Neuropsychological Assessment Following Concussion: an Evidence‐Based Review of the Role of Neuropsychological Assessment Pre- and Post-Concussion

  • Anthony P. KontosEmail author
  • Alicia Sufrinko
  • Melissa Womble
  • Nathan Kegel
Concussion and Head Injury (T Seifert, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Concussion and Head Injury


Neuropsychological evaluation is one component of a comprehensive and multifaceted assessment following concussion. Although some neuropsychologists use a “hybrid” assessment approach integrating computerized neurocognitive testing batteries with traditional paper and pencil tests, computerized neurocognitive test batteries are the predominant testing modality for assessment of athletes from the youth to professional level. This review summarizes the most recent research supporting the utility of neuropsychological evaluation and highlights the strengths and weaknesses of both computerized and traditional neuropsychological testing approaches. The most up to date research and guidelines on baseline neurocognitive testing is also discussed. This paper addresses concerns regarding reliability of neuropsychological testing while providing an overview of factors that influence test performance, both transient situational factors (e.g., pain level, anxiety) and characteristics of particular subgroups (e.g., age, preexisting learning disabilities), warranting the expertise of an experienced neuropsychologist for interpretation. Currently, research is moving forward by integrating neuropsychological evaluation with emerging assessment approaches for other domains of brain function (e.g., vestibular function) vulnerable to concussion.


Neuropsychological evaluation Neurocognitive tests Concussion Sport Computerized assessment battery Baseline 


Compliance with Ethical Standards

Conflict of Interest

Anthony P. Kontos declares grant support from the National Institute on Deafness and Other Communication Disorders, and grant support from the GE-NFL Head Health Initiative.

