The Importance of Baseline Testing

By Dr. Kevin Carroll.

Back in the day, working as a neuropsychologist, I used to do return-to-play evaluations for local collegiate and professional athletes who had incurred a head injury.  These evaluations were critical, as an athlete returning to play prior to being fully healed from a head injury could face very significant, and potentially a life-threatening injury should they get another head injury.  This phenomenon is called second-impact syndrome.

Unfortunately, it can be hard to diagnose a head injury in the first place.  A traumatic brain injury (TBI) or concussion is essentially a brain dysfunction caused by an outside force, usually a violent blow to the head. With many TBIs, there may not be any obvious imaging findings or even loss of consciousness.  Thus, cognitive testing is the best way to detect and conclude if there was a head injury as well as determine when the injury has fully healed.

These return-to-play evaluations were always stressful, as there were pressures to ensure an athlete’s safety as well as pressures to return them to playing as soon as possible.  For many collegiate athletes, not being allowed to return to play could jeopardize their scholarship and team standing.  So, athletes tended to minimize their complaints and typically professed to feeling fine, denying any symptoms of TBI.

A Blow to the Head – and a Tough Decision to Make

One particular evaluation stands out.  A local college basketball player was injured in a game.  The left side of his head collided with another player’s head — causing a very momentary lapse of consciousness.  As per NCAA rules, the athlete had to be cleared of his head injury before he could return to play.

As I said, this was a small local college that had made it into the playoffs for the first time.  That said, I faced pressure from the team to clear him for play, but the coach did acknowledge that the team was unlikely to advance to the next round of play.  So, I conducted my evaluation and found some cognitive findings that I felt were consistent with a TBI.  I recommended that the athlete not return to play and created a therapy plan for his improvement.

Unfortunately (or fortunately, depending on your perspective), the team against all expectations won the next game, and advanced to the next round of the playoffs.  Now the coach and player were feeling like returning to play was important.  So, they came back to me and requested another evaluation, both proclaiming that the athlete had returned to normal.   About a week later, I re-assessed the player.  This time, the findings did show some improvement, but also showed some continued and specific language problems.  This was important, because language problems are closely linked to the left side of the brain, where he was injured.  When I reviewed my new findings with the coach and player, they both insisted that he was healed and that he always had difficulties with language and should be cleared for play because this was such an important game.

This presented quite a conundrum for me.  I did not know this athlete before his injury, and it is very possible that he did have long-standing language problems, as many athletes can have learning disorders that have nothing to do with their new injury.  The problem was that I had no proof that this was the case, no findings from prior tests to compare.  I consulted with a number of my colleagues and decided conservatively not to clear the athlete to return to play.

This was a difficult decision for me, and I definitely felt the pressure from the coach, team, and player.  I was very worried that I was in error, and that this athlete had a long-standing language problem, that would never improve.

The fact that there was no information or data to compare his results with the findings of similar athletes remained a challenge until a few years later, when IMPACT came along.  IMPACT is a cognitive-testing program — a type of baseline testing — that is completed prior to players starting to practice.  Then if a player is injured, they are retested, and their results easily compared to the baseline findings.

The advent of baseline testing significantly improved my confidence in return-to-play evaluations, and it became very clear from then on when an athlete had suffered a TBI and was still recovering.

Unfortunately, IMPACT only works for athletes, and the majority of head injuries are not sports related but more likely due to falls, particularly in the elderly.   Today, I find a different  challenge when I see an elderly person who has a presumed head injury, and I have to determine if there has been a head injury or if their cognitive findings represent more of a prior or premorbid (or some people say “uncovered”) dementia.  This is where Savonix comes in.  I am hoping that in the future it will become common for the elderly to undergo baseline testing around age 60, and then should any head injuries occur, retesting will be easy and facilitate both diagnoses as well as treatments.

About author: Dr. Carroll is a clinical neuropsychologist and researcher in the areas of traumatic brain injury, rehabilitation, and dementia. He has also been researching the development of virtual reality games to assist in recovery.