THE PHYSICIAN AND SPORTSMEDICINE - VOL 29 - NO. 8 - AUGUST 2001

How Effective Is Computerized Concussion Management?

In the 1990s, neuropsychological testing was recognized as a useful clinical tool for making return-to-play decisions in athletes who had sustained concussions. Its use, though, was limited to professional and college teams that were located near academic centers and could afford the tests.

Now, however, any team that has computer access and can pay a testing fee can use new services that offer automated, sophisticated neuropsychological testing. At least three companies recently began marketing new concussion software to the sports medicine market. They include CogState (CogState Ltd, Victoria, Australia), HeadMinder (HeadMinder Inc, New York City), and ImPACT (University of Pittsburgh Medical Center [UMPC] Sports Medicine Concussion Program) (table 1).

TABLE 1. Selected Specifications for Concussion Management Software Systems
Product	Interface	System Requirements	Functions Measured	Test Length, Cost
CogState www.cogstate.com	Software download from Web site; tests administered off-line; results scored and analyzed via e-mail	Windows 95 or above; Mac OS 8.6 or above; Internet access for scoring and analysis	Reaction time, information processing, memory, attention, problem solving, decision making	< 18 min, $100 per test, volume and academic discounts available
HeadMinder www.headminder.com	Tests taken, scored, and reported, and stored on Web site	Any computer with Internet access; current browser, Macromedia flash player; optional integration of SAC via handheld computer*	Reaction time, processing speed	< 25 min, $500 annual site fee for high schools, $1,000 for colleges, $2,000 for professional teams
ImPACT www.impacttest.com	Software from CD-ROM or Internet download; data remain with administering team; consultants available to assist interpretation	Windows NT or 95 or higher	Attention, memory, reaction time, impulse control, visual processing speed and accuracy	< 22 min, $750 one-time site fee for high schools, $1,000 for colleges
*SAC = standardized assessment of concussion, a 5-minute neuropsychological screen for cognitive symptoms designed for sideline use.

David M. Erlanger, PhD, president of HeadMinder, Inc, and clinical neuropsychologist in Manhattan, says the concussion management software programs address a major public health issue. "Head injuries occur about 250,000 times a year on the football field, and there is no clear way to assess these injuries," he says. "We're finding a way to deliver these healthcare tools [neuropsychological testing] at a fraction of the cost."

Mark R. Lovell, PhD, director of the Sports Medicine Concussion Program and assistant professor of orthopedics at UPMC, is one of the primary forces behind the ImPACT system and has worked on computerized neuropsychological testing protocols for the National Football League and the National Hockey League (NHL) since 1995. "One of the advantages of computerized tests is that we can measure brain processes that we could not using traditional neuropsychological tests," he says. "I am delighted that others are now developing programs that utilize this approach."

How Do They Work?

The features and functions of the three products vary, but each has the same goals and operates similarly. Each athlete takes a brief (about 20 minutes) computerized test before the season to determine the neuropsychological baseline, then the results are stored in an onsite or off-site database. The tests measure cognitive functions such as brain processing speed, memory, and visual motor skills.

When head injuries occur, injured athletes repeat the tests at regular intervals. The physician receives automated reports back from the testing company, or from the software package itself (ie, ImPACT), that details differences between the preseason and postinjury performances. The goal is to help physicians gauge when athletes have returned to their baselines, which is an important, though not sole, factor in making return-to-play decisions. Cognitive impairments can be difficult to measure and may be the last symptoms to clear after a head injury.

A Role for Testing

Robert C. Cantu, MD, chief of neurosurgery and director of sports medicine at Emerson Hospital in Concord, Massachusetts, applauds the wide accessibility to neuropsychological testing that the new software programs will offer teams. And though Cantu strongly supports the concept of neuropsychological testing, he worries that the ease of use of these new systems might lead to overdependence on them for making return-to-play decisions. "These are fine to use as one means of assessment, but not to the exclusion of others," he says, noting that the test results should be considered along with postconcussion symptoms, the neurologic exam, and imaging tests that look for the presence of structural defects.

Cantu, an editorial board member of The Physician and Sportsmedicine, also points out that physicians should be aware that the computerized tests are still being validated against the full battery of neuropsychological tests that have traditionally been used to evaluate the effects of head injuries.

