Neuropsychological Assessment Of Sports-Related Concussion: Measuring Clinically Significant Change

  • Aaron M. Rosenbaum
  • Peter A. Arnett
  • Christopher M. Bailey
  • Ruben J. Echemendia


In recent years there has been a dramatic increase in the use of neuropsychological tests to evaluate the effects of concussion in competitive athletes and assist in return to play decisions. In this chapter, we focus on one factor that can limit the sensitivity of neuropsychological tests to concussion--practice effects. The data we present suggests that the HVLT-R, Trails B, Stroop 2, and SDMT are most susceptible to practice effects upon repeated administration. Nonetheless, we show that even for these tests, a majority of control athletes do not show significant practice effects after several administrations when the reliability of the measures and regression to the mean are controlled for. Still, the fact that a significant minority of athletes show practice effects on these tests should serve as a note of caution for interpreting these commonly used clinical neuropsychological tests post-concussion. In contrast to these test indices, the Stroop 1 and Trails A showed little evidence for practice effects even when administered several times. Because the Stroop 1 also showed evidence for sensitivity to concussion, it emerged as perhaps the best test in terms of combined resistance to practice effects and concussion sensitivity. In terms of return to play decisions, because we found that a negligible number of controls displayed evidence for reliable decline from baseline on all six test indices, the data we present in this chapter strongly suggest that when concussed athletes continue to show performance reliably below baseline performance at one-week post-concussion on any of the noted test indices, great caution should be exercised in recommending return to play. Additionally, any athlete who is still reliably below baseline on two of the test indices at one-week post-concussion should not return to play because residual persisting cognitive effects from the concussion are highly likely. Future work can extend this research by using larger samples, better matching on overall cognitive ability.


Concussion Neuropsychology Cognitive tests Mild traumatic brain injury 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. McCrory, P., Johnston, K., Meeuwisse, W., Aubry, M., Cantu, R., Dvorak, J., Graf-Baumann, T., Kelly, J., Lovell, M., and Schamasch, P. (2005). Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. British Journal of Sports Medicine, 39, 196–204.PubMedGoogle Scholar
  2. Kelly, J. P., Rosenberg, J.H. (1997). Diagnosis and management of concussion in sports Neurology, 48(3), 575–580.PubMedGoogle Scholar
  3. Guskiewicz, K. M, Weaver, N.L., Padua, D.A., and Garrett, W.E. Jr. (2000). Epidemiology of concussion in collegiate and high school football players. American Journal of Sports Medicine, 28(5), 643–650.PubMedGoogle Scholar
  4. Gerberich, S. G., Priest, J. D., Boen, J. R., Straub, C. P., and Maxwell, R. E. (1983). Concussion incidences and severity in secondary school varsity football players. American Journal of Public Health, 73(12), 1370–1375.PubMedGoogle Scholar
  5. National Institutes of Health Consensus Development Panel on Rehabilitation of Persons with Mild Traumatic Brain Injury (1999). Rehabilitation of persons with mild traumatic brain injury. Journal of the American Medical Association, 282(10), 974–982.CrossRefGoogle Scholar
  6. Thurman, D. J., Branche, C. M., & Sniezek, J. E. (1998). The epidemiology of sports related traumatic brain injuries in the United States: Recent developments. Journal of Head Trauma Rehabilitation, 13(2), 1–8.PubMedGoogle Scholar
  7. Echemendia, R. J., and Cantu, R.C. (2004). Return to Play Following Cerebral Brain Injury. In M. R. Lovell, Collins, M.W., Echemendia, R.J., and Barth, J.T. (Ed.), Traumatic Brain Injury in Sports (Vol. 1, pp. 479–498). New York: Taylor and Francis.Google Scholar
