Traumatic Brain Injury in Sports

Mark Lovell, Jeffrey Barth, Michael Collins, Ruben Echemendia

• Publisher: Taylor & Francis
• Year: 2020
• ISBN:
  9781000722802
• Edition: 1
• Topic: Medicine
• Subtopic: Sports Medicine

Traumatic brain injury (TBI) in sports has become an important international public health issue over the past two decades. However, until recently, return to play decisions following a sports-related traumatic brain injury have been based on anecdotal evidence and have not been based on scientifically validated clinical protocols. Over the past decade, the field of Neuropsychology has become an increasingly important component of the return to play decision making process following TBI. Neuropsychological assessment instruments are increasingly being adapted for use with athletes throughout the world and the field of sports neuropsychology appears to be a rapidly evolving subspecialty.
This book provides a comprehensive overview of the application of neuropsychological assessment instruments in sports, and it is structured to present a global perspective on contemporary research. In addition to a review of current research, Traumatic Brain Injury in Sports: An International Neuropsychological Perspective, presents a thorough review of current clinical models that are being implemented internationally within American and Australian rules football, soccer, boxing, ice hockey, rugby and equestrian sports.

Section II
Models of Neuropsychological Assessment

EDITED BY
MARK R. LOVELL

Chapter 7
Collegiate and High School Sports

Michael W. Collins University of Pittsburgh Medical Center
Ruben J. Echemendia Pennsylvania State University
Mark R. Lovell University of Pittsburgh Medical Center

Introduction and Background

The management of sports-related concussion is currently one of the most hotly debated topics in sport medicine. Much of this debate centers on the determination of when it is safe to return to participation following concussion. This determination is often a difficult one and neuropsychological testing may contribute significantly to the clinical decision making process.

Most experts believe that neurocognitive manifestations of concussion are related to acute metabolic dysfunction (Giza & Hovda, 2001; Hovda et al., 1998). Post-traumatic hyperglycolysis and concomitant decreased cerebral blood flow have been implicated for the cause of this dysfunction. This systematic dysautoregulation, described in detail elsewhere in this text, may not be seen until 2-3 days post-injury and may last for several weeks. Furthermore, it has been postulated that metabolic dysfunction, until fully resolved, may lead to significantly increased neurologic vulnerability if a subsequent trauma (even minor) is sustained. Such metabolic dysfunction is theoretically linked to second impact syndrome and may also form the basis for the less severe, though occasionally incapacitating, presentation of post-concussion syndrome (Cantu, 1986). Although long-term deficits in the form of postconcussion syndrome have been observed from a single concussive event, it is typically assumed that proper management of the concussive injury should lead to good prognosis and minimal deleterious effects with regard to brain function. Conversely, it is our current assumption that returning an athlete to participation prior to complete metabolic recovery may greatly increase the risk of lingering, long-term, or catastrophic neurologic sequelae. As such, acute assessment of injury and determination of existing neurologic difficulties proves critical to the safe management of the concussed athlete.

The focus of this chapter is on the utilization of neuropsychological testing protocols in high school and college athletics. The intent of this chapter is threefold. First, we wish to outline general considerations in the management of the concussed high school and collegiate athlete. To this end, we will emphasize an individualized approach to assessment. Next, we will introduce the reader to two contemporary clinical/research programs that utilize neuropsychological testing protocols for the clinical purpose of managing sports-related concussion. Specifically, the clinical and research protocols of the University of Pittsburgh Sports Medicine Concussion Program and The Pennsylvania State University Concussion Program will be discussed in detail. Although organized differently, these programs both provide sound methodology for the widespread utilization of neuropsychological testing at the college and high school levels of participation. Research using this described methodology has buttressed our theoretical and methodological foundation for advances in our understanding of sports concussion and is likely to be an area of significant growth over the next decade. The third section of the chapter will summarize and review existing peer-reviewed data that outlines the contributions of Sports Neuropsychology at the high school and college levels.

