Poverty and Living in a Highly Deprived Neighborhood Affect Student-Athletes’ Baseline Concussion Testing Scores, New UH Study Finds

UH Clinical Update | November 2023

Christopher Bailey, PhD

Sports trainers and coaches across America use computer-based neurocognitive testing with their athletes during the pre-season to generate baseline scores. They then compare these scores to new neurocognitive tests when an athlete sustains a suspected concussion, documenting the extent of the injury and providing important guidance about when the athlete can return to play, among other factors.

But now, a new study from University Hospitals and Case Western Reserve University has identified a previously unknown factor that can lead these crucial baseline scores to be invalid, possibly putting athletes at risk when baseline testing is not repeated to get a valid value. Neuropsychologist Christopher Bailey, PhD, in the UH Concussion Management Program in the UH Neurological Institute, and colleagues have found that social determinants of health such as poverty or living in a highly deprived neighborhood can affect the validity of the baseline neurocognitive test.

Study details: In their study of 6,495 student-athletes in Cuyahoga County, recently published in the Journal of Athletic Training, the team found that youth who experienced persistent poverty in both early childhood and adolescence had significantly lower odds of having a valid concussion baseline score. Poverty was defined as enrollment in the Supplemental Nutrition Assistance Program or Temporary Assistance for Needy Families.

In addition, study results show that student-athletes who lived in a highly deprived neighborhood at their baseline test had significantly lower odds of valid test performance. Together, these factors lowered the odds of achieving a valid baseline test by between 50 and 72 percent.

“Adversity does have an influence on the neurocognitive testing that we're talking about here, and it increases the risk,” Dr. Bailey says. “If an athlete has a history of different sorts of adversity, especially poverty and neighborhood deprivation, then it increases the risk that we may not get accurate data on them. And so part of what it really points to is the need to make sure that we're actually reviewing the baselines and confirming that they're valid.”

One of many factors: Things beyond social determinants of health can cause an invalid baseline test, Dr. Bailey says, such as disengagement, noise, fatigue and other factors. The test software is programmed to flag a test that isn’t going as expected. What’s new now, he says, is that coaches and trainers should be alert to repeating baseline testing where social determinants of health come into play for a student-athlete. Though it takes some effort, the payoff is worth it, Dr. Bailey says.

Getting valid baseline scores: The UH Concussion Management Program collaborates with UH Drusinsky Sports Medicine Institute to provide athletic trainers and concussion baseline testing to more than 70 high schools and seven Northeast Ohio colleges, as well as the Cleveland Browns and Lake Erie Monsters. The policy is to always repeat every invalid baseline test, Dr. Bailey says.

“One of the more interesting things we found in this study is that if we did see an invalid test and we repeated that test, 95 percent of the time it actually then moved into the valid ranges,” he says. “It's just that some people who have this history of adversity may need more than one administration. Again, that requires extra resources and extra time, but it's clear that it's important.”

The worst-case scenario, Dr. Bailey says, would be having an artificially low, invalid neurocognitive baseline score and then trying to use it to gauge a young athlete’s recovery after a concussion. The true effect of the injury could be invisible.

“Without adequate retesting, youth with particular patterns of adversity may face compounded disadvantage, both from the adversities themselves and by not getting accurate neurocognitive diagnostics, including failing to detect concussion symptoms after a sports-related concussion due to invalid baseline testing,” he says. “We are committed to getting good data to make sure this doesn’t happen.”