Immediate Post-Concussion Assessment And Cognitive Testing Scores Research Articles

Effects of hours of sleep on ImPACT concussion testing: comparing baseline with postinjury scores.

The influence of sleep on baseline and postconcussion neurocognitive performance prior to Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) is poorly understood. Since ImPACT is widely used in youth sport to assess neurocognitive performance before and after head injury, it is important to delineate factors that affect testing performance. While some have reported correlations between fewer hours of sleep and lower scores on baseline tests, others have not observed any such associations. Therefore, the authors sought to compare the relationship between sleep and neurocognitive performance on ImPACT at both baseline and postinjury. The authors queried a database of 25,815 ImPACT tests taken from 2009 to 2019 by athletes aged 12-22 years. There were 11,564 baseline concussion tests and 7446 postinjury concussion ImPACT tests used in the analysis. Linear regression was used to model the effect of sleep on baseline and postconcussion ImPACT scores adjusting for sex, age, learning disability, attention-deficit/hyperactivity disorder, number of prior concussions, number of games missed, and strenuous exercise before testing. Mean composite scores expectedly were all significantly lower in the post-head injury group compared with the baseline group. In the multivariable analysis, at baseline, hours of sleep significantly affected symptom scores (β = -1.050, 95% CI -1.187 to -0.9138; p < 0.0001). In the postinjury multivariable analysis, verbal memory (β = 0.4595, 95% CI 0.2080-0.7110; p = 0.0003), visual memory (β = 0.3111, 95% CI 0.04463-0.5777; p = 0.0221), impulse control (β = -0.2321, 95% CI -0.3581 to -0.1062; p = 0.0003), and symptom scores (β = -0.9168, 95% CI -1.259 to -0.5750; p < 0.0001) were all affected by hours of sleep. Hours of sleep did not alter neurocognitive metrics at baseline but did have an impact on post-head injury metrics. These findings suggest that individuals may be able to compensate for lack of sleep at baseline but not immediately after concussion. Concussions may reduce cognitive reserve or detract from the brain's resources, making sleep even more important for proper neurocognitive functioning postconcussion. Future work will analyze the effects of sleep on postconcussion test performance.

Population-based normative data and language effects of the Immediate Post-Concussion Assessmentand Cognitive Testing (ImPACT)

Objective When test results are interpreted based on the norms of the U.S. population, misdiagnoses of neurocognitive impairment could occur with subgroups of individuals whose demographic characteristics differ from the overall population. The present study compared locally-based normative test data of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) of high school athletes in Hawaii, where diverse ethnicity and bilingualism are prominent, versus published test norms. Method 8637 high school athletes in Hawaii underwent ImPACT baseline testing. Non-parametric group comparisons of age, sex, and language groups were performed. Classification ranges for the ImPACT Composite scores and Total Symptom of the Hawaii sample were presented in percentile ranks that corresponded to the published ImPACT normative tables. Results Mann–Whitney U Test indicated significant differences in ImPACT Verbal Memory, Visual Memory, Visual Motor Speed, and Reaction Time Composite scores between age groups and sexes, although the effect sizes were small. Kruskal–Wallis H Test indicated no differences among the language groups. Percentile ranks of the Hawaii scores were predominantly similar to the ImPACT norms, except for Visual Motor Speed in the Impaired and Borderline ranges. Conclusion The findings suggest that locally based normative data should be considered for sub-populations that may differ from the general population. Language factors, such as bilingualism, did not have significant effect on the ImPACT scores.

A multicenter, longitudinal survey of headaches and concussions among youth athletes in the United States from 2009 to 2019

