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Validity of ImPACT for Measuring Processing Speed Following Sports-Related Concussion


Abstract and Figures

The purpose of this study was to examine the validity of ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing), a computerized neuropsychological test battery, for measuring attention and processing speed in athletes with concussions. This was accomplished by comparing the computerized testing to a traditional neuropsychological measure, the Symbol Digit Modalities Test (SDMT). Participants were 72 amateur athletes who were seen within 21 days of sustaining a sports-related concussion (Mean = 9.4, SD = 5.4 days). As predicted, the SDMT correlated more highly with the Processing Speed and Reaction Time composites than the Verbal Memory and Visual Memory Composites from ImPACT. The composite scores from ImPACT and the SDMT were subjected to exploratory factor analysis, revealing a two-factor solution interpreted as Speed/Reaction Time and Memory. It appears as if the Processing Speed Composite, Reaction Time Composite, and SDMT are measuring a similar underlying construct in this sample of concussed amateur athletes.
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Validity of ImPACT 1
Validity of ImPACT for Measuring Attention & Processing Speed
Following Sports-Related Concussion
Grant L. Iverson, Ph.D.
University of British Columbia & Riverview Hospital
Mark R. Lovell, Ph.D.
University of Pittsburgh Medical Center
Michael W. Collins, Ph.D.
University of Pittsburgh Medical Center
Author Notes: The authors thank Jennifer Bernardo for assistance with manuscript
preparation. Please address correspondence to Grant Iverson, Ph.D., Department of
Psychiatry, 2255 Wesbrook Mall, University of British Columbia, Vancouver, B.C.
Canada, V6T 2A1.
Draft #4: April 29, 2004
Validity of ImPACT 2
The purpose of this study was to examine the validity of ImPACT (Immediate Post-
Concussion Assessment and Cognitive Testing), a computerized neuropsychological test
battery, for measuring attention and processing speed in athletes with concussions. This
was accomplished by comparing the computerized testing to a traditional
neuropsychological measure, the Symbol Digit Modalities Test (SDMT). Participants
were 72 amateur athletes who were seen within 21 days of sustaining a sports-related
concussion (Mean = 9.4, SD = 5.4 days). As predicted, the SDMT correlated most highly
with the Processing Speed and Reaction Time composites from ImPACT. The composite
scores from ImPACT and the SDMT were subjected to exploratory factor analysis,
revealing a two-factor solution interpreted as Speed/Reaction Time and Memory. It
appears as if the Processing Speed Composite, Reaction Time Composite, and SDMT are
measuring a similar underlying construct in this sample of concussed amateur athletes.
Key Words: Concussion, Sports, ImPACT, Validity, Computerized Testing
Validity of ImPACT 3
Validity of ImPACT for Measuring Attention & Processing Speed
Following Sports-Related Concussion
Neuropsychological tests are sensitive to the subtleties of cognitive decrements
associated with concussions in sports (Barr & McCrea, 2001; Collins et al., 1999;
Echemendia, Putukian, Mackin, Julian, & Shoss, 2001; Kelly, 2001; Macciocchi et al.,
1996; McCrea, Kelly, Randolph, Cisler, & Berger, 2002; Randolph, 2001). The general
course begins with disruption of cognitive functioning immediately following injury,
particularly in the areas of orientation, attention and concentration, mental set shifting,
memory, information processing, and executive functioning (Collins et al., 1999;
Delaney, Lacroix, Gagne, & Antoniou, 2001; Erlanger et al., 1999; Guskiewicz, Ross, &
Marshall, 2001; Johnston et al., 2001; Matser, Kessels, Lezak, & Troost, 2001; Randolph,
2001). Gradual recovery occurs within several hours and full recovery to baseline
cognitive and functional status typically is reached within a few days, regardless of
concussion severity (Barr & McCrea, 2001; Guskiewicz, Marshall, Broglio, Cantu, &
Kirkendall, 2002; Johnston et al., 2001; Lovell et al., 2003; Macciocchi et al., 1996;
McCrea et al., 2002; McCrea et al., 2003; Powell & Barber-Foss, 1999).
Individualized approaches to concussion management have recently been
implemented by many sports organizations across the United States. Increasingly,
organizations are using baseline and post-injury neuropsychological testing. This
approach is currently being used clinically with the National Football League (Lovell,
1999), Major League Baseball (Collins, 2001), and it is mandated within the National
Hockey League (Lovell & Burke, 2000). With the availability of computerized
neuropsychological testing (e.g., Maroon, Lovell, Norwig, Podell, Powell, & Hartl, 2000;
Validity of ImPACT 4
Erlanger et al., 2001), many high schools and colleges are implementing this approach to
injury management.
