1 Introduction to ImPACT Immediate Post Concussion Assessment and Cognitive Testing Gary Solomon, Ph.D. Associate Professor of Neurological Surgery, Orthopaedic Surgery and Rehabilitation, and Psychiatry, Co-Director, Vanderbilt Sports Concussion Center Vanderbilt University School of Medicine Team Neuropsychologist, Nashville Predators Consulting Neuropsychologist, Tennessee Titans
2 ImPACT is a neuropsychological screening tool designed specifically for sport-related concussion. Norms are available for male and female athletes ages ImPACT is computer administered and takes about 30 minutes. ImPACT is not a substitute for neuropsychological testing. Neuropsychological testing is a much more in-depth assessment of cerebral functioning, and can take 2-8 hours to complete (paper and pencil and/or computer based tests). Norms for formal neuropsychological testing are available for children through 90+ years.
3 What does ImPACT Measure? Demographic/Concussion History Questionnaire Concussion Symptom Scale - 21 Item, 0-6 Likert scale (e.g., headache, dizziness, nausea, etc.) Neurocognitive Measures - Measures domains of Visual and Verbal Memory, Reaction Time, & Visual Motor (Processing) Speed yields Composite Scores Detailed Clinical Report - Automatically computer scored - Outlines demographic, symptom, neurocognitive data
4 What does ImPACT enable us to do? Provides objective data to help determine an athlete s status Protects the student-athlete and the professional athlete Helps determine safe RTP Helps prevent the potential effects of repeat concussions
5 Clinical Protocol ImPACT Testing Concussion Hours Day 5-10 Baseline Testing Beyond if necessary (Ideal, but not necessary for decision making; VSCC uses the baseline model)
6 There have been several iterations of ImPACT since 2001; current version is 2.1 First major change was the separation of the Memory Composite into Verbal Memory and Visual Memory Initial version of ImPACT was a disk & desktop version with local storage Current version is on-line, with HIPPA compliant on-line storage at ImPACT (but test results are printable and downloadable) Current slides show old and new versions of ImPACT
7 You will log in with your and password. Your will have access to baseline/follow-up testing and review of results for your team(s).
10 Demographics First Name Last Name Organization Height Weight Gender Handedness
11 Identifying Data
12 Country/Language (18 languages)
13 Demographics/Modifying Factors/Sport (Years of education completed: college freshman = 12; 9 th grader = 8) - Years in North America Years of education completed Check any of the following that apply - Received speech therapy - Attended special education classes - Repeated one or more years of school - Diagnosed ADD or Hyperactive - Diagnosed learning disability Current sport - Current position/event/class - Current Level Years experience
14 Medical History/Modifying Factors
15 Recent demographic additions Ethnicity
16 Concussion History
17 Post Concussion Symptom Scale 0= Not having the symptom 1-6 rating scale if the athlete is having the symptom 1 = Minor, 6 = Severe How they are feeling past 24 hrs.
18 Symptom Checklist (PCS; n=22)
19 Module 1: Word Discrimination Verbal learning and recognition memory
20 Module 1 (Word Discrimination) Evaluates attentional processes/verbal recognition memory Utilizes a word discrimination paradigm. Twelve target words are presented for 750 milliseconds (twice to facilitate learning of the list) The subject is then tested for recall via the presentation of the 24-word list that is: comprised of 12 target words and 12 non-target words Words chosen from the same semantic category as the target word. EX: the word ice is a target word, while the word snow represents the non-target word. The subject responds by mouse-clicking the yes or no buttons Individual scores are provided both for correct yes and no responses -In addition, a total percent correct score is provided. There are five different forms of the word list. Delay Condition: Following the administration of all other test modules (approximately 20 minutes), the subject is again tested for recall via the same method described above. The same scores that are described above are provided for the delay condition.
23 Module 2: Design Memory Visual learning and recognition memory
24 Module 2 (Design Memory) Evaluates attentional processes and visual recognition memory Utilizes a design discrimination paradigm. Twelve target designs are presented for 750 milliseconds (twice to facilitate learning) The subject is then tested for recall via the presentation of the 24-designs comprised of 12 target designs and 12 non-target designs EX: target designs that have been rotated in space The subject responds by mouse-clicking the yes or no buttons Individual scores are provided both for correct yes and no responses In addition, a total percent correct score is provided There are five different forms of this task
27 Module 3: X s and O s Visuospatial memory and processing speed
28 Module 3 (X s s and O s) O Measures visual working memory, visual processing speed, and visual memory paradigm Incorporates a distractor task. The subject can practice the distractor task prior to presentation of the memory task The distractor is a choice reaction time test: the subject is asked to click the left mouse button if a blue square is presented and the right mouse button if a red circle is presented. Once the subject has completed this task, the memory task is presented. Memory task: a random assortment of X s and O s is displayed for 1.5 seconds For each trial: three of the X s or O s are illuminated in YELLOW (the subject has to remember the location of the illuminated objects). Immediately after the presentation of the 3 X s or O s, the distractor task re-appears on the screen. Following the distractor task, the memory screen (X s and O s) re-appears and the subject is asked to click on the previously illuminated X s and O s. Scores are provided for correct identification of the X s and O s (memory), reaction time for the distractor task, and number of errors on the distractor task. For each administration of ImPACT, the subject completes 4 trials.
