Reliability of Computerized Neurocognitive Tests for Concussion Assessment: A Meta-Analysis

Position comparison of sport-related concussions in female youth soccer players

OBJECTIVES

Youth soccer participation, particularly among females, continues to grow worldwide. With the high incidence of sport-related concussion (SRC) in soccer, it is important to investigate if SRC occurs disproportionally by positions. Our hypothesis was to see no positional differences in SRCs, SRC-related characteristics, and outcomes among in female youth soccer athletes.

METHODS

Data were prospectively collected from participants at a single sports medicine institution between August 2015-April 2021. Female participants aged 8-18 diagnosed with SRC sustained during an organized soccer practice, scrimmage, or game were separated into 4 groups based on position: Forward, Midfielder, Defender, and Goalkeeper. Demographics, medical history, injury-related details, and outcomes were reviewed. A chi-square test or Fisher's exact test was used for categorical variables. Continuous variables were compared with Mann-Whitney or Kruskal-Wallis test.

RESULTS

Two hundred fourteen participants were included: 52 Forwards, 65 Midfielders, 63 Defenders, and 34 Goalkeepers. There were no significant differences between the groups in age, race, ethnicity, or previous concussion history. Differences in mechanism existed with Goalkeepers most commonly reporting Head to Body Part. Goalkeepers, which make up 1/11 of the total positions on the field, had a significantly higher proportion of SRCs compared to Field Positions. (9.1% vs 15.9%)At 3-month post-enrollment, there were no significant differences in reported symptoms or return-to-play between the different positions.

CONCLUSION

In youth female soccer players, goalkeepers sustained a higher proportion of sport-related concussions compared to field players based upon the composition of a soccer team. The mechanism of injury also differed among the different soccer positions. However, no differences in concussion characteristics, outcomes, or RTP were seen across the different soccer positions.

The Significance of Off-Season Tailor-Made Baseline Measurements in the Assessment of Post-Concussion in University Athletes

This study aimed to investigate the significance of baseline measurements for amateur team athletes playing contact and collision team sports with a specific focus on the Sports Concussion Assessment Tool (SCAT) to improve concussion management. Symptoms of sports-related concussions (SRCs) can be diverse and long-lasting and include cognitive impairment, sleep disturbances, and vestibular dysfunction. Therefore, comprehensive baseline data are essential to preventing recurrent concussions and secondary injuries. This study was conducted during the 2023 off-season and evaluated the baseline condition of 65 male university rugby players using the SCAT5, which includes self-reported symptoms, and the modified Balance Error Scoring System (mBESS). The athletes were assessed for the presence or absence of SRC, and the mean values were compared using the Mann-Whitney U test. Among the participants, 35.38% (23/65) reported symptoms, with an average of 1.5 ± 2.8 symptoms per player and an average symptom score of 2.66 ± 5.93. In the mBESS, no errors were observed in the tandem stance test; however, 72.31% (47/65) made errors in the single-leg stance test on the non-dominant foot, with an average of 1.7 ± 1.5 errors. Many athletes self-reported symptoms and balance errors, even during asymptomatic periods before experiencing concussion, indicating unresolved issues. In the injury history survey, the baseline evaluations and injury histories of the participants classified into the SRC and non-SRC groups were compared. In the mBESS single-leg stance test (non-dominant foot), 84.21% (32/38) of the SRC group participants made errors, with an average score of 2.13 ± 1.52, whereas 55.55% (15/27) of the non-SRC group participants made errors, with an average score of 1.15 ± 1.35, showing a significant difference (p = 0.007). Additionally, significant differences were observed in the average number of ankle sprains (p = 0.027) and fractures (p = 0.048) between patients with and without a history of SRC. These findings indicate that athletes may have underlying issues even during normal periods before concussion. Moreover, the results highlighted the impact of previous concussions on motor control and injury risk. This underscores the importance of preseason baseline measurements using the SCAT to identify at-risk athletes and implement preventive measures. These findings align with the recommendations of the 6th International Conference on Concussion in Sport and suggest further refinement of concussion assessment tools.

