Is baseline testing for concussions worth it for your kids?

When 12-year-old Sebastian Giannotti was hit from behind during a minor hockey game in the Toronto area three years ago, his parents, Melissa and Benny, didn't know what baseline testing was.

What they did know was that Sebastian had suffered a serious injury.

"He had a severe concussion, was out of commission for six weeks. He had whiplash, he lost peripheral vision," recalls Melissa.

The Giannottis were eventually told about baseline testing for concussions by both a family friend (a fire captain) and the physician Sebastian went to see following the hit.

Sebastian was baseline tested in September 2014, putting Melissa and Benny among the growing number of Canadian parents who have had their children take part in the procedure prior to the start of the season for contact sports like hockey, lacrosse or rugby.

But while the use of baseline testing has spread rapidly across Canada, a contentious debate over its usefulness burns in the background.

What is baseline testing?

Baseline testing is any combination of neuropsychological and physical tests which, when conducted on a non-injured athlete, is meant to provide a helpful reference point in case of a future injury.

The service can be found at many physiotherapy and chiropractic clinics, and usually costs between $60 and $100.

If a possible concussion occurs, the athlete takes the tests again and the results are then compared to their baseline measures.

Supporters of baseline testing say these results are critical to making a return-to-play decision. This is because a concussion can't be spotted by MRI or CT scan technology, and problems may still exist even though symptoms have disappeared.

Neither the Ontario Minor Hockey Association nor Hockey Canada has mandated or taken a position on baseline testing, although both have an extensive concussion awareness protocol.

A lack of evidence

Some Canadian medical researchers are extremely doubtful of baseline testing's efficacy, especially in children.

"The fundamental conclusion these days is we don't have enough evidence to justify spending a lot of money and time doing baseline testing," says Dr. Keith Yeates, professor and lead of the Integrated Concussion Research Program at the University of Calgary.

The most recent consensus statement, released following the 4th International Conference on Concussion in Sport in Zurich back in 2012, did not endorse baseline testing. 

The 2016 conference is being held this week in Berlin, Germany.

Yeates was part of the conference's systematic review specific to children and expects the consensus will again not endorse baseline testing.

Many parents still buying in

However, some on-the-ground clinical therapists continue to market and administer baseline tests with their own rationale and compiled evidence.

Dr. Cameron Marshall is a Toronto chiropractor who launched Complete Concussion Management. The organization says on its website that there are about 200 clinics across Canada that offer its proprietary program.

Marshall firmly believes baselines tests are necessary for return-to-play decisions.

"It just comes down to, how are you going to manage [potential concussion cases] without having some objectivity?" he says. "I still get a lot of patients coming in without a baseline. It makes the return-to-play decision a little bit harder. You can still manage it, I just don't think it's as effective as having that tool.

"I feel a lot more comfortable in clearing somebody when I have some test, and not just any test."

Marshall says he has put together a collection of baseline tests that his organization has administered to children as young as nine years old.

Marshall says Complete Concussion Management will explain to parents and coaches that the evidence is lacking, especially in children under 13, but a great many go ahead anyway.

It's this commercialization of baseline testing that concerns Dr. Yeates.

"There's a lot of money in this game," he says. "Some of it is motivated legitimately by concerns for patient care, but there are people who have irons in the fire in terms of why they would be supporters of baseline testing."

What are the alternatives to baseline testing?

"In reality, the vast majority of children and adolescents with concussion can be successfully managed by family medicine physicians and pediatricians without any baseline testing," wrote Dr. Mike Ellis, a neurosurgeon and Medical Director of the Pan Am Concussion Program in Winnipeg, Manitoba.

His clinic does not offer baseline testing. Neither does Concussion North, an Ontario clinic opened by sports medicine physician Dr. Shannon Bauman in 2014 following her own two-year battle with a hockey concussion. 

She recommends evaluation by a physician. If treatment is necessary, she says her clinic offers a multi-disciplinary team of experts.

Bauman says she bases her return-to-play decisions on her assessments and those of the experts in her clinic.

She is critical of baseline testing.

"Clinics are primarily using baseline testing to make money with little or no training on how to interpret them properly," she says. "I have been discouraging people from doing baseline testing and have demonstrated in many instances where previous baselines have provided no benefit when clearing athletes from future concussions.

"Rather than spending money on a test with no proven value, I think parents, coaches and players should be advised to save their money for other sport-related expenses or future concussion care if required."