Concussion testing for student athletes is common, but some question its worth
By Arthur Allen,
If you have a child playing ice hockey, lacrosse, soccer or football this fall, chances are good he or she has taken a computerized examination called ImPACT, for Immediate Post-Concussion Assessment and Cognitive Testing.
About 2 million U.S. athletes of all ages have taken the test, which measures mental abilities such as word and shape recall, reaction time, attention and working memory. Athletes are given a baseline test at the start of a season; those who suffer a concussion are tested again before being allowed to return to play.
The increased prevalence of ImPACT reflects growing public unease about the state of our kids’ gray matter. News stories about brain-damaged former NFL football players and reports from Afghanistan and Iraq, where 200,000 U.S. service members have suffered head injuries over the past decade, have also raised concerns about concussions, which almost seem routine in some sports.
As research intensifies, scientists seem to be finding evidence of brain injury after apparently benign concussions. At Washington Hospital Center, researchers recently conducted MRI scans on 100 consecutive patients admitted for concussion, which is usually defined as a blow to the head that shakes the brain inside the skull and causes a variety of cognitive and other symptoms, such as difficulty thinking clearly, headaches, dizziness and mood changes. They found that roughly a third had evidence of damage to brain tissue, Lawrence Latour of the National Institute of Neurological Disorders and Stroke reported last month at a military conference on traumatic brain injury.
In the past two years, 33 states and the District have passed laws requiring medical clearance of concussed athletes, says Jean Rickerson of Sequim, Wash., who started a group advocating for such laws after her son, a high school quarterback, suffered a serious concussion in 2008. While the laws don’t explicitly require baseline testing, it is often recommended by specialists.
“We don’t want crippled 13-year-olds because they were put back into a sporting event they should have been left out of,” says David Milzman, an emergency physician at Washington Hospital Center who has led the introduction of ImPACT at area schools. “It’s not that complicated. Enough of this ‘Shake it off, kid,’ stuff.”
Not much can be done
Not much can be done to treat concussion, other than rest, regardless of the severity. But it’s important to keep athletes from playing while concussed, mainly to prevent “second impact syndrome” — rare instances of severe brain damage sustained while a person is healing from initial injuries.
Jon Almquist, who is in charge of athletic training for Fairfax County school athletics and began using neuro-
psychological tests in 2004, says there’s also evidence that kids who have suffered even mild concussions recover more slowly if they return to sports too quickly.
“We’ll get kids who come to a neurologist a week after getting a hit saying they’re having headaches. The doctor asks them when they stopped playing, and they say, ‘I’m still playing.’ If they’d been rested after the concussion, the headaches might have disappeared sooner and they wouldn’t have been stumbling through school for a week.”
“Kids don’t like being pulled out of a game,” says Milzman. “But I ask them, ‘Would you rather be sucking oatmeal out of a straw the rest of your life?’ ”
The 30-minute computer-based ImPACT test, the mostly widely used of several similar concussion-management tools, consists of four sections that measure word and image recall, processing speed and reaction time. More recently, Milzman has also been establishing students’ abilities in a balance test invented by North Carolina researcher Kevin Guskiewicz, who won a MacArthur “genius” grant last month.
But as ImPACT’s popularity grows — it’s available in 15 languages, according to the Web site of its developer, which charges $2 per test — so have questions about what it can and cannot deliver. Critics note that ImPACT can’t prevent concussions and that it may not be as reliable as many assume. They also suggest its introduction has more to do with fear of lawsuits than effectiveness. Several injured athletes have sued colleges for returning them to play after concussions.
“A lot of school districts think they’re running liability risk if they’re not doing something,” says Christopher Randolph, a clinical professor of neurology at Loyola University in Chicago.
Randolph, who was a team physician for the Chicago Bears for seven years, takes the rather surprising view that fear of concussions is overblown. He notes that most severe sports head injuries are caused by subdural hematoma — internal bleeding and swelling of the brain lining — which isn’t the same as concussion, though a hit to the head can cause both.
Supporters of ImPACT testing acknowledge that second impact syndrome is rare.
“It happens maybe once a year on a football team somewhere in the United States — or not even that often,” says Ramon Diaz-Arrastia, director of clinical research at the Center for Neuroscience and Regenerative Medicine, a collaboration involving the Uniformed Services University, the National Institutes of Health and area hospitals.
