A team approach to concussion management in youth and high school sports, which includes a sports physician, neuropsychologist and athletic trainer, is optimal, especially given the vulnerability of youth to traumatic brain injury.
Ideally, the care of youth athletes who sustain concussions should be overseen by:
- A physician. Physicians are needed to rule out any neuropathology (more than a concussion), neurological damage, or more severe brain injury that requires additional or more immediate medical care;
- A neuropsychologist. Neuropsychologists are specifically trained in brain-behavior
relationships and in the interpretation of neuropsychological tests,1 and pioneered their use in the evaluation of
concussions at the college and professional level in the 1980s and 1990s.2 A neuropsychologist should be part of the concussion care team in order to:
- provide critical supervision of the school's or organization's concussion program;
- monitor and interpret cognitive/neuropsychological test results;
- help physicians diagnose concussions;
- help determine when an athlete has cognitively recovered from a concussion; and
- provide academic planning for students in their transition back to school and a full academic workload after a sports-related concussion.
- An athletic trainer. Athletic trainers should be part of the concussion care team to provide exertional and balance testing, and to execute a progressive, graduated exercise program prior to the athlete returning to sports and/or full contact play after symptoms have cleared and cognitive function (memory, thinking, concentrating, learning, and reasoning) has returned to baseline or better.
A different reality
Although this may be the optimal team, in reality many schools or athletic programs do not have such healthcare professionals available to them.
- As a recent study3 points out, although physicians assess almost 60% of concussions in U.S. high schools that have an athletic trainer, and make 50% of the return to play decisions, many admit to being unaware of current concussion management guidelines or to finding the guidelines too confusing to put into practice.
- According to the National Athletic Trainers' Association,4 only 42% of U.S. high schools employ an athletic trainer (AT).
- Similarly, there are probably not enough neuropsychologists to service every school.
But just because there may not be enough of all of these trained healthcare professionals to go around does not mean we shouldn't strive for optimal care.
Possible solutions
So where do we go from here?
- More concussion training for primary care physicians. Specific educational outreach to pediatricians, internists, emergency department physicians, and family practitioners - through the medical journals they read and at national continuing medical education conferences they attend3 - should be undertaken. In July, 2011, for instance, I was a presenter at a concussion symposium sponsored by the Athletic Trainers Society of New Jersey that targeted the state's physicians. Increased awareness of concussion management and return to play guidelines will likely be a by-product of strong new concussion safety laws now in place in a growing majority of states requiring that the return to play decision be made by a health care professional with specific training in and knowledge of concussions;
- More athletic trainers for high schools. Continued lobbying by advocacy groups and individuals at the local, state and national level will hopefully increase the percentage of high schools with ATs on staff.
- More neuropsychologists as part of the concussion management team. Two recent studies - - one on which I am lead author,5 the other on which I am a co-author,6 suggest that between 6% and 12% of baseline computerized neuropychological test results at the high school level are invalid for a variety of reasons. Such studies make it critical that, despite their increased popularity in recent years (a new study3 shows the they are used to evaluate 4 out of 10 concussions at high schools with athletic trainers), such tests not be used in a cookbook fashion by untrained individuals. It is not enough for a school to purchase and use a concussion testing program and then to expect athletic trainers alone to interpret post-concussion neuropsychological test results (although many believe that they, and other medical personnel, can be taught to administer and interpret computerized neuropsychological tests for the limited purpose of assessing sports-related concussions without having to complete the full training of neuropsychologist, as long as they do so in conjunction with a consulting neuropsychologist).
School psychologists: untapped resource?
One possible solution to the shortage of neuropsychologists (and the expense that hiring them would entail) would be to include school psychologists already on staff in school districts, and who already have some training in brain disorders and neurocognitive testing, as part of a school's concussion care team. Such psychologists could be particularly instrumental in transitioning the concussed youth back to school with appropriate academic accommodations and a 504 or Individual Education Plan as needed.7
We have an obligation to care for the brains of our youth athletes and to make sports safe and fun. To that end, U.S. Representative Bill Pascrell Jr. and U.S. Senator Robert Menendez, co-sponsors of the ConTACT bill, officially announced on September 27, 2011 that the Centers for Disease Control and Prevention (CDC) will be convening a panel of experts to develop national guidelines for the management of sports concussion in youth.
1. Moser RS, Iverson G, Echemendia R, Lovell M, Schatz P, Webbe F, Ruff R, Barth J., et al. NAN Position Paper: Neuropsychological evaluation in the diagnosis and management of sports-related concussion. Arch. Clin Neuropsychology 2007; 22:909-916.
2. Barth, JT. Athletic Laboratory (1998). Recovery, 9(3), 301-331.
3. Meehan WP, d'Hemecourt P, Collins C, Comstock RD, Assessment and Management of Sport-Related Concussions in United States High Schools. Am. J. Sports Med.2011;20(10)(published online on October 3, 2011 ahead of print) as dol:10.1177/0363546511423503 (accessed October 3, 2011).
4. Waxenberg R, Satloff E. Athletic trainers fill a necessary niche in secondary schools. National Athletic Trainers' Association: 2009. Available at: http://www.nata.org/NR031209.
5. Moser RS, Schatz P, Neidzwski K, Ott SD. Does Group vs. Individual Administration Affect Baseline Neurocognitive Test Performance? Am. J. Sports Med. 2011; DOI: 10.1177/0363546511417114.
6. Schatz P, Moser RS, Solomon GS, Ott SD, Karpf R. Incidence of invalid computerized baseline neurocognitive test results in high school and college students. J. Ath. Tr. (in press)
7. Moser, RS. The growing public health concern of sports concussion: The new psychology practice frontier. Professional Psychology: Research and Practice. 2007;38(6), 699-704.
Posted October 12, 2011; updated December 28, 2011
