Medical Necessity of Neuropsychological Assessment after Sports Concussions
In what circumstances is a neuropsychological assessment medically necessary after sports concussions or traumatic brain injury?
In the case of an athlete who has experienced a concussion or traumatic brain injury, the neuropsychologist plays an important role in determining safe return to work and clearing people after sports concussion. The neuropsychologist performs comprehensive cognitive testing to detect whether there are residual changes in thinking (for example, attention and memory) and behavior, personality, or mood after concussion and brain injury, and she helps determine a safe schedule to return to play. This can prevent lawsuits and negative consequences for all involved later. The comprehensive nature of this testing captures any mild, more subtle changes in cognitive functioning.
The athlete, the sports team, and healthcare providers who provide care for the athlete are subject to marketing claims about a variety of sports concussions assessment and brain injury prevention tools. It is important to examine the scientific evidence for these in deciding whether to invest in them. For example, the ImPACT concussion assessment tool is widely used to obtain pre- and post-concussion assessments of cognitive functioning (memory and thinking). Unfortunately, this assessment does not examine or assess the cause of any emotional, behavior, or personality changes that can be seen after a traumatic brain injury. This assessment method also does not include assessment of effort or motivational factors that could play a role in recovery. Failing to assess for these changes can leaves one liable to incomplete understanding of the person’s functioning after brain injury. It is also important to recognize that ImPACT is a screening tool. Would you want major decisions about your athlete’s health and career to be made based on a screening tool rather than a thorough and complete exam?
Further, ImPACT awaits a sufficient number of prospective, controlled studies behind it (aside from those conducted by its investors) which would support that it does what it claims to do. Because ImPACT is a screening tool, it may miss cognitive inefficiencies that a more comprehensive evaluation with well-validated measures might detect. False negatives with use of screening measures can occur (this means that the test indicates the test-taker’s brain functioning is “normal” when in fact it is NOT), and thus increase the risk associated with “premature” return to play decisions that are made based off of this alone. This test is also recognized to yield a high rate of false positives (indicating that the person has a problem when in fact they do not). In cases where symptoms do not clear within several days to weeks, the best and safest practice for all involved is to instead conduct symptom assessment, balance assessment, physical/neurologic assessment/exam, and comprehensive neuropsychological assessment, including cognitive testing and clinical interview. The neuropsychologist conducts the comprehensive neuropsychological assessment, and a neurologist or physical medicine and rehabilitation doctor (PM&R doctor) can conduct the other aspects of the evaluation.
While a single mild traumatic brain injury or concussion is not typically associated with long-term deficits that can be attributed to brain dysfunction, it is important to be assessed, especially in the case of persisting symptoms. This way the athlete is not returned to play or sport prematurely, which can prevent unnecessary re-injury.
The neuropsychologist will try and determine why symptoms are not going away, if they persist. The athlete may have had previous concussions, or there may be other factors such as sleep problems or medication or other factors that may be slowing recovery or mimicking symptoms of concussion.
The neuropsychologist will conduct cognitive testing to assess memory, attention, and other cognitive skills, as well as psychological factors. The evaluation will tell us what abilities have been most affected. Repeat testing can be useful to document improvement over time.
The neuropsychologist will provide education about recovery patterns. Even one single session to review the results can stop people from mistakenly attributing every day memory slips or other problems to their concussion when in fact their brain has healed from concussion. A rehabilitation program may be developed by the neuropsychologist, based on the results. A program of rest for a specific duration may be prescribed.
Dr. Messler has conducted hundreds of comprehensive neuropsychological evaluations post-concussion, and is the Charlotte area neuropsychologist experienced in conducting these evaluations across multiple settings in the field (e.g., in clinic, at the hospital bedside, immediately after an athlete has exited the playing field or sport, in combat zone in Afghanistan). Unlike ImPACT and other computer-generated cognitive screenings, her evaluations are flexibly tailored to the specific needs and injury severity of the athlete in front of her. Her practice since 2009 has primarily focused on post-concussion evaluation.