Objective/ backgroundChronic headaches and sports-related concussions are among the most common neurological morbidities in adolescents and young adults. Given that the two can overlap in presentation, studying the effects of one on another has proven difficult. In this longitudinal study, we sought to assess the relationship between chronic headaches and concussions, analyzing the role of historic concussions on chronic headaches, as well as that of premorbid headaches on future concussion incidence, severity, and recovery.MethodsThis multi-center, longitudinal cohort study followed 7,453 youth athletes who were administered demographic and clinical surveys as well as a total of 25,815 Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) assessments between 2009 and 2019. ImPACT was administered at baseline. Throughout the season concussions were examined by physicians and athletic trainers, followed by re-administration of ImPACT post-injury (PI), and at follow-up (FU), a median of 7 days post-concussion. Concussion incidence was calculated as the total number of concussions per patient years. Concussion severity and recovery were calculated as standardized deviations from baseline to PI and then FU in Symptom Score and the four neurocognitive composite ImPACT scores: Verbal Memory, Visual Memory, Processing Speed, and Reaction Time. Data were collected prospectively in a well-organized electronic format supervised by a national research-oriented organization with rigorous quality assurance. Analysis was preformed retrospectively.ResultsOf the eligible athletes, 1,147 reported chronic headaches (CH) at the start of the season and 6,306 reported no such history (NH). Median age of the cohort was 15.4 ± 1.6 years, and students were followed for an average of 1.3 ± 0.6 years. A history of concussions (OR 2.31, P < 0.0001) was associated with CH. Specifically, a greater number of past concussions (r2 = 0.95) as well as concussions characterized by a loss of consciousness (P < 0.0001) were associated with more severe headache burden. The CH cohort had a greater future incidence of concussion than the NH cohort (55.6 vs. 43.0 per 100 patient-years, P < 0.0001). However, multivariate analysis controlling for demographic, clinical, academic, and sports-related variables yielded no such effect (OR 0.99, P = 0.85). On multivariable analysis the CH cohort did have greater deviations from baseline to PI and FU in Symptom Score (PI OR per point 1.05, P = 0.01, FU OR per point 1.11, P = 0.04) and Processing Speed (OR per point 1.08, P = 0.04), suggesting greater concussion severity and impaired symptomatic recovery as compared to the NH cohort.ConclusionA history of concussions was a significant contributor to headache burden among American adolescents and young adults. However, those with chronic headaches were not more likely to be diagnosed with a concussion, despite presenting with more severe concussions that had protracted recovery. Our findings not only suggest the need for conservative management among youth athletes with chronic headaches, they also indicate a potential health care gap in this population, in that those with chronic headaches may be referred for concussion diagnosis and management at lower rates than those with no such comorbidity.

Incidence and Severity of Concussions Among Young Soccer Players Based on Age, Sex, and Player Position

Background:Previously studied risk factors for sports-related concussion in soccer players include sex, age, and player position. However, prior studies were limited in number, they reported conflicting results, and most did not assess initial concussion severity.Purpose/Hypothesis:The purpose of this study was to conduct an in-depth analysis of soccer players across key demographic groups (sex, age, position) for both concussion incidence and severity. It was hypothesized that concussion incidence and severity would be higher among male players, players aged ≥17 years, and goalkeepers.Study Design:Cohort study; Level of evidence, 3.Methods:The authors analyzed baseline and postinjury ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) scores for athletes aged 12 to 22 years between July 2009 and June 2019. Players were assigned to an age group based on when they had their most recent baseline test. Concussion incidence and concussion severity index were compared using t tests and multivariate logistic regression.Results:For 1189 individuals who reported soccer as their primary sport, 1032 contributed 1754 baseline ImPACT tests (some individuals had multiple baseline tests), whereas 445 individuals were suspected of sustaining a concussion and then referred for a postinjury 1 test. Of these players, 254 (24.6%) had both a baseline and a postinjury test and were analyzed for concussion severity. Linear regression showed that forwards had a lower incidence of ImPACT-proxied concussions than goalkeepers had (P = .008). Female players had a significantly higher incidence of ImPACT concussions compared with male players (mean, 0.07 [female] vs 0.04 [male] concussions per person-year; P = .05). Players in the ≥17-year age group had a higher incidence of ImPACT concussions than players in the 15- to 16-year age group (P = .04), although the 15- to 16-year age group had more severe concussions than the ≥17-year age group (mean severity index, 2.91 [age 15-16 years] vs 1.73 [age ≥17 years]; P = .001).Conclusion:Female soccer players experienced a higher incidence of concussion than did male players, and goalkeepers experienced a greater incidence of ImPACT concussions than did forwards. Players of both sexes and all positions in the 15- to 16-year age group showed increased initial concussion severity compared with the ≥17-year age group, despite a lower comparative incidence of ImPACT concussions. Further study is needed to understand whether sex and player position affect concussion severity.

Concussion Incidence and Recovery Among Youth Athletes With ADHD Taking Stimulant-Based Therapy.

