Role of Neuropsychologists in the Evaluation and Management of Sport-Related Concussion: An Inter-Organization Position Statement

Article (PDF Available)inThe Clinical Neuropsychologist 25(8):1289-1294 · November 2011with38 Reads
DOI: 10.1080/13854046.2011.618466
Abstract
Over the past 20 years, clinical neuropsychologists have been at the forefront of both scientific and clinical initiatives aimed at developing evidence-based approaches to the evaluation and management of sport-related concussion. These efforts have directly impacted current policy on strategies for injury assessment and return-to-play by athletes after concussion. Many states are considering legislation requiring (a) education of athletes, parents, coaches, and school/organization officials on the recognition, evaluation, and management of sport-related concussions; (b) removal from play of any youth athlete that is suspected of having sustained a concussion; and (c) not allowing the student to return to participation until the student is evaluated and cleared for return to participation in writing by an appropriate healthcare professional. It is the official position of the American Academy of Clinical Neuropsychology (AACN), American Board of Neuropsychology (ABN), Division 40 (Neuropsychology) of the American Psychological Association (APA), and the National Academy of Neuropsychology (NAN) that neuropsychologists should be included among the licensed health care professionals authorized to evaluate, clinically manage, and provide return to play clearance for athletes who sustain a sport-related concussion.
Commentary
Role of Neuropsychologists in the Evaluation and Management of
Sport-Related Concussion: An Inter-Organization Position Statement
Ruben J. Echemendia
1,
*, Grant L. Iverson
2
, Michael McCrea
3
, Donna K. Broshek
4
, Gerard A. Gioia
5
,
Scott W. Sautter
6
, Stephen N. Macciocchi
7
, William B. Barr
8
1
Psychological and Neurobehavioral Associates, Inc., State College, PA, USA
2
University of British Columbia, Vancouver, BC, Canada
3
Medical College of Wisconsin, Milwaukee, WI, USA
4
University of Virginia School of Medicine, Charlottesville, VA, USA
5
Children’s National Medical Center and George Washington University School of Medicine, Rockville, MD, USA
6
Hampton Roads Neuropsychology, Inc., Virginia Beach, VA, USA
7
Shepherd Center, Atlanta, GA, USA
8
New York University School of Medicine, New York, NY, USA
*Corresponding author at: Psychological and Neurobehavioral Associates, Inc., State College, 204 East Calder Way, Suite 205, PA 16801, USA.
Tel.: +1-814-235-5588; fax: +1-814-272-0043.
E-mail address: rechemendia@comcast.net (R.J. Echemendia).
Accepted 14 August 2011
Abstract
Over the past 20 years, clinical neuropsychologists have been at the forefront of both scientific and clinical initiatives aimed at developing
evidence-based approaches to the evaluation and management of sport-related concussion (SRC). These efforts have directly impacted
current policy on strategies for injury assessment and return-to-play by athletes after concussion. Many states are considering legislation
requiring (a) education of athletes, parents, coaches, and school/organization officials on the recognition, evaluation, and management of
SRCs; (b) removal from play of any youth athlete that is suspected of having sustained a concussion; and (c) not allowing the student to
return to participation until the student is evaluated and cleared for return to participation in writing by an appropriate healthcare professional.
It is the official position of the American Academy of Clinical Neuropsychology (AACN), American Board of Professional Neuropsychology
(ABN), Division 40 (Neuropsychology) of the American Psychological Association (APA), and the National Academy of Neuropsychology
(NAN) that neuropsychologists should be included among the licensed healthcare professionals authorized to evaluate, clinically manage,
and provide return to play clearance for athletes who sustain a SRC.
