Ruben J. Echemendia

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012

This paper is a revision and update of the recommendations developed following the 1st (Vienna 2001), 2nd (Prague 2004) and 3rd (Zurich 2008) International Consensus Conferences on Concussion in Sport and is based on the deliberations at the 4th International Conference on Concussion in Sport held in Zurich, November 2012.1–3 The new 2012 Zurich Consensus statement is designed to build on the principles outlined in the previous documents and to develop further conceptual understanding of this problem using a formal consensus-based approach. A detailed description of the consensus process is outlined at the end of this document under the Background section. This document is developed primarily for use by physicians and healthcare professionals who are involved in the care of injured athletes, whether at the recreational, elite or professional level. While agreement exists pertaining to principal messages conveyed within this document, the authors acknowledge that the science of concussion is evolving, and therefore management and return to play (RTP) decisions remain in the realm of clinical judgement on an individualised basis. Readers are encouraged to copy and distribute freely the Zurich Consensus document, the Concussion Recognition Tool (CRT), the Sports Concussion Assessment Tool V.3 (SCAT3) and/or the Child SCAT3 card and none are subject to any restrictions, provided they are not altered in any way or converted to a digital format. The authors request that the document and/or the accompanying tools be distributed in their full and complete format. This consensus paper is broken into a number of sections 1. A summary of concussion and its management, with updates from the previous meetings; 2. Background information about the consensus meeting process; 3. A summary of the specific consensus questions discussed at this meeting; 4. The Consensus paper should be read in conjunction with the SCAT3 assessment tool, the Child SCAT3 and the CRT …

Neuropsychological test performance prior to and following sports-related mild traumatic brain injury

ObjectiveTo examine the utility of neuropsychological tests in assessing college athletes prior to and following a sports-related mild Traumatic Brain Injury (mTBI). DesignA prospective study of college athletes who sustained mTBI while engaged in sport. Preinjury baseline neuropsychological test data were obtained for athletes at risk for mTBI. Following an mTBI, the athlete and his or her matched noninjured control were evaluated at 2 hours, 48 hours, 1 week, and 1 month postinjury. SettingMale and female athletes from a Division I college. ParticipantsMale and female athletes from the football, mens ice hockey, mens and womens soccer, and mens and womens basketball teams at Penn State University. A total of 29 injured and 20 noninjured athletes participated in the study. InterventionsNeuropsychological test batteries were administered at baseline and serially following mTBI. Main Outcome MeasuresPost-Concussion Symptom Checklist, Hopkins Verbal Learning Test, Symbol Digit Modalities Test, Stroop Color-Word Test, Trail Making Test, VIGIL/W, List Learning, Digit Span, Penn State Cancellation Test, and Controlled Oral Word Association. ResultsNeuropsychological test data yielded significant differences between injured athletes and controls at 2 hours and 48 hours following cerebral concussion; injured athletes performing significantly worse than controls. Injured athletes reported a significantly greater number of postconcussion symptoms 2 hours following injury but not at the 48-hour assessment. No multivariate group differences were found at 1 week, but univariate analyses suggested significant differences on a few measures. At 1 month postinjury, a statistically significant difference was found on one measure with injured athletes marginally outperforming controls. ConclusionsNeuropsychological tests are useful in the detection of cognitive impairment following mTBI. The test data appear to be more effective than subjective report of symptoms in differentiating between injured and noninjured athletes at 48 hours postinjury. Although significant individual variability existed, most injured athletes recovered within 1 week of injury. A battery of tests, rather than any single test, is necessary to capture the variability that exists among injured athletes.

Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016

The 2017 Concussion in Sport Group (CISG) consensus statement is designed to build on the principles outlined in the previous statements1–4 and to develop further conceptual understanding of sport-related concussion (SRC) using an expert consensus-based approach. This document is developed for physicians and healthcare providers who are involved in athlete care, whether at a recreational, elite or professional level. While agreement exists on the principal messages conveyed by this document, the authors acknowledge that the science of SRC is evolving and therefore individual management and return-to-play decisions remain in the realm of clinical judgement. This consensus document reflects the current state of knowledge and will need to be modified as new knowledge develops. It provides an overview of issues that may be of importance to healthcare providers involved in the management of SRC. This paper should be read in conjunction with the systematic reviews and methodology paper that accompany it. First and foremost, this document is intended to guide clinical practice; however, the authors feel that it can also help form the agenda for future research relevant to SRC by identifying knowledge gaps. A series of specific clinical questions were developed as part of the consensus process for the Berlin 2016 meeting. Each consensus question was the subject of a specific formal systematic review, which is published concurrently with this summary statement. Readers are directed to these background papers in conjunction with this summary statement as they provide the context for the issues and include the scope of published research, search strategy and citations reviewed for each question. This 2017 consensus statement also summarises each topic and recommendations in the context of all five CISG meetings (that is, 2001, 2004, 2008, 2012 as well as 2016). Approximately 60 000 published articles were screened by the expert panels for the Berlin …

Consensus statement on concussion in sport: the 4th international conference on concussion in sport, Zurich, november 2012

Paul McCrory, MBBS, PhD*; Willem H. Meeuwisse, MD, PhD†; Mark Aubry, MD‡; Robert C. Cantu, MD§; Jiři Dvořak, MD||; Ruben J. Echemendia, PhD¶; Lars Engebretsen, MD, PhD#; Karen Johnston, MD, PhD**; Jeffrey S. Kutcher, MD††; Martin Raftery, MBBS‡‡; Allen Sills, MD§§; Brian W. Benson, MD, PhD||||; Gavin A. Davis, MBBS¶¶; Richard Ellenbogen, MD##; Kevin M. Guskiewicz, PhD***; Stanley A. Herring, MD†††; Grant L. Iverson, PhD‡‡‡; Barry D. Jordan, MD§§§; James Kissick, MD||||||; Michael McCrea, PhD¶¶¶; Andrew S. McIntosh, PhD###; David Maddocks, LLB, PhD****; Michael Makdissi, MBBS, PhD††††; Laura Purcell, MD‡‡‡‡; Margot Putukian, MD§§§§; Kathryn Schneider, PhD||||||||; Charles H. Tator, MD, PhD¶¶¶¶; Michael Turner, MD####

Human Diversity and Professional Competence: Training in Clinical and Counseling Psychology Revisited.

Psychologists have increasingly recognized the need to appropriately train students to serve individuals from diverse groups. These groups have been characterized by racial-ethnic membership or defined by sexual orientation, socioeconomic status, gender, and physical ability. Recent reports have documented that many applied graduate training programs still do not provide courses and experiences specific to working with diverse populations. This study presents results from a survey of 259 graduates of counseling and clinical psychology programs. Respondents were asked about training and professional work experiences with diverse groups. Results indicate restricted opportunities for training with diverse clients. Training experiences reported to be most effective are presented. Findings are discussed in light of continuing efforts to promote appropriate services.

Mild Traumatic Brain Injury in Sports: Neuropsychology's Contribution to a Developing Field

Mild traumatic brain injuries are common at all levels of athletic competition. Although once considered a “routine part of the game,” a significant amount of attention has recently been placed on these injuries at the professional, college, and high school levels. This paper reviews the epidemiology of sports-related brain injuries, the pathophysiology of the injuries, and the role of neuropsychology in this newly emerging area. Issues related to the adequacy of neuropsychological test instruments and approaches are discussed in light of future directions for research.

The acute neuropsychological effects of heading in soccer: a pilot study.

ObjectiveThe main objective of this study was to prospectively examine the acute effects of heading in soccer on cognitive function. DesignThis was a prospective cross-over study using a brief neuropsychological battery to assess cognitive function. The tests were performed before and after two separate practice sessions, with athletes serving as their own controls. SettingMale and female Division I college athletes. ParticipantsMembers of the mens and womens varsity collegiate Penn State University soccer teams. Forty-four males and 56 females entered and finished the study. All athletes had a normal physical examination. InterventionsBefore and after both practice sessions, all athletes had a brief battery of neuropsychological tests and a symptom checklist. Main Outcome MeasuresNeuropsychological tests symptom checklist compared at baseline with those after the practice sessions. ResultsThere were no significant differences in pretest scores between groups and no difference on posttest scores between heading and nonheading groups. A significant difference was detected using MANOVA (p = < 0.001) between pre-and posttest scores for measures of attention and concentration, indicating a practice effect. A gender-specific effect in one test measuring attention and concentration was found. There was no difference in symptoms before and after heading as compared with exertional controls. ConclusionsIn this study, soccer players heading the ball does not appear to lead to acute changes in cognitive function as assessed by a brief neuropsychological battery. There are practice effects that occur with repetitive neuropsychological testing and gender differences with certain tests.