Background:Attention deficit hyperactivity disorder (ADHD) may affect concussion risk and recovery in youth athletes.Purpose:To evaluate the association between incidence of concussion and postinjury recovery of symptoms and neurocognitive dysfunction among youth athletes with ADHD and differential stimulant use.Study Design:Cohort study; Level of evidence, 3.Methods:From 2009 to 2019, the authors administered the Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) to youth athletes at the beginning of each season. Throughout the season, athletes with concussions were examined and readministered the ImPACT both postinjury and again 7 days after the postinjury administration. These athletes (N = 7453) were divided into those with ADHD on stimulant-based therapy (ADHD+meds; n = 167), those with ADHD not on stimulant-based therapy (ADHD-only; n = 354), and those with no ADHD (non-ADHD; n = 6932). Recovery of neurocognitive dysfunction at postinjury and follow-up was calculated using the ImPACT symptom score, verbal memory, visual memory, visual motor skills, and reaction time (calculated as standardized deviations from baseline). Univariate results were confirmed with multivariate analysis.Results:The ADHD+meds cohort had a lower incidence of concussion (37.3 concussions per 100 patient-years) compared with the ADHD-only group (57.0 concussions per 100 patient-years) (odds ratio [OR], 0.51 [95% CI, 0.37-0.71]; P < .0001) and non-ADHD group (52.8 concussions per 100 patient-years) (OR, 0.50 [95% CI, 0.37-0.67]; P < .0001). At postinjury, ImPACT scores were elevated from baseline to a similar extent in the ADHD+meds cohort compared with the other 2 groups. By follow-up, however, deviations from baseline were lower among the ADHD+meds group compared with the non-ADHD group in verbal memory (OR, 0.46 [95% CI, 0.28-0.76]; P = .002), visual memory (OR, 0.27 [95% CI, 0.10-0.66]; P = .005), and visual motor skills (OR, 0.58 [95% CI, 0.33-0.99]; P = .048). The deviation at follow-up was also lower among the ADHD+meds group compared with the ADHD-only group in visual memory (OR, 0.56 [95% CI, 0.33-0.96]; P = .04) and visual motor skills (OR, 0.42 [95% CI, 0.22-0.81]; P = .01).Conclusion:Stimulant use among youth athletes with ADHD was independently associated with reduced incidence for concussion and lower deviation from baseline in verbal memory, visual memory, and visual motor skills at 7 days postconcussion, suggesting lower neurocognitive impairment at follow-up in this group versus their peers.

Using Dynamics of Eye Movements, Speech Articulation and Brain Activity to Predict and Track mTBI Screening Outcomes

Repeated subconcussive blows to the head during sports or other contact activities may have a cumulative and long lasting effect on cognitive functioning. Unobtrusive measurement and tracking of cognitive functioning is needed to enable preventative interventions for people at elevated risk of concussive injury. The focus of the present study is to investigate the potential for using passive measurements of fine motor movements (smooth pursuit eye tracking and read speech) and resting state brain activity (measured using fMRI) to complement existing diagnostic tools, such as the Immediate Post-concussion Assessment and Cognitive Testing (ImPACT), that are used for this purpose. Thirty-one high school American football and soccer athletes were tracked through the course of a sports season. Hypotheses were that (1) measures of complexity of fine motor coordination and of resting state brain activity are predictive of cognitive functioning measured by the ImPACT test, and (2) within-subject changes in these measures over the course of a sports season are predictive of changes in ImPACT scores. The first principal component of the six ImPACT composite scores was used as a latent factor that represents cognitive functioning. This latent factor was positively correlated with four of the ImPACT composites: verbal memory, visual memory, visual motor speed and reaction speed. Strong correlations, ranging between r = 0.26 and r = 0.49, were found between this latent factor and complexity features derived from each sensor modality. Based on a regression model, the complexity features were combined across sensor modalities and used to predict the latent factor on out-of-sample subjects. The predictions correlated with the true latent factor with r = 0.71. Within-subject changes over time were predicted with r = 0.34. These results indicate the potential to predict cognitive performance from passive monitoring of fine motor movements and brain activity, offering initial support for future application in detection of performance deficits associated with subconcussive events.

Using Oculomotor Features to Predict Changes in Optic Nerve Sheath Diameter and ImPACT Scores From Contact-Sport Athletes.

