introduction to impact™

Introduction to ImPACT™

John Neidecker, D.O., ATCSports Medicine Physician

Cooper Bone and Joint Institute

COMPUTERIZED NEUROCOGNITIVE TESTING

• Why do we use it?– Quantify the injury with a highly sensitive

measure of brain function – Provides objective data to help determine

athlete’s injury status– Help determine safe return to play.

Types of Testing

• ImPACT

• Cogsport

• Headminders

• CNS Vital Signs

• ANAM

ImPACT™

• Immediate Post-Concussion Assessment and Cognitive Testing

• Computerized test developed by clinical researchers at the University of Pittsburgh Medical Center (UPMC)

• Accounts for individual differences in cognitive ability and symptom reporting through the use of baseline testing

• Utilized throughout professional and amateur sports across the country and internationally

Who uses ImPACT™? - 2010

• All NFL Teams• All MLB Teams• All NHL Teams• MLS• Major/Minor League

Umpires• Team USA (Winter

Olympics)• Cirque du Soleil• WWE

• USA Rugby• South African Rugby• New Zealand Rugby• US Military Academy• US Air Force Academy• Army• Navy• 3000+ High Schools• 1000+ Colleges and

Universities

WHAT DOES ImPACT MEASURE?

† Demographic/Concussion History Questionnaire

† Concussion Symptom Scale- 22 Items (e.g. headache, dizziness, nausea, etc)

† Eight Neurocognitive Measures- Measures domains of Memory, Working Memory, Attention, Reaction Time, Mental Speed, Verbal Memory, Visual Memory, Reaction Time, Processing Speed - Summary Scores

† Detailed Clinical Report- Automatically computer scored- Outlines demographic, symptom, neurocognitive data

24-72 Hours Dayy 5-

10ConcussioConcussionn

Beyond (if necessary)

Baseline Testing

(Normative data available for decision making when baseline data not available)

How its doneHow its done

IS ImPACT SENSITIVE?(2003 ImPACT Data)

Concussed Not Concussed

+ Test 93% 7%

(107) (8)

- Test 12% 88% (6) (43)

95% Sensitivity 84% Specificity

N=115 concussedN=49 controls

UNIQUE CONTRIBUTION OF ImPACT TO CONCUSSION MANAGEMENT

50556065707580859095

100

V erb al M em o ryC o m p o site

V isu al M em o ryC o m p o site

S ym p to m atic A sym p to m atic C o n tro l

N=115

ImPACT reveals cognitive deficits in asymptomatic athletes within 4 days post-injury

0.2

0.3

0.4

0.5

0.6

0.7

0.8

Reaction Time

Symptomatic Asymptomatic Control

N=115

UNIQUE CONTRIBUTION OF ImPACT TO CONCUSSION MANAGEMENT

The Test

► First Name

► Last Name

► Organization

► Height

► Weight

► Gender

► Handedness

► Country

► Native language

► Second language

- Years speaking

- 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

Number of times diagnosed with a concussion

Total number of concussions that resulted in loss of consciousness

Total number of concussions that resulted in confusion

Total number of concussions that resulted in difficulty with memory for events occurring immediately after injury

Total number of concussions that resulted in difficulty with memory for events occurring immediately before injury

Total games were missed as a direct result of all concussions combined.

List the 5 most recent concussions

Indicate whether you have experienced the following

Treatment for headaches by physician

Treatments for migraine headaches

Treatment for epilpsy/siezures

History of brain surgery

History of meningitis

Treatment for substance/alcohol abuse

Treatment for psychiatric condition (depression, anxiety, etc.)

CURRENT SYMPTOMS

Headache

Nausea

Vomiting

Balance Problems

Dizziness

Fatigue

Trouble falling asleep

Sleeping more than usual

Sleeping less than usual

Drowsiness

Sensitivity to light

Sensitivity to noise

Irritability

Sadness

Nervousness

Feeling more emotional

Numbness or tingling

Feeling slowed down

Feeling mentally foggy

Difficulty concentrating

Difficulty remembering

Visual problems (blurry or double vision)

Module 1 Module 1 (Word Discrimination)(Word Discrimination)

Evaluates attention processes/verbal recognition memory 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 category as the target word. EX: the word “ice” is a target word, while the word “snow” represents the non-target word.

There are five different forms of the word list.

