Helpful Websites ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) http://www.impacttest.com/ Center for Disease Control – United States http://www.cdc.gov/concussion/HeadsUp/sports_specific.html NHS – United Kingdom http://www.nhs.uk/conditions/head-injury-minor/Pages/Introduction.aspx Downloaded from bjsm.bmj.com on 6 November 2008 Computerised cognitive assessment of athletes with sports related head injury A Collie, D Darby and P Maruff Br. J. Sports Med. 2001;35;297-302 doi:10.1136/bjsm.35.5.297 Updated information and services can be found at: http://bjsm.bmj.com/cgi/content/full/35/5/297 These include: References This article cites 23 articles, 6 of which can be accessed free at: http://bjsm.bmj.com/cgi/content/full/35/5/297#BIBL 19 online articles that cite this article can be accessed at: http://bjsm.bmj.com/cgi/content/full/35/5/297#otherarticles Rapid responses You can respond to this article at: http://bjsm.bmj.com/cgi/eletter-submit/35/5/297 Email alerting Receive free email alerts when new articles cite this article - sign up in the box at the service top right corner of the article Notes To order reprints of this article go to: http://journals.bmj.com/cgi/reprintform To subscribe to British Journal of Sports Medicine go to: http://journals.bmj.com/subscriptions/ Downloaded from bjsm.bmj.com on 6 November 2008 Br J Sports Med 2001;35:297–302 297 Review Computerised cognitive assessment of athletes with sports related head injury A Collie, D Darby, P MaruV Abstract maybediYcult to diagnose with certainty using Professional and amateur participants in on field or subjective medical assessment many sports are at risk of brain injury techniques.3 This, in turn, complicates decisions caused by impact with other players or about real time return to play, as well as objects. In many cases, mild cognitive decisions about the longer term health conse- deficits may persist after the common quences of the injury, including risk of further neurological signs of brain injury have injury. Sports in which repeated TBIs are com- passed. In recent years, the athlete’s mon, such as boxing,4 also raise the problem of cognitive status after concussion has been cumulative cognitive damage,1 the assessment measured with conventional “paper and and management of which is currently poorly pencil” neuropsychological tests. How- codified. In addition, people who participate in ever, such tests are not ideal for sporting sports such as scuba diving or high altitude settings, as they are designed for the climbing are at risk of brain injury through other detection of gross cognitive impairments mechanisms of brain damage (ischaemia, nitro- 5 6 at a single assessment, not for the identifi- gen narcosis, hypoxia ) that may also contribute cation of mild cognitive deficits on re- to persistent cognitive deficits. These problems peated assessment. A number of are not limited to professional sportspeople. Amateur and recreational participants in box- computerised cognitive assessment tests 4 and test batteries have been developed ing, some martial arts, and varieties of football including soccer,7 rugby,8 American football,9 over the past two decades. These batteries 10 oVer major scientific and practical advan- and Australian Rules football, may exhibit Centre for tages over conventional neuropsychologi- cognitive deficits following head injury incurred Neuroscience, cal tests which make them ideal for the in the sporting arena. Although many sports have modified their rules to reduce the incidence University of assessment of cognitive function in sports- Melbourne, Parkville, of TBI, such injuries still occur regularly. people. This review first describes the Victoria, Australia Conventional neurological and neuro- problems associated with cognitive assess- A Collie psychological techniques have significant limi- D Darby ment of people with sports related cogni- tations for the accurate evaluation of these tive deficits, and then critically examines conditions during field play.11 For example, Neuropsychology the utility of conventional neuropsycho- neuropsychological tests are expensive in both Laboratory, Mental logical and computerised cognitive tests in Health Research time and skilled labour requirements. Even if sporting settings. Institute of Victoria, suYcient resources are available to baseline test (Br J Sports Med 2001;35:297–302) Parkville, Victoria, an entire team or training squad before a Australia A Collie Keywords: cognitive assessment; head; injury; concus- season, the measurement properties of most P MaruV sion; computerised; neuropsychology neuropsychological tests are not ideal for repeated testing. New approaches using Behavioural Neurology shorter “paper and pencil” test batteries, as Laboratory, Mental