There is mounting evidence linking the cumulative effects of repetitive head impacts to neuro-degenerative conditions. Robust clinical assessment tools to identify mild traumatic brain injuries are needed to assist with timely diagnosis for return-to-field decisions and appropriately guide rehabilitation. The focus of the present study is to investigate the potential for oculomotor features to complement existing diagnostic tools, such as measurements of Optic Nerve Sheath Diameter (ONSD) and Immediate Post-concussion Assessment and Cognitive Testing (ImPACT). Thirty-one high school American football and soccer athletes were tracked through the course of a sports season. Given the high risk of repetitive head impacts associated with both soccer and football, our hypotheses were that (1) ONSD and ImPACT scores would worsen through the season and (2) oculomotor features would effectively capture both neurophysiological changes reflected by ONSD and neuro-functional status assessed via ImPACT. Oculomotor features were used as input to Linear Mixed-Effects Regression models to predict ONSD and ImPACT scores as outcomes. Prediction accuracy was evaluated to identify explicit relationships between eye movements, ONSD, and ImPACT scores. Significant Pearson correlations were observed between predicted and actual outcomes for ONSD (Raw = 0.70; Normalized = 0.45) and for ImPACT (Raw = 0.86; Normalized = 0.71), demonstrating the capability of oculomotor features to capture neurological changes detected by both ONSD and ImPACT. The most predictive features were found to relate to motor control and visual-motor processing. In future work, oculomotor models, linking neural structures to oculomotor function, can be built to gain extended mechanistic insights into neurophysiological changes observed through seasons of participation in contact sports.

A Cohort Study of the Temporal Stability of ImPACT Scores Among NCAA Division I Collegiate Athletes: Clinical Implications of Test-Retest Reliability for Enhancing Student Athlete Safety.

In this study we examined the temporal stability of the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) within NCAA Division I athletes across various timepoints using an exhaustive series of statistical models. Within a cohort design, 48 athletes completed repeated baseline ImPACT assessments at various timepoints. Intraclass correlation coefficients (ICC) were calculated using a two-way mixed effects model with absolute agreement. Four ImPACT composite scores (Verbal Memory, Visual Memory, Visual Motor Speed, and Reaction Time) demonstrated moderate reliability (ICC=0.51-0.66) across the span of a typical Division I athlete's career, which is below previous reliability recommendations (0.90) for measures used in individual decision-making. No evidence of fixed bias was detected within Verbal Memory, Visual Motor Speed, or Reaction Time composite scores, and minimal detectable change values exceeded the limits of agreement. The demonstrated temporal stability of the ImPACT falls below the published recommendations, and as such, fails to provide robust support for the NCAA's recommendation to obtain a single preparticipation cognitive baseline for use in sports-related concussion management throughout an athlete's career. Clinical interpretation guidelines are provided for clinicians who utilize baseline ImPACT scores for later performance comparisons.

Return to Sport Following Adolescent Concussion: Epidemiologic Findings From a High School Population.

High school athletes sustaining a concussion require careful attention when determining return-to-sport (RTS) readiness. The purpose of this study was to determine epidemiological and RTS data of a large cohort of high school athletes who sustained 1 or more concussions. Records of 357 consecutive youth patients who sustained concussions and presented to a single health care system between September 2013 and December 2016 were reviewed. Demographic data, RTS, and concussion-related variables were obtained via chart review. Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) scores at baseline and following concussions were performed by neuropsychologists. The average age at injury was 15.5 years (range, 14-18 years), 61.9% of patients were male, 6.7% reported a loss of consciousness, and 14.3% reported amnesia, requiring 30.4±23.3 days of recovery prior to RTS. The most common sport of injury was football (27.7%). There was a high incidence of previous concussion (33.1%), and 32 athletes sustained a recurrent concussion. A multivariate model demonstrated that females, players with a history of concussion, and those diagnosed in-clinic rather than in-game required increased time to RTS. Memory ImPACT scores were found to increase as players had recurrent concussions. Visual motor speed and reaction time scores decreased with recurrent concussions. [Orthopedics. 2020;43(4):e306-e310.].

Assessing the predictive value of primary evaluation with the Immediate Post-Concussion Assessment and Cognitive Test following head injury.