Psychometric Properties of Computerized Cognitive Tools and Standard Neuropsychological Tests Used to Assess Sport Concussion: A Systematic Review

Athletic programs are more frequently turning to computerized cognitive tools in order to increase efficiencies in concussion assessment. However, assessment using a traditional neuropsychological test battery may provide a more comprehensive and individualized evaluation. Our goal was to inform sport clinicians of the best practices for concussion assessment through a systematic literature review describing the psychometric properties of standard neuropsychological tests and computerized tools. We conducted our search in relevant databases including Ovid Medline, Web of Science, PsycINFO, and Scopus. Journal articles were included if they evaluated psychometric properties (e.g., reliability, sensitivity) of a cognitive assessment within pure athlete samples (up to 30 days post-injury). Searches yielded 4,758 unique results. Ultimately, 103 articles met inclusion criteria, all of which focused on adolescent or young adult participants. Test-retest reliability estimates ranged from .14 to .93 for computerized tools and .02 to .95 for standard neuropsychological tests, with strongest correlations on processing speed tasks for both modalities, although processing speed tasks were most susceptible to practice effects. Reliability was improved with a 2-factor model (processing speed and memory) and by aggregating multiple baseline exams, yet remained below acceptable limits for some studies. Sensitivity to decreased cognitive performance within 72 h of injury ranged from 45%-93% for computerized tools and 18%-80% for standard neuropsychological test batteries. The method for classifying cognitive decline (normative comparison, reliable change indices, regression-based methods) affected sensitivity estimates. Combining computerized tools and standard neuropsychological tests with the strongest psychometric performance provides the greatest value in clinical assessment. To this end, future studies should evaluate the efficacy of hybrid test batteries comprised of top-performing measures from both modalities.

Neurocognitive Test Performance and Concussion-Like Symptom Reporting Among Adolescent Athletes With Self-Reported Autism on Preseason Assessments

OBJECTIVE

To examine baseline neurocognitive functioning and symptom reporting among adolescents with self-reported autism.

METHOD

Participants in this cross-sectional, observational study were 60,751 adolescents who completed preseason testing. There were 425 students (0.7%) who self-reported an autism spectrum disorder (ASD) diagnosis. Cognitive functioning was measured by Immediate Post-Concussion Assessment and Cognitive Testing and symptom ratings were obtained from the Post-Concussion Symptom Scale.

RESULTS

Groups differed significantly across all neurocognitive composites (p values <.002); effect size magnitudes for most differences were small, though among boys a noteworthy difference on visual memory and among girls differences on verbal memory and visual motor speed composites were noted. Among boys, the ASD group endorsed 21 of the 22 symptoms at a greater rate. Among girls, the ASD group endorsed 11 of the 22 symptoms at a greater rate. Some examples of symptoms that were endorsed at a higher rate among adolescents with self-reported autism were sensitivity to noise (girls: odds ratio, OR = 4.38; boys: OR = 4.99), numbness or tingling (girls: OR = 3.67; boys: OR = 3.25), difficulty remembering (girls: OR = 2.01; boys: OR = 2.49), difficulty concentrating (girls: OR = 1.82; boys: OR = 2.40), sensitivity to light (girls: OR = 1.82; boys: OR = 1.76), sadness (girls: OR = 1.72; boys: OR = 2.56), nervousness (girls: OR = 1.80; boys: OR = 2.27), and feeling more emotional (girls: OR = 1.79; boys: OR = 2.84).

CONCLUSION

Students with self-reported autism participating in organized sports likely experience a low degree of functional impairment, on average. If they sustain a concussion, their clinical management should be more intensive to maximize the likelihood of swift and favorable recovery.

