THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 7 - JULY 98
Baseline Neurologic Testing Grows: Pro Teams Lead the Way
Baseline neuropsychological testing in athletes, once strictly an academic pursuit, is evolving into a clinical tool that can help physicians monitor athletes' recovery from concussion and make return-to-play decisions. In the United States, the annual incidence of sports-related traumatic brain injuries is estimated at 300,000 (1).
Like many other developments in sports medicine, clinical use of baseline testing began with professional teams and is starting to spread to the college and high school levels. The Pittsburgh Steelers of the National Football League (NFL) were first to institute baseline testing when they did it 5 years ago, says Mark R. Lovell, PhD, division head of neuropsychology at Henry Ford Hospital in Detroit, who with Joseph Maroon, MD, initiated testing of the Steelers.
Last season the National Hockey League (NHL) made baseline testing mandatory for all teams. Lovell estimates that about half of NFL teams have adopted baseline testing—most as ongoing research projects. "Several college teams are doing screening as part of research projects, but it's becoming increasingly useful at the clinical level," he adds. Some of the college teams that have instituted baseline testing programs include Pennsylvania State University, Michigan State University, the University of Florida, the University of Pittsburgh, and the University of Georgia (2).
What Is Baseline Testing?
Baseline neurologic testing measures an athlete's cognitive status before the season. Physicians use the results to gauge the cognitive effects of head injuries that occur during the season. Testing generally focuses on memory, attention, mental processing speed, and motor speed. Players who sustain suspected concussions are retested at least twice—within 24 hours after injury and within 5 days after injury.
Neuropsychological testing of athletes is patterned after that of nonathletes with brain injuries. The practice had been considered experimental because few validity tests have been done with large groups of athletes (2). Currently, only one large-scale study (3,4) has evaluated neuropsychological testing in college athletes. The study of more than 2,300 athletes revealed that concussed athletes had subtle differences in measures of information processing speed when compared with controls. Lovell says many other studies are underway, including a multicenter study headed by Michael Collins, MA, at the University of Florida.
Lovell asserts that baseline neuropsychological testing has numerous benefits, including:
Lovell warns that physicians should not make return-to-play decisions solely on the basis of baseline and postinjury neuropsychological testing. "Noncognitive symptoms of concussions are very important—for example, headache, fatigue, and trouble sleeping," he says. "This is not a substitute for established medical practice—it's just a tool that team physicians can use to evaluate along with other aspects."
Craig Milhouse, MD, an internist at the Kerlan-Jobe Orthopaedic Clinic in Inglewood, California, has had about 2 years of experience with neuropsychological testing in his role as team physician for the Anaheim Mighty Ducks of the NHL. Milhouse says he is cautiously optimistic about the usefulness of testing. The test reveals some subtleties that are helpful, says Milhouse, who is also team physician of baseball's Anaheim Angels.
However, he says the physical symptoms such as headaches, insomnia, and depression remain more helpful markers of concussion status. "I have found that if you're very diligent about the time you spend with players, they are honest with you, and you see them frequently, that tells you all you need to know."
To be most useful, Milhouse says, baseline testing should be done as early as possible—before the player ever sustains a concussion. One problem in the NHL, he says, is that players are coming into the league already having sustained several concussions. Thus, Milhouse supports testing in high school. "That's the best scenario of all," he says.
What Tools Are Available?
So far, the sophistication of the testing tool varies by competitive level. Professional hockey players, for example, undergo formal testing administered by neuropsychologists, says Lovell, who helped organize a network of neuropsychologists in each NHL city.
Some colleges and high schools are using an abbreviated set of neuropsychological tests that is inexpensive and easy for nonspecialists to use: the Standardized Assessment of Concussion (SAC) (5), which was developed in conjunction with the concussion practice parameter released by the American Academy of Neurology in 1997 (6). The 5-minute standardized test screens for cognitive symptoms that often accompany a mild head injury—disorientation, memory deficits, and impaired attention and concentration. SAC comes in three versions to minimize "practice" effects. It is not a substitute for formal neurologic or neuropsychological testing.
In a study (5) of its clinical utility, the SAC was given to 568 high school and college football players before the 1995 and 1996 seasons. During the seasons, 33 players suffered apparent mild concussions and were immediately given the test again. Their average score (22.88 out of 30) was significantly below the average baseline score of all players (26.58) and their own average baseline score (26.3). In follow-up testing of 28 of the concussed players 48 hours after injury, all returned to their baseline scores. The authors said the findings support the test's effectiveness in detecting concussion and tracking recovery.
J. Christopher Daniel, MD, a family physician and adolescent medicine fellow at the Naval Medical Center in San Diego, is studying the usefulness of the SAC among high school football players in the San Diego area. "We feel that SAC is a tool that can be used now," says Daniel, who is a member of a national sports neuropsychology panel. "But we need to continue the research on it; there's a lot more validation that needs to occur."