Concussions are a major public health concern, especially for high school and college student athletes. However, there are few prognostic metrics that can accurately quantify concussion severity in order to anticipate recovery time and symptom regression. The Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) is a widely used neurocognitive assessment that can diagnose and track recovery from concussions. This study assesses whether initial ImPACT scores, collected within 48 hours of the injury, can predict persistence of concussion at follow-up. Results from 6912 ImPACT tests were compiled in 2161 unique student athletes, ages 12-22 years. The authors defined a novel metric, the Severity Index (SI), which is a summation of the number of standard deviations from baseline at the 80% CI for each of the 5 composite scores reported by ImPACT. Patients were binned into groups based on SI (0-3.99, 4-7.99, 8-11.99, 12+) and the relationships between SI groups, composite scores, symptom profiles, and recovery time were characterized using 1-way and 2-way ANOVAs and Kaplan-Meier plots. A logistic regression assessed the value of SI for predicting concussion at follow-up. Patients with a higher SI at diagnosis were more likely to still be concussed at their first follow-up (F3,2300 = 93.06; p < 0.0001). Groups with a higher SI also displayed consistently slower recovery over a 42-day period and were more likely to report symptoms in all 4 symptom clusters (Migraine, Cognition, Sleep, and Neuropsychiatric). When controlling for sex, age, number of previous concussions, days between assessments, and location, SI significantly increased the odds of being concussed at follow-up (OR 1.122, 95% CI 1.088-1.142; p < 0.001). This model showed good discrimination with an area under the curve of 0.74. SI is a useful prognostic tool for assessing head injury severity. Concussions with higher initial SI tend to last longer and have broader symptomatic profiles. These findings can help patients and providers estimate recovery based on similar ImPACT score profiles.

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

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.

Preliminary Examinations of Concussion in Older Adults

Abstract Purpose This study sought to investigate whether concussion in older adults improves through evaluating their performance on the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) and Vestibular/Ocular-Motor Screen (VOMS) across visits and to describe and better characterize concussion in this at-risk population. Methods We conducted a retrospective review of medical records for 69 older adult patients (40 females, 29 males) that presented to a concussion specialty clinic. Participants averaged 64.71 (SD=4.1) years in age and presented within 6-998 days of injury (SD=170.9). Demographics and clinical data were recorded at intake through last appointment. Descriptive analysis, including frequencies, means, and standard deviations were performed as well as paired T-test to compare mean scores for first and last visit. Statistical significance was determined by two-sided p-values &lt;.05. Results Twenty out of 69 participants (29%) reported a previous concussion. Concussion symptom severity scores at participants’ first clinic visit averaged 56.19 (SD=26.56) compare with 39.51 (SD=25.53) at their final clinic visit. When comparing ImPACT data, all scores improved comparatively from Visit 1 to Last Visit (P values =0.000-0.014); all VOMS total scores improved as well (P =0.00-0.047). The most frequent primary profile among participants was Vestibular (31.9%). Conclusion Older adults diagnosed with concussion showed improvement on ImPACT scores and their symptom severity scores decreased. The most frequent primary concussion profile at initial visit was Vestibular. Further research with this at-risk population is needed.

Test-Retest Reliability of ImPACT Across a Two-Year Interval in Collegiate Athletes

Abstract Purpose To examine the two-year test-retest reliability of Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) in a sample of collegiate athletes. Methods A total of 163 college athletes (63.8% female) completed two pre-season baseline assessments two years apart as mandated by their athletic programs. Participants completed the first baseline prior to their first year of competition (M age=18.38, M edu=12.13). Individuals with baselines flagged as invalid by ImPACT were excluded. No diagnosed concussions occurred between baseline assessments. Results Pearson r correlations for ImPACT composite scores between assessments ranged from .32 to .70. Paired samples t-tests indicated significant differences between verbal memory (t(162)=-4.61, p&lt;.001, MD=-3.6) and visual-motor speed (t(162)=-4.10, p&lt;.001, MD=-1.5) at time 1 and time 2. Intraclass correlation coefficients (ICCs) with a “two-way mixed” model and “consistency” type indicated higher reliability for all composite scores. Visual-motor speed (mean ICC=.83; .76–.87 95% confidence interval [CI]) was the most reliable composite score, followed by visual memory (.66; 95% CI .53-.75), impulse control (.62; 95% CI .48–.72), verbal memory (.58; 95% CI .43–.69), and reaction time (.49; 95% CI .30-.62). The total symptom score showed moderate reliability (.63; 95% CI .50–.73). Conclusion Overall, ImPACT composite and total symptom scores appear to maintain relative long-term stability in a collegiate sample across a two-year period. ImPACT composite scores showed moderate to good reliability, and total symptom scores showed moderate reliability. Results of this study corroborate previous research indicating moderately stable ImPACT scores across a 2-year test-retest period in collegiate athletes (Schatz, 2010).