Return to play following sports-related mild traumatic brain injury: the role for neuropsychology

Cerebral concussions frequently occur at all levels of athletic competition. The effects from these concussions can be transient or may lead to chronic, debilitating symptoms. A growing literature has established that neuropsychological tests are useful in detecting the subtle neurocognitive changes that occur following concussions. The identification of these deficits and subsequent recovery of function can be important components in making return-to-play (RTP) decisions. This article describes the emergence of neuropsychology in sports medicine, discusses the context in which RTP decisions are made, outlines factors that are important to RTP decisions, and presents a model that views the RTP decision as a dynamic risk-benefit analysis that involves complex interactions among variables. It is argued that neuropsychology has a unique, but not exclusive, role in the decision making process. Implications for future research are discussed.

The Utility of Post-Concussion Neuropsychological Data in Identifying Cognitive Change Following Sports- Related MTBI in the Absence of Baseline Data

Neuropsychological tests have become commonplace in the assessment of sports-related concussion. Typically, post-injury test data are compared to pre-injury “baselines.” Baseline testing can be expensive and logistically challenging, yet the usefulness of neuropsychological baseline testing has not been tested empirically. This paper examines the extent to which baseline testing is useful for detecting neurocognitive deficits following sports concussion in a college-age population. A total of 223 collegiate athletes from multiple sports who sustained concussions and had both baseline and post-injury testing using Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) were included in the study. Reliable change (RC) in scores was determined by two approaches, the Jacobson and Truax (JT) and the Gulliksen-Lord-Novick (GLN) methods. The 90% confidence interval was used for both. Classification using these methods was compared to standard normative methods that compared post-concussion performance to baseline population means. Agreement between reliable change and normative methods was examined using Cohens Kappa scores to determine whether post-injury scores alone could identify reliable cognitive decline. Mean time from concussion to post-injury testing was 3.40 days. The percentage of athletes who declined when using the JT method was similar to the percentage that would be expected to decline due to chance alone. Although the GLN and JT methods demonstrated moderate to substantial agreement, the GLN method consistently identified more cognitively compromised athletes than the JT method. Post-injury scores alone identified a significant majority of athletes with a reliable decline on ImPACT. Although preliminary and in need of replication across age groups and instruments, these findings suggest that the majority of collegiate athletes who experience clinically meaningful post-concussion cognitive decline can be identified without baseline data.

Advances in neuropsychological assessment of sport-related concussion

Objective To critically review the literature from the past 12 years regarding the following key issues in sports-related neuropsychological assessment: (1) the advantages and disadvantages of different neuropsychological assessment modalities; (2) the evidence for and against the current paradigm of baseline/postinjury testing; (3) the role of psychological factors in the evaluation and management of concussion; (4) advances in the neuropsychological assessment of children; (5) multi-modal assessment paradigms; (6) the role of the neuropsychologist as part of the sports healthcare team and (6) the appropriate administration and interpretation of neuropsychological tests. Design Targeted computerised literature review (MEDLINE, PubMed, CINAHL and PsychInfo) from 2000 to the present using key words: neuropsychological, neurocognitive, assessment, testing, concussion and sports. Results More than 2600 articles were identified using key word searches of the databases, including many duplicates. Several books were also reviewed. The articles were pared down for review if they specifically addressed the key areas noted above. Conclusions Traditional and computerised neuropsychological tests are useful in the evaluation and management of concussion. Brief cognitive evaluation tools are not substitutes for formal neuropsychological assessment. At present, there is insufficient evidence to recommend the widespread routine use of baseline neuropsychological testing. Although scant, research suggests that psychological factors may complicate and prolong recovery from concussion in some athletes. Age-appropriate symptom scales for children have been developed but research into age-appropriate tests of cognitive functions lags behind. Neuropsychologists are uniquely qualified to interpret neuropsychological tests and can play an important role within the context of a multifaceted-multimodal approach to manage sports-related concussions.