The Need for Neuropsychological Assessment in College and High School Athletics

The determination of lingering difficulties associated with concussion has traditionally proven problematic for a variety of reasons. First, mainstream neurodiagnostic techniques, such as CT scan and MRI, though invaluable in discerning more serious intracranial pathology (e.g. skull fracture, hematoma, parenchymal lesion), are typically insensitive in measuring the subtle effects of concussion. Further, relying on the self-report of the athlete may also prove ineffective because athletes may not be aware of the subtle signs of concussion (e.g. headache, personality changes, memory difficulties, dizziness). In addition, athletes are often taught to “play-through” injury and may minimize symptoms to solidify their playing status and career. Given these issues, ancillary neurodiagnostic strategies have proven critical to the safe management of the concussed athlete. These techniques have also provided a valuable research paradigm from which to gain a better understanding of this complex injury. At the forefront of these approaches is the advent of neuropsychological testing.

Historical Foundation of Sports Neuropsychology

The historical foundation of neuropsychological testing for sports-related concussion began in the college population. Specifically, Jeffrey Barth and colleagues were the first to initiate a prospective research methodology in the mid 1980’s with football players in the Ivy League and the University of Pittsburgh (Barth et al., 1989; Macciocchi et al., 1997). For a review of this work, please refer to Chapter 1 of this textbook.

The work of Barth and his colleagues was pioneering in several respects. First, this approach laid the methodological foundation for future neuropsychological studies that built upon their initial findings. Of critical importance was the inclusion of baseline evaluation since individual athletes displayed disparate performance based upon myriad pre-existing factors (e.g. learning disability, cognitive reserve, test anxiety, etc). In addition, this work highlighted the objective nature of neuropsychological evaluation and the ability to uncover even subtle cognitive deficits associated with concussive injury. Notably, however, this initial work also revealed the need for appropriate control groups and the inherent learning or “practice effects” associated with neuropsychological tests. In short, athletes, as a group, revealed ipsitive and relative cognitive deficit, even though they were above baseline levels on each of the individual measures. This finding proved critical to the eventual construction of alternate testing forms and more comprehensive neuropsychological test batteries.

Subsequent to the work conducted by Barth and colleagues, the next systematic utility of neuropsychological testing for sports concussion was implemented with the Pittsburgh Steelers in the early 1990s. This work is discussed elsewhere in this text. This was followed by the development of the NHL League-wide neuropsychological testing program. Such work has resulted in a solid methodological foundation for more widespread utilization of neuropsychological testing protocols for both professional and amateur athletes (Lovell, 2002). In fact, promulgation and utilization of neuropsychological testing protocols for sports concussion management have essentially become the standard for safe management. Evidence of this fact is that neuropsychological testing was recently deemed the “cornerstone” of concussion management by a multi-disciplinary panel of international concussion experts (Aubry et al., 2002). Over the past several years and subsequent to the work by Barth and colleagues, many advances have been made from both a test development and methodological standpoint. We will now review two clinical/research programs that highlight the nature of these advances and illustrate a practical and user-friendly methodology for protocol implementation.

Contemporary Models for the Evaluation of Collegiate and High School Athletes

This section will review two current models of neuropsychological assessment that involve the large-scale participation of collegiate and high school athletes. These models are presented to provide some guidance for researchers and clinicians who desire to implement large scale programs at these levels of participation.

University of Pittsburgh Medical Center (UPMC) Sports Medicine Concussion Program

The UPMC Sports Medicine Concussion program was initiated in September, 2000 and is housed within the Department of Orthopaedic Surgery at UPMC. Dr. Mark Lovell, a neuropsychologist, serves as Director of the newly developed program and Dr. Micky Collins, also a neuropsychologist, serves as Assistant Director. In addition to this core staff, the program also includes Dr. Joseph Maroon, team neurosurgeon of the Pittsburgh Steelers, Dr. Charles Burke, Pittsburgh Penguins physician and Chair of the NHL Concussion Committee, and Dr. Freddie Fu, Departmental Chair of UPMC’s Department of Orthopaedic Surgery and head team physician of the Pittsburgh Panthers football team. The daily workings of the program are conducted at the UPMC Center for Sports Medicine, a complex that houses both the Pittsburgh Steelers Football Club and University of Pittsburgh Football Team. The UPMC Sports Concussion Program currently oversees the neuropsychological testing programs for approximately 300 high schools and 100 college programs nationally.