Daniel is also involved with a group that teaches physicians, athletic trainers, and coaches how to use the SAC. "Trainers and physicians can learn to use SAC in less than an hour," he says. Responses to the test have been favorable among physicians and trainers, but a few coaches are hesitant about using it. "Their concern is that baseline testing might prompt parents of high school athletes to have second thoughts about [their kids'] playing football," he says. "We don't want to force this on coaches—we need their support."
A manual for administering, scoring, and interpreting the SAC test can be ordered from the Brain Injury Association in Alexandria, Virginia, at (800) 321-7037. The cost is $25. A fax order form is available on the association's web site at www.biausa.org/Cer12.htm.
Raising Player Consciousness
One of the most promising aspects of baseline testing, says Lovell, is that it fosters dialogue between players and healthcare personnel about concussions—traditionally a taboo topic among players because admitting to symptoms jeopardizes their clearance to play. Baseline testing can give players who have had one or more concussions concrete evidence of cognitive impairment and recovery. "For example, we'd explain to an athlete 'You've slowed down to 60% of your baseline,'" Lovell says. "Professional players are very positive. They feel the league is watching out for their health."
C-Spine Management Guidelines Proposed
Representatives from 23 national sports and medical organizations met in Indianapolis in May to propose the first guidelines for emergency management of athletes who have suspected spinal cord injuries. The group unanimously agreed on the proposed guidelines, but formal adoption of the guidelines awaits approval from each organization.
The meeting of the "Interassociation Spine Task Force" was organized by the National Athletic Trainers Association (NATA), says Kent Falb, ATC, PT, who is president of NATA and head athletic trainer for the Detroit Lions.
"The intent was to get all organizations involved in the immediate care of athletes with C-spine injuries to sit down at the table and agree on what the recommended guidelines should be—we primarily looked at football," Falb says. Healthcare professionals differ in their approach to athletes who have suspected cervical-spine injuries, he adds. "We were not there to critique anybody's procedure, but to establish what's best for injured athletes."
David C. Thorson, MD, a family physician at MinnHealth Banning in White Bear Lake, Minnesota, attended the meeting on behalf of the American Academy of Family Physicians. He says cervical spine management guidelines fill a crucial gap. "Many doctors who treat athletes aren't trained in sports medicine. The guidelines get everyone on the same page," he says. Some of the groups involved will likely publish position papers on the guidelines, Thorson says. "The language might be different, but the philosophy will be the same."
The major issue the group resolved was when to remove the football helmet, he says. (See "Helmet Removal in Head and Neck Trauma.") Some groups have stated that the football helmet should always be removed immediately, Falb says. The proposed guidelines state that the helmet and chin strap should be removed only when:
The group also addressed face mask removal. The proposed guidelines state that the face mask should be removed before transport, regardless of the player's respiratory status. The group discussed difficulties medical personnel are having in removing face masks, but Falb and Thorson report the group did not make specific recommendations on how to remove the masks. New loops that attach the face mask to the helmet are thicker, and removal is very difficult, even with a tool specifically designed for face mask removal.
NCAA Strengthens Weight-Cutting Rules
In response to the deaths of three college wrestlers last season, apparently from weight-cutting practices, the National Collegiate Athletic Association (NCAA) in Overland Park, Kansas, has adopted rules to make the sport safer. The new rules go beyond changes that went into effect in midseason in response to the deaths.
An NCAA press release says the new rules expand the midseason prohibitions against artificial weight loss practices such as use of laxatives, emetics, and steam rooms to include hot practice rooms; temperatures over 75°F are banned. The rules were proposed by the NCAA Wrestling Rules Committee along with members of the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports. Committees for the three NCAA divisions have approved the rule changes, according to Marty Benson, publishing editor at the NCAA.
The rules also:
"Just as with all changes, some will find these changes inconvenient at first," said Mike Moyer, chair of the wrestling rules committee, in a press release. "But we believe they are in the best long-term interest of both the student-athletes and the sport itself," he said.
Meanwhile, two recent research reports shed light on the effect of weight cutting on physical and cognitive performance.
A study (1) of 159 high school varsity wrestlers associated wrestling below one's recommended minimal wrestling weight with greater success in wrestling. The study also determined that wrestlers who took part in a voluntary body-fat measurement and diet education program still wrestled below recommended minimal weight. The authors concluded that wrestlers should not be told that cutting weight hurts their performance.
Another recent study (2) examined the cognitive effects of rapid weight loss in wrestlers. The study involved 14 wrestlers who cut weight and 15 controls. Wrestlers who cut weight had physiologic effects that influenced their moods and impaired short-term memory. The changes were reversible. The authors suggest that rapid weight cutting raises academic as well as health issues.
The American Board of Pediatrics is accepting applications for the 1999 sports medicine certifying examination. The deadline for first-time applicants is September 30. For reregistrants, applications will be accepted from September 1 through November 30. The examination date is April 16, 1999. Applicants must apply through their respective boards of primary certification. For application materials, contact the American Board of Pediatrics at (919) 929-0461.
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