Athletes with concussions show performance decrements on computerized
neuropsychological tests (Erlanger et al., 2001; Erlanger et al., 2003; Makdissi et al.,
2001; Warden et al., 2001). In essence, demonstrating the sensitivity of computerized
testing to the acute effects of concussion is the most important aspect of the test
validation process. The following are some recent examples of the sensitivity of
computerized neuropsychological testing to concussions in athletes: (a) high school
athletes with Grade I (“ding”) concussions showed a decline in memory between 1-3
days post injury followed by a return to baseline at 5-10 days post injury (Lovell, Collins,
Iverson, Johnston, & Bradley, 2004), (b) some concussed athletes showed a clear increase
in simple and choice reaction times at approximately two days post injury with
improvement at approximately 6 days post injury (Erlanger et al., 2003), (c) concussed
athletes reporting headaches at one week post injury had slower reaction times and lower
memory scores than concussed athletes who did not report headaches (Collins et al., in
press), and (d) concussed athletes reporting perceived “fogginess” at one week post
injury had slower reaction times, reduced processing speed, and lower memory scores
than concussed athletes who did not report fogginess (Iverson, Gaetz, Lovell, & Collins,
in press).
The purpose of this study was to examine the construct validity of ImPACT
(Immediate Post-Concussion Assessment and Cognitive Testing; (Maroon et al., 2000), a
computerized neuropsychological test battery, for measuring attention and processing
speed in athletes with concussions. This was accomplished by comparing the
Validity of ImPACT 5
computerized testing to a traditional neuropsychological measure, the Symbol Digit
Modalities Test (SDMT; Smith, 1982). The SDMT has been routinely used in sport
concussion research (e.g., Collins et al., 1999; Erlanger et al., 2003; Hinton-Bayre,
Geffen, McFarland, 1997; Guskiewicz, Marshall, Broglio, Cantu, & Kirkendall, 2002;
Macciocchi, Barth, Littlefield, & Cantu, 2001; McRea et al., 2003; Mrazik et al., 2000;
Zillmer, 2003). It is believed to measure scanning and tracking aspects of attention and
speed of processing (Spreen & Strauss, 1998). It was hypothesized that the SDMT would
be more highly related to the Processing Speed and Reaction Time composites on
ImPACT than the two memory composites.
Participants & Procedures
Participants were 72 amateur athletes who were seen within 21 days of sustaining
a sports-related concussion (Mean = 9.4, Median = 9, SD = 5.4 days). The breakdown of
athletes by concussion severity, based on the American Academy of Neurology
guidelines, was as follows: Grade 1 = 33%, Grade 2 = 49%, and Grade 3 = 18%. Their
average age was 17.1 years (SD = 1.9), and their average education was 10.5 years (SD =
1.8). The majority of athletes were male (83.8%). The breakdown of athletes by sport was
as follows: football = 58.3%, hockey = 11.2%, soccer = 9.7%, basketball = 6.9%,
wrestling = 5.6%, and other sports = 8%. This was the first documented concussion for
59% of the sample. Twenty-one percent reported one previous concussion, 14% reported
two previous concussions, and 6% reported three or more previous concussions.
Validity of ImPACT 6
Version 2.0 of ImPACT is a computer administered neuropsychological test
battery that consists of six individual test modules that measure aspects of cognitive
functioning including attention, memory, reaction time, and processing speed. Version
1.0 of the battery has been used in multiple studies relating to outcome from concussion
(Collins et al., in press; Iverson, Gaetz, Lovell, & Collins, 2002; Iverson, Gaetz, Lovell,
Collins, & Maroon, 2002; Lovell et al., 2003; Lovell, Collins, Iverson, Johnston, &
Bradley, in press). Five composite scores were used for this study. In general, the test
battery is designed to yield multiple types of information within a brief period of time.
Each test module may contribute scores to multiple composite scores. The
Memory composite score represents the average percent correct for a word recognition
paradigm, a symbol number match task, and a letter memory task with an accompanying
interference task. The
Visual Memory
composite score is comprised of the average
percent correct scores for two tasks; a recognition memory task that requires the
discrimination of a series of abstract line drawings, and a memory task that requires the
identification of a series of illuminated X’s or O’s after an intervening task (mouse
clicking a number sequence from 25 to 1). The
Reaction Time
composite score represents
the average response time (in milliseconds) on a choice reaction time, a go/no-go task,
and the previously mentioned symbol match task. The
Processing Speed
represents the weighted average of three tasks that are done as interference tasks for the
memory paradigms. The
Impulse Control
composite score represents the total number of
errors of omission or commission on the go/no-go test and the choice reaction time test.
