Do you have an NCAA athlete in the family?

What happens to a college athlete who sustains a head injury while playing for the school?With all of the recent publicity about concussions one might think these athletes would be protected and served the way most high school athletes are now mandated to be cared for by laws to that effect in almost every state in the Union.  But no.  The NCAA has long maintained that each school should develop its own policy rather than promulgate standard Association guidelines.  As a result NCAA athletes can really be “on their own” to figure out how to get the best care following a head injury.  And they may experience intense pressure from respected and beloved coaches to get back in the game much sooner than medical experts recommend.

In a remarkable short article on CBSSports.com, Mike Freeman reveals how resistant the NCAA has been to promulgating policy about head injury. He quotes from a recent survey of concussion management by the NCAA.

Most disturbing was that fewer than 50 percent of the NCAA schools, the NCAA’s own documents show, stated a physician was required to see an athlete post-concussion. Also, 39 percent of schools did not have an established return-to-play guideline.

 

Many NFL athletes are involved in a well publicized class action suit over their symptoms and dysfunction and since many of them probably concussed in high school and college before going Pro, Freeman contends that this  might create the thorny situation in which “the NFL could possibly be in an awkward position of attacking its feeder system.” Will the NFL blame middle age dementia, depression and cognitive dysfunction on college concussions rather than assume responsibility for their own poor care?  Will these two organizations duke it out or will they begin to recognize that they have both erred and begin to change their protocols, practices and patterns?

Until we have confidence that the NCAA is shouldering the responsibility for these young lives, every parent of an NCAA athlete needs to ask about concussion management in their child’s sport.  Here are some questions to consider:

Is an athlete allowed to return to the game after a head injury?

What are the sideline diagnostic tools used?

Who makes the call about a head injury and who can over-ride that call?

How does the team determine when an athlete is clear to play again?

Who makes that determination?

What if recovery is prolonged?

How does the team coordinate with the academic community to help the athlete while his or her cognitive (thinking) skills clear up?

Sometimes those collegiate athletes who are on their own following injury need to have a helpful roadmap for recuperation.  My book It’s All in Your Head: Everyone’s Guide to Managing Concussions has proven time and time again to be helpful for people in recovery.  The anecdotes and stories ring true because they are.  Each concussed person knows that only he or she perceives what doesn’t feel right.  Although reading is never a recommended activity in the first few days, a caregiver can read the book aloud and learn at the same time what to expect in the days ahead.

Above all, loved ones need to advocate for the injured person.  This “invisible injury” will soon enough be on the radar of the NCAA in a way the organization may not even be able to imagine.  It’s a new ballgame and they better figure out the plays.

Warnings about using online testing for concussion management

Awareness about the dangers of concussion has spread around the country.  Over two thirds of school districts now are mandated by their state’s law to have a concussion policy in place.  Many of these schools have bought a Computerized Neuropsychological Assessment Device (CNAD) to aid in the difficult decision making about managing students with head injuries.  The most common and widely distributed CNAD is ImPACT, developed in Pittsburgh by the sports medicine department at the University of Pittsburgh.

These CNAD tests were recently described, dissected and analyzed in a joint position paper by the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology in the journal Archives of Nueropsychology.  The bottom line is a warning call to the developers of the CNAD as well as the end-users.

brief online article about the concern over “sandbagging” these tests points out some of the very real concerns:

in a practice known as “sandbagging,” athletes intentionally attempt to reduce their baseline scores in order to circumvent the guidelines. A lower baseline score may mean that a poor post-concussion score won’t reveal impairment and keep the injured athlete from being allowed to return to play. Quarterback Peyton Manning famously claimed he sandbagged a preseason CNAD test in 2011.

Although highly trained and experienced professionals claim to be able to detect intentional sandbagging, up to 35% of “sandbagged” tests were not detected in one study.

The authors of this post conclude that  “improperly used CNADs, both for baseline and post-concussion assessment, create the illusion that effective, scientifically valid measures are being deployed to combat the sport concussion problem. It’s a dangerous illusion that doesn’t serve the interests of athletes at risk of concussion.”

Sandbagging is only one of the concerns expressed by the joint statement in the Archives of Neuropsychology.  Other concerns addressed include:

  • technical (hardware/software/firmware) issues (different links, internet speeds and programs as well as laptops and mouse quality can affect test results)
  • privacy, data security, identity verification, and testing environment; (who holds the data? Are HIPPAA rules being observed? What is done with the data?  Are students and families fully informed?
  • psychometric development issues, especially reliability, and validity; (test interpreters need to understand the statistical issues of reliability, predictive value, sensitivity and specificity)
  • cultural, experiential, and disability factors affecting examinee interaction with CNADs; (students with certain disabilities or who need medication but are not taking it when tested will not give reliable results.  Test interpreters need access to all of this information.)
  • the need for checks on response validity and effort in the CNAD environment; (students are often left on their own in an unsupervised environment when taking the test: these factors should be taken into account when interpreting.)

An anecdote may suffice to clarify the delicacy and difficulty of interpreting CNAD or ImPACT tests;

As part of my work as a school medical director I review the ImPACT tests in my school.  A few years ago a student scored very low on her baseline test.  When I reviewed the test and the symptom checklist that is a part of the test, it was clear that this student was scoring very high on emotional and psychological issues (depression, sadness, irritablity, difficulty sleeping).  It is important for the test interpreter (me in this case) to follow up on such a test in the same way one would if the patient were in the office.  The athletic director sought out the student and after questioning her it was determined that many of her responses and low scores were due to the fact that she had just broken up with her boyfriend.  She was not sandbagging the test. This example just goes to show that multiple factors can affect test results and the interpretation of a CNAD is only one factor in understanding the complicated brain of a teenager, much less the brain of a concussed teen!