High schools across the country are preparing to launch newly created concussion management programs in response to public health concerns, as well as new state laws. These multi-faceted programs will serve to educate staff and parents, protect youth athletes, and provide specific policy on return to play decisions following concussion.
An increasing number of U.S. high schools are including baseline neurocognitive testing as part of their concussion management programs. The use of baseline testing started at the college level in the 1980s, with the NHL becoming the first to begin formal baseline testing at the professional level in 1997. The original baseline testing programs used a short battery of paper-pencil tests which measured neurocognitive functions such as attention, memory, and mental speed that are believed to be commonly affected by concussion.
The idea behind baseline testing is that if we know how athletes "normally" function on such a test, then, after a concussion, they can be re-tested, and the post-concussion scores compared to the athlete's normal or baseline, as one tool to help those involved in the athlete's concussion care determine if and when they have sufficiently recovered from the concussion to safely return to play. Over the last decade or so, test batteries have become computerized to allow for greater efficiency in the testing process and access to athletes.
Ongoing controversy regarding access
The distribution of and access to these neurocognitive tests has become a controversial issue, especially among neuropsychologists and neurocognitive specialists. Neurocognitive tests are developed in a scientific manner and constantly evaluated for validity and reliability. The tests are validated through testing on large, representative groups of individuals to be sure that they indeed measure what they are supposed to measure.
To protect the public, the American Psychological Association has established ethical rules and guidelines governing their use. Thus, tests of neurocognition are not intended for unregulated, open access. Rather, they are intended for distribution, purchase, and use by trained individuals who will ensure the validity and reliability of the testing procedure and standardized administration. Once such a test becomes open to use by the general public, its effectiveness is jeopardized.
To understand this better, consider the following example: if a cognitive ability test that is used to measure a child's abilities for the purpose of school programming and accommodations were on sale at a big box department store, available for purchase by anyone, someone could look up and learn the answers to the test, rendering the test useless for its purpose and invalidating future use by schools to help students.
The concern with computerized baseline/concussion tests is whether we are being careful in the distribution of these tests and the need to protect the integrity of the test, which ultimately protects the consumer.
Sandbagging
The phenomenon of "sandbagging" a baseline test is a reality: many athletes try to perform poorly on the baseline test, so that after a concussion, their post-concussion test results may look as good as or even better than baseline test results, when, in fact, their cognitive function is still impaired from the concussion. We know that there are athletes, young and old, who would rather do without concussion testing. The concussion tests have validity indicators to help spot those who sandbag, and trained neuropsychologists can detect these types of discrepancies or peculiar results. However, making a test openly available on-line, with unregulated access to anyone in the comfort of their homes, provides athletes with the opportunity to practice the test, and to learn its nuances, which has the potential to result in incorrect return to play decisions and jeopardize the health of youth athletes.
Proper oversight essential
My concern, as a sports concussion neuropsychologist, is that when tests are available to parents, coaches, and athletes to take at home or in uncontrolled environments, without (1) oversight by a health care professional with specific training and expertise in concussion management; (2) anyone present to educate them about the purpose of the test; or (3) knowledge about how and when it is to be used, and what the test does or doesn't say, then the validity of the test results can be at risk.
Unfortunately, many parents, coaches and athletes gain a false sense of security if they can say that baseline testing has taken place. In reality, baseline testing by itself does not protect against concussion. It is just one tool to help the health care professional evaluate and treat the injured athlete. If athletes and their parents don't know how to identify the often extremely subtle signs and symptoms of a concussion, or know when to seek a medical evaluation, then baseline testing is of little use.
The Centers for Disease Control agrees. In its recently issued "FAQs about Baseline Testing among Young Athletes (1), the CDC makes two important points: first, that baseline tests should only be administered by a trained health care professional; and, second, that "only a trained health care professional with experience in concussion management should interpret the results of [a] baseline exam," and, "when possible, ideally a neuropsychologist should interpret the computerized or paper-pencil neuropsychological test components of a baseline exam."
This is not to say that accessibility is not an issue (access to all should be the goal), but I believe it is one that the youth sports community has the responsibility to address directly, working with sports concussion testing companies to develop creative strategies for outreach to make baseline and post-concussion testing accessible to all youth athletes in contact and collision sports without sacrificing quality or control. Accessibility should not be at the expense of proper test administration, control of testing conditions (which can lead to invalid baseline test results), and test validity and reliability. Legislators need to step up to the plate by providing tangible financial support for all youth sports organizations so they can afford and properly implement testing programs. For their part, health insurers and third-party payors should cover the cost of baseline testing as a routine part of pediatric well visits.
Look before you leap
My bottom line recommendation to potential purchasers of online concussion testing programs is to thoroughly review the tests' websites, read the research on the tests' validity and reliability, and check to see that proper test security and administration is implemented, before making a decision as to which concussion testing program is best suited to the needs of your school or independent youth sports organization.
1. Centers for Disease Control and Prevention. FAQs about Baseline Testing among Young Athletes (http://www.cdc.gov/concussion/pdf/baseline_testing_FAQs-a.pdf)(accessed April 16, 2012)
Most recently revised May 10, 2013
