Sports Neuropsychology: Assessment and Management of Traumatic Brain Injury, edited by Ruben J. Echemendía, brings together a variety of experts in the area of sports concussion, in an effort to introduce psychologists and neuropsychologists to the rapidly developing area of sports neuropsychology. The book is organized into five parts. Part I, Sports Neuropsychology in Context, outlines the historical context for the development of sports neuropsychology as a professional endeavor. Chapter 1 (Barth, Broshek, and Freeman), introduces the readers to a number of important definitions that are used throughout the book, including concussion, post-concussion syndrome, second-impact syndrome, and the system of grading concussion severity. Importantly, Barth, a pioneer in the study of sports-related concussion, describes his early efforts at the University of Virginia using pre- and posttrauma assessment with the Sports as a Laboratory Assessment Model (SLAM)—a method of examining concussion in a controlled environment, which has become a standard for current practice. Chapter 2 (Zillmer, Schneider, Tinker, and Kamineris) provides a fascinating historical account of sports-related injuries, dating from the 8th century B.C. (ancient Olympic games) to the present. Their account chronicles the medical and behavioral assessment of head trauma (beginning with Hippocrates, who wrote extensively about head injury), to the modern-day three-tiered grading system introduced by Cantu (1986) and the American Academy of Neurology (1997), and provides a unique perspective on how neuropsychologists have come to play such a critical role in sports medicine. Chapter 3 (Echemendía) takes on the important task of highlighting the potential pitfalls inherent in consulting with athletes, including those at the collegiate and professional levels. Echemendía directly confronts the different “rules” associated with athletic consultation (e.g., flexibility of scheduling, dealing with the media) and challenges psychologists to examine their motivation for pursuing this type of specialty practice (i.e., the need to be around “celebrities”). The chapter even describes the down side of sports neuropsychology practice, including not being treated with the same level of professional respect that they are accustomed to receiving from their clients.

Part 2, Concussion Assessment and Management, outlines the state of practice in concussion management. Chapter 4 (Webbe) addresses in greater detail the definition of concussion, including physiology and severity grading. This is a valuable chapter, which can potentially be a useful teaching tool outside the area of sports neuropsychology. Webbe reviews the historical literature on potential mechanisms of injury, including biomechanics (linear and rotational force) and pathophysiological theories (including vascular, reticular, pontine cholinergic and convulsive theories). He then addresses our current understanding of the physiology of injury in concussion including changes in cerebral blood flow, ion flux (neurotoxicity), glucose hypometabolism, electrical changes, and mitochondrial swelling. The chapter concludes with a review of injury caused by physical force, with a recommendation (based on animal studies) that an injury with peak accelerative force of 200 g should be considered a threshold for single impact to cause “significant brain injury” in humans. In Chapter 5 (Macciocci) the extent and epidemiology of sports concussion is delineated in greater detail, including the challenges associated with variable terminology used in epidemiological research. Much of the initial section of this chapter repeats information presented earlier in the book. The chapter contains specific sections on incidence of injury in football, soccer, hockey, and a combined section on baseball, lacrosse, basketball, and wrestling; however, interestingly, there is no mention of other popular sports with high likelihood of concussion, including skiing/snowboarding, boxing, gymnastics/cheerleading, and “extreme” sports (e.g., skateboarding, BMX biking, motocross). Chapter 6 (Barr) addresses components of sideline assessment of concussion and specific procedures (including review of history, orientation, concentration and memory tests, and motor/gait/balance assessment) that are used in making return to play decisions. The chapter makes several crucial observations. First, it is the athletic trainer and team physician who typically make sideline assessments—not neuropsychologists. Secondly, sideline assessment requires great caution, especially because of the non-ideal (i.e., noisy) setting for assessment, the incidence of pre-existing learning disorders/ADHD among athletes, and base rates of proficiency on tests of attention (e.g., he cites a study in which only 50% of healthy high school athletes could accurately perform serial seven subtractions). Chapter 7 (Echemendía) introduces the reader to the complex, dynamic, decision-making process regarding return-to-play. The neuropsychologist frequently has a significant role in the process although it is usually the team physician or athletic trainer making the final decision. A very useful element of this chapter is the diagram of Echemendía's return to play model (p. 122), which includes: medical factors, neuropsychological data, concussion factors, player factors (e.g., age, personality, style of play), team factors (elite vs. recreational), and extraneous factors (e.g., playing surface, field condition).

Sports concussion is a public health concern, and management occurs at all age levels. Part 3, Testing Programs, outlines concussion management programs for school age, high school, college, and professional athletes. In Chapter 8, Brooks reports that 30 million children and adolescents participate in out-of-school sports programs in the United States each year. As such, she emphasizes general surveillance and preventative education. Pardini and Collins (Chapter 9) address the unique challenges of concussion management in high schools. They provide useful, “high school relevant” methods for on-field screening, and raise the important issue of estimating an athlete's pre-injury cognitive ability using available data (level of coursework, grade point average, SAT scores). Three case studies are provided, although it is not clear whether these are actual cases, or composites used to illustrate points in the chapter. In Chapter 10 (Schatz and Covassin), the challenges of concussion management in college are described. This chapter also reviews general issues in concussion that are described earlier in the book, but is particularly useful for psychologists who have never worked with athletes in the college setting. One important point emphasized in the chapter is the variability in approach, depending on sport (e.g., football vs. lacrosse), or depending on size and scope of the athletic programs (e.g., Division I vs. Division III). Part 3 concludes with the section on working with professional athletes by Mark Lovell (Chapter 11). Lovell highlights two decades of experience working with professional football and hockey teams to this chapter, and addresses the role of neuropsychology not just in working with individual players but also in developing guidelines for prevention. The unique challenges of working with professional athletes are discussed, including athletes' minimizing of symptoms, the potentially opposing priorities of coaches, and the prevalence of athletes for whom English is not a primary language.