This composite is used to identify athletes who are not putting forth maximum effort or
Validity of ImPACT 7
who are seriously confused about test instructions. This composite was not one of the
dependent measures for this study. In addition to the cognitive measures, ImPACT also
contains a
Post-Concussion Symptom Scale
that consists of 22 commonly reported
symptoms (e.g. headache, dizziness, “fogginess”) that is utilized throughout organized
sports (Lovell & Collins, 1998; Aubry, 2001). The dependent measure is the total score
derived from this 22-Item scale.
Most research to date has used version 1.0 of the program. ImPACT 2.0 is very
similar to the original version. However, there are some significant changes. Version 2.0
includes an additional test module (design memory). In addition, one of the working
memory tasks (X's and O's) was expanded and modified, making it more difficult than the
previous version. Version 2.0 also yields two memory composite scores (Verbal Memory
and Visual memory) while Version 1.0 contains only one memory composite score.
Version 2.0 has been shown to be sensitive to the acute effects of concussion (Iverson,
Lovell, & Collins, 2004).
The Symbol Digit Modalities Test (Smith, 1982) was developed in the 1960s. The
manual was first published in 1973, and was last revised in 1982 (although it is now in its
printing, as of March of 2000). The SDMT requires the examinee to quickly substitute
a number for a randomized series of geometric figures. The target number is presented at
the top of the page with each corresponding geometric figure. The test items present the
geometric figures only, and the examinee must quickly write in the target number that
goes with each figure. The total number of correctly completed numbers in 90 seconds is
the score derived from this test. The SDMT has been used extensively, over several
decades, in dozens of studies with diverse clinical groups.
Validity of ImPACT 8
Descriptive statistics for the measures are provided in Table 1. The Pearson
correlations between the ImPACT composite scores and the SDMT also are presented in
Table 1. The SDMT correlated more highly with the Processing Speed and the Reaction
Time composites than with the memory composites or total symptoms score.
Insert Table 1 About Here
Exploratory principal components factor analysis was conducted using the five
ImPACT composite scores and the SDMT. The subject to variable ratio was 12:1. The
communalities for the seven variables were high, ranging from .70 to .95. With the
eigenvalues set at .5, three components were extracted accounting for 81.9% of the total
variance. The first component accounted for approximately 55.1%, the second
component for 15.6%, and the third component for 11.3% of the variance. A varimax
rotation with Kaiser normalization was applied to the components. The rotated
components were interpreted as follows: (a)
Speed/Reaction Time
: SDMT .87,
Processing Speed Composite .85, and Reaction Time Composite -.76; (b) Memory
Verbal Memory Composite .87 and Visual Memory Composite .80; and (c) Total
symptoms .93.
The validation of neuropsychological tests is a gradual process, involving
numerous studies over extended periods of time. One aspect of validity is to correlate
computerized test scores with traditional test scores to better understand the presumed
Validity of ImPACT 9
underlying constructs being measured by the computerized tests. As predicted, the SDMT
correlated most highly with the Processing Speed and Reaction Time composites from
ImPACT. Exploratory factor analysis revealed a two-factor solution interpreted as
Speed/Reaction Time and Memory. The total symptoms score was extracted as a unique
component, but as a single variable it should not be considered a factor. It appears as if
the Processing Speed Composite, Reaction Time Composite, and SDMT are measuring a
similar underlying construct in this sample of concussed amateur athletes.
Similar results were obtained by Erlanger and colleagues (2003), who compared
the Concussion Resolution Index to the Symbol Digit Modalities Test and other
traditional neuropsychological measures. The Concussion Resolution Index is a web-
based, online, computerized neuropsychological assessment comprised of six cognitive
subtests. They found that the Processing Speed Index correlated .66 with the SDMT. The
correlations between the SDMT and the Simple Reaction Time (r = .31) and the Complex
Reaction Time (r = .39) Indexes were smaller.
The ongoing validation of a test relates to its clinical use, not to the test itself. Our
goal should be to validate the clinical inferences we derive from tests (Franzen, 1989,
2000). By focusing on the validity of inferences, we focus on the decision-making
process of the clinician. Toward that end, ImPACT has been used in multiple studies of
athletes with concussions. The composite scores, especially the memory and symptoms
composites from Version 1 (Collins et al., 2003; Iverson et al., in press; Lovell et al.,
2003; Lovell et al., in press) and the Verbal Memory, Reaction Time, and symptoms
composites from Version 2 (Iverson et al., 2004), are very sensitive to the initial effects
of concussion in amateur athletes.
Validity of ImPACT 10
Current ongoing research at the University of Pittsburgh Medical Center
employing ImPACT and functional magnetic resonance imaging (fMRI) can also be
conceptualized as validity work. The physiological changes following concussion at the
cellular level have been clarified over the past 15 years, through animal and in vitro
modeling (e.g., see Gaetz, 2002; Giza & Hovda, 2004; ADD 2 others for reviews).
Essentially, it is believed that cerebral concussion triggers a multilayered neurometabolic
cascade of physiological changes at the cellular level (Giza & Hovda, 2004). It is these
physiological changes that are believed to underlie the symptoms reported by athletes in
the initial hours and days post injury, as well as the decrements in neuropsychological
test performance. Conducting baseline and serial postconcussion evaluations with
ImPACT, in tandem with fMRI, might (a) help us better understand the underlying
physiological constructs being measured by the test, and (b) facilitate decision making
regarding the clinical management of athletes with concussions. Initial results from this
work will be forthcoming in the near future.
Validity of ImPACT 11
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Validity of ImPACT 16
Table 1. Descriptive statistics and correlations.
Measure Mean SD Range r
Verbal Memory 81.2 12.4 46 – 100 .46**
Visual Memory 72.3 14.9 29 – 95 .37**
Procession Speed 35.6 8.3 16.1 – 53.8 .70**
Reaction Time .58 .12 .41 – 1.04 -.60**
Total Symptoms 17.4 16.3 0 – 60 -.29*
SDMT 58.0 10.0 39 – 83 ---
p < .05, **p < .01
... Convergent and discriminant validity were examined most frequently for ImPACT. Maerlender et al. (2010) found ImPACT correlated with the California Verbal Learning Test-2 (ImPACT Verbal Memory r = 0.40), Brief Visuospatial Memory Test-Revised (BVMT-R) (ImPACT Visual Memory r = 0.59), Connor's Continuous Performance Test SDMT correlations were stronger for ImPACT speeded subtests (r = -0.60 and 0.70) and weaker for ImPACT memory subtests (r = 0.37 and 0.46), providing support for convergent and discriminant validity (Iverson et al., 2005). ...
... Factor analysis generally supports factor validity (i.e., that performance reflects the aspect of cognition theoretically underlying the test domain). ImPACT memory and processing speed factors have been identified in samples of healthy and concussed athletes using exploratory (Gerrard et al., 2017;Iverson et al., 2005;Thoma et al., 2018) and confirmatory factor analysis (Maietta et al., 2021;Masterson et al., 2019;Schatz & Maerlender, 2013) as well as multitrait-multimethod analysis with traditional pencil-and-paper assessments (Thoma et al., 2018). Factors of memory and executive functioning have emerged within baseline pencil-and-paper assessments comprising the HVLT-Revised (HVLT-R), BVMT-R, TMT, and COWAT using exploratory factory analysis (Lovell & Solomon, 2011). ...
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Athletic programs are more frequently turning to computerized cognitive tools in order to increase efficiencies in concussion assessment. However, assessment using a traditional neuropsychological test battery may provide a more comprehensive and individualized evaluation. Our goal was to inform sport clinicians of the best practices for concussion assessment through a systematic literature review describing the psychometric properties of standard neuropsychological tests and computerized tools. We conducted our search in relevant databases including Ovid Medline, Web of Science, PsycINFO, and Scopus. Journal articles were included if they evaluated psychometric properties (e.g., reliability, sensitivity) of a cognitive assessment within pure athlete samples (up to 30 days post-injury). Searches yielded 4,758 unique results. Ultimately, 103 articles met inclusion criteria, all of which focused on adolescent or young adult participants. Test–retest reliability estimates ranged from .14 to .93 for computerized tools and .02 to .95 for standard neuropsychological tests, with strongest correlations on processing speed tasks for both modalities, although processing speed tasks were most susceptible to practice effects. Reliability was improved with a 2-factor model (processing speed and memory) and by aggregating multiple baseline exams, yet remained below acceptable limits for some studies. Sensitivity to decreased cognitive performance within 72 h of injury ranged from 45%–93% for computerized tools and 18%–80% for standard neuropsychological test batteries. The method for classifying cognitive decline (normative comparison, reliable change indices, regression-based methods) affected sensitivity estimates. Combining computerized tools and standard neuropsychological tests with the strongest psychometric performance provides the greatest value in clinical assessment. To this end, future studies should evaluate the efficacy of hybrid test batteries comprised of top-performing measures from both modalities.
