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Sport-related concussion is a serious neurodegenerative condition with a complex pathophysiology, which is not well understood. Rising cases of concussion have resulted in attempts to manage the condition after the injury. Neuropsychological testing has been widely applied to assist injured athletes during cognitive disorder assessment and recovery management. While the tests are now popular, their validity and reliability have not been ascertained. Consequently, further research is necessary to develop reliable tools for neuropsychological tests for sport-related concussion.
Sport-related Concussion: A Brief Overview
Much attention has been directed to contact sports in the recent past. Specifically, the source of concern has been the immediate and long-term outcomes of sport-related concussion (SRC). Chronic traumatic encephalopathy (CTE), which is a progressive neurodegenerative disease caused by repetitive head trauma, is now studied to determine long-term effects of contact sports (Saulle & Greenwald, 2012; Yi, Padalino, Chin, Montenegro, & Cantu, 2013). Football, the prestigious National Football League (NFL), now faces lawsuits and criticism regarding player management and safety following cases of mild traumatic brain injuries.
More strikingly, most cases have originated from a majority of retired players. Understandably, the sport is based on toughness, powerful impacts, full contact and the ability to overcome attackers. To date, many researchers have presented studies on concussion and contact sports players. Concussion refers to traumatically prompted transient disruption of brain functions and constitutes an intricate pathophysiological process (Sisodia & Kumar, 2013). Sport-related concussion is not only restricted to football, but is also reported in boxing (the first known identified cases), soccer, hockey, and professional wrestling. Although neurological outcomes of sport-related concussion are well documented, neuropsychological tests and their relevance to concussion are not yet fully understood. This essay focuses on the reliability of neuropsychological tests following sport-related concussion.
Management of Sports-related Concussion
Medical management of sport-related concussion can be viewed as having two different elements. The first aspect of management encompasses acute care management of injuries suffered immediately after the contact with the goal of identifying and treating any possible neurological outcomes, such as cerebral haemorrhage. This form of intervention is usually not necessary since most sport-related concussions entail mild concussions that may not result in acute neurological crises. Medical personnel consider the second aspect of management vital. It requires observing various symptoms associated with concussion over time with the aim of noting the progress for return-to-play decisions. In instances of extremely mild concussions, absolute recovery is often noted after few minutes, allowing players to resume sports and usually eliminating the need for any additional workup.
Sports-related concussions are normally linked to more than a single symptom, reduced balance, and cognitive insufficiencies (Echemendia et al., 2013). Balance assessment, symptom scales, and neurocognitive testing are available to assess these issues. According to Echemendia et al. (2013), these assessment modalities can be used to observe any changes within the first few days after an insult. Symptoms presentation and the rate of recovery normally differ, which indicate the importance of evaluating all the three factors as components of a thorough sport concussion management.
Neuropsychological evaluation of concussion is considered a vital aspect of management. Today, concussion management efforts that rely on neuropsychological assessment to help in clinical decision-making have been widely adopted across sport institutions, including professional sports and schools (Echemendia et al., 2013). Cognitive insufficiencies linked to concussion are generally elusive and could be found in multiple domains, implying that it is difficult to assess concussions. As a result, the diagnosis of concussion is based on clinical decisions depending on the evaluation of a wide range of domains with related symptoms, such as headache, loss of consciousness, cognitive deficiency and neurobehavioral changes, including irritability (Makdissi, Davis, & McCrory, 2014). Players often find it difficult to process information, and they display impaired memory and are slow to react. The application of neuropsychological tests in handling concussion is seen as an opportunity to overcome the dependence on subjective symptoms, which are also associated with other neurodegenerative conditions, such as Alzheimer’s disease, and are poorly recognized and reported differently (Gavett, Stern, & McKee, 2011). Moreover, such symptoms have also been associated with other outcomes, which do not necessarily reflect specific symptoms associated with concussion.
According to Sisodia and Kumar (2013), neuropsychological testing offers an objective means of evaluating sport-related concussion, as well as linking outcomes to specific individual-related factors, such as gender, age, and history past concussion. Based on neuropsychological results in sport-related concussion, patients have often displayed the above-mentioned symptoms. Notably, neuropsychological testing has undergone significant changes from the use of paper and pencil, balance field tests and now to the more commonly used computer-based test batteries (Sisodia & Kumar, 2013). Currently, multiple computerized neuropsychological test batteries are available in the mainstream markets, and they are marketed to athlete intervention programs across different institutions.