Other factors that influence the diagnostic usefulness of the tests are that concussion guidelines are ever evolving, and no strong scientific consensus exists about how to weigh various postconcussion symptoms, including cognitive symptoms, when grading concusssions. For example, prospective studies are finding that loss of consciousness isn't always a reliable indicator of head injury severity.

Craig Milhouse, MD, an internist and sports medicine physician in Anaheim, California, who is a team physician for the Anaheim Mighty Ducks of the NHL, says that although he continues to do neuropsychological testing on each team member, he believes that tests have limited usefulness. "You would expect symptomatic patients to have abnormal neuropsychological tests, but that's not always the case," he says. "You still have to go by symptoms and the clinical status of the patient."

How to Evaluate Competing Products

Alex Collie, PhD, who codeveloped CogState with the research assistance of Paul R. McCrory, MBBS, PhD, an editorial board member of The Physician and Sportsmedicine, advises physicians to consider several factors when selecting a computerized neuropsychological test system. Most important, the test must be reliable, with a large number of alternate forms that allow the test to be administered on multiple occasions with short test-retest intervals. Second, the test battery should be validated for use among athletes of all abilities and cultural backgrounds, and third, the test should assess major cognitive functions such as memory, attention, and problem solving. "Also, I think one of the most important features of a computerized program is that it has been reviewed by peers and had data published in peer-reviewed journals," says Collie, who is a senior reserch fellow of the neuropsychology laboratory at the Mental Health Research Institute of Victoria in Parkville, Victoria, Australia. So far, validation studies involving CogState (1) and HeadMinder (2) are scheduled to be published in peer-reviewed journals.

The role of validity tests may be especially important when considering a concussion software program because so far, psychological tests do not require approval by the US Food and Drug Administration. Erlanger notes that the line between psychological applications and medical devices can sometimes blur. Though he notes that the lengthy peer review process often weeds out substandard testing products, "the problem arises when a psychological test is marketed to nonpsychologists who may not have the training to make an independent judgment."

In addition, Collie notes that several practical issues should be considered before a system is selected, such as external hardware requirements, staff training, operating system requirements, data security, ability to provide detailed reports quickly and efficiently, and cost.

What's on the Horizon?

Milhouse says he's started doing some balance and vestibular testing when evaluating athletes who have had head injuries, but he doesn't have enough data on its usefulness.

At the annual meeting of the American College of Sports Medicine, speakers noted additional tests that are being explored as possible concussion management tools, including positron emission tomography imaging, transcranial Doppler ultrasound, vestibular dysfunction tests that measure balance, and glucose uptake testing.

In addition, Lovell says more studies are needed to determine if changes in brain function on magnetic resonance imaging correlate with performance on postconcussion neuropsychological tests.

Lisa Schnirring
Minneapolis

REFERENCES

1. Makdissi M, Collie A, Maruff P, et al: Computerised cognitive assessment of concussed Australian rules footballers. Br J Sports Med, to be published
2. Erlanger D, Saliba E, Barth J, et al: Monitoring resolution of post-concussion symptoms in athletes: preliminary results of a Web-based neuopsychological test protocol. J Athletic Train, to be published

Field Notes

Gene Therapy Enters Doping Discussions
Anticipating the arrival of gene therapy as the next performance enhancer for elite athletes, the Medical Commission of the International Olympic Committee (IOC) recently sought guidance from a panel of international academic and industry experts.

According to a press release from the IOC, the Gene Therapy Working Group met on June 6 with the goal of defining gene therapy and assessing its potential impact on sports from ethical and scientific points of view. In its conclusions, released after the 1-day session, the group defined gene therapy as "the transfer of genetic material to human somatic cells for the treatment or prevention of disease or disorders."

Members acknowledged that gene therapy holds promise for all people, including Olympic athletes, and endorsed the development and application of gene therapy for disease prevention and treatment. However, they recognized the potential for abuse of gene therapy medicines. They called for the establishment of testing methods, including antigen detection, gene chip analysis, and proteomic analysis.

Other experts believe that gene therapy holds promise for the treatment of sports injuries. (See "Gene Therapy and Tissue Engineering in Sports Medicine," February 2000.)