Real Reasons Athletes Need Regular Neurocognitive Checkups

Growing knowledge about the lifelong impact of concussions has radically changed the sports landscape in recent years for athletes of all ages. The potential risk of brain injuries caused by blows to the head has caused many parents to refrain from allowing their children to play certain sports.

For example, a recent study (Liller et al., 2019) reported that concussions are the leading cause of injury for children (ages 5-11) who play recreational soccer, football, softball, or baseball. Reports like these can cause some parents to panic, overreact, and dissuade their children from joining a recreational sports team.

As the father of an 11-year-old and a passionate advocate for youth participation in athletic programs, this all-or-nothing trend is concerning. Of course, from a public health perspective, increased awareness of the potential risks associated with head impact exposure is a good thing. That said, kids need to "run wild," take some risks, and have access to independent outdoor play; they also benefit greatly from organized recreational sports and being part of a team.

If the pendulum associated with "neurotically fearing concussions" swings too far, it could result in crippling anxiety, less physical activity, and increased sedentary behaviors.

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This post presents a handful of recent studies that shed light on evidence-based ways to navigate and manage some of the concussion-related risks associated with playing sports. Taken together, the body of research provides an overview that drives home the importance of regular neurocognitive assessments to establish a baseline of an athlete's brain health before, during, and after each sport season.

State-of-the-art research on concussions at Stanford University (Hernandez et al., 2019) incorporates some exciting high-tech advances (e.g., head-impact tracking devices embedded in mouthguards). Hopefully, this type of technology will be available to general consumers in the near future.

Also, someday soon there may be head-impact tracking devices that pair with a smartphone app. This type of gadget could give nervous parents some peace of mind by allowing them to track the severity of every head impact their child may experience on the playing field.

4 Evidence-Based Reasons Athletes of All Ages Should Have Regular Neurocognitive Checkups

1. Athletes Often Hide or Fail to Report Concussion Symptoms

Most symptoms of traumatic brain injury (TBI) and concussion—such as blurry vision, brain fog, headaches, nausea, ringing in the ears—are internal and require athletes to self-report their symptoms. That said, collegiate coaches at the NCAA level have sounded alarm bells regarding the low rate of athletes self-reporting potential concussion symptoms.

To address this concern, a recent study (2019) led by Steven Corman of Arizona State University examined various factors that drive NCAA male and female athletes who participate in basketball, football, lacrosse, soccer, wrestling, or field hockey to hide (or fail to report) severe head impacts (SHIs) and concussion symptoms.

The study found that whether or not NCAA Division 1 athletes are inclined to report concussion symptoms depends on a combination of factors that include each individual's vested interests, his or her understanding of the health implications of concussions, the overall "win at all costs" team culture, and societal influences such as sports performance narratives circulating in the media.

2. New ImPACT Equation Makes It Harder to “Sandbag” Baseline Concussion Testing

Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) is an FDA-approved tool that establishes cognitive baselines and post-injury testing for concussion care.

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Some athletes have undertaken the duplicitous practice of “sandbagging” or making a lackadaisical effort during baseline ImPACT concussion-related tests to record a lower score in the hope of being able to play sooner after a concussion. Sandbagging throws off the validity of neurocogntive assessments.

To address the “sandbagging” phenomenon, researchers at the University of Nebraska-Lincoln recently developed a stealth equation for identifying athletes who sandbagged the ImPACT test and may be playing while impaired. These findings (Higgins et al., 2017) were published in the Archives of Clinical Neuropsychology.

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3. The Value of Pre- and Post-Season Neurocognitive Assessments

An ongoing prospective study (Rose et al., 2019) is investigating the possible correlation between neurocognitive function and sports-related head impacts. The researchers have been tracking 166 youth tackle football players (ages 9 to 18) for two seasons and plan to track the same cohort for another two years. The latest findings (2019) of this prospective cohort study were recently published in the Journal of Neurotrauma.

According to the authors, until now, most studies on the link between neurocognition and sub-concussive head impacts have been retrospective and inconclusive.

"When trying to determine the effects of repeated, sub-concussive head impacts, prospective outcomes studies are an important addition to the existing retrospective studies," lead author Sean Rose said in a statement. "We designed this study to include a wide variety of neurocognitive outcomes tests, to give us new insights into how repeated hits might influence outcomes." Rose is a pediatric sports neurologist and co-director of the Complex Concussion Clinic at Nationwide Children's Hospital in Columbus, Ohio.

As part of this prospective study, Rose and colleagues are also using sensors placed inside football helmets to measure and record sub-concussive head impacts during practice and games.

4. How Many Hits to the Head Is Too Many for an Athlete?

A recent comparison of head impact exposure between concussed NCCA Division 1 college football players and matched controls (Stemper et al., 2018) suggests that repetitive head impact exposure may push the brain to a tipping point where an athlete's odds of suffering a concussion increase. This study was led by Brian Stemper of Marquette University and the Medical College of Wisconsin.

The authors sum up their findings: “This unique analysis provided further evidence for the role of repetitive head impact exposure as a predisposing factor for the onset of concussion. The clinical implication of these findings supports contemporary trends of limiting head impact exposure for college football athletes during practice activities in an effort to also reduce risk of concussive injury.”

Stemper speculates that whether or not a football player gets a concussion after a single hit to the head may depend on heightened risk caused by the number (and severity) of head impacts the athlete experienced in the days, weeks, and months leading up to a final head blow that ultimately causes a concussion. In a statement, Stemper emphasized, "While these trends require further validation, the clinical implication of these findings supports the contemporary trend of limiting head impact exposure for college football athletes during practice sessions."