Concussion certainly is not rare. CDC says that as many as 1.7 million of the events occur in the United States each year; the numbers of student athletes annually treated for sports-related brain injuries in emergency rooms increased 62 percent over the past decade, according to a new CDC study. The CDC said much of the increase may be due to better reporting. Last year alone, 830 of the 25,000 Fairfax County school athletes suffered concussions, Almquist said.
Others argue the opposite point: that concussion’s effects are more severe than most physicians realize, and aren’t always picked up by neurocognitive tests. Lester Mayers, director of sports medicine at Pace University in New York, argued in a recent Archives of Neurology article that concussed athletes should stay out for four to six weeks. Yet an athlete who suffered a bad concussion still might return to baseline on the ImPACT test within a week or so, Mayers says, which raises concerns that the test could give false assurances.
Supporters of ImPACT say that comparisons to baseline should not be used as the sole method of establishing an athlete’s readiness to return to play but as one of several tools, including cognitive and balance testing, symptom questionnaires and talking with the athlete.
Almquist gives baseline tests to ninth-graders and 11th-graders, because their brains and neurocognitive abilities are likely to have changed. They get another ImPACT test 24 to 72 hours after a concussion to look for any neurological domains that might be hurt. Before returning to play, students must submit to another ImPACT after their symptoms disappear.
In a case where an individual desperately wants to return to the field, ImPACT may detect a lingering cognitive issue the patient has tried to mask. However, some professional athletes, including Indianapolis Colts quarterback Peyton Manning, claim to have intentionally done poorly on their baseline tests to make the results of any post-concussion test look better.
Skating into trouble
Gina Palermo, in charge of testing at Howard High School in Ellicott City, says ImPACT tests help educate parents, coaches and teachers. “It isn’t the golden ticket giving the athlete the clearance to play. But it gives athletic trainers and physicians the ability to look at how the brain is doing, and it allows the school support staff to make adjustments to the student’s education plan.”
One of the major issues with a concussed athlete, she says, is that he or she needs cognitive rest, meaning “no reading, writing or arithmetic — not to mention Facebook, Twitter, TV or texting.”
Virginia, Maryland and the District each enacted laws in the past year that require the benching of any athlete suspected of having sustained a concussion, with written medical authorization required before return to practice or play. Baseline testing is part of the management program recommended in the laws. Beginning this year, all high school atheletes in Howard, Fairfax and Arlington counties use ImPACT, as do many individual teams in the District and Montgomery and Prince George’s counties.
Other measures — such as using football helmets with additional padding and the requirement that all hockey players wear chin guards on the ice — have proponents but little proof that they prevent or lessen the severity of concussions.
Five years ago, Steve Katz’s son was scrambling for control of a puck near the goal when another player struck him from behind, making him fall forward and smack his forehead on the ice. His son, then in eighth grade, managed to skate off the rink but suffered from headaches and dizziness for several days, and on doctor’s orders did not play for three weeks. The rest of his season was uneventful, but the following year, an opponent checked him hard into the boards, causing him to strike the back of his head on the ice. Katz’s son has suffered migraines and balance issues since then and no longer plays contact sports.
The boy’s injuries occurred before baseline testing was used in his hockey league, but it wouldn’t have made any difference, his father notes. “Once you begin addressing the lasting impact and seriousness of a head injury to a child of any age, the baseline testing becomes a small and distant light in the rearview mirror,” says Katz, who lives in Potomac. “Parents should not consider baseline testing as prevention or protection.”
If sports authorities want to prevent concussions, Katz says, it would make more sense to address the dangers directly — by banning checking from most recreational hockey. “More-advanced players and parents who want to assume the risks can always find an advanced league to play in,” he says.
The Montgomery Youth Hockey Association, following USA Hockey guidelines, last year forbade checking in games involving children younger than 13. Arguably, even older children shouldn’t be slamming into each other at high speed on the ice, acknowledges Rob Keegan, coaching director for the league.
But “even without checking you have kids running into each other,” he says, adding that there is debate each year about whether to ban checking, at least for lower-level players. “The argument for keeping it is that a lot of these kids are going to play high school hockey,” he says. “If they don’t have checking experience, you’re setting them up for risks.”
Some brain experts argue that children shouldn’t take part in contact sports at all until their late teens. “My kids don’t play tackle football or ice hockey, and they aren’t going to,” says Philip Schatz, a neuropsychologist at Saint Joseph’s University in Pennsylvania. “We’re talking about protecting my kids’ brains. They won’t get a second one.”
Allen is a freelance writer based in Washington and author of “Vaccine: The Controversial Story of Medicine’s Greatest Lifesaver” and “Ripe: the Search for the Perfect Tomato.”