Computerized neurocognitive testing within 1 week of sport-related concussion: Meta-analytic review and analysis of moderating factors
Kontos A., Braithwait R., Dakan S., Elbin RJ. Journal of the International Neuropsychological Society. 2014; 20:1-9.
Take Home Message: Computerized neurocognitive testing results suggest athletes suffer small impairments within one week of a concussion. Several factors may lead to more pronounced impairments: age, type of neurocognitive test, and test administrator.
Clinicians commonly use computer neurocognitive testing to assess concussion. The reliability and validity of these tests have come into question based on several reviews (e.g., Mayers & Redick, 2012); however, Schatz et al (2012) pointed out flaws in those reviews. It is imperative that we have an objective examination of computer neurocognitive tests to determine their ability to identify the subtle effects of concussion so that we can implement them and interpret them optimally. Therefore, Kontos et al performed a meta-analysis of 37 studies to determine the effects of concussion as measured by computerized neurocognitive testing administered within the first week of injury as well as to examine results among subgroups (i.e., type of neurocognitive exam, sport, & age). Overall, the authors found that computerized neurocognitive testing indicate that there are impairments after a concussion. The most sensitive outcome measures after a concussion included code substitution, visual memory, processing speed, and composite memory. In contrast, reaction time improved after a concussion. It is important to note though that the amount of impairment varied a lot across the 37 studies, which suggest there may be important factors influencing the results. For example, the authors found that computer neurocognitive testing detected more impairments among younger adolescence (12-15 years old) compared with older adolescence (16-18 years old) and college-aged (over 19 years old) athletes. Athletes also demonstrated more pronounced impairments when they competed in collision/contact sports, were tested by a neuropsychologist, or tested with ImPACT.
This large meta-analysis substantiates the need for a comprehensive approach to concussion assessment. The small impairments detected with computerized neurocognitive testing are likely a reflection of the complex and individualized nature of a concussion injury. Unfortunately, we do not know for sure how much impairment each concussion causes; we only know what the test is telling us. From my previous experience, I have observed larger differences with ImPACT between baseline and post concussion testing. Among computerized neurocognitive assessments, ImPACT may be the most sensitive to changes after a concussion. ImPACT may be beneficial because it includes a balanced set of components that demonstrate an effect for concussion. Still, despite ImPACT being used in 23 studies the size of impairment detected was very variable, which may indicate that there are other important factors influencing the ability to detect changes after a concussion (such as, test administrator or athlete’s age). As expected younger athletes experienced the greatest effect, which may indicate that younger athletes are at a greater risk for greater impairment, this age group has smaller learning curves, or they take the test more seriously than the older population. The authors also found that computer neurocognitive testing detected large impairments when the test was administered by a neuropsyochologist or researcher. It is important to note though that it remains unclear if this is because of the administrator or that the test was administered in a smaller group or a quieter setting, which we’ve previously discussed was better than testing in a large group (see below). It is important to note that the definition of concussion varied across the studies, which may be another reason why this meta-analysis found that the amount of impairment varied a lot across studies. This study is important because it reinforces the individualized nature of concussions. There are numerous factors that may influence computer neurocognitive test results that need to be considered since we are only detecting small impairments with these tests. Therefore, it may be ideal to test other impairments in addition to neurocognitive; such as, vestibular and ocular-motor changes.
Questions for Discussion: Do you believe computerized neurocognitive testing is helpful in concussion assessment? What other tests do you use to assess and return an athlete to play following a concussion?
Written by: Jane McDevitt, PhD
Reviewed by: Jeffrey Driban
Typical vs Prolonged Recovery Time and Predictors Following Concussion in High School and College Athletes