Neuro-Metabolite Changes in a Single Season of University Ice Hockey Using Magnetic Resonance Spectroscopy

Background: Previous research has shown evidence for transient neuronal loss after repetitive head impacts (RHI) as demonstrated by a decrease in N-acetylaspartate (NAA). However, few studies have investigated other neuro-metabolites that may be altered in the presence of RHI; furthermore, the relationship of neuro-metabolite changes to neurocognitive outcome and potential sex differences remain largely unknown.Objective: The aim of this study was to identify alterations in brain metabolites and their potential association with neurocognitive performance over time as well as to characterize sex-specific differences in response to RHI.Methods: 33 collegiate ice hockey players (17 males and 16 females) underwent 3T magnetic resonance spectroscopy (MRS) and neurocognitive evaluation before and after the Canadian Interuniversity Sports (CIS) ice hockey season 2011–2012. The MRS voxel was placed in the corpus callosum. Pre- and postseason neurocognitive performances were assessed using the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT). Absolute neuro-metabolite concentrations were then compared between pre- and postseason MRS were (level of statistical significance after correction for multiple comparisons: p < 0.007) and correlated to ImPACT scores for both sexes.Results: A significant decrease in NAA was observed from preseason to postseason (p = 0.001). Furthermore, a trend toward a decrease in total choline (Cho) was observed (p = 0.044). Although no overall effect was observed for glutamate (Glu) over the season, a difference was observed with females showing a decrease in Glu and males showing an increase in Glu, though this was not statistically significant (p = 0.039). In both males and females, a negative correlation was observed between changes in Glu and changes in verbal memory (p = 0.008).Conclusion: The results of this study demonstrate changes in absolute concentrations of neuro-metabolites following exposure to RHI. Results suggest that changes in Glu are correlated with changes in verbal memory. Future studies need to investigate further the association between brain metabolites and clinical outcome as well as sex-specific differences in the brain's response to RHI.

Concussion Recovery In Adolescents

An estimated 500,000 to 800,000 concussions occur annually among U.S. high school athletes. However, the association of sex and race/ethnicity with recovery remains unclear. PURPOSE: The aim of this study was to examine influence of sex and race/ ethnicity on the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) in adolescents. METHODS: This was a retrospective cohort study of adolescents, 13-19 years old, evaluated for an acute concussion (≤10 days from injury) at a university- based concussion clinic. General linear models (GLM) were used to examine race and sex interaction on post-concussion ImPACT composite scores on verbal memory, visual memory, visual motor, reaction time, and symptoms. RESULTS: A total of 227 charts that met inclusion criteria. There were no differences in the distributions of age and sex. The sample (N = 227) was primarily male (75%), and the median age was 15 years. Minorities (Blacks and Hispanics) constituted 46% of the sample. White females had the longest recovery time (median 27.5 days) and minority males had the shortest recovery time (median 11 days). Univariate tests indicated that the interaction of sex and race was statistically significant for visual memory (F(3,223) = 3.83, p = .011, η 2 = .049), reaction time (F(3,223) = 2.87, p = .037, η 2 = .037), and symptoms (F(3,223) = 9.46, p < .001, η 2 = .113). On these ImPACT subscales, White females had the poorest performance, and minority males had the best performance. Compared to the scores for minority males, ImPACT scores for White females on these subscales were as follows: visual memory (70.67±14.1 vs. 60.95±14.5), reaction time (.67±.17 vs. .76±.19), and symptom scores (12.19±14.5 vs. 28.29±22.04). Multivariate tests for the main effect of the interaction of race and sex (F(15,663) = 3.00, p = <.001, η 2 = .06) were statistically significant. CONCLUSION: This study found that both race and sex appear to influence concussion recovery. White females took longest to recover and had worse ImPACT visual memory, reaction time, and symptoms scores than White males, minority females, and minority males. In contrast, minority males had shorter recovery times and better ImPACT scores on these subscales than all other race-sex categories.

