An updated review of the prevalence of invalid performance on the Immediate Post-Concussion and Cognitive Testing (ImPACT)

Neuropsychological Evaluation in Traumatic Brain Injury

Neuropsychological evaluations can be helpful in the aftermath of traumatic brain injury. Cognitive functioning is assessed using standardized assessment tools and by comparing an individual's scores on testing to normative data. These evaluations examine objective cognitive functioning as well as other factors that have been shown to influence performance on cognitive tests (eg, psychiatric conditions, sleep) in an attempt to answer a specific question from referring providers. Referral questions may focus on the extent of impairment, the trajectory of recovery, or ability to return to work, sport, or the other previous activity.

The prevalence and correlates of scores falling below ImPACT embedded validity indicators among adolescent student athletes

Objective: Valid performance on preseason baseline neurocognitive testing is essential for accurate comparison between preseason and post-concussion test results. Immediate Post-Concussion and Cognitive Testing (ImPACT) is commonly used to measure baseline neurocognitive function in athletes. We examined the prevalence of invalid performance on ImPACT baseline testing and identified correlates of invalid performance. Method: The sample included 66,998 adolescents (ages 14-18, M = 15.51 years, SD = 1.22) who completed ImPACT baseline tests between 2009 and 2019. Invalid performance was determined by the embedded validity indicators (EVI). Associations between invalid performance, demographic characteristics, and health conditions were assessed using chi-square tests and odds ratios (ORs). Results: Overall, 7.2% of adolescents had baseline tests identified as invalid by one or more of the EVIs. Individual validity indicators classified between 0.5% and 3.7% tests as invalid. Higher frequencies of invalid scores were observed among youth with neurodevelopmental, academic, and medical conditions. Youth who reported having learning disabilities (n = 3126), receiving special education (n = 3563), or problems with attention-deficit/hyperactivity disorder (ADHD; n = 5104) obtained invalid baselines at frequencies of 16.4%, 16.0%, and 11.1%, respectively. Moreover, youth who reported receiving treatment for a substance use disorder (n = 311) or epilepsy (n = 718) obtained invalid baselines at frequencies of 17.0% and 11.1%, respectively. Conclusions: The base rate of invalid performance on ImPACT's EVIs was approximately 7%, consistent with prior research. Adolescents self-reporting neurodevelopmental conditions, academic difficulties, or a history of treatment for medical conditions obtained invalid baseline tests at higher frequencies. More research is needed to better understand invalid scores in youth with pre-existing conditions.

iPad-Based Neurocognitive Testing (ImPACT-QT) in Acute Adult Mild Traumatic Brain Injury/Concussion: Study on Practicality and Bedside Cognitive Scores in a Level-1 Trauma Center

BACKGROUND

There lacks rapid standardized bedside testing to screen cognitive deficits following mild traumatic brain injury (mTBI). Immediate Post-Concussion Assessment & Cognitive Testing-Quick Test (ImPACT-QT) is an abbreviated-iPad form of computerized cognitive testing. The aim of this study is to test ImPACT-QT utility in inpatient settings. We hypothesize ImPACT-QT is feasible in the acute trauma setting.

METHOD

Trauma patients ages 12-70 were administered ImPACT-QT (09/2022-09/2023). Encephalopathic/medically unstable patients were excluded. Mild traumatic brain injury was defined as documented-head trauma with loss-of-consciousness <30 minutes and arrival Glasgow Coma Scale 13-15. Patients answered Likert-scale surveys. Bivariate analyses compared demographics, attention, motor speed, and memory scores between mTBI and non-TBI controls. Multivariable logistic regression assessed memory score as a predictor of mTBI diagnosis.

RESULTS

Of 233 patients evaluated (36 years [IQR 23-50], 71% [166/233] female), 179 (76%) were mTBI patients. For all patients, mean test-time was 9.3 ± 2 minutes with 93% (73/76) finding the test "easy to understand." Mild traumatic brain injury patients than non-TBI control had lower memory scores (25 [IQR 7-100] vs 43 [26-100], P = .001) while attention (5 [1-23] vs 11 [1-32]) and motor score (14 [3-28] vs 13 [4-32]) showed no significant differences. Multivariable-regression (adjustment: age, sex, race, education level, ISS, and time to test) demonstrated memory score predicted mTBI positive status (OR .96, CI .94-.98, P = .004).

DISCUSSION

Immediate Post-Concussion Assessment & Cognitive Testing-Quick Test is feasible in trauma patients. Preliminary findings suggest acute mTBIs have lower memory but not attention/motor scores vs non-TBI trauma controls.

Experiences of Adversity and Validity of Baseline Concussion Testing

CONTEXT

Neurocognitive testing is a critical tool in the management of sport-related concussions. Adversity during childhood and adolescence affects cognitive tasks, behavioral outcomes, and academic performance. Adversity may be important in baseline concussion test validity as well; however, the influence of these experiences is not well understood.

OBJECTIVE

To examine the relationship between individual-level experiences of adversity and baseline test validity of Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). We hypothesized that experiences of poverty, maltreatment, or extreme neighborhood deprivation would be associated with lower odds of baseline test validity.

DESIGN

Case-control study.

SETTING

Cuyahoga County, Ohio.

PATIENTS OR OTHER PARTICIPANTS

A total of 6495 student-athletes born from 1995 through 2005 who completed a baseline ImPACT test between 10 and 18 years old and were identified in the Child-Household Integrated Longitudinal Data system, a comprehensive data system with demographic and social service usage outcomes for children in Cuyahoga County, Ohio.