  8. Alves, W., Macciocchi, S. N., and Barth, J. T. (1993). Postconcussive symptoms after uncomplicated mild head injury. Journal of Head Trauma Rehabilitation, 8(3), 48–59.CrossRefGoogle Scholar
  9. Berlanger, H. G., Curtiss, G., Demery, J.A., Lebowitz, B.K., and Vanderploeg, R.D. (2005). Factors moderating neuropsychological outcomes following mild traumatic brain injury: A meta-analysis. Journal of the International Neuropsychological Society, 11, 215–227.Google Scholar
  10. Cantu, R. C. (2001). Postraumatic retrograde and anterograde amnesia: Pathophysiology and implications in grading and safe return to play. Journal of Athletic Training, 36(3), 244–248.PubMedGoogle Scholar
  11. Gouvier, W. D., Cubic, B., Jones, G., Brantley, P., and Cutlip, Q. (1992). Postconcussion symptoms and daily stress in normal and head-injured college populations. Archives of Clinical Neuropsychology, 7, 193–211.PubMedCrossRefGoogle Scholar
  12. Guskiewicz, K. M., Riemann, B. L., Perrin, D. H., and Nashner, L. M. (1997). Alternative approaches to the assessment of mild head injury in athletes. Medical Science and Sports Exercise, 29(Suppl. 7), 5213–5221.Google Scholar
  13. Zasler, N. (1999). Medical aspects. In S. A. a. M. Raskin, C. A. (Ed.), Neuropsychological management of mild traumatic brain injury (pp. 23–38). New York: Oxford University Press.Google Scholar
  14. Echemendia, R. J., and Julian, L.J. (2001). Mild traumatic brain injury in sports: Neuropsychology’s contribution to a developing field Neuropsychology Review, 11(2), 69–88.PubMedCrossRefGoogle Scholar
  15. Lovell, M. R., Iverson, G. L., Collins, M. W., McKeag, D., and Maroon, J. C. (1999). Does loss of consciousness predict neuropsychological decrements after concussion? Clinical Journal of Sports Medicine, 9(4), 193–198.CrossRefGoogle Scholar
  16. Cantu, R. C. (1998). Second-impact syndrome. Clinics in Sports Medicine: Neurologic Athletic Head and Neck Injuries, 17(1), 37–44.Google Scholar
  17. Chelune, G. J., Naugle, R.I., Luders, H., Sedlak, J., and Awad, I.A. (1993). Individual change after epilepsy surgery: Practice effects and base-rate information. Neuropsychology, 7(l),41–52.CrossRefGoogle Scholar
  18. Iverson, G. L. and Gaetz, M. (2004). Practical Considerations for Interpreting Change Following Brain Injury. In M. R. Lovell, Collins, M.W., Echemendia, R.J., and Barth, J.T. (Ed.), Traumatic Brain Injury in Sports (Vol. 1, pp. 323–356). New York: Taylor and Francis.Google Scholar
  19. Mackin, R. S., Sabsevitz, D.S., Julian, L., Junco, R., Dwyer, M. and Echemendia, R.J. (1997). Stability Coefficients and Practice Effects of Neuropsychological Tests in College Athletes: Preliminary Findings. Paper presented at the Sports Related and Nervous System Injuries Orlando, Florida.Google Scholar
  20. Barth, J. T., Alves, W.M., Ryan, T.V., Macciocchi, S.N., Rimel, R.W., Jane, J.A., and Nelson, W.E. (1989). Mild head injury in sports: Neuropsychological sequelae and recovery of function. In H. E. H. Levin, and A. Benton (Ed.), Mild Head Injury (pp. 257–275). New York, NY: Oxford University Press.Google Scholar
  21. McCrea, M., Barr, W.B., Guskiewicz, K., Randolph, C.R., Marshall, S.W., Cantu, R., Onate J.A., and Kelly, J.P. (2005). Standard regression-based methods for measuring recovery after sport-related concussion. Journal of the International Neuropsychological Society, 11, 58–69.PubMedCrossRefGoogle Scholar
  22. Dikmen, S. S., Heaton, R.K., Grant, I., and Temkin, N.R. (1999). Test-retest reliability and practice effects of Expanded Halstead-Reitan Neuropsychological Test Battery. Journal of the International Neuropsychological Society, 5(4), 346–356.PubMedCrossRefGoogle Scholar
  23. Jacobson, N. S., and Truax., P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59(1), 12–19.PubMedCrossRefGoogle Scholar
  24. Barr, W. B., and McCrea, M. (2001). Sensitivity and specificity of standardized neurocognitive testing immediately following sports concussion Journal of the International Neuropsychological Society, 7(6), 693–702.PubMedCrossRefGoogle Scholar