... Generally, every sport activity consistently uses maximum intensity in a short time with the main energy source being anaerobic. Increasing the speed of a kenshi in doing mawashi geri kicks is one very important element to win a match and prevent the opponent from counterattacking [54]. The ability of a kenshi to perform mawashi geri kicks with good speed will give victory in the art of free fighting or randori. ...
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... An important consideration for monitoring of concussion is that improvements are likely to reflect the joint contribution of retest learning and recovery from the injury. That is, concussion recovery is associated with improvements in processing speed (2,(41)(42)(43)(44)(45), and retest effects should trend in the same direction. Application of cognitive process models may help dissociate retest-from recovery-related improvements. ...
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Concussion is a mild traumatic brain injury that is characterized by a wide range of physical, emotional, and cognitive symptoms as well as neurocognitive, vestibular, and ocular impairments that can negatively affect daily functioning and quality of life. Clinical consensus statements recommend a targeted, clinical profile-based approach for management and treatment. This approach requires that clinicians utilize information obtained via a clinical interview and a multi-domain assessment battery to identify clinical profile(s) (e.g., vestibular, mood/anxiety, ocular, migraine, cognitive fatigue) and prescribe a corresponding treatment/rehabilitation program. Despite this comprehensive approach, the clinical picture can be limited by the accuracy and specificity of patient reports (which often conflate timing and severity of symptomology), as well as frequency and duration of exposure to symptom exacerbating environments (e.g., busy hallways, sitting in the back seat of a car). Given that modern rehabilitation programs leverage the natural environment as a tool to promote recovery (e.g., expose-recover approach), accurate characterization of the patient clinical profile is essential to improving recovery outcomes. Ambulatory assessment methodology could greatly benefit concussion clinical care by providing a window into the symptoms and impairments experienced by patients over the course of their daily lives. Moreover, by evaluating the timing, onset, and severity of symptoms and impairments in response to changes in a patient's natural environment, ambulatory assessments can provide clinicians with a tool to confirm clinical profiles and gauge effectiveness of the rehabilitation program. In this perspective report, we review the motivations for utilizing ambulatory assessment methodology in concussion clinical care and report on data from a pilot project utilizing smart phone-based, ambulatory assessments to capture patient reports of symptom severity, environmental exposures, and performance-based assessments of cognition for 7 days following their initial evaluation.
Objective: To examine the frequency and association of neck pain symptoms in patients with a concussion. Study setting and participants: Three-hundred and thirty-one consecutively enrolled patients aged 9 to 68 years with a diagnosed concussion 1 to 384 days post-injury were enrolled at a concussion clinic from a single integrated healthcare system in Western Pennsylvania between 2019 and 2021. Design: Retrospective cohort analysis of prospectively collected concussion screening tool intake survey responses and clinical outcomes data. The primary outcome was self-reported neck pain or difficulty with neck movement on the Concussion Clinical Profiles Screening (CP Screen) tool, recovery time, and incidence of treatment referral. Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) composite scores, Vestibular/Ocular Motor Screening (VOMS) item scores, type and severity of neck symptoms, mechanism of injury, time from injury to clinic presentation, medical history, and concussion symptom profile were secondary outcomes. Results: Of the 306 consecutively enrolled eligible patients in the registry, 145 (47%) reported neck pain, 68 (22.2%) reported difficulty moving their neck, and 146 (47.7%) reported either symptom. A total of 47 (15.4%) participants reported more severe neck symptoms, and this group took longer to recover (40 ± 27 days) than those not reporting neck symptoms (30 ± 28 days; U = 8316, P < .001). Stepwise logistic regression predicting more severe neck symptoms was significant (Nagelkerke R2 = 0.174, χ2 = 9.315, P = .316) with older age (P = .019) and mechanism of injury including motor vehicle collisions (MVCs) (P = .047) and falls (P = .044) as risk factors. MVCs and falls were associated with over 4 times and 2 times greater risk, respectively, for reporting more severe neck symptoms. Conclusion: Neck pain and stiffness symptoms are common in patients with a concussion following high-energy mechanisms of injury including MVCs or falls from height. These symptoms are associated with prolonged recovery. Providers should evaluate neck symptoms and consider targeted treatment strategies to limit their effects in patients with a concussion.