Alicia Sufrinko, Melissa Womble, and Nathan Kegel declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    McCrory P, Meeuwisse WH, Aubry M, Cantu B, Echemendia RJ, Engebretsen L, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013;47(5):250–8.CrossRefPubMedGoogle Scholar
  2. 2.•
    Collins M, Kontos A, Reynolds E, Murawski C, Fu F. A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion. Knee Surg Sports Traumatol Arthrosc. 2014;22(2):235–46. Collins and colleagues propose one of the first models of clinical subtypes or trajectories of concussion integrating theoretical risk factors and individualized treatment recommendations. This paper calls for future research to examine clinical profiles and associated pattern of neurocognitive deficits. CrossRefPubMedGoogle Scholar
  3. 3.
    Morgan JE, Ricker JH. Textbook of clinical neuropsychology: Taylor & Francis New York; 2008.Google Scholar
  4. 4.
    De Marco AP, Broshek DK. Computerized cognitive testing in the management of youth sports-related concussion. J Child Neurol. 2014:0883073814559645.Google Scholar
  5. 5.
    Webbe FM, Zimmer A. History of neuropsychological study of sport-related concussion. Brain Inj. 2014;29(2):129–38.CrossRefPubMedGoogle Scholar
  6. 6.
    Ferrara MS, McCrea M, Peterson CL, Guskiewicz KM. A survey of practice patterns in concussion assessment and management. J Athl Train. 2001;36(2):145.PubMedPubMedCentralGoogle Scholar
  7. 7.
    Williams RM, Welch CE, Weber ML, Parsons JT, McLeod TCV. Athletic trainers’ management practices and referral patterns for adolescent athletes after sport-related concussion. Sports Health. 2014;6(5):434–9.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Iverson GL, Schatz P. Advanced topics in neuropsychological assessment following sport-related concussion. Brain Inj. 2014;29(2):263–75.CrossRefPubMedGoogle Scholar
  9. 9.
    Solomon GS, Lovell MR, Casson IR, Viano DC. Normative neurocognitive data for National Football League players: an initial compendium. Arch Clin Neuropsychol. 2015:acv003.Google Scholar
  10. 10.
    West TA, Marion DW. Current recommendations for the diagnosis and treatment of concussion in sport: a comparison of three new guidelines. J Neurotrauma. 2014;31(2):159–68.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Harmon KG, Drezner JA, Gammons M, Guskiewicz KM, Halstead M, Herring SA, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med. 2013;47(1):15–26.CrossRefPubMedGoogle Scholar
  12. 12.
    McCREA M, Barr WB, Guskiewicz K, Randolph C, Marshall SW, Cantu R, et al. Standard regression-based methods for measuring recovery after sport-related concussion. J Int Neuropsychol Soc. 2005;11(01):58–69.CrossRefPubMedGoogle Scholar
  13. 13.
    Kontos A, Webbe F, Selby C, Sufrinko A. The concussion toolkit for psychologists. Published 2014. Accessed November 6, 2015.Google Scholar
  14. 14.
    Segalowitz SJ, Mahaney P, Santesso DL, et al. Retest reliability in adolescents of a computerized neuropsychological battery used to assess recovery from concussion. NeuroRehabilitation-An Interdisciplinary Journal. 2007;22(3):243.Google Scholar
  15. 15.
    Cole WR, Arrieux JP, Schwab K, Ivins BJ, Qashu FM, Lewis SC. Test-retest reliability of four computerized neurocognitive assessment tools in an active duty military population. Arch Clin Neuropsychol. 2013;28(7):732–742.Google Scholar
  16. 16.
    Collie A, Maruff P, Makdissi M, McCrory P, McStephenson M, Darby D. CogSport: Reliability and correlation with conventional cognitive tests esed in postconcussion medical evaluations. Clin J Sport Med. 2003;13:28–32.Google Scholar
  17. 17.
    Gualtieri CT, Johnson LG. Reliability and validity of a computerized neurocognitive test battery, CNS vital signs. Arch clin neuropsychol. 2006;21(7):623–643.Google Scholar
  18. 18.
    Broglio SP, Ferrara MS, Macciocchi SN, et al. Test-retest reliability of computerized concussion assessment programs. J Athl Train. 2007;42(4):509.Google Scholar
  19. 19.
    Resch J, Driscoll A, McCaffrey N, Brown C, Ferrara MS, Macciocchi S, Baumgartner T, Walpert K. ImPact test-retest reliability: reliably unreliable? J Athl Train. 2013;48(4):506–511.Google Scholar
  20. 20.
    Elbin R, Schatz P, Covassin T. One-year test-retest reliability of the online version of ImPACT in high school athletes. Am J Sports Med. 2011;39(11):2319–2324.Google Scholar
  21. 21.
    Schatz P. Long-term test-retest reliability of baseline cognitive assessments using ImPACT. Am J Sports Med. 2010;38(1):47–53.Google Scholar
  22. 22.
    Broglio SP, Macciocchi SN, Ferrara MS. Sensitivity of the concussion assessment battery. Neurosurgery. 2007;60(6):1050–8.CrossRefPubMedGoogle Scholar
  23. 23.
    Alsalaheen B, Stockdale K, Pechumer D, Broglio SP. Measurement error in the Immediate Postconcussion Assessment and Cognitive Testing (ImPACT): systematic review. J Head Trauma Rehabilitation. 2015. doi: 10.1097/HTR.0000000000000175.
  24. 24.
