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Dr. Munro Cullum: Sports And Concussion

Ed Yourdon

State law now requires high school athletes who show concussion symptoms to be pulled from competition and receive written medical clearance from a medical provider before returning. Dr. Munro Cullum has helped design concussion testing programs for teams in the NFL and NHL for more than a decade. He wishes more athletes would take the requirement seriously.

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.

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 didn’t have a brain injury or dementia.  He was sandbagging.

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

Rather than try to score as high as possible, some athletes choose to do poorly on their tests, and establish a low-performing baseline or standard 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.

At the high school level, my colleagues and I often see invalid baseline results from computerized testing, sometimes as high as 20 percent. Sometimes it’s sandbagging, or perhaps disinterest, being distracted during the test, or not understanding how important it is.

Texas law now requires 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.

The computerized cognitive tests, while helpful, are essentially a CliffsNotes version of a traditional, thorough neuropsychological examination. A thorough exam typically involves several hours of tests to measure intellect, memory, attention/concentration, language skills and nonverbal abilities. They’re 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.

What this means is that 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.

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