Background Technology for concussion identification and management is rapidly expanding across the continuum of care. Although many technologies offer a range of services around concussion, there is an absence of a non-commercial online location for medical providers to access regarding the functionality of the various technologies used in concussion identification and management. Objective The purpose of this review is to present research findings on technology for concussion identification and management. Methods Searches for eligible studies were conducted using the PubMed, EMBASE, and Scopus databases with specific search criteria. Through a stepwise process, full-text articles were selected for inclusion if they described clinically useful electronic technologies (i.e. electronics able to be used in standard clinical environments including telehealth) by healthcare providers or end users (i.e. parents or athletes). Results A total of 29 articles were included in this review and described technology used to measure symptoms (3), neurocognitive performance (7), the visual system (4), and balance or dual task performance (18). Within the results, various technologies demonstrated increased utility for concussion identification, often detecting subtle deficits not possible with current low-tech clinical methods, differentiating those with concussion from those without concussion, with strong reliability and validity. Conclusion Innovative technologies included in this review demonstrate enhanced ability to identify and manage symptoms of concussion, neurocognitive deficits, visual deficits, and balance and dual-task deficits.
Sports-related concussions (SRC) are frequent injuries occurring in most contact and collision sports across all ages and all levels of play. Once thought of as a “ding” or simply “part of the game,” it is now understood that concussions are brain injuries that can have significant neurocognitive consequences if not evaluated and managed appropriately. This chapter reviews the definition of concussion, mechanism of injury, the pathophysiology underlying the injury, epidemiology, and the clinical management of players who have sustained a concussion. The focus then turns to prevention of the injury and, more importantly, the prevention of deleterious consequences from improper management. Various prevention strategies are discussed ranging from education to legislative reform.KeywordsSports concussionNeuropsychological assessmentConcussion pathophysiologyConcussion advocacyConcussion prevention
Objective: To determine whether slow processing speed is associated with risk of sport-related concussion. Design: We conducted a retrospective cohort study using computerized neurocognitive assessments (Immediate Post-concussion Assessment and Cognitive Testing [ImPACT]) from the Massachusetts Concussion Management Coalition. Slow processing speed was defined as 2 SD below the sample mean (n = 131) and fast processing speed as 2 SD above the sample mean (n = 259). We used a binary logistic regression model to determine the odds of sustaining a concussion with our main predictor being processing speed (high or low) adjusted for the effects of age, sex, and prior number of concussions. Setting: Massachusetts Concussion Management Coalition, Institutional care. Participants: Three hundred ninety junior high soccer players ages 10 to 15 with a baseline score for ImPACT. Independent variables: Processing Speed. Main outcome measures: Risk of sustaining a concussion. Results: Those with slow processing speed had a visual motor composite score of ≤19.92, those with fast-processing speed had a score of ≥46.20. Athletes with slow processing speed were younger (13 vs 14 years; P < 0.001) and more likely to be male (57% vs 49%; P = 0.014). After adjusting for the effects of age, sex, and prior concussions, there was no significant difference in the odds of sustaining a concussion between groups (aOR 1.01; 95% CI, 0.99-1.04). Conclusions: Despite previous research showing that slow processing speed is a risk factor for musculoskeletal injuries during sports, our study suggests that processing speed is not associated with the risk of sustaining a concussion among junior high school soccer players.
Concussion screening among collegiate lacrosse athletes is a major safety priority. Although attention has been directed at concussion management following injury, less is known about the association between cognition and balance during preseason screening. The purpose of the study was to assess the relationship between balance and neurocognition among collegiate male lacrosse players and to examine predictive determinants of postural stability. Participants included a convenience sample of 49 male collegiate Division 3 lacrosse players who completed a demographic survey and performed the immediate postconcussion test and instrumented sensory organization test (SOT). There was a significant association between balance SOT performance and both verbal memory (r = .59, p < .01) and visual motor speed scores (r = .43, p < .05). Significant correlations between verbal memory and SOT Conditions 2, 5, and 6 were also noted (all p < .05). Verbal memory predicted 33% of the variance in the SOT composite balance score (p < .001). Our results indicate a significant relationship exists between postural stability and both verbal memory and visual processing speed among collegiate male lacrosse players and supports vestibulocortical associations. Findings warrant ongoing performance and executive function tracking and can serve as a conduit for integrated sensorimotor and dual-task training.