Sensitivity and Specificity of Exercise Intolerance on Graded Exertion Testing for Diagnosing Sport-Related Concussion: A Systematic Review and Exploratory Meta-Analysis

Abstract There is no single gold standard test to diagnose sport-related concussion (SRC). Concussion-related exercise intolerance, that is, inability to exercise to the individual's appropriate level due to exacerbation of concussion-like symptoms, is a frequent finding in athletes early after SRC that has not been systematically evaluated as a diagnostic test of SRC. We performed a systematic review and proportional meta-analysis of studies that evaluated graded exertion testing in athletes after SRC. We also included studies of exertion testing in healthy athletic participants without SRC to assess specificity. Pubmed and Embase were searched in January 2022 for articles published since 2000. Eligible studies included those that performed graded exercise tolerance tests in symptomatic concussed participants (> 90% of subjects had an SRC, seen within 14 days of injury), at the time of clinical recovery from SRC, in healthy athletes, or both. Study quality was assessed using the Newcastle-Ottawa Scale. Twelve articles met inclusion criteria, most of which were of poor methodological quality. The pooled estimate of incidence of exercise intolerance in participants with SRC equated to an estimated sensitivity of 94.4% (95% confidence interval [CI]: 90.8, 97.2). The pooled estimate of incidence of exercise intolerance in participants without SRC equated to an estimated specificity of 94.6% (95% CI: 91.1, 97.3). The results suggest that exercise intolerance measured on systematic testing within 2 weeks of SRC may have excellent sensitivity for helping to rule in the diagnosis of SRC and excellent specificity for helping to rule out SRC. A prospective validation study to determine the sensitivity and specificity of exercise intolerance on graded exertion testing for diagnosing SRC after head injury as the source of symptoms is warranted.

Reliability and Usefulness of the SKILLCOURT as a Computerized Agility and Motor-Cognitive Testing Tool

INTRODUCTION

Agility and cognitive skills are essential in sports. However, standardized agility assessment tools often lack a reactive component, and cognitive assessments are performed using computer-based or paper-pencil tests. The SKILLCOURT is a newly developed testing and training device allowing agility and cognitive assessments in a more ecologically valid setting. This study evaluated the reliability and sensitivity to changes in performance (usefulness) of the SKILLCOURT technology.

METHODS

In a test-retest (7 d, 3 months) design, 27 healthy adults (♀ = 12; age, 24.9 ± 3.3 yr) performed three trials of agility (Star Run, Random Star Run) and motor-cognitive tests (1-back, 2-back, executive function). Absolute and relative intersession and intrasession reliability was determined using the intraclass coefficient (ICC) and coefficient of variation (CV). A repeated-measures ANOVA was applied to identify potential learning effects between trials and test sessions. The smallest worthwhile change and typical error (TE) were calculated to investigate the intrasession and intersession usefulness of the tests.

RESULTS

Agility tests revealed good relative and absolute intersession (ICC, 83-0.89; CV, 2.7%-4.1%) and intrasession (ICC, 7-0.84; CV, 2.4%-5.5%) reliability accompanied by adequate usefulness from test day 3 onward. Motor-cognitive tests showed good relative intersession reliability (ICC, 0.7-0.77) with marginal CV values (4.8%-8.6%). Adequate intrasession reliability and usefulness can be assumed from test day 2 (1-back test, executive function test) and day 3 (2-back test) onward. For all tests, learning effects were observed within and compared with test day 1.

CONCLUSIONS

The SKILLCOURT is a reliable diagnostic tool for assessing reactive agility and motor-cognitive performance. Because of learning effects, sufficient familiarization with the tests is required when used for diagnostic purposes.

Reliability and Minimal Detectable Change of the Standardized Assessment of Reaction Time

CONTEXT

Postconcussion reaction time deficits are common, but existing assessments lack sport-related applicability. We developed the Standardized Assessment of Reaction Time (StART) tool to emulate the simultaneous cognitive and motor function demands in sport, but its reliability is unestablished.

OBJECTIVES

To determine the intrarater, interrater, and test-retest reliability of StART and to examine the dual-task effect, time effect, and relationships between StART and computerized and laboratory-based functional reaction time assessments.

DESIGN

Prospective cohort study.

SETTING

Clinical laboratory.

PATIENTS OR OTHER PARTICIPANTS

Twenty healthy, physically active individuals (age = 20.3 ± 1.8 years, females = 12, no concussion history = 75%).

MAIN OUTCOME MