes on to argue that neuropsychological tests have ‘minimal value for an individual athlete and does not support mandating (their) use,’ (Shrier, 2012) and then examines the arguments for using the tests related to asymptomatic athletes at rest, athletes who are asymptomatic at rest but symptomatic on exertion, and athletes who are asymptomatic on exertion.

Whilst there is still academic debate surrounding the clinical usefulness of neuropsychological tests in the setting of sport-related concussions, doubt must also be levelled at their applicability and cost-effectiveness, a point also argued by Shrier in his conclusion. He also mentions that there are not enough neuropsychologists with appropriate expertise available to be able to warrant mandatory neuropsychological testing on a population level for them to be considered as standard of care, which is certainly true.

In his conclusion, Shrier argues that ‘NP testing provides only a small increase in prognostic information and does not change the management of athletes who are symptomatic at rest or with exercise,’ and points out that ‘There is no evidence that abnormal NP testing is associated with increased risk of further injury or delayed recovery in athletes who are asymptomatic at rest and exertion.’ (Shrier, 2012). 

The Concussion in Sport group, however,  in their last consensus statement mentioned that ‘the application of neuropsychological testing in concussion has been shown to be of clinical value and continues to contribute significant information in concussion evaluation.’ (McCrory et al, 2009).

No doubt Shrier’s article will fuel much continuing academic debate on the use of neuropsychological tests in the setting of sport-related concussion.

Are you using these tests as part of your overall concussion management programme?

CJSM would like to hear your thoughts on the debate.


1) Shrier i. 2012. Neuropsychological testing and Concussions: A Reasoned Approach. CJSM 22(3): 211-213

2) McCrory  P et al. 2009. Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport Held in Zurich, November 2008. CJSM 19(3): 185-200

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Repeated heading of the ball in soccer – is there a link to brain injury?

Another day, another article related to concussion and head injury in sport in the New York Times – this time, concerning a possible link between repeated heading of the ball in soccer and brain damage.

The article, ‘A new worry for soccer parents – heading the ball’ highlighted some new research recently presented at the Conference of the Radiological Society of North America.

Michael Lipton, associate director of the Gruss Magnetic Resonance Research Center at the Albert Einstein College of Medicine and medical director of MRI services at Montefiore Medical Center in New York, together with colleagues used diffusion tensor imaging (DTI) to study the effects of repeated heading of the ball in soccer, and found that players who repeatedly head the ball with a high frequency had brain abnormalities on scanning similar to patients with traumatic brain injury.

DTI was used to examine for areas of fractional anisotropy (FA) in the white matter of the subjects, which is thought to have a relation to healthy brain tissue – healthy white matter having a relatively high FA.

Dr Lipton and colleagues used DTI on 32 amateur soccer players who had played the sport since childhood, and estimated how often each player headed the ball on an annual basis based on a standardised questionnaire. They then ranked players based on estimated heading frequency.

The researchers went on to compare brain images of the players estimated to have executed the most frequent headers with those of the remaining players, and identified areas of the brain where FA values differed significantly in certain ‘regions of interest’ (ROI) in the brain responsible for attention, memory, executive functioning and higher-order visual functions.

Using statistical analysis, Lipton and colleagues found that greater heading frequency was associated with low FA. They concluded that exceeding a threshold for heading frequency (1000-1500) may result in brain abnormalities similar to those seen in TBI, and went on to suggest that ‘the exposure threshold we identify suggests public health interventions to minimize excess exposure and, thereby, the adverse outcomes.’

Critics of the study may wish to point out the possible issues of recall bias, plus possible errors in the estimates of frequency of heading and statistical analysis as weaknesses of the study.

For those who wish to read more, there is a great summary of the study on the Radiological Society of North America website. This includes links to video footage of Dr Lipton himself describing the study and related issues, together with the views of a participant in the study.

There have been other studies of heading in soccer related to brain injury, but most of these have been subject to methodological flaws making it difficult to draw conclusions. In addition, some studies have included subjects from the days before the modern soccer balls were used, when leather balls could weight considerably more and especially when wet.

Zetterberg and colleagues examined biomarkers for neuronal injury collected by lumbar puncture following repeated headings in a training session and found no significant changes in neurofilament light protein, total tau, glial fibrillary acidic protein, and albumin concentrations 7-10 days after the repeated headings, with only a mild elevation of CFS S-100B concentration. They concluded that repeated low-severity head impacts due to heading in soccer are not associated with neurochemical signs of brain injury.

Cognitive deficits have been associated with repeated headings in football by some authors such as Tysvaer, although others such as Janda and colleagues who studied a youth population found no abnormalities in cognitive function other than difficulty in learning new words.

The debate about heading in soccer and its correlation with brain injury seems set to rage on into the future.

In the meantime, what should we tell concerned parents requesting medical advice about the issue? Where do YOU stand on this? CJSM would like to know.

References :

Zimmerman M et al. 2011. Making Soccer safer for the Brain : DTI-defined Exposure Thresholds for White Matter Injury Due to Soccer Heading

Zetterberg H et al. 2007. No neurochemical evidence for brain injury caused by heading in soccer. Br.J.Sp.Med. 41:574-577

Tysvaer A & Lochen E. 1991. Soccer injuries to the brain. A neuropsychological study of former soccer players. Am.J.Sp.Med. 19:56-60

Janda D et al. 2002. An evaluation of the cumulative effect of soccer heading in the youth population. Inj. Control Saf.Promot.9:25-31

(Image – England v Scotland 1872 at The Oval, London at Wikimedia commons)

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National Collegiate Athletic Association targeted for legal action on the issue of concussions amongst student athletes

There was an interesting article in the New York Times this week highlighting a recent class action lawsuit aimed at the NCAA over alleged negligence in relation to prevention and treatment of brain injuries in athletes.

