using impact in concussion management - cbirt · 2018-04-27 · baseline testing with

Using ImPACT in Concussion ManagementVIVIANE UGALDE, MD

PHYSICAL MEDICINE & REHABILITATION

MEDICAL DIRECTOR CONCUSSION MANAGEMENT PROGRAM FOR THE CENTER FOUNDATION, BEND, OR

“Mandatory” Baseline neurocognitive (ImPACT) Testing for high risk sports Football

Girls and Boys soccer

Girls and boys basketball

Wrestling

Recommended for Lacrosse, rugby, alpine skiing, volleyball, others

Paid for by OSAA for mandatory testing, offered $a fee for all others, Call 541-382-2321at the Center

Tests memory, reaction time and ability to do “new learning”

Baseline testing

How old and when to test?

Baseline every 2 years for high school age

Ages 12-59, now with a new Pediatric ImPACT test for 5-11

The original is controversial for <14

Sandbagging – deliberate poor performance on baseline Difficulty in protocol review of valid baselines (impulse control composite score) Learning effect with repeated tests Effects on test performance if <7 hours of sleep, environmental distractions

(testing >20 at a time), caffeine consumption, anxiety/distress etc. Sensitivity 79-95%, Specificity 89-97% (4 peer reviewed papers) Validity ranged between .2 -.88 compared to traditional NP test Reliability – test/retest was poor for shorter intervals, better for longerResch, et al. Neuropsychol Rev (2013) 23:335-349McClure, et al. Testing in Sports-Related Concussion. Am J Sports Med 2014;42:472-8

ImPact testing controversies

Be aware of limitations

ImPACT continuing to improve

Recent adjustment of “Reliable change” or statistically significant differences reported for comparison with baseline to post-injury scores

Should be considered only a part of a multi-dimensional approach to concussion management

With “passport” any clinician can access ImPACT scores, but interpretation is a concern.

Recommendations for computerized NT testing

Adult SCAT 5

ADULT SCAT 5

CHILD SCAT 5 (ages 5-12)

CHILD SCAT 5

No longer in protocol for automatic post-injury test within 72 hours if it is clearly a concussion. Yes, if any question that there was a concussion.

Athlete and parents are given instructions for cognitive and physical rest.

Academic accommodations are provided to student and school.

Immediate IMPACT post injury test

Athlete is symptom free

BESS testing is within a normal range or back to baseline

School performance is at baseline (no longer needing accommodations)

ImPACT testing is performed at that time

Asymptomatic ImPACT test

Is the test valid?

Quick check: Look at percentile scores

For baseline testing, none of the scores should be <1%

For baseline testing Impulse Control Composite Score <25

For post injury testing:

A/B student percentiles should be >65-75%

B/C student percentiles should be >35-40%

D/F student percentiles should be >20%

Average C Student Raw Scores

Word Memory 11-12

Design Memory 9-10

X/O’s 9

Symbol Match Total Correct Hidden 9

Color Match 9

Unexpected Scores

Baseline testing with <1%

If visual motor speed composite is <1% - possible that the X and O’s testing where you are supposed to count backwards from 25, the test taker may not have understood the directions and counted upwards from 1 instead. The score for Three Letters – average counted correctly would be 0.

May have unidentified learning disability or ADHD

May reflect poor effort, especially if academic performance is high.

Analysis of Results

Composite scores: raw and percentile score Composite scores are a combination of performance on different parts of the

test. Verbal Memory Visual Memory Visual Motor Speed Reaction Time Impulse Control Total Symptom Score Cognitive Efficiency Index

Interpretation of results

If you have a baseline – look for any highlighted reliable change

Reliable change means that the score is statistically significantly poorer than the baseline score. (poor performance in that category compared to how they performed prior to a head injury)

If they have 2 areas of highlighted reliable change, then the person would be considered to still be performing cognitively poorer than prior to injury and is still recovering.

If you don’t have a baseline, then compare their scores to expected norms for their reported academic performance, i.e. an A student would be expected to score >65%.

https://concussioncaretraining.com/course-category/free-courses/