Keywords: Concussion; Traumatic brain injury; Children; Legislation
Overview of Concussion
Sport-related concussion (SRC), widely recognized as a major public health issue in the USA and worldwide, has become
the focus of increasing concern from clinicians, researchers, sporting organizations, and athletes themselves over the last two
decades (DeKosky et al., 2007; DeKosky, Ikonomovic, & Gandy, 2010; Gilchrist, Thomas, Wald, & Langlois, 2007; Kelly,
1999; Langlois, Rutland-Brown, & Wald, 2006; McCrory et al., 2005, 2009). It is estimated that 1.63.8 million SRCs
This Position Statement is a summary of the literature regarding current issues raised by the diagnosis and management of sports concussion. The report has
been approved by the American Academy of Clinical Neuropsychology (AACN), American Board of Professional Neuropsychology (ABN), Division 40
(Neuropsychology) of the American Psychological Association (APA), and the National Academy of Neuropsychology (NAN), with the goal of providing
information of relevance on an important public policy matter within their respective areas of expertise. The report is not intended to establish guidelines
or standards for the professional practice of psychology, nor has it been adopted as official policy by the American Psychological Association.
Archives of Clinical Neuropsychology 27 (2012) 119 122
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might occur each year in the USA (Langlois et al., 2006). The true incidence of SRC is thought to be higher than that reported
in conventional epidemiological studies, in large part due to a tendency by athletes to either not recognize or report these inju-
ries (Echlin et al., 2010; McCrea, Hammeke, Olsen, Leo, & Guskiewicz, 2004).
A concussion is a mild traumatic brain injury typically caused by acceleration/deceleration forces from a blow to the head or
body. These forces produce biochemical and neurometabolic changes in the brain that typically evolve dynamically over time
following the injury. A concussion can result in diverse symptoms that are somatic (e.g., headache, nausea, or dizziness), cog-
nitive (e.g., difficulty with attention and concentration, memory, or information processing speed), and psychological (e.g.,
anxiety and emotional lability). The symptoms of concussion usually resolve within 7 10 days in college-age and professional
athletes. Some people might be vulnerable to slower or more complicated recoveries, including women, athletes with comorbid
neurologic or psychiatric disorders or substance abuse issues, or individuals with previous prior history of multiple concus-
sions. Children and adolescents might be at greater risk for slower recovery than young adults. Although most athletes
recover relatively quickly from a concussion, some experience protracted symptoms and problems that can linger for many
weeks to months (cf. Echemendia, 2006; McCrory et al., 2009).
Neuropsychologists and Sports Medicine
Over the past 20 years, clinical neuropsychologists have been at the forefront of both scientific and clinical initiatives aimed
at identifying the symptoms and problems associated with concussions, monitoring recovery, and facilitating return to school
and sports. Several large, prospective studies led by neuropsychologists have not only advanced the science of concussion, but
also provided an evidence base that now drives evidence-based approaches to the clinical assessment and management of con-
cussion in athletes.
There is a mature multidisciplinary body of evidence establishing the value of neuropsychological assessment in detecting
neurocognitive changes following SRC (Broglio, Macciocchi, & Ferrara, 2007; Broshek et al., 2005; Bruce & Echemendia,
2003; Collie, Makdissi, Maruff, Bennell, & McCrory, 2006; Collins et al., 1999, 2003; Covassin, Schatz, & Swanik, 2007;
Echemendia, Putukian, Mackin, Julian, & Shoss, 2001; Erlanger et al., 2003; Fazio, Lovell, Pardini, & Collins, 2007;
Guskiewicz, Ross, & Marshall, 2001; Iverson, Brooks, Collins, & Lovell, 2006; Iverson, Lovell, & Collins, 2003; Lovell
et al., 2003; Lovell, Collins, Iverson, Johnston, & Bradley, 2004; Macciocchi, Barth, Alves, Rimel, & Jane, 1996; Makdissi
et al., 2001; Matser, Kessels, Lezak, & Troost, 2001; McClincy, Lovell, Pardini, Collins, & Spore, 2006; McCrea et al.,
2003; Sosnoff, Broglio, Hillman, & Ferrara, 2007; Van Kampen, Lovell, Pardini, Collins, & Fu, 2006). Neuropsychologists
have also contributed significantly to the development of standardized sideline concussion assessment tools (Barr &
McCrea, 2001; McCrea et al., 1998), objective methods of symptom assessment (Gioia, Schneider, Vaughan, & Isquith,
2009; Lovell, 1996, 1999; Lovell & Collins, 1998; Lovell et al., 2006; Randolph et al., 2009), and office assessments
(Gioia, Collins, & Isquith, 2008).