The action represents the first attempt to target the NCAA rather than individual colleges or schools, as pointed out by Nikki Wilson on the Collegiate and Professional Sports Law Blog. Four plaintiffs, three with a history of participation in College football and one who played soccer, have filed lawsuits alleging a ‘long-established pattern of negligence and inaction with respect to concussions and concussion-related maladies sustained by (the NCAA’s) student athletes.’

There are a wide range of claims made, including allegations that the NCAA has failed to implement :

– A support system for players unable to continue to play or lead a normal life after sustaining concussions

– Legislation addressing treatment and eligibility of players who have sustained multiple concussions

– Guidelines for screening and detection of head injuries

– Return-to-play guidelines for players who have sustained concussions

– Effective ways of addressing or correcting coaching of tackling methods that cause head injuries

One plaintiff, Adrian Arrington, claims to have suffered ‘numerous and repeated concussions’ during his playing time at Eastern Illinois and now is alleged to suffer from memory loss, depression, and near-daily migraines as a result. The lawsuit claims that the NCAA ‘..has failed its student-athletes choosing instead to sacrifice them on an altar of money and profits.’

Perhaps unsurprisingly, Donald Remy, the NCAA General Counsel and Vice President for legal affairs, has called the lawsuit ‘wholly without merit.’

The organisation responded by stating that ‘..the NCAA has been concerned about the safety of all of its student-athletes, including those playing football, throughout its history,’ and claimed that ‘..we have specifically addressed the issue of head injuries through a combination of playing rules, equipment requirements, and medical best practices.’

The NCAA and the CDC have collaborated to create educational resources for coaches, student-athletes, medical staff and college sports supporters. The NCAA Sports Medicine Handbook has 4 pages on concussions including information on symptoms, and has a revised management plan for all athletes with concussion.

The outcome of the legal actions will no doubt be watched closely by all former college athletes who believe that they may be suffering from ongoing symptoms as a result of repeated concussions during play.

For a further discussion on the lawsuit issues, readers can listen to the EDUsports podcast on the subject.

In the meantime, CJSM would like to hear your thoughts.

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Sideline assessment of concussion and return to play – are we practising what we preach?

The seventh Rugby Union World Cup competition ended last saturday in a tense final between strong favourites, the famous New Zealand All Blacks, and France, the former holding out for a one-point win 8-7 over Les Bleues.

The game featured a number of injuries, but one caused more of a stir than most – the injury to the French number 10 Morgan Parra.

Parra took what appeared to be an accidental blow to the side of his head from the knee of All Blacks’ Captain Richie McCaw in a ruck, and appeared to be visibly concussed, looking shaky on getting up after receiving lengthy on-field medical attention. The incident can be seen in this video.

He was taken from the field of play and replaced by Trinh-Duc. Surprisingly, however, he re-appeared on the field after around 5 minutes and continued to play on for another 5 minutes until he experienced another knock during a tackle and eventually went off for good.

The circumstances surrounding his departure from the field in the first instance appear to be a little unclear. Parra thought that he had gone off for a blood injury, which would fit with him being allowed back onto the pitch later on in the absence of having suffered a concussive injury. Of course, there is no ‘concussion bin’ to allow time for observation and recovery prior to return to play. However, there is a ‘blood injury bin’ where players are permitted to have blood injuries attended to prior to return to the field as appropriate. To this viewer, it did appear that Parra had indeed suffered a concussive injury following the blow from McCaw’s knee, in which case it is surprising that he was allowed to re-enter the field of play.

Parra mentioned ‘I was bleeding a bit, I took a knock and I was a bit dazed,’ adding ‘I was trying to get out from under the ruck, I took a knee to the face, it wasn’t when (Ma’a) Nonu tackled me, but afterward. Did he (McCaw) mean it? I don’t know. I haven’t seen the footage. But it wasn’t from Nonu.’

Parra went on to mention ‘I wanted to come back on, but my neck and head were hurting, and then I took another kick to it … that’s how it goes. What can you do? I wasn’t targeted any more than last week. I know that when you play No. 10 and you weigh 80 kilos people go looking for you more.’

What is of great concern is that if Parra was indeed allowed back onto the pitch following a concussive injury, then this would been in direct contravention of the IRB’s own Concussion guidelines which clearly state that ‘Players suspected of having concussion must be removed from play and must not resume play in the match, ‘ and this would have occurred during Rugby’s showcase, the World Cup Final which was watched by record figures of TV viewers worldwide this year. The IRB guidelines are in agreement with the Concussion in Sport Group’s guidelines – see point 2.2 ‘On-field or Sideline Evaluation of Acute Concussion – (e) A player with diagnosed concussion should not be allowed to return to play on the day of injury.’

In the Concussion in Sport group’s guidelines, there is a caveat that adult athletes, in some settings, may return to play more rapidly providing certain conditions and a level of support may be met, but that there should still be the same management principles for return to play, starting with complete cognitive and symptom recovery. The issue of the appropriateness of return to play on the same day following an acute concussion is hotly debated, but there is no doubt that it still occurs. However, if Parra was indeed concussed, then return to play in the same match would have been in direct contravention of the IRB’s own Concussion guidelines.

Those of us who manage head injuries and concussion at the pitchside are well aware of the many difficulties of translating concussion guidelines into practice, especially when players get up and run off in the middle of assessments and such, but if Parra was indeed concussed, then surely he should never have been allowed back onto the field of play.

The Rugby Law blog was particularly vociferous on these events.

For those interested in the topic of Concussion in Sport, don’t miss the chance to view the recent Ovid Webcast with Margot Putukian and John D. Corrigan here.

Have you had problems and issues with interpreting and applying concussion guidelines to clinical practice?

CJSM would like to hear your experiences and opinions.

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