Doctors Warn: Do Not Rely Only On What Young Athletes Say When Managing Concussions
Neurocognitive testing is crucial for kids’ safety given the potential unreliability of self-reported symptoms, says University of Pittsburgh study
PITTSBURGH, September 11, 2006 — When it comes to managing concussions in sports, relying only on an athlete’s self report of symptoms is inadequate and likely to result in under-diagnosing the injury and the athlete unsafely returning to play following the concussion, warn doctors at the University of Pittsburgh Medical Center (UPMC) Sports Medicine Concussion Program. Along with assessing symptoms, the doctors stress, using computer-based neurocognitive function testing is crucial for accurate, objective evaluation of concussion and determining a safe return-to-play time for the athlete.
“Because of the tendency of some athletes to under-report their symptoms, presumably in an attempt to speed their return to the playing field, neurocognitive testing following suspected concussion is particularly important in keeping kids safe,” said Mark Lovell, Ph.D., director of the UPMC Sports Medicine Concussion Program. Research has shown at least one in 10 high school or college athletes sustains a concussion each year.
Dr. Lovell’s alert is based on a recent UPMC study of concussed high school and college athletes that showed unreliability of the athletes’ self-reported symptoms and demonstrated the value of neurocognitive testing in significantly increasing the capacity to detect post-concussion abnormalities, decreasing the potential of exposure to additional injury. Previous research has shown that young concussed athletes who are returned to play too soon, before their brains have healed, are highly vulnerable to further injury, including post-concussion syndrome, or in rare cases, fatal second-impact syndrome. The current study is published in the upcoming issue of the American Journal of Sports Medicine, available online at www.ajsm.org.
“Given our study results, it is concerning that most return-to-play decisions following concussion have relied heavily on the athlete’s self report of symptoms. In fact, in many sports settings, return-to-play decisions have been based almost exclusively on what the athlete says,” said Dr. Lovell, author of the study. “This research further proves what we have learned from years of experience in our clinic – that even athletes who report being symptom free may continue to exhibit neurocognitive deficits that they are either unaware of or are failing to report.”
Although neurocognitive testing has been recognized in recent years as a cornerstone of concussion management by the leading international Concussion in Sport groups, the UPMC study is the first to formally evaluate the sensitivity and specificity of computer-based neurocognitive testing when used in combination with the athlete’s report of symptoms.
The current study involved 122 concussed high school athletes, all of whom had undergone pre-season neurocognitive function baseline testing with ImPACT™ (Immediate Post-Concussion Assessment and Neurocognitive Testing) as well as ImPACT testing again post-concussion to compare to baseline. Sixty-four percent of the concussed athletes reported a significant increase in symptoms compared to their pre-injury baselines at two days post-injury. Eighty-three percent of the concussed athletes demonstrated significantly poorer neurocognitive test results relative to their own baseline performance. Therefore, the addition of neurocognitive testing resulted in a net increase in sensitivity of 19 percent. The use of both symptom and neurocognitive test scores resulted in an increased sensitivity of 29 percent over reliance on symptoms alone. In contrast, zero percent of a control group of 70 non-concussed athletes demonstrated both symptoms and abnormal neurocognitive testing.
A concussion is any alteration of mental status resulting from the brain being jolted inside of the skull due to a blow to the head or upper body. Symptoms can include amnesia, dizziness, confusion, headache, nausea, disorientation and sometimes loss of consciousness.
“Generally, an athlete who sustains an initial concussion can fully recover as long as the brain has had time to heal before sustaining another hit,” explained Mickey Collins, Ph.D., study co-author and assistant director of the UPMC Sports Medicine Concussion Program. “The tricky part is that concussion signs and symptoms are not always straightforward and the effects and severity of the injury can be difficult to determine. Symptoms can typically occur with no visual indication by medical personnel and traditional neurodiagnostic tests such as CT, MRI and EEG are generally insensitive in measuring the subtle neurological changes following injury; thus, the need for careful clinical evaluation of symptoms in addition to objective neurocognitive testing.”
Neurocognitive testing with ImPACT, as in the UPMC study, is utilized nationwide by more than 900 high schools, 250 colleges and universities, 125 professional sports teams, including the majority of NFL teams, 250 sports medicine clinics and numerous other national and international athletic organizations. ImPACT involves a 30-minute test battery that athletes complete on a laptop or desktop computer. It can precisely measure even the subtle effects of a concussion, such as decline in memory, visual motor skills, information processing speed and reaction time, as well as symptom levels. Athletes can take an individual pre-season baseline test whose data is stored for comparison to post-injury test scores, should an athlete sustain a concussion during the season.
“A concussed athlete should never be cleared for return to play until neurocognitive scores on tests such as ImPACT match pre-injury baseline scores and all reported symptoms have resolved both at rest and at exertion,” stressed Dr. Collins.
“Other factors that especially concern us are related to information we’ve learned, with the aid of ImPACT, in numerous previously published UPMC research studies – notably that younger athletes are more vulnerable to further injury post-concussion and require longer recovery time than older athletes, and even seemingly mild concussions, or ‘bell ringers,’ need to be taken very seriously since deficits on ImPACT can be seen several days or even weeks post-injury,” said Dr. Lovell. “These and other UPMC findings have led to a re-examination of traditional return-to-play guidelines and a reconsideration of return-to-play standards that were heavily symptom-based.”
Other authors of the current UPMC study are Jamie Pardini, Ph.D., and Freddie Fu, M.D., both of UPMC and the University of Pittsburgh School of Medicine’s department of orthopaedic surgery, and Derk Van Kampen, who is completing his medical training in the Netherlands.
ImPACT, developed by Dr. Lovell more than a decade ago, is the first and most widely used computerized sports concussion evaluation system. ImPACT Applications, Inc., is a Pittsburgh-based company that owns and licenses the ImPACT tool, and is partly owned by Drs. Lovell and Collins. Dr. Lovell is assistant professor in the department of orthopaedic surgery at Pitt’s School of Medicine, where Dr. Collins is a clinical instructor. More information is available at www.impacttest.com .
The UPMC Sports Medicine Concussion Program, established in 2000, is an ongoing clinical service and research program that focuses on the diagnosis, evaluation and management of sports-related concussions in athletes of all levels.