    Amin DJ, Coleman J, Herrington LC. The test-retest reliability and minimal detectable change of the balance error scoring system. J Sports Sci. 2014;2:200–7.Google Scholar
  25. 25.
    Chang JO, Levy SS, Seay SW, Goble DJ. An alternative to the balance error scoring system: using a low-cost balance board to improve the validity/reliability of sports-related concussion balance testing. Clin J Sport Med. 2014;24(3):256–62.CrossRefPubMedGoogle Scholar
  26. 26.
    Wojtys EM, Hovda D, Landry G, Boland A, Lovell M, McCrea M, et al. Concussion in sports. Am J Sports Med. 1999;27(5):676–87.PubMedGoogle Scholar
  27. 27.
    Hinton-Bayre AD, Geffen GM, Geffen LB, McFarland KA, Frijs P. Concussion in contact sports: reliable change indices of impairment and recovery. J Clin Exp Neuropsychol. 1999;21(1):70–86.CrossRefPubMedGoogle Scholar
  28. 28.
    Echemendia RJ, Iverson GL, McCrea M, Macciocchi SN, Gioia GA, Putukian M, et al. Advances in neuropsychological assessment of sport-related concussion. Br J Sports Med. 2013;47(5):294–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Littleton AC, Schmidt JD, Register-Mihalik JK, Gioia GA, Waicus KM, Mihalik JP, et al. Effects of attention deficit hyperactivity disorder and stimulant medication on concussion symptom reporting and computerized neurocognitive test performance. Arch Clin Neuropsychol. 2015;30(7):683–93.CrossRefPubMedGoogle Scholar
  30. 30.
    Ott S, Schatz P, Solomon G, Ryan JJ. Neurocognitive performance and symptom profiles of Spanish-speaking Hispanic athletes on the ImPACT test. Arch Clin Neuropsychol. 2014;29(2):152–63.CrossRefPubMedGoogle Scholar
  31. 31.
    Jones NS, Walter KD, Caplinger R, Wright D, Raasch WG, Young C. Effect of education and language on baseline concussion screening tests in professional baseball players. Clin J Sport Med. 2014;24(4):284–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Maerlender A, Molfese DL. Repeat baseline assessment in college-age athletes. Dev Neuropsychol. 2015;40(2):69–73.CrossRefPubMedGoogle Scholar
  33. 33.
    Randolph C. Baseline neuropsychological testing in managing sport-related concussion: does it modify risk? Curr Sports Med Reports. 2011;10(1):21–6.CrossRefGoogle Scholar
  34. 34.
    Moser RS, Schatz P, Lichtenstein JD. The importance of proper administration and interpretation of neuropsychological baseline and postconcussion computerized testing. Applied Neuropsychology: Child. 2015;4(1):41–8.Google Scholar
  35. 35.
    Erdal K. Neuropsychological testing for sports-related concussion: how athletes can sandbag their baseline testing without detection. Arch Clin Neuropsychol. 2012:acs050.Google Scholar
  36. 36.
    Schatz P, Glatts C. “Sandbagging” baseline test performance on ImPACT, without detection, is more difficult than it appears. Arch Clin Neuropsychol. 2013;28(3):236–44.CrossRefPubMedGoogle Scholar
  37. 37.
    Bailey CM, Echemendia RJ, Arnett PA. The impact of motivation on neuropsychological performance in sports-related mild traumatic brain injury. J Int Neuropsychol Soc. 2006;12(04):475–84.CrossRefPubMedGoogle Scholar
  38. 38.
    Hill BD, Womble MN, Rohling ML. Logistic regression function for detection of suspicious performance during baseline evaluations using concussion vital signs. Applied Neuropsychology: Adult. 2015;22(3):233–40.CrossRefGoogle Scholar
  39. 39.
    Lichtenstein JD, Moser RS, Schatz P. Age and test setting affect the prevalence of invalid baseline scores on neurocognitive tests. Am J Sports Med. 2014:0363546513509225.Google Scholar
  40. 40.
    Moser RS, Schatz P, Neidzwski K, Ott SD. Group versus individual administration affects baseline neurocognitive test performance. Am J Sports Med. 2011;39(11):2325–30.CrossRefPubMedGoogle Scholar
  41. 41.
    Vaughan CG, Gerst EH, Sady MD, Newman JB, Gioia GA. The relation between testing environment and baseline performance in child and adolescent concussion assessment. Am J Sports Med. 2014:0363546514531732.Google Scholar
  42. 42.
    Rabinowitz AR, Merritt VC, Arnett PA. The return-to-play incentive and the effect of motivation on neuropsychological test-performance: implications for baseline concussion testing. Dev Neuropsychol. 2015;40(1):29–33.CrossRefPubMedGoogle Scholar
  43. 43.
    McClure DJ, Zuckerman SL, Kutscher SJ, Gregory AJ, Solomon GS. Baseline neurocognitive testing in sports-related concussions: the importance of a prior night’s sleep. Am J Sports Med. 2014;42(2):472–8.CrossRefPubMedGoogle Scholar
  44. 44.
    Yengo-Kahn A, Zuckerman S, Solomon G. The effect of psychotropic medications and psychiatric illness on the baseline neurocognitive assessment of young athletes using the ImPACT test battery: a pilot study. Neurosurgery. 2015;62:231–2.CrossRefGoogle Scholar
  45. 45.
    Covassin T, Weiss L, Powell J, Womack C. Effects of a maximal exercise test on neurocognitive function. Br J Sports Med. 2007;41(6):370–4.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Schatz P, Kelley T, Ott SD, Solomon GS, Elbin R, Higgins K, et al. Utility of repeated assessment after invalid baseline neurocognitive test performance. J Athl Train. 2014;49(5):659–64.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Van Kampen DA, Lovell MR, Pardini JE, Collins MW, Fu FH. The ‘value added’ of neurocognitive testing after sports-related concussion. Am J Sports Med. 2006;34(10):1630–5.CrossRefPubMedGoogle Scholar