MAIN OUTCOME MEASURE(S)

Baseline concussion test validity was determined using the ImPACT built-in validity measure. Experiences of adversity during the sensitive developmental periods of early childhood and adolescence were key independent variables.

RESULTS

Our findings suggested that social mobility may play an important role in baseline validity. Youth with upward social mobility (ie, poverty or neighborhood deprivation in early childhood only) were not different from youth without such experiences (odds ratio [OR] = 0.91, P = .74). Youth with persistent adversity across childhood or downward social mobility (ie, poverty or high neighborhood deprivation in adolescence only) had 50% to 72% lower odds of achieving a valid baseline test (persistent poverty, OR = 0.59, P = .05; adolescent poverty only, OR = 0.50, P = .004; adolescent neighborhood deprivation only, OR = 0.28, P < .001). Maltreatment had no significant effect on test validity.

CONCLUSIONS

These findings indicated that certain patterns of adversity may predispose youth to invalid baseline testing scores, potentially increasing their risk of inappropriate injury management and poor outcomes.

National Athletic Trainers' Association Bridge Statement: Management of Sport-Related Concussion

OBJECTIVE

To provide athletic trainers and team physicians with updated recommendations to the 2014 National Athletic Trainers' Association (NATA) concussion position statement regarding concussion management, specifically in the areas of education, assessment, prognostic factors, mental health, return to academics, physical activity, rest, treatment, and return to sport.

BACKGROUND

Athletic trainers have benefited from the 2 previous NATA position statements on concussion management, and although the most recent NATA position statement is a decade old, knowledge gains in the medical literature warrant updating several (but not all) recommendations. Furthermore, in various areas of the body of literature, current evidence now exists to address items not adequately addressed in the 2014 statement, necessitating the new recommendations. This document therefore serves as a bridge from the 2014 position statement to the current state of concussion evidence, recommendations from other organizations, and discrepancies between policy and practice.

RECOMMENDATIONS

These recommendations are intended to update the state of the evidence concerning the management of patients with sport-related concussion, specifically in the areas of education; assessment advances; prognostic recovery indicators; mental health considerations; academic considerations; and exercise, activity, and rehabilitation management strategies.

Prevalence of invalid ImPACT baseline test results among high school athletes with invalidity and sandbagging indices

Objective: The comparison of baseline neuropsychological test results with post-concussion neuropsychological test results is a common practice to assess the aftermath of a sport-related concussion. The effectiveness of this approach is compromised when invalid baseline test performances occur. The present study was designed to assess the prevalence of invalid baseline test results of high school athletes, using the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). Method: A large sample of 8938 high school athletes' baseline test data were examined, including the four ImPACT Composite scores and three sets of embedded invalid indices: five ImPACT Invalidity Indicators, four ImPACT sandbagging red flags, and two ImPACT sandbagging subtest flags. Results: There were 8394 (93.91%) Valid scorers, who failed no Invalidity Indicators; 544 (6.09%) Invalid scorers, who failed at least one Invalidity Indicator, 2718 (30.41%) Red Flag scorers, who had at least one Red Flag score; and 4154 (46.47%) Subtest Flag scorers, who had at least one Subtest Flag score. Of the entire sample, 4485 (54.65%) failed at least one of the invalid indices. Conclusions: As in prior studies of high school athletes, the Invalidity Indicators identified a low portion (6.09%) of the athletes with invalid baseline test results, while other invalidity measures found 30.41% to 46.48% of the athletes producing questionable test results. The high rate of invalid test findings suggested in this research calls for greater efforts to improve the accuracy of baseline test results.

Failing Performance Validity Cutoffs on the Boston Naming Test (BNT) Is Specific, but Insensitive to Non-Credible Responding

This study was designed to examine alternative validity cutoffs on the Boston Naming Test (BNT).Archival data were collected from 206 adults assessed in a medicolegal setting following a motor vehicle collision. Classification accuracy was evaluated against three criterion PVTs.The first cutoff to achieve minimum specificity (.87-.88) was T ≤ 35, at .33-.45 sensitivity. T ≤ 33 improved specificity (.92-.93) at .24-.34 sensitivity. BNT validity cutoffs correctly classified 67-85% of the sample. Failing the BNT was unrelated to self-reported emotional distress. Although constrained by its low sensitivity, the BNT remains a useful embedded PVT.

Methodological considerations of assessing meaningful/reliable change in computerized neurocognitive testing following sport-related concussion

OBJECTIVE

Traditional reliable change index (RCI) methods may be psychometrically limited due to their inability to account for particularly high or low baseline performance and regression to the mean following serial testing. The current study sought to examine differences between RCI and standardized regression-based (RBz) methods in a cohort of adolescent athletes engaged in sport-related concussion recovery.

METHODS

Consultation records and results of computerized testing data via the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) battery were retrospectively reviewed among 240 adolescent athletes involved in return-to-play protocols following a sport-related concussion.

RESULTS

High concordance rates were found between RCI and RBz metrics across ImPACT composites, consistent with previous literature. However, especially for those with lower baseline performance, RBz scores tended to suggest cognitive performance not meeting or exceeding baseline scores despite RCI metrics being appropriate across speed-based ImPACT composites. In contrast, results revealed high rates of RCI scores suggesting continued cognitive difficulties despite RBz metrics being within normal limits, especially for adolescents with higher baseline performance.

CONCLUSIONS

Results suggest value in interpreting RBz values in addition to RCI values as these allow for clinical interpretation more sensitive to statistical confounds, including baseline performance and regression to the mean.