Role of the Neuropsychologist
Neuropsychologists receive extensive specialized training in brain-behavior science and are licensed as independent clinical
practitioners. The neuropsychologist is formally defined as follows:
A clinical neuropsychologist is a professional within the field of psychology with special expertise in the applied science of brain-behavior
relationships. Clinical neuropsychologists use this knowledge in the assessment, diagnosis, treatment, and/or rehabilitation of patients across the
lifespan with neurological, medical, neurodevelopmental and psychiatric conditions, as well as other cognitive and learning disorders. The clinical
neuropsychologist uses psychological, neurological, cognitive, behavioral, and physiological principles, techniques and tests to evaluate patients’
neurocognitive, behavioral, and emotional strengths and weaknesses and their relationship to normal and abnormal central nervous system
functioning (Barth et al., 2003).
The complexity of both neurological and psychological factors relevant to concussion management underscores the important
role of the neuropsychologist based on their training, expertise, and scope of clinical practice. Neuropsychologists are uniquely
qualified to assess an athlete’s cognitive and psychological functioning following SRC. Neuropsychologists can provide early
intervention in the form of education and reassurance, monitor an athlete’s return to school, and treat emotional problems that
might arise during the recovery period.
The widespread use of neuropsychological testing to evaluate SRC has led to questions about who should administer the
tests and who should interpret the results. Echemendia, Herring, and Bailes (2009) discussed this issue at length and concluded
that (a) paraprofessionals can be adequately trained for the administration of tests, and (b) neuropsychologists are uniquely
qualified to interpret the results.
120 R.J. Echemendia et al. / Archives of Clinical Neuropsychology 27 (2012) 119–122
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Legislative Position
Many states are considering legislation requiring (a) education of athletes, parents, coaches, and school/organization
officials on the recognition, evaluation, and management of SRC; (b) removal from play of any youth athlete who is suspected
of having sustained a concussion; and (c) not allowing the student to return to participation until the student is evaluated
and cleared for return to participation in writing by an appropriate healthcare professional. It is the official position of the
American Academy of Clinical Neuropsychology (AACN), American Board of Professional Neuropsychology (ABN),
Division 40 (Neuropsychology) of the American Psychological Association (APA), and the National Academy of
Neuropsychology (NAN) that neuropsychologists should be included among the licensed healthcare professionals authorized
to evaluate, clinically manage, and provide return to play clearance for athletes who sustain SRC.
Conflict of Interest
None declared.
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    • "Neuropsicología Clínica, Vol. 1, No. 1, Enero-Abril 2016 requiere de amplia experiencia clínica para detectar cambios sutiles en el funcionamiento cerebral. necesidad de incluir a un neuropsicólogo dentro del equipo de especialistas en medicina deportiva a todos los niveles: profesional, colegial y amateur (Guskiewicz et al., 2004; Echemendia et al., 2011 "
    [Show abstract] [Hide abstract] ABSTRACT: La conmoción cerebral se caracteriza por el deterioro inmediato y transitorio postraumático de la función neurológica inducido por fuerzas biomecánicas. En la mayoría de los casos cuando se realizan estudios convencionales de neuroimagen no se encuentra evidencia de alteraciones en la estructura cerebral, las alteraciones que se presentan son de tipo funcional. Después de sufrir una conmoción cerebral existen dificultades en diversos procesos cognitivos (memoria, atención, inhibición, velocidad de procesamiento) que en la gran mayoría de casos se resuelven entre los 7 y 10 días posteriores al evento. En nuestro medio profesional no existe la conciencia de la importancia de estas condiciones, ni los protocolos para la atención y manejo de los deportistas. La evaluación neuropsicológica es una herramienta importante para evaluar el funcionamiento cognitivo y establecer medidas de acción en caso de secuelas, evitando el deterioro serio e irreversible.