Collegiate Student Athletes With History of ADHD or Academic Difficulties Are More Likely to Produce an Invalid Protocol on Baseline ImPACT Testing.

Attention deficit hyperactivity disorder (ADHD) and other academically-relevant diagnoses have been suggested as modifiers of neurocognitive testing in sport-related concussion, such as Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). These preexisting conditions may suppress ImPACT scores to the extent that they are indistinguishable from low scores because of poor effort. The present study hypothesized that student athletes with history of ADHD or academic difficulties produce lower ImPACT composite scores and are more likely to produce invalid protocols than those without such conditions. Cross-sectional study. Midsized public university. Nine hundred forty-nine National College Athletic Association athletes (average age = 19.2 years; 6.8% ADHD, 5.6% Academic Difficulties, 2.0% comorbid ADHD/Academic Difficulties). Three seasons of baseline ImPACT protocols were analyzed. Student athletes were grouped using self-reported histories of ADHD or academic difficulties taken from ImPACT demographic questions. ImPACT composite scores and protocol validity. Student athletes in the academic difficulties and comorbid groups performed worse on ImPACT composite scores (Pillai's Trace = 0.05), though this pattern did not emerge for those with ADHD. Student athletes with comorbid history were more likely to produce an invalid baseline (10.5% invalid) (χ (2) = 11.08, P = 0.004). Those with ADHD were also more likely to produce an invalid protocol (7.7% invalid, compared with 2.6% in student athletes with no history) (χ (2) = 10.70, P = 0.005). These findings suggest that student athletes reporting comorbid histories or histories of academic difficulties alone produce lower ImPACT composite scores, and that those with comorbid histories or histories of ADHD alone produce invalid protocol warnings more frequently than student athletes without such histories. Future studies should further examine invalid score thresholds on the ImPACT, especially in student athletes with conditions that may influence test performance. Student athletes with history of ADHD or academic difficulties may more frequently fall below validity score thresholds, suggesting caution in interpreting test performance.

Performance of the Immediate Post-Concussion Assessment and Cognitive Testing Protocol Validity Indices.

Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) is a computerized neuropsychological test battery. Athletes provide preseason baseline ImPACT scores to which post-injury scores can be compared to aid concussion diagnosis. However, if baseline scores are not accurately representative of abilities, the utility of post-injury score comparison is diminished. For this reason, ImPACT includes low score thresholds on five validity indices to identify insufficient effort at baseline, though evidence of these indices' performance is limited. The present study examines the classification accuracy and concurrent validity of the existing ImPACT validity indices and three proposed indices (Word Memory Correct Distractors, Design Memory Correct Distractors, Total Symptom Score). The ImPACT, Word Memory Test (WMT) and Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) were administered to 242 undergraduate students. Participants were instructed to either give full effort on testing or to simulate SRC. Sensitivity of the existing ImPACT validity indices was marginally improved with adjusted score thresholds while maintaining acceptable specificity (0.90). Alternative score thresholds and novel validity indices demonstrated adequate specificity while improving sensitivity overall. Positive and negative predictive powers are provided to inform use of protocol validity indices across diverse treatment settings. The existing ImPACT indices' high specificity at the expense of lower sensitivity compared to external validity measures may under-identify poor effort, resulting in premature return-to-play decisions for athletes with concussion. Improvements or additions to the existing indices may raise sensitivity while maintaining acceptable specificity, aiding in the protection of athletes and safe athletic participation.

Self-reported history of seizure and baseline neurocognitive test performance in student-athletes: an initial investigation