Module 2 (Design Memory)Module 2 (Design Memory)

Evaluates attention 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

There are five different forms of this task

Module 3 (X’s and O’s)

Module 3 (X’s and O’s)Module 3 (X’s and O’s)

Measures visual working memory, visual processing speed, and visual memory paradigm

Subject shown the yellow X’s and O’s Subject is then asked click the left mouse/”Q” button for red circle as quick

as possible Subject is then asked click the right mouse/”P” button for blue square as

quick as possible X’s and O’s are then displayed again, Subject has to pick what ones were

yellow For each administration of ImPACT, the subject completes 4 trials.

Module 3 (X’s and O’s)

Module 3 (X’s and O’s)

Module 4 (Symbol Matching)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. Subject is asked to click on the matching numberAfter 27 symbols, the top symbols disappear

Module 5 (Color Match)Module 5 (Color Match)

Represents a choice reaction time task and measures impulse control/response inhibition

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.

Module 6 (Three Letters)

• Remember these three letters

S T B

Module 6 (Three letters)Module 6 (Three letters)

Measures working memory and visual-motor response speedSubject shown the three lettersSubject is then asked to count backwards on grid, starting from 25 as quick

as possibleAfter 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. Five trials of this task are presented for each administration of the test. Both the number placement on the grid and letters displayed are randomized

for each trial.

Module 6 (Three Letters)

• Do you remember the three letters?

S T B

Module 6 (Three Letters)

• Do you remember the three letters?

S T B

Back to the words…

• Words are then asked again

So what do we get?

• A print out consisting of – Demographic information– Symptom scores– Module scores– Composite scores

• Scores displayed in both grid and bar graph format

Total Symptom CompositeTotal Symptom CompositeIs also displayed graphically. This score represents the total for all 22-symptom descriptors.

Graphic Display of Total Symptom Graphic Display of Total Symptom Composite over time Composite over time

CURRENT SYMPTOMS

Headache

Nausea

Vomiting

Balance Problems

Dizziness

Fatigue

Trouble falling asleep

Sleeping more than usual

Sleeping less than usual

Drowsiness

Sensitivity to light

Sensitivity to noise

Irritability

Sadness

Nervousness

Feeling more emotional

Numbness or tingling

Feeling slowed down

Feeling mentally foggy

Difficulty concentrating

Difficulty remembering

Visual problems (blurry or double vision)

Numeric Display of all Composites over Time Numeric Display of all Composites over Time

Verbal Memory CompositeVerbal Memory Composite

Is comprised of the average of the following scores:

1) Total percent correct score from Module 1 (Word Discrimination)

2) Total correct hidden symbols from Module 4 (Symbol Matching)

3) Percent of total letters correct from Module 6 (3 Letters)

Visual Memory CompositeVisual Memory Composite

This score in its current form is comprised of the average of:

1) Total percent correct score from module 2 (Design Memory)

2) Total correct-memory score from module 3 (X’s & O’s)

Reaction Time CompositeReaction Time Composite

Is comprised of the average of the following scores: 1) Average Correct RT of interference stage of module 3 (X’s & O’s) 2) Average Correct RT /3 of module 4 (Symbol Match) 3) Average Correct RT of module 5 (Color Match)

Processing/Visual Motor Speed CompositeProcessing/Visual Motor Speed Composite

Is comprised of the average of following scores: 1) Total number correct during interference of module 3 (X’s & O’s)2) Average counted correctly x3 from countdown phase of module 6 (3

Letters)

Impulse Control CompositeImpulse Control Composite

This score indicates the sum of errors committed during different phases of the test and while it clinical decisions should not be based on this composite, its inclusion may help in the interpretation of other composites. This score is obtained by adding:1) Total errors on the interference phase of module 3 (X’s & O’s) 2) Total omissions from module 5 (Color Match)

Graphic Display of Impulse Control Composite over time Graphic Display of Impulse Control Composite over time

Composite Scores

• Also have an age related percentile score

• Flag statistically significant change from baseline

• These are the scores we consider when determining return to play

If Used Correctly, ImPACT will…

- Help determine severity of concussion

- Provide valuable information to the athlete, parents, athletic trainers, physicians

- Provide information on academic deficits associated with concussion

- Promote safe return to play

- Reduce liability for school districts

ImPACT will NOT…..

- Prevent a concussion from occurring

-Eliminate the risk of concussion

-Differentiate those with learning disabilities

-Be the sole determining factor to RTP

For more information

• www.impacttest.com