Neuropsychological testing is used to assess cognitive domains such as attention, memory, processing speed, executive function, and reasoning in individuals with suspected traumatic brain injury (TBI). These assessments are most commonly indicated in complex or prolonged concussion, where symptoms persist beyond expected recovery timelines or where return-to-work, return-to-play, or medico-legal decisions are required¹.
Performance on neuropsychological tests is influenced by numerous non-injury-related factors, including prior concussion history, depression or anxiety, sleep disturbance, medication use, fatigue, pain, and motivation. These factors can either prolong recovery or mimic concussion symptoms, complicating interpretation of results².
In elite sport and research settings, neuropsychological testing is often performed pre-season to establish an individual baseline, allowing post-injury performance to be compared against the athlete’s own normative function rather than population averages³. This approach is widely used in professional leagues and collegiate sport.
However, baseline testing introduces its own limitations. Performance can be affected by effort, environmental conditions, and learning effects. In some cases, individuals may intentionally underperform at baseline (“sandbagging”), reducing the sensitivity of post-injury comparisons⁴. Even when conducted appropriately, neuropsychological tests remain indirect measures of brain function rather than direct indicators of biological injury.
While neuropsychological testing provides valuable clinical information, it is predominantly behavioural and performance-based, meaning that changes over time may not reliably reflect underlying biological recovery. Many commonly used concussion tools and symptom scales were adopted into widespread use before comprehensive validation, and their reliability, sensitivity, and specificity vary considerably⁵.
No single neuropsychological or sideline assessment tool is universally accepted as the “gold standard” for concussion diagnosis or recovery tracking. Contemporary consensus statements emphasise that these tools should be used as part of a multimodal clinical assessment, rather than in isolation⁶.
To address these limitations, several adjunctive approaches are being explored or implemented alongside traditional neuropsychological testing:
These approaches aim to improve diagnostic confidence, reduce reliance on subjective reporting, and better capture sub-concussive and cumulative injury.
Neuropsychologists play an important role in education, monitoring, and rehabilitation following concussion. Interventions may include psychoeducation regarding normal recovery, cognitive behavioural therapy (CBT) for maladaptive symptom focus, and structured cognitive rehabilitation in cases of persistent impairment¹.
Repeat neuropsychological testing can be useful to document functional improvement over time, but results must be interpreted cautiously and in conjunction with clinical findings, symptom evolution, and—where available—objective biological measures.
Modern guidelines emphasise that each concussion should be managed individually, using as much objective information as feasible, and interpreted within the context of the individual’s baseline, medical history, and recovery trajectory⁶. Neuropsychological testing remains a valuable but incomplete component of concussion assessment, reinforcing the need for complementary objective tools that can more directly reflect underlying brain injury.