ABSTRACTObjectives: Baseline neurocognitive assessment data can be critical in return to play (RTP) decision-making following a sport-related concussion (SRC). The literature indicates that many modifying factors of SRC have been studied empirically; however, there has been little investigation into the effect of a self-reported history of seizure(s) on baseline neurocognitive test data. The objective of this investigation was to determine whether a self-reported history of seizure(s) is associated with differences in baseline Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) performance.Methods: A retrospective analysis of 18,245 adolescent and young adult athletes’ ImPACT scores was performed. After application of inclusion and exclusion criteria, 7,391 participants were dichotomized into groups based on the presence or absence of a self-reported history of seizure. Participants reporting a history of seizure (n = 60) were matched on multiple variables in a 1:3 ratio with controls (n = 180) without a history of self-reported seizure. Baseline ImPACT composite scores were then compared between groups using either a 2-tailed t-test or a Mann-Whitney U-Test.Results: A significant between-group difference was observed in ImPACT visual motor speed composite scores (35.28 vs. 37.64, p = 0.029, Hedge’s g = 0.327), with the group self-reporting a history of seizure performing at inferior average scores. No significant between-group differences were detected in verbal memory, visual memory, reaction time, impulse control, or total symptom scores.Conclusion: Athletes with a history of self-reported seizure scored significantly lower on ImPACT visual motor speed compared to matched controls. As a solitary finding with a small effect size, the clinical significance of this difference is unclear. Apart from the decrease in visual-motor speed, this preliminary analysis suggests that athletes with a history of seizure might not have significantly different neurocognitive baseline test scores when compared with matched controls. Further empirical investigation is warranted to determine if a history of seizure is a modifying factor for SRC.

Characteristics of paediatricpediatric concussion patients utilisingutilizing emergency department services prior to initial concussion clinic evaluation

ObjectiveTo evaluate characteristics of paediatric concussion patients utilising the emergency department (ED) prior to initial concussion clinic evaluation.DesignProspective cohort.SettingClinics of an American urban/suburban family practice (12/2014–04/2015).SubjectsConsented concussion patients 8–18 years presenting to clinic within 3 days of injury (n=195; age=14.3, SD=2.1 years; female=42.3%).InterventionParticipants completed a systematic evaluation at initial clinic visit and survey at 4-6 weeks (73.8% follow-up). Criterion variables included demographics, prior head injury, time of injury (TOI) factors, total symptom severity, Immediate Postconcussion Assessment and Cognitive Test (ImPACT) composites, one-month persistent symptoms, one-month Paediatric Quality of Life (PedsQL).Outcome measuresED visit before clinic evaluation (yes/no) served as the dependent variable.ResultsED visits were reported for 12.8% (n=25) of participants. Amnesia (36.0% vs. 10.1%; p&lt;0.001), loss of consciousness (LOC) (20.8% vs. 6.7%; p=0.021), confusion (40.0% vs. 20.0%; p&lt;0.0255), difficulty remembering (52.0% vs. 26.5%; p&lt;0.0091), paresthesias (16.0% vs. 4.7%; p&lt;0.0282), and CT imaging (60.0% vs. 0.6%; p&lt;0.0001) were greater for the ED group. Initial symptom severity and ImPACT composite scores, and one-month outcomes of persistent symptoms and PedsQL, were no different for the ED group.ConclusionsPaediatric patients presenting to concussion clinic with 72 hours of injury who first visited an ED, have more dramatic symptoms at the TOI, yet do not appear to have any worse initial symptom severity, ImPACT scores, or one-month persistent symptoms or PedsQL than those who presented first to clinic. Future study should evaluate these relationships in larger samples.Competing interestsThe current study is funded in part by the National Operating Committee on Standards for Athletic Equipment.Ms. Fonseca is employed at the study setting.Ms. Phillips is employed at the study setting.Dr. Bloom is employed at the study setting.

Auditory comprehension performance of college students with and without sport concussion on Computerized-Revised Token Test Subtest VIII.

Aim:Auditory comprehension (AC) and visually assessed cognitive functions were compared in early stage postconcussed (PC) athletes and healthy controls using the Subtest VIII of the Computerized-Revised Token Test (C-RTT) and Immediate Postconcussion Assessment and Cognitive Test (ImPACT).Results:As compared with healthy controls (n = 30), PC subjects (n = 30) had significantly lower C-RTT efficiency scores (p = 0.018), and lower ImPACT scores; total symptom score (p = 0.000.), verbal memory (p = 0.000), visual memory (p = 0.000), visual motor speed (p = 0.000) and reaction time (p = 0.004) in this post-test only matched subject design. Impulse Control was not significant (p = 0.613). Multiple regression and ANOVA indicated an association with reaction time only (p = 0.012) for the PC subjects. After controlling for reaction time, a significant difference in AC remained.Conclusion:The relationship between AC and other visually assessed cognitive functions was inconsistent suggesting that the C-RTT and ImPACT assessed different functional systems.