    Full-text · Article · Apr 2016 · Brain Injury
    • "We now turn attention to specific ethical considerations for the practice of sports neuropsychology. Athletes with SRC often present with a complex admixture of psychological and neurocognitive symptoms, which place sports neuropsychologists in unique role of being able to evaluate, manage, and treat this injury (Echemendia et al., 2012 ). Sports neuropsychology is defined as, " A subspecialty of clinical neuropsychology that applies the science and understanding of brainbehavior relationships to the assessment and treatment of sports-related brain injury. "
    [Show abstract] [Hide abstract] ABSTRACT: There has been unprecedented interest in sport-related concussions from many and varied sources including media, sports leagues, players’ unions, lawyers, legislators, scientists, clinicians, parents, coaches, and the athletes themselves. This interest has been fueled by epidemiologic data which indicate that concussions frequently occur at all ages, at all levels of play, and across a broad range of sports. The ubiquitous nature of the injury has also been coupled with concerns about whether and what type of relationships may exist between sports-related brain injury and the development of later neurodegenerative disease processes. The development of Sports Neuropsychology has largely paralleled the interest in sports concussions, making it a young and rapidly growing area of clinical and research interest. The youth of sports neuropsychology coupled with a focus on a poorly defined injury while being subject to unprecedented media, public, legislative, and legal scrutiny presents unique and important challenges to the ethical practice of sports neuropsychology. This paper explores these challenges by reviewing the brief history of sports neuropsychology, providing a basic review of the APA Code of Ethics, and discussing key ethical constructs such as beneficence, non-maleficence, and autonomy. The role of ethnic/racial cultural considerations in sports neuropsychology is discussed as well as ethical questions related to test use and development, the various roles that sports neuropsychologists play in sports medicine, and several illustrations of the challenges faced by sports neuropsychologists related to confidentiality, competence, role definition, and role boundaries. Although this article does not provide simple answers to complex questions, it does highlight areas in need of thoughtful discourse for clinicians engaged in the dynamic and evolving nature of ethical sports neuropsychology practice.
    Full-text · Article · Nov 2015
    • "An additional departure from existing guidelines was that athletes diagnosed with a concussion should not be returned to the same game or practice. As the focus on concussions continued to increase in the scientific and popular press, several different guidelines or statements from professional organizations emerged, including the position statement of the National Athletic Trainers' Association (NATA) [34], the Team Physician's Consensus Statements [35, 36], the consensus statement of the American College of Sports Medicine [37] and the neuropsychologists' Inter-Organizational Statement [38]. These statements discuss the role of each particular group in the evaluation and management of sports concussions as well as providing discipline-specific guidelines based on a review of the literature . "
    [Show abstract] [Hide abstract] ABSTRACT: Abstract Background: Sports-related concussions are commonplace at all levels of play and across all age groups. The dynamic, evolving nature of this injury coupled with a lack of objective biomarkers creates a challenging management issue for the sports medicine team. Athletes who return to play following a concussion are known to be at higher risk for an additional brain injury, which necessitates a careful, informed return to play (RTP) process. The goal of this paper is to outline historical attempts at developing RTP guidelines and trace their evolution over time, culminating in a discussion of the process and outcomes of the most recent consensus statements/guidelines published by the international Concussion In Sport Group (CISG), the American Academy of Neurology (AAN), the National Athletic Trainers' Association, and the 2013 Team Physician Consensus Statement Update. An evaluation of the pros and cons of these guidelines is presented along with suggestions for future directions. In addition, the Institute of Medicine recently conducted a comprehensive report outlining the current state of evidence regarding youth concussions, which provides specific recommendations for future research. The different methodologies utilized in the development of consensus statements have distinct advantages and disadvantages, and both approaches add value to the everyday management of sports concussions. Importantly, the overall approach for management of sports concussion is remarkably similar using either consensus-based or formal evidence-based methods, which adds confidence to the current guidelines and allows practitioners to focus on accepted standards of clinical care. Moving forward, careful study designs need to be utilized to avoid bias in selection of research subjects, collection of data, and interpretation of results. Although useful, clinicians must venture beyond consensus statements to examine reviews of the literature that are published in much greater frequency than consensus statements.
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