  48. 48.
    Berryman C, Stanton TR, Bowering KJ, Tabor A, McFarlane A, Moseley GL. Do people with chronic pain have impaired executive function? A meta-analytical review. Clin Psychol Rev. 2014;34(7):563–79.CrossRefPubMedGoogle Scholar
  49. 49.
    Weyer Jamora C, Schroeder SC, Ruff RM. Pain and mild traumatic brain injury: the implications of pain severity on emotional and cognitive functioning. Brain Inj. 2013;27(10):1134–40.CrossRefPubMedGoogle Scholar
  50. 50.
    Covassin T, Crutcher B, Bleecker A, Heiden EO, Dailey A, Yang J. Postinjury anxiety and social support among collegiate athletes: a comparison between orthopaedic injuries and concussions. J Athl Train. 2014;49(4):462–8.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Collins MW, Field M, Lovell MR, Iverson G, Johnston KM, Maroon J, et al. Relationship between postconcussion headache and neuropsychological test performance in high school athletes. Am J Sports Med. 2003;31(2):168–73.PubMedGoogle Scholar
  52. 52.
    Register-Mihalik J, Guskiewicz KM, Mann JD, Shields EW. The effects of headache on clinical measures of neurocognitive function. Clin J Sport Med. 2007;17(4):282–8.CrossRefPubMedGoogle Scholar
  53. 53.
    Kontos AP, Elbin R, Lau B, Simensky S, Freund B, French J, et al. Posttraumatic migraine as a predictor of recovery and cognitive impairment after sport-related concussion. Am J Sports Med. 2013;41(7):1497–504.CrossRefPubMedGoogle Scholar
  54. 54.
    Kostyun RO, Milewski MD, Hafeez I. Sleep disturbance and neurocognitive function during the recovery from a sport-related concussion in adolescents. Am J Sports Med. 2014:0363546514560727.Google Scholar
  55. 55.
    Sufrinko A, Pearce K, Elbin R, Covassin T, Johnson E, Collins M, et al. The effect of preinjury sleep difficulties on neurocognitive impairment and symptoms after sport-related concussion. Am J Sports Med. 2015:0363546514566193.Google Scholar
  56. 56.
    Buckley TA, Munkasy BA, Clouse BP. Acute cognitive and physical rest may not improve concussion recovery time. J Head Trauma Rehabil. 2015. doi: 10.1097/HTR.0000000000000165.
  57. 57.••
    Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015;135(2):213–23. Results of this study revealed that athletes who were placed on strict rest following concussion did not perform better than those without rest on neurocognitive testing, which was the first RCT dispelling the common myth that “strict brain rest” if vital to cognitive recovery immediately following concussion.Google Scholar
  58. 58.
    Brown NJ, Mannix RC, O’Brien MJ, Gostine D, Collins MW, Meehan WP. Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics. 2014;133(2):e299–304.CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Mucha A, Collins MW, Elbin R, Furman JM, Troutman-Enseki C, DeWolf RM, et al. A brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions preliminary findings. Am J Sports Med. 2014:0363546514543775.Google Scholar
  60. 60.•
    Pearce KL, Sufrinko A, Lau BC, Henry L, Collins MW, Kontos AP. Near point of convergence after a sport-related concussion measurement reliability and relationship to neurocognitive impairment and symptoms. Am J Sports Med. 2015:0363546515606430. This study was one of the first to demonstrate that performance on computerized neurocognitive testing is influenced by oculomotor dysfunction following concussion.Google Scholar
  61. 61.
    Vernau BT, Grady MF, Goodman A, Wiebe DJ, Basta L, Park Y, et al. Oculomotor and neurocognitive assessment of youth ice hockey players: baseline associations and observations after concussion. Dev Neuropsychol. 2015;40(1):7–11.CrossRefPubMedGoogle Scholar
  62. 62.
    Benedict PA, Baner NV, Harrold GK, Moehringer N, Hasanaj L, Serrano LP, et al. Gender and age predict outcomes of cognitive, balance and vision testing in a multidisciplinary concussion center. J Neurol Sci. 2015;353(1):111–5.CrossRefPubMedGoogle Scholar
  63. 63.
    Alsalaheen BA, Whitney SL, Marchetti GF, Furman JM, Kontos AP, Collins MW, et al. Relationship between cognitive assessment and balance measures in adolescents referred for vestibular physical therapy after concussion. Clin J Sport Med 2015.Google Scholar
  64. 64.
    Lau BC, Collins MW, Lovell MR. Cutoff scores in neurocognitive testing and symptom clusters that predict protracted recovery from concussions in high school athletes. Neurosurgery. 2012;70(2):371–9.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Anthony P. Kontos
    • 1
    Email author
  • Alicia Sufrinko
    • 1
  • Melissa Womble
    • 1
  • Nathan Kegel
    • 1
  1. 1.UPMC Sports Medicine Concussion Program/Department of Orthopaedic SurgeryUniversity of PittsburghPittsburghUSA

Personalised recommendations