Modern sport is highly competitive, with the well as computerised tests, have emerged to Health Research health of elite sports men and women regarded overcome these problems and facilitate both on Institute of Victoria as major assets by themselves, their sporting D Darby field and subsequent decisions about fitness to associations, and the community. Their cogni- play. Computerised testing oVers the theoreti- School of Psychology, tive health in particular is one of the most cal advantages of infinite randomised forms, La Trobe University, important factors in their continuing success, as standardised self administration, rapid testing, Bundoora, Victoria, measured by performance statistics. Head injury internet based delivery, and centralised data Australia is a significant risk whenever athletes perform storage, analysis, and reporting. These ap- P MaruV competitively in sports entailing physical contact proaches are relatively new and not yet widely Correspondence to: with other players or objects. Traumatic brain adopted, in part because of continuing evolu- Dr Collie, Neuropsychology injury (TBI) can lead to overt problems such as tion. Although computerised testing has defi- Laboratory, Mental Health acute headache, nausea, vomiting, dizziness, nite advantages over conventional neuro- Research Institute of 1 Victoria, Locked Bag 11, syncope, confusion, and coma. However, in psychological testing, there are also a number Parkville, Victoria, Australia many cases the signs of TBI are covert, of limitations that must be considered before 3052 manifesting as mild cognitive deficits that may they can be applied to identify subtle TBI in [email protected] be detected only through careful neuropsycho- sporting contexts. This review will describe the Accepted 4 May 2001 logical testing.2 Such subclinical impairment problems associated with cognitive assessment www.bjsportmed.com Downloaded from bjsm.bmj.com on 6 November 2008 298 Collie, Darby, MaruV of people with sports related cognitive deficits, as a result of prior head injury, learning and then critically examine the utility of diYculties in young athletes, and other sources conventional neuropsychological and compu- of individual variability. However, this ap- terised cognitive tests in sporting settings. As proach presents a number of methodological most reports describe athletes with sports and practical problems that are diYcult to related head injury, our discussion will be overcome when conventional neuropsychologi- restricted to the use of cognitive tests in cal tests are used. For example, a typical concussed and head injured athletes. This neuropsychological assessment battery may information should form a basis for the wider require two to three hours to administer and development and implementation of compu- requires that a neuropsychologist or trained terised testing in all sporting arenas. technician be present to supervise the athlete. Research and review articles were consid- These requirements make the baseline assess- ered for discussion in this review if they had ment of an entire sporting team or squad an been published in international peer reviewed unreasonably time consuming and expensive scientific journals in sports medicine, neurol- exercise. To overcome this problem, recent ogy, or neuropsychology and had in our studies have used shortened test batteries com- opinion met one or more of the following crite- prising five or six neuropsychological tests that ria: (a) the article reported the results of com- require about 20–30 minutes to administer.9 puterised cognitive or conventional neuro- These “screening” batteries provide an ad- psychological assessment of athletes with a equate guide to the athlete’s baseline cognitive sports related brain injury; (b) the article had status, while still allowing comparisons with the made an inference about the neurological status after concussion in a number of cognitive and/or cognitive consequences of sports related domains. However, this approach still fails to brain injury; (c) the article provided adequate overcome many of the methodological and description of a computerised cognitive test or practical problems that occur when repeated test battery; or (d) the article discussed the neuropsychological assessments are required limitations of conventional neuropsychological (discussed below). or computerised cognitive tests. Computerised cognitive tests oVer a solution to many of these methodological and practical Assessment of cognitive function in problems. Computerised tests were designed sportspeople with head injury initially to detect quite severe impairments in Conventionally, athletes who have received a patients with neurological and psychiatric head injury through sports related incidents