  25. Hinton-Bayre, A. D., Geffen, G.M., Geffen, L.B., McFarland, K.A., and Friis, P. (1999). Concussion in contact sports: Reliable change indices of impairment and recovery Journal of Clinical and Experimental Neuropsychology, 27(1), 70–86.CrossRefGoogle Scholar
  26. Iverson, G. L., Lovell, M.R., and Collins, M.W. (2003). Interpreting Change on ImPACT Following Sport Concussion. Clinical Neuropsychologist, 17(4), 460–467.PubMedGoogle Scholar
  27. Brandt, J., and Benedict, R.H.B. (2001). Hopkins Verbal Learning Test-Revised professional manual Odessa, FL: Psychological Assessment Resources.Google Scholar
  28. Trennery, M. R., Crosson, B., DeBoe, J., and Leber, W.R. (1989). Stroop Neuropsychological Screening Test Manual. Odessa, FL: Psychological Assessment Resources.Google Scholar
  29. Reitan, R. M. (1958). Validity of the Trail-Making Test. Perceptual and Motor Skills, 8, 271–276.CrossRefGoogle Scholar
  30. Smith, A. (1982). Symbol Digit Modalities Test Manual (Revised). Los Angeles: Western Psychological Services.Google Scholar
  31. Echemendia, R. J. (1997). Neuropsychological assessment of the college athlete: The Penn State concussion program. Neuropsychology, 10(2), 189–193.Google Scholar
  32. Basso, M. R., Bornstein, R.A., and Lang, J.M. (1999). Practice effects on commonly used measures of executive function across twelve months. Clinical Neuropsychologist, 13(3), 283–292.PubMedGoogle Scholar
  33. Bornstein, R. A., Baker, G.B., and Douglass, A.B. (1987). Short-term retest reliability of the Halstead-Reitan Battery in a normal sample. The Journal of Nervous and Mental Disease, 175(4), 229–232.PubMedGoogle Scholar
  34. desRosiers, G. a. K., D. (1987). Cognitive assessment in closed head injury: Stability, validity, and parallel forms for two neuropsychological measures of recovery. The International Journal of Clinical Neuropsychology, 9(4), 162–173.Google Scholar
  35. Matarazzo, J. D., Wiens, A.N., Matarazzo, R.G., and Goldstein, S.G. (1974). Psychometric and clinical test-retest reliability of the Halstead Impairment Index in a sample of healthy, young, normal men. The Journal of Nervous and Mental Disease, 158(1), 37–49.PubMedGoogle Scholar
  36. Craddick, R.A., and Stern, M.R. (1963). Practice effects on the trail making test. Perceptual and Motor Skills, 17, 651–653.PubMedGoogle Scholar
  37. Mitrushina, M., and Satz, P. (1991). Effects of repeated administration of a neuropsychological battery in the elderly. Journal of Clinical Psychology, 47(6), 790–801.PubMedGoogle Scholar
  38. Dikmen, S. S., Reitan, R.M., and Temkin, N.R. (1983). Neuropsychological recovery in head injury. Archives of Neurology, 40(6), 333–338.PubMedGoogle Scholar
  39. Dye, O. A. (1979). Effects of practice on trail making test performance. Perceptual and Motor Skills, 48, 296.Google Scholar
  40. Macciocchi, S. N., Barth, J.T., Littlefield, L., and Cantu, R.C. (2001). Multiple concussions and neuropsychological functioning in collegiate football players. Journal of Athletic Training, 36(3), 303–306.PubMedGoogle Scholar
  41. Macciocchi, S. N., Barth, J.T., Alves, W., Rimel, W.R., and Jane, J.A. (1996). Neuropsychological functioning and recovery after mild head injury in collegiate athletes. Neurosurgery, 39, 510–514.PubMedCrossRefGoogle Scholar
  42. Guskiewicz, K. M., Ross, S.E., and Marshall, S.W. (2001). Postural stability and neuropsychological deficits after concussion in collegiate athletes. Journal of Athletic Training, 36, 263–273.PubMedGoogle Scholar
  43. Davidson, D. J., Zacks, R.T., and Williams, C.C. (2003). Stroop interference, practice, and aging. Aging Neuropsychology and Cognition, 10(2), 85–98.Google Scholar
  44. Houx, P. J., Shepherd, J., Blauw, G-J., Murphy, M.B., Ford, I., Bollen, E.L., Buckley, B., Stott, D.J., Jukema, W., Hyland, M., Gaw, A., Norrie, J., Kamper, A.M., Perry, I.J., MacFarlane, P.W., Edo Meinders, A., Sweeney, B.J., Packard, C.J., Twomey, C., Cobbe, S.M., and Westendorp, R.G. (2002). Testing cognitive function in elderly populations: The PROSPER study. Journal of Neurology, Neurosurgery, and Psychiatry, 73(4), 385–389.PubMedCrossRefGoogle Scholar
  45. Stroop, J. R. (1935). Studies of interference in serial verbal reactions. Journal of Experimental Psychology, 18, 643–662.CrossRefGoogle Scholar
  46. Golden, C.G. (1978). A manual for clinical and experimental users: Stroop color and word test. Stoelting: Wood Dale, IL.Google Scholar
  47. Connor, A., Franzen, M., and Sharp, B. (1988). Effects of practice and differential instructions on Stroop performance. The International Journal of Clinical Neuropsychology, 10(1), 4..Google Scholar
  48. Hinton-Bayre, A. D., and Geffen, G. (2004). Australian rules football and rugby league. In M. R. Lovell, Collins, M.W., Echemendia, R.J., and Barth, J.T. (Ed.), Traumatic Brain Injury in Sports. New York: Taylor and Francis.Google Scholar
  49. Franzen, M. D., Tishelman, A.C., Sharp, B.H., and Friedman, A.G. (1987). Test-retest reliability of the Stroop Word Color Test across two intervals. Archives of Clinical Neuropsychology, 2, 265–272.PubMedCrossRefGoogle Scholar
  50. Uchiyama, C. L., D’Elia, L.F., Dellinger, A.M., Seines, O.A., Becker, J.T., Wesch, J.E., Chen, B.B., Satz, P., van Gorp, W., and Miller, E.N. (1994). Longitudinal comparison of alternate versions of the Symbol Digit Modalities Test: Issues of form comparability and moderating demographic variables. Clinical Neuropsychologist, 8(2), 209–218.Google Scholar
  51. Bohnen, N., Twijnstra, A, and Jolles, J. (1992). Post-traumatic and emotional symptoms in different subgroups of patients with mild head injury. Brain Injury, 6(6), 481–487.PubMedGoogle Scholar
  52. Erlanger, D., Feldman, D., Kutner, K., Kaushik, T., Kroger, H., Festa, J., Barth, J., Freeman, J., and Broshek, D. (2003). Development and validation of a web-based neuropsychological test protocol for sports-related return to play decision-making. Archives of Clinical Neuropsychology, 18, 293–316.PubMedCrossRefGoogle Scholar
  53. Echemendia, R. J., Putukian, M., Mackin, R.S., Julian, L.J., and Schoss, N. (2001). Neuropsychological test performance prior to and following sports-related mild traumatic brain injury. Clinical Journal of Sports Medicine, 77,23–31.CrossRefGoogle Scholar
  54. Sattler, J. M. (2001). Assessment of Children: Cognitive Applications, 4th Edition. La Mesa, California: Jerome M. Sattler, Publisher, Inc.Google Scholar
  55. Barr, W. B. (2003). Neuropsychological testing of high school athletes: Preliminary norms and test-retest indices. Archives of Clinical Neuropsychology, 18, 91–101.PubMedCrossRefGoogle Scholar
  56. Bruce J.M., a. E., R.J. (2004). Concussion history predicts self-reported symptoms before and following a concussive event. Neurology, 63, 1516–1518.PubMedGoogle Scholar
  57. Bailey, C. M., and Arnett, P.A. (in press). Motivation and the assessment of sports-related concussion. In S. S. a. W. Sebastianelli (Ed.), Foundations of Sports-Related Concussion. Springer-Verlag.Google Scholar
  58. Cohen, J., and Cohen, P. (1983). Applied multiple regression/correlation analysis for the behavioral sciences, 2nd Edition. Hillsdale, NJ: Lawrence Erlbaum Associates, Publishers.Google Scholar
  59. Chelune, G. J., Naugle, R.I., Luders, H., Sedlak, J., and Awad, I.A. (1993). Individual change after epilepsy surgery: Practice effects and base-rate information. Neuropsychology, 7(1), 41–52.CrossRefGoogle Scholar
  60. Temkin, N. R., Heaton, R.K., Grant, I, and Dikmen, S.S. (1999). Detecting significant change in neuropsychological test performance: A comparison of four models. Journal of the International Neuropsychological Society, 5(4), 357–369.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, Inc. 2006

Authors and Affiliations

  • Aaron M. Rosenbaum
    • 1
  • Peter A. Arnett
    • 1
  • Christopher M. Bailey
    • 1
  • Ruben J. Echemendia
    • 2
  1. 1.Department of PsychologyThe Pennsylvania State UniversityUniversity Park
  2. 2.Psychological and Neurobehavioral Associates, Inc.State College

Personalised recommendations