30 Replaced by p for red dot and q for blue square
31 Click the three that were yellow
32 Module 4: Symbol Matching Processing speed and memory
33 Module 4 (Symbol Matching) Evaluates visual processing speed, learning and memory Initially, the subject is presented with a screen that displays 9 common symbols (triangle, square, arrow, etc). Directly under each symbol is a number button from 1 to 9.Below this grid, a symbol is presented. The subject is required to click the matching number as quickly as possible and to remember the symbol/number pairings Correct performance is reinforced through the illumination of a correctly clicked number in GREEN. Incorrect performance illuminates the number button in RED. Following the completion of 27 trials, the symbols disappear from the top grid. The symbols again appear below the grid and the subject is asked to recall the correct symbol/number pairing by clicking the appropriate number button. This module provides an average reaction time score and a score for the memory condition.
34 After a period of time, the numbers disappear and the athlete has to remember which symbol corresponds with which number
35 Module 5: Color Match Reaction time and impulse control
36 Module 5 (Color Match) Represents a choice reaction time task and measures impulse control/response inhibition First, the subject is required to respond by clicking a red, blue or green button as they are presented on the screen. This procedure is completed to assure that subsequent trials would not be affected by color blindness Next, a word is displayed on the screen in the same colored ink as the word (e.g. RED), or in a different colored ink (GREEN or BLUE) The subject is instructed to click in the box as quickly as possible only if the word is presented in the matching ink. In addition to providing a reaction time score, this task also provides an error score.
39 Module 6: Three Letters Working memory and processing speed
40 Module 6 (Three letters) Measures working memory and visual-motor response speed First, the subject is allowed to practice a distractor task Consists of 25 numbered buttons (5 x 5 grid). The subject is instructed to click as quickly as possible on the numbered buttons in backward order starting with 25. (has an initial practice task) Then they are presented with three consonant letters displayed on the screen. Immediately following display of the 3 letters, the numbered grid re-appears and the subject is instructed to click the numbered buttons in backward order, again After a period of 18 seconds, the numbered grid disappears and the subject is asked to recall the three letters by typing them from the keyboard. Both the number placement on the grid and letters displayed are randomized for each trial. Yields a memory score (total number of correctly identified letters) and a score for the average number of correctly clicked numbers per trial from the distractor test. Five trials of this task are presented for each administration of the test.
41 C S W
43 What were the 3 letters? Type them in order
44 Delayed Recall Word Discrimination (Module 1; stimuli and distractors)
45 Delayed Recall Design Memory (Module 2; stimuli and distractors)
46 Test is now completed and is automatically scored & saved Athlete is automatically logged out and cannot access the results Results will be interpreted according to Team Physician s preference
47 ImPACT s Composite Scores Verbal Memory Visual Memory Reaction Time Visual-Motor Speed (Processing Speed) Impulse Control Total Symptoms
48 Report: Composite Scores Red = raw scores; Green = percentile scores (age/gender)
49 Report: Raw Scores
50 Report: Raw Scores
51 ImPACT subscales and Loadings on Composite Scores Verbal Memory Composite Average of: (Word Memory- Total Percent Correct) (Symbol Match- Total Correct/Hidden)/9*100 (Three Letters- Total Sequence Correct)/5*100 Visual Memory Composite Average of: (Design Memory- Total Percent Correct) (X s and O s- Total Correct/Memory)/12*100 Visual-Motor Speed Composite (Processing Speed) Average of: (X s and O s- Total Correct/Interference)/4 (Three Letters-Average Counted Correctly)*3
52 ImPACT subscales and Loadings on Composite Scores Reaction Time Composite Average of: (X s and O s- Average Correct Reaction Time Interference) (Symbol Match- Average Correct Reaction Time/Visible)/3 (Color Match- Average Correct Reaction Time) Impulse Control Composite Average of: (X s and O s- Total Incorrect/Interference) (Color Match- Total Commissions) Symptom Total Score Sum of: All symptoms reported by athlete on the Post-Concussion Symptom Scale
53 Report: Symptom Scores
54 Report: Graph of Composite Scores
55 Recent and Forthcoming additions to ImPACT ImPACT Symptom Increase Score Performed for post concussion assessments Athlete completes the symptom scale again (how he/she feels now after taking the test), assessing whether the cognitive exertion of taking the test provoked symptoms Cognitive Efficiency Index Speed and Memory Scores (Forthcoming)
56 Symptom Increase Score in Red
57 Cognitive Efficiency Index The Cognitive efficiency Index measures the interaction between accuracy (percentage correct) and speed (reaction time) in seconds on the Symbol Match test Determines the extent to which the athlete tried to work very fast on symbol match (decreasing accuracy) or attempted to improve their accuracy by taking a more deliberate and slow approach (jeopardizing speed) The range of scores is from approximately zero to approximately.70 with a mean of.34. A higher score indicates that the athlete did well in both the speed and memory domains on the symbol match test. A low score (below.20) means that they performed poorly on both the speed and accuracy component. If this score is a negative number, the test taker performed very poorly on the reaction time component.
58 Two-Factor Theory (Schatz, UPMC, 2013) Archives of Clinical Neuropsychology, in press Factor analysis results Baseline Group (N=22,000) Concussion Group (N=560)
59 ImPACT is a screening tool that is extremely useful in assessing the neurobehavioral and cognitive symptoms of concussive injury. When used appropriately, it is a valuable piece of the concussion puzzle. Having a baseline is ideal, but not necessary. ImPACT is not a concussion test ; No such test exists There is no pregnancy test for concussion