The specific goal of the UPMC Sports Concussion Program is to provide objective clinical data through the use of ImPACT (i.e. computerized concussion testing software) to help assist team medical personnel in making safe and appropriate return to play decisions following sports concussion. A second goal is to use this clinical information from a research perspective to investigate a number of pertinent issues regarding management of concussion that have yet to be answered.

The UPMC model emphasizes baseline neuropsychological testing with post-concussion follow-up at 24-48 hours after injury and again five to seven days after injury, and subsequently if needed. In accordance with the recent Concussion in Sports (CIS) group consensus, we also emphasize return to play only after neuropsychological test results have returned to baseline levels and the athlete is symptom free, both at rest and following vigorous physical exertion (Aubry et al., 2002).

There were several driving forces behind the development of the UPMC Sports Concussion Program. Of primary importance was the emergence of neuropsychological testing as a reliable and valid means of assisting in the diagnosis of concussions and in quantifying the severity of the injury. In addition, this program as well as others have grown to fill a growing need for more better concussion assessment technology. As outlined throughout this text, the evolving consensus in the field of sports medicine has been that concussion management “guidelines” (Cantu, 1986; Kelly & Rosenberg, 1997) provide useful information for the initial diagnosis of concussive injury, but are not specific enough to be useful in making individualized return to play decisions regarding return to participation (Collins et al., 1999). In fact the CIS group, which included the developers of the major concussion guidelines, recently agreed that no current guideline system is adequate (Aubry et al., 2002). Through the research efforts described throughout this chapter, as well as through the success of the NFL and NHL neuropsychological testing programs, it is generally understood that individualized evaluation in the form of pre-season/post-injury neuropsychological testing in conjunction with individualized medical management has become the current “cornerstone” in delineating safe return to participation following concussive injury. A second consideration is that many sports medicine physicians (e.g. Primary Care Sports Medicine, Orthopaedic Surgeons) may have only limited knowledge regarding recovery from concussion and may have difficulty detecting the more subtle aspects of injury. Lastly, there is a general paucity of prospective research studies outlining the potential moderating effects of sports concussion and data-driven analysis of acute recovery curves following sports concussion. Thus, there exists a strong need for both research and clinical applications in the area of sports concussion. In short, Sports Neuropsychology should be considered a burgeoning specialty for the application of clinical neuropsychological practice.

The UPMC Sports Medicine Concussion Program rests on the foundation of the National Football League (NFL) and National Hockey League (NHL). However, based on our experience with these more traditional programs, we have recognized the need to institute several important changes that allow us to evaluate large groups of athletes. First, traditional neuropsychological testing is difficult to implement with large groups of athletes due to expense and manpower issues. In fact, it is not uncommon for neuropsychological consultants who work with high school athletes to be asked to perform baseline testing on hundreds of athletes over the course of several days. Second, many of the traditional domains typically assessed with more severe head trauma (e.g. extensive personality, executive, language, malingering assessment) may not be entirely relevant to gain an understanding of the status of the concussed athlete. As outlined above, athletes, in general, are highly motivated to return to sport participation and circumscribed cognitive domains (e.g. speed of processing, verbal/visual/working memory, reaction time) have been shown to be the most sensitive to the effects of mild concussion. In short, sensitive and time-efficient neuropsychological test batteries are critical to the success of Sports Neuropsychology, at the college and high school level. Third, another issue of concern in working with college or high school athletes is the need for serial evaluations. This requires the re-administration of the test or test battery multiple times and raises issues regarding improvement in performance based on exposure rather than on clinical recovery. These “practice effects” may complicate the interpretation of test results and need to be carefully evaluated (Echemendia & Petukian, 2001). In fact, given the need for baseline assessment and serial post-injury evaluation, it is not uncommon that an athlete may be evaluated up to five tim...

Table of contents

• Cover
• Half Title
• Series Title
• Title
• Copyright
• Contents
• FROM THE SERIES EDITOR
• INTRODUCTION
• SECTION I BASIC CONCEPTS
• SECTION II MODELS OF NEUROPSYCHOLOGICAL ASSESSMENT
• SECTION III METHODOLOGICAL ISSUES
• SECTION IV SPECIAL TOPICS
• INDEX