A Normative Reference vs. Baseline Testing Compromise for ImPACT: The CARE Consortium Multiple Variable Prediction (CARE-MVP) Norms.

Abstract

Sports medicine clinicians routinely use computerized neurocognitive testing in sport-related concussion management programs. Debates continue regarding the appropriateness of normative reference comparisons versus obtaining individual baseline assessments, particularly for populations with greater likelihood of having below- or above-average cognitive abilities. Improving normative reference methods could offer alternatives to perceived logistical and financial burdens imposed by universal baseline testing. To develop and validate the Concussion Assessment, Research, and Education (CARE) Consortium Multiple Variable Prediction (MVP) norms for the Immediate Postconcussion Assessment and Cognitive Testing (ImPACT). We developed the CARE-MVP norms for ImPACT composite scores using regression-based equations. Predictor variables included sex, race (white/Caucasian, black/African American, Asian, or Multiple Races), medical history [attention-deficit/hyperactivity disorder (ADHD), learning disorder (LD), prior concussion(s), prior psychiatric diagnosis], and an estimate of premorbid intellect (Wechsler Test of Adult Reading). CARE-MVP norms were first validated in an independent sample of healthy collegiate athletes by comparing predicted and actual baseline test scores using independent-samples t-tests and Cohen's d effect sizes. We then evaluated base rates of low scores in athletes self-reporting ADHD/LD (vs. non-ADHD/LD) and black/African American race (vs. white/Caucasian) across multiple normative reference methods (Chi square, Cramer's V effect size). Lastly, we validated the CARE-MVP norms in a concussed sample (dependent samples t test, Cohen's d effect size). A total of 5233 collegiate athletes (18.8 ± 1.2years, 70.5% white/Caucasian, 39.1% female) contributed to the CARE-MVP norms (development N = 2616; internal validation N = 2617). Race and WTAR score were the strongest and most consistent ImPACT score predictors. There were negligible mean differences between observed and predicted (CARE-MVP) baseline scores (Cohen's d < 0.1) for all ImPACT composite scores except Reaction Time (predicted ~ 20ms faster than observed, d = - 0.28). Low score base rates were similar for athletes across subpopulations when using CARE-MVP norms (ADHD/LD, V = 0.017-0.028; black/African American, V = 0.043-0.053); while, other normative reference methods resulted in disproportionately higher rates of low scores (ADHD/LD, V = 0.062-0.101; black/African American race, V = 0.163-0.221). Acute (24-48h) postconcussion ImPACT scores were significantly worse than CARE-MVP norms but notably varied as a function of concussion symptom severity. Results support CARE-MVP norm use in populations typically underrepresented or not adjusted for in traditional normative reference samples, such as those self-reporting ADHD/LD or black/African American race. CARE-MVP norms improve upon prior normative methods and may offer a practical, simple alternative for collegiate institutions concerned about logistical and financial burden associated with baseline testing. An automated scoring program is provided.