Don’t let athletes do end run around concussions standards

by Munro Cullum, PhD

Health Talks

Ten years ago as part of standard preseason cognitive testing, a famous pro athlete tried to recite from memory the dozen words I had just read aloud.

At first, he gave me only four of the words. After two more repetitions, he got up to five.

Munro Cullum, PhD

I did not feel that he was giving me his best effort, so I told him he was performing like a patient who had either a severe head injury or was in the early stages of Alzheimer’s disease. “Sorry, doc,” he said. “That’s all I’ve got.”

He was not suffering from a brain injury, and he did not have dementia. He was sandbagging.

Neuropsychologists have seen this attitude on occasion ever since professional sports leagues initiated concussion testing programs starting about 15 years ago.

Rather than do their best and score as high as possible, some athletes choose to do poorly on their tests, establishing a low-performing baseline that is easier to emulate after they’re taken out of a game with a suspected concussion. That’s because post-concussion test results are compared with the baseline to help determine whether someone’s cognitive function is back to normal.  These athletes want to play no matter the cost – even if it means returning to action with a brain injury.

Sandbagging isn’t the only way to invalidate a cognitive test. At the high school level, my colleagues and I often see invalid baseline results from computerized testing, as high as 20 percent in some samples. Among teenagers, invalid results can have a variety of sources: sandbagging, disinterest, being distracted during the test, or not understanding how important it is.

State legislatures and high school athletic associations increasingly have become active in establishing concussion monitoring programs. In my football-crazy home state of Texas, a law took effect last year requiring the signature of a physician before a high school student with a suspected concussion can return to play. And more and more high school teams, especially football teams, now typically require their players to take 30-minute computerized tests to establish cognitive baselines.

All of these are positive steps. But they’re not solutions. And they shouldn’t be enough to convince parents not to worry about concussions.

For example, the computerized cognitive tests, while helpful, are essentially a CliffsNotes version of a traditional, thorough neuropsychological examination. Such exams typically involve several hours of tests to measure intellect, memory, attention/concentration, language skills and nonverbal abilities. These standardized assessments are designed to tap into primary cognitive functions and represent the most sensitive means of examining cognition. Brief computerized testing is more of a snapshot, and a lower-definition one at that.

Despite all the progress and policies designed to help protect athletes, parents still need to be active and engaged. My son plays soccer, another sport that sees its share of head injuries. Here’s what I told him about the concussion testing:

Take it seriously in a quiet environment, away from your cell phone, family, friends and other distractions. Make sure you give it your best effort. Treat these exams just as if you are seeing a doctor for a medical test. Be as honest in your testing as you are with your physician.

There is still so much we don’t know about the brain – and the damage caused by concussions. We don’t know what the risks of contact sports are. We know that multiple concussions aren’t good for the brain, but we don’t know how many is too many. We don’t know why some children who get their bell rung are totally fine the next minute and others aren’t OK for weeks.

Some kids are more vulnerable than others. Is it shape of the skull? Thickness of the skull? Nature of the hit to the head? Genetic risk factors? We simply don’t know.

I’m driven to determine the best way to assess players and help them safely return to play. I am heartened to see that we are starting to change the culture around concussions, and widespread baseline cognitive testing and concussion awareness programs are welcome signs of that. But such tests are of little value if not taken seriously by the athletes they are designed to protect.

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Dr. Munro Cullum is a clinical neuropsychologist and professor of psychiatry and neurology and neurotherapeutics at the University of Texas Southwestern Medical Center. He has helped design concussion testing programs for teams in the NFL and NHL for more than a decade. 

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