For cognitive function, formal neuropsychological testing is recognized as the clinical standard for evaluating cognitive impairment. Such a test is commended in any situations in which chances of recovery remain unclear or cases are difficult, specifically in prolonged recovery. Screening neuropsychological tests have been applied to evaluate cognitive recovery following the injury. Preferably, test results should be gauged against a person’s own pre-injury baseline results. In instances where no such baseline results are available, which is usually the case, normative data should be used. These standardized or formal neuropsychological tests are used as short measurement tools, formulated for the sideline evaluation of athletes following concussion in order to quantify the severity of the injury.
They are also used alongside other clinical data to determine suitability for return to play decisions. In this respect, the Standardized Assessment of Concussion (SAC) has gained significant recognition, and its reliability, sensitivity, and change-score analyses have been sufficiently studied. It, therefore, has been observed that baseline testing can be vital for assessing cognitive limitations after injury and for evaluating recovery (Iverson & Schatz, 2015). Additionally, many screening neuropsychological tests have been authenticated for management of concussion in athletes and are easily accessible. For instance, ImPACT or Axon Sports are computerized options for concussion management. The basic paper and pencil cognitive evaluations have been used to determine or estimate cognitive impairment, but they require other conservative return-to-play strategies and cautious observation of symptoms as athletes recover to play (Makdissi et al., 2014).
Limitations of Neuropsychological Testing
Researchers have observed that athletic trainers and other sports medicine personnel generally lack adequate knowledge on psychometrics to make informed choices on the use of such tools (Randolph, McCrea, & Barr, 2005). Moreover, currently available guidelines are not peer reviewed on the use of these assessment tools (Randolph et al., 2005). While neuropsychologists can use psychometric criteria required for the implementation of a specific tool for the purpose of clinical evaluation, trainers may not get services provided by neuropsychological consultants to assist in decision-making processes. In addition, it has been observed that neuropsychological tests to assess recovery following concussion have some unique features in terms of reliability and validity, which underscore the need for further reviews and studies (Randolph et al., 2005).
Neuropsychological tests, however, face some critical drawbacks related to assessment tools, which generally focus on reliability (Sisodia & Kumar, 2013). According to results of a study conducted by Randolph et al. (2005), no available traditional or computerized neuropsychological batteries adopted for use in the evaluation and management of sport-related concussion have satisfied all the standards required to permit regular clinical use. As such, fundamental issues concerning the reliability, validity, and clinical application of these tools remain largely unresolved. In this regard, it has been shown that test-retest data from these neuropsychological tests could be difficult to interpret, and any possible interpretation is better off as a function of clinical judgment instead of statistical algorithms (Randolph et al., 2005). It also appears that the field has made abysmal achievements in improving both traditional and computerized neuropsychological tests because some recent studies have demonstrated a lack of sufficient evidence to support a widespread regular use of baseline neuropsychological tests (Echemendia et al., 2013). Nevertheless, these tests are still recognized as extremely important in the assessment and management of concussion (Echemendia et al., 2013).
Some studies have also suggested that different factors, such as psychological state, may also complicate and extend recovery from concussion in athletes (Maroon et al., 2015). In addition, age is seen as a possible major factor that may accelerate recovery in young players because of increased brain plasticity, but the same may not apply to older retired athletes. Echemendia et al. (2013) further point out that age-appropriate testing may not be available or is not well researched to be used.
Given these facts on limitations of neuropsychological testing, further research is obviously required before these assessment tools can be declared effective for regular evaluation and management of sport-related concussion. Nevertheless, the relevance of baseline testing for quantifying cognitive impairment after insults and for evaluating recovery remains important for management and decision-making purposes. Many researchers have decried the lack of sufficient evidence to ascertain the importance of baseline test results and their validity (Iverson & Schatz, 2015; Yengo-Kahn, Johnson, Zuckerman, & Solomon, 2016). Invalid test results may be detected in some instances, but validity indicators cannot expressly show specific causes of errors during testing. Thus, such outcomes explain why Yengo-Kahn et al. (2016) insist that the scientific community and the public must treat such data with caution. Interpretation of results, therefore, requires advanced psychometric systems to help with accuracy of documentation of cognitive insults and regular management of recovery.
The past few decades have recorded a fast increase in the application of neuropsychological tests to manage athletes after concussive insults. Neuropsychological testing is now widely recognized across various sporting institutions globally, as well as by sports medicine physicians who apply it as a component of clinical management of brain injuries. It is generally observed that neuropsychological evaluation in the management of sport-related concussion is important because of supporting empirical evidence. However, reliability and validity of these assessment tools remain unclear, as most studies have demonstrated. Therefore, further research is necessary to advance neuropsychological testing in sport-related concussion to encourage their use.
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