Within professional neuropsychology, concussion management is unique because of the need for brief, serial assessments. As a result, computerized neuropsychological assessments have become standard for larger scale concussion management programs. They are cost-effective, can usually be administered in 30 minutes or less by personnel other than neuropsychologists, and they were designed to be used repeatedly and to be sensitive to subtle changes in cognitive skills relevant to concussion. Each of the chapters in Part 4, Computerized Testing Batteries, outlines programs used in concussion management today, including ImPACT Neuropsychological Test Battery (Chapter 12), HeadMinder Concussion Resolution Index (Chapter 13), CogSport (Chapter 14), and the Automated Neuropsychological Assessment Metrics (ANAM; Chapter 15) developed by the United States Department of Defense (DoD). Three of these four computerized batteries are commercially available (ImPACT, HeadMinder, and CogSport), and one or more of their developers wrote the respective chapters. The ANAM is owned by the DoD and is available free of charge. This section is essential to the book, because it provides an in-depth overview of each of the computerized programs. Unfortunately, the reader is left to compare and contrast the utility of each program since no real attempt is made to draw conclusions about the populations who would be best served by each tool. Each battery certainly has its own unique strengths. ImPACT (Chapter 12, Lovell) incorporates a symptom rating scale with performance-based testing; HeadMinder (Chapter 13, Kaushik and Erlanger) is Internet based; CogSport (Chapter 14, Collie et al.) uses familiar playing cards as stimuli, minimizing language demands; and, ANAM (Chapter 15, Bleiberg, Cernich, and Reeves) has the added benefit of cost efficiency. The computerized model is one that can potentially be adapted for use in other areas of neuropsychology (e.g., response to medication or behavioral treatments). Nevertheless, after reading these four chapters, there are two issues that need to be better resolved. First, all four computerized batteries have reported test-retest reliability coefficients averaging around .70. Using regression or reliable change index (RCI) methodology, relatively large standard score changes would be required to be declared “significant” or “statistically rare,” given this level of reliability. Secondly, all four programs rely on timing mechanisms of individual computers (sometimes down to 100 msec intervals and below) in measuring change scores. None of the authors address the potential variability in scores due to the between-computer differences in millisecond timing that should be considered (Schatz & Browndyke, 2002).

The book concludes with Part 5, Views From Within the Sports Medicine Team, which includes a chapter by an athletic trainer (Furtado, Chapter 16), and a team physician (Putukian, Chapter 17). These chapters are an important addition to the book. They emphasize the interdisciplinary nature of concussion management and delineate the background and training of the other professionals involved in working with athletes. Athletic trainers and team physicians often work as an integrated unit. Knowing this professional landscape is crucial to the neuropsychologist aspiring to work in sports concussion management. Chapter 17 concludes with three case studies that illustrate (from the team physician's perspective) the added benefit of neuropsychological assessment over and above sideline screening and initial physical assessment, showing how return-to-play decisions rely on more than initial presentation of symptoms.

I recommend Sports Neuropsychology: Assessment and Management of Traumatic Brain Injury as a starting point for neuropsychologists interested in potentially subspecializing in sports concussion management. The book is also potentially useful for professionals in other fields (athletic trainers, physical therapy, sports medicine) who deal regularly with concussion management. The rapidly developing area of sports neuropsychology is evolving, and this text represents a good overview of the field. Nevertheless, to quote Barth and colleagues from Chapter 1; “Twenty years of scientific inquiry in this area have only begun to scratch the surface in our attempt to understand sports concussion and identify interventions to reduce morbidity associated with these injuries” (p. 7). Clearly there is much to learn about the role of neuropsychology in concussion management. The problems with computerized assessment of sports concussion are, in many ways, the same problems associated with neuropsychological testing in general (normative data, limited reliability, mixed results in validity studies). In general, the book addresses the limitations of computerized neuropsychological assessment batteries in a straightforward manner; however, continued development of tests with higher reliability is necessary along with a greater emphasis on validation of these instruments. Widespread use of baseline testing is potentially costly. Most cognitive symptoms associated with concussions that are detected by computerized assessment remit around the same time as self-report of symptoms. Thus, as neuropsychologists, we will need to continue to justify the “value added” by these comprehensive assessment programs, over and above careful screening programs by athletic trainers and physicians (Randolph, McCrea, & Barr, 2005). Finally, as mentioned in several chapters, the role of the neuropsychologist in concussion management should go beyond testing and include education and reassurance regarding recovery, and assessment of psychosocial factors that could complicate recovery.