Background: The symptom presentation after sport-related concussion is highly subjective, while the clinical test of reaction time (RT) has been presented as an objective tool to the effects of sport-related concussion. A multimodal assessment approach supports concussion management; therefore, it is appropriate to explore the relationship between modals. The aim of the present study is to investigate the relationship of clinical RT and post-concussion symptom (PCS) score, number of experienced concussions, and time since concussion. Methods: Based on retrospective concussion history, 53 athletes were selected for this study. Athletes were questioned using a standardized questionnaire to obtain concussion history data, such as number of cumulative concussions and date of most recent concussion. Symptom scores were gathered through Sport Concussion Assessment Tool. A clinical RT test was used to obtain RT data. Results: A significant positive correlation was found between RT and the PCS score. A linear regression revealed that the PCS score but neither the cumulative number of experienced concussions, nor the time post-concussion significantly predicts increased RT. Reaction time positively correlates with the symptoms neck pain, dizziness, balance problems, light sensitivity, feeling slowed down, feeling like in a fog, do not feel right, drowsiness, and irritability. Conclusions: This study presents that the PCS score particularly predicts increased RT after sport-related concussions. Furthermore, a specific set of symptoms significantly impacts the RT of athletes. The results suggest that not a single symptom drives the relationship between PCS score and RT, highlighting the heterogeneity of this injury.
Objectives: To investigate the relationship between sleep disturbance, neurocognition, symptom severity, and recovery in children and adolescents with concussion. Sex-related comparisons were also examined. Setting: Pediatric tertiary referral concussion clinic. Participants: Children and adolescents (aged 6-18 years; n = 554) diagnosed with concussion. Design: Cross-sectional retrospective study. Main measures: Assessment data were obtained from Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) Applications. Sleep disturbance was quantified using the sleep-related domains of the Post-Concussion Symptom Scale (PCSS) and self-report sleep duration. Sleep duration was categorized as short (<7 hours), intermediate (7-9 hours), and long (≥9 hours). Outcome measures included neurocognition, measured via composite scores of ImPACT cognitive domains (verbal memory, visual memory, visual motor speed, reaction time); symptom severity, using the PCSS; and concussion recovery time (days). Results: Short sleep resulted in significantly poorer verbal memory (P = .03), visual memory (P = .02), and reaction time (P = .01). Sleep disturbance was strongly associated with total symptom burden (ρ = 0.90, P < .001). Recovery time, median (interquartile range), was significantly prolonged with short sleep, 61 (30-136) days, compared with intermediate, 38 (21-72) days, and long, 34 (19-71) days, sleep (P < .001). Overall, female participants demonstrated significantly longer recovery times than male participants (mean 91 ± 95 vs 58 ± 85 days, P < .001). Females exhibited similar concussion recovery times irrespective of reported sleep duration (P = .95), whereas mean recovery time in males was significantly longer with short sleep (84 ± 82 days) than with intermediate (61 ± 106 days) and long (49 ± 62 days) sleep (P < .001). Conclusion: Sleep disturbance following concussion poses as a promising modifiable risk factor to alleviate postinjury impairments, including cognitive deficits and symptom burden. Female children were found to experience more severe concussion symptoms and protracted recovery times than their male counterparts. Investigations into the factors that may contribute to sex-related differences following concussion are warranted.
1. Preliminary Measurement Considerations in Clinical Neuropsychology. 2. General and Theoretical Considerations in the Assessment of Reliabilty. 3. Practical and Methodological. 4. Elemental Considerations in Validity. 5. Validity as Applied to Neuropsychological Assessment. 6. The Wechsler Adult Intelligence Scale-Revised and Wechsler Adult Intelligence Scale-III. 7.The Wechsler Intelligence Scale for Children-Revised and Wechsler Intelligence Scale for Children-III. 8. Test of General Intelligence. 9. The Halstead-Reitan Neuropsychological Battery and Luria-Nebraska Neuropsychological Battery. 10. Benton's Neuropsychological Assessment. 11. The Minnesota Multiphasic Personality Inventory. 12. The Rorschach Inkblots. 13. The Wechsler Memory Scale and its Revisions. 14. Tests of Memory. 15. Tests of Visual and Construction Function. 17. Tests of Higher Cognitive Function. 18. Screening Devices. 19. Tests of Aptitude and Achievement. 20. Methods for Evaluating the Validity of Test Scores. 21. The Assessment of Child Neuropsychological Function. Postscript. References.
