Princeton, New Jersey, USA
Thursday 12th December 2013
After last week's trip to visit Byron (Hansen) & the team at the Giants, this week it was time to see how American football players trained in the collegiate system.  A few weeks ago I had been in contact with Jason Galluci, the Director of Conditioning at Princeton University, to arrange a visit to their facility & this afternoon I spent time with the recent Ivy League football champions as Jason put them through their paces in the gym.

As an Ivy League institution, Princeton does not hand out athletic scholarships & therefore their football teams aren't as strong as the superpowers of collegiate gridiron.  Nevertheless, their name is secured in the history of the game as they contested the first ever Intercollegiate American Football game against Rutgers University in 1869.  

Whilst the team of 2013 has not qualified for the NCAA tournament, Princeton finished the season with an 8-2 winning record & a share of the Ivy League Championship.  The magnitude of the achievement is further underlined when the record books show a mere 7 victories over the last 3 seasons combined, whilst the transformation played out with several players reaching Princeton milestones & even breaking an NCAA record.

I enjoyed a really interesting chat with Jason about the differences between the pro & collegiate games, whilst I was also able to make first hand comparisons with the physical capabilities of these players as they lifted & performed a couple of post-season screening tests.  

Some of Jason's frustrations with the NCAA rules stem from the limitations of involvement that the teams can have with the players during exam time.  For example, during certain times of the year, conditioning staff are only allowed to supervise player-led sessions in the gym with the intention of ensuring safety, however, the higher risk activities that are likely to be conducted by a player outside of weights room are off limits for supervision.

In contrast to the NFL, however, Jason does have more time in the off-season to work with players & design properly periodised weights programmes.  One of the rules I find counter-productive in the NFL player bargaining agreement is the protected time players are away from the team staff in the build up to pre-season.  

This is the time where rugby teams spend valuable hours working with players to achieve strength & hypertrophic gains that help reduce risk of injury throughout the season.  If you lose that time, it's a risk (I have seen played out) that conditioning staff feel the need to do strength development work in-season, which then increases the risk of subjecting players to loads consistent with over-training. 

The current hot topic in contact sports, that of concussion management, was also on the agenda & we discussed the management regimes that the university's medical, athletic training & sports physiotherapy staff have in place.  Interestingly, a review paper published earlier in the month has once again called the reliability of many of the computerised neurocognitive testing software packages into question.  This isn't an isolated accusation & the research analysis follows on from a paper published by Randolph et al in 2005, which raised the same concerns.

Since 2005, a further 29 peer-reviewed papers have investigated the value of the various tools on the market & these were included in the current study by Resch et al (2013).  The field of concussion management is a much busier place than it was 8 years ago & the teams behind the software have spent vast sums on development of the systems, in addition to the marketing of the platforms.  However, it appears that the evidence available doesn't support many of the claims made.

The review included prospective & retrospective investigations of adult & paediatric (predominantly) sporting samples to assess the validity & reliability of the four most widely-used tools on the market.  The tools by name are CogState, ImPACT, HeadMinder & ANAM.

One of the papers included in the review was a study co-authored by my friend & colleague, Mike Ferrara & was published earlier in the year, also in the Journal of Athletic Training.  The study, also citing Resch as the title author, conducted tests using the ImPACT software & found variable test-retest measures of reliability, with particular issue related to the visual memory & verbal metrics.

The authors concluded that neurocognitive testing software should only be used as a component of a full neurological assessment procedure, encompassing clinical examinations, symptom reports & balance testing in addition to the computer tests.  This sentiment is echoed in the consensus statement from the 4th Concussion in Sport meeting, authored by McCrory et al:

"Brief computerised cognitive evaluation tools are the mainstay of these assessments [neuropsychological assessments] worldwide given the logistical limitation in accessing trained neuropsychologists, however it should be noted that these are not substitutes for formal neuropsychological assessment.  At present, there is insufficient evidence to recommend the widespread routine use of baseline neurocognitive testing."  

It must be noted, however, that Dr. Mark Lovell, one of the founders of the ImPACT programme, agrees that like any of the other tests on the market, ImPACT is not perfectly reliable.  Furthermore, Lovell believes that part of the problem stems from the practice of some clinicians who try to use the test as a stand-alone tool for diagnosing concussion & determining return to play status.

Speaking to the NFL earlier in the year, Lovell said:

"I need to emphasise this, & have always said this:  I don't think that ImPACT or any other test should be used in a vacuum...It shouldn't be looked at to say 'he's good to go or he's not good to go.'  We've never said that."

Maybe another issue is that in the scramble to protect themselves from potential negligence claims at a later date, some organisations that have responsibility for player health have passed hasty legislation.  Unfortunately, such legislation often isn't necessarily supported by the available scientific evidence & nor does it seem to be written by people with an in depth knowledge of the subject.  For example, an article published on the ESPN website last year reported that Rhode Island's law uses the term "ImPACT" as a generic term for all neurocognitive baseline testing.

Another recent article reported "nearly 40% of athletic trainers" disclosing that they routinely used some form of computerised neurocognitive testing as a component of their management of sports-related concussion (source unknown).  If the information is accurate, this highlights the need for enhanced education regarding the intended use & limitations of such tools.  The risk otherwise is that, as with all other walks of life "a little knowledge is a dangerous thing" & the misuse of computerised neurocognitive tests becomes widespread, with potentially catastrophic results.

In the meantime, Resch is continuing to work on a long-term, prospective study to investigate the management of concussion in a population of young athletes.  In its third year, the research involves a cohort of over 2,000 children from the Texan middle & high school systems.  This is just an example of the necessity for further research in the field.

In the absence of more conclusive research, the authors suggest:

1)  Conducting extensive research when choosing what testing platform to use & educating all users as to how it should be used, as well as to its limitations
2)  Incorporating the test into a comprehensive battery of concussion management assessments
3)  Involving a clinical neuropsychologist in the team responsible for the management of sports-related concussion & having them advise on appropriate interpretation of test results
4)  Ensure satisfactory training of all staff involved in the testing procedure
5)  Conduct regular evidence-based performance reviews of the baseline testing procedures

For further information regarding the management of sporting concussions, click on the link below to read my previous blog discussing the Consensus Statement on Concussion in Sport & the studies that informed it.


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