The cornerstone in diagnosing and treating concussions is neuropsychological assessment. This aims to evaluate an individual’s neurocognitive skills. The purpose is to determine how an individual’s brain is functioning, which is quite different and more vital than examining the structure of the brain after concussion, which is what CT scans or MRI’s show. Traditional but lengthy 4-6 hour neuropsychological batteries are not able to be utilized in the immediate time period when one has sustained a concussion, so numerous brief batteries have been developed.
Nowadays, the most widely used computerized baseline and post-concussion assessments is ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing). The goal of this test is to evaluate and determine neurocognitive functioning in only 20 minutes. At the present time, this program aggressively competes to try and corner the market in management of sports concussions.
Despite the well-intentions of the developers, significant loopholes remain in the management of concussions. Particularly concerning is that many of the tests these days can be administered by anyone who takes a “concussion course.” Athletic directors, physical therapists and athletic trainers are not qualified to properly assess an individual’s neuro-cognitive, emotional and behavioral abilities. Yet, they remain the group of individuals who have become regarded by many as the experts in administering these tests.
Many hail the fact that these computerized tests allow for the evaluation of a large group of individuals at one time. What they fail to discuss, however, is that there is no way to ensure that the athletic trainer administering the test provides proper testing methods (noise reduction, proper lighting, no distractions, etc). Additionally, there is no ability for the trainer to assist or document that the individual being tested has learning disabilities or ADD and may have difficulty being evaluated within that setting. Trainers are not able to take into account and make adjustments to a student’s performance who is dyslexic, has right-left confusion on the keyboard or has a history of personality or mood disorders and is prone to poor or uneven performance due to depression.
Although each of the developers of the various tests make it a point to state that the tests should be properly administered and in all cases utilize a neuropsychologist, the fact remains that this has not been the case. These approaches have dangerous potential consequences, particularly in adolescents who play contact sports and sustain concussions. Despite the school’s best intentions, many are reluctant to properly assess or diagnose because of the liabilities of then needing to address a student’s decline in academic performance secondary to their concussion. If cognitive symptoms persist, a more comprehensive neuropsychological battery of tests should be administered, and referrals for this are not readily made. A collaborative approach by parents/teachers/health care professionals may require a 504 plan to be implemented due to newly acquired disabilities. This results in the need for intervention, services, accommodations (rest breaks, less time at school, more time to do assignments, help with homework).
In September 2011, Gov. Cuomo of New York signed into law the Concussion Management Awareness Act (bill S. 3953). It required that students who sustain concussions be kept out of physical activities for at least 24 hours after they have become symptom free. Although many in the state have praised the legislation, the final bill in fact did not require each school district to establish a concussion management team consisting of experts as well as school personnel. It only encouraged each district to establish a concussion management team and recommend but not require students to undergo baseline examinations.
The awareness of concussions and the impact on brain functioning has increased dramatically. There remains, however, great concern over who assesses, diagnoses, and treats. The fact remains that not everyone is an expert. Taking a one to two day course does not make one an expert evaluator or clinician. If that were the case, then anyone taking a CPR course could be a cardiologist. Schools, teams, and the public needs to understand that understanding the brain and its role on cognition and behavior/emotions is complex. The need for true expertise is vital, especially in developing brains during adolescence.
The most important factor that needs to be considered is that each of the tests alone should not be utilized as the deciding factors in diagnosis or management of symptoms. Each test is one of the “tools” that when examined together with other tests, medical examinations, and symptoms, should be used to help diagnose and treat. If school districts or training staffs utilize only one test, the risk of misdiagnosis, inadequate assessment, or poor treatment exists. The result could very well be lifelong, permanent health concerns as well as liability issues that many still do not fully understand.
The result has rendered the role of the neuropsychologist, who is truly the most trained in understanding brain behavior, inappropriately diminished in today's concussion world.
—Mark Herceg, Ph.D.
Director, Rehabilitation Psychology and Neuropsychology