The Children's Orientation and Amnesia Test (COAT) was developed to assess posttraumatic amnesia (PTA) and cognitive functioning in children and adolescents who are in the early stages of recovery from traumatic brain injury. The COAT is composed of 16 items designed to assess general orientation, temporal orientation, and memory. The original norms are inadequate for several age groups because they were based on small sample sizes and may have been compromised by ceiling effects. In this study, normative data were collected for children between the ages of 8 and 13 (N=248). Regression-predicted age norms were calculated and presented in tabular form. These results provide important reference data for interpreting COAT scores of children who have sustained traumatic brain injuries. (C) 2001 National Academy of Neuropsychology. Published by Elsevier Science Ltd.
Recent evidence suggests significant short-term neurocognitive deficits following mild traumatic brain injury (MTBI) in sports. However, sequelae of mild head injuries is complicated by many factors including a history of multiple head injuries and injury severity. Few studies have considered the influence these variables may have on proper classification of a MTBI and their meaning for return-toplay guidelines. This study presents the short-term neuropsychological and balance outcomes of four college athletes who sustained mild head injuries of different severity (grade I, grade II, grade III and multiple head injured with a grade II based on American Academy of Neurology guidelines). The results demonstrated that self-report symptoms of concussion were slow to resolve in the grade III and multiple concussed individuals. For neuropsychological testing, Trails A & B, Symbol Digit Modalities Test and Digits Span Backwards were the most sensitive in identifying differences between the injuries. For balance ...
Background Recent concussion management guidelines have suggested that athletes with mild (grade 1) concussions may be returned to play if asymptomatic for 15 minutes. The purpose of this study was to assess the utility of a current concussion management guideline in classifying and managing mild concussion. Hypothesis High school athletes diagnosed with a grade 1 concussion will demonstrate measurable decline in neuropsychological functioning that persists during the 1st week of recovery. Study Design Prospective study designed to evaluate neuropsychological functioning both prior to and following concussion. Methods Forty-three high school athletes completed neuropsychological test performance and symptom ratings prior to the season and at two times during the 1st week following mild concussion. Results Thirty-six hours after injury, mildly concussed high school athletes demonstrated a decline in memory (P < 0.003) and a dramatic increase in self-reported symptoms (P < 0.00001) compared to baseline performance. Conclusions Athletes with grade 1 concussion demonstrated memory deficits and symptoms that persisted beyond the context in which they were injured. These data suggest that current grade 1 return-to-play recommendations that allow for immediate return to play may be too liberal. Clinical Relevance A reconsideration of current concussion grading systems appears to be warranted.
Background—“Paper and pencil” neuropsychological tests play an important role in the management of sports related concussions. They provide objective information on the athlete's cognitive function and thus facilitate decisions on safe return to sport. It has been proposed that computerised cognitive tests have many advantages over such conventional tests, but their role in this domain is yet to be established. Objectives—To measure cognitive impairment after concussion in a case series of concussed Australian Rules footballers, using both computerised and paper and pencil neuropsychological tests. To investigate the role of computerised cognitive tests in the assessment and follow up of sports related concussions. Methods—Baseline measures on the Digit Symbol Substitution Test (DSST), Trail Making Test-Part B (TMT), and a simple reaction time (SRT) test from a computerised cognitive test battery (CogState) were obtained in 240 players. Tests were repeated in players who had sustained a concussive injury. A group of non-injured players were used as matched controls. Results—Six concussions were observed over a period of nine weeks. At the follow up, DSST and TMT scores did not significantly differ from baseline scores in both control and concussed groups. However, analysis of the SRT data showed an increase in response variability and latency after concussion in the injured athletes. This was in contrast with a decrease in response variability and no change in latency on follow up of the control players (p<0.02). Conclusion—Increased variability in response time may be an important cognitive deficit after concussion. This has implications for consistency of an athlete's performance after injury, as well as for tests used in clinical assessment and follow up of head injuries.
The Concussion Resolution Index (CRI) is an online assessment tool designed to track resolution of symptoms following sports-related concussion. The CRI is composed of six subtests measuring reaction time, visual recognition, and speed of information processing. Three factors are derived from the subtests: Simple Reaction Time (SRT), Complex Reaction Time (CRT), and Processing Speed (PS). Multiple alternate forms within subtests afford simple, reliable, assessment of change, relative to a baseline test completed by an athlete. The test also assesses self-reported neurophysiological symptoms at the time of injury and tracks resolution of these symptoms. The data demonstrate the CRI is a valid and reliable measure of cognitive performance in a relatively heterogeneous group of athletes aged 13–35. Two methods of statistical analysis for assessing change from baseline were compared to establish a psychometric basis for return-to-play decision-making: the Reliable Change Index (RCI) and multiple regression. Multiple regression was more accurate than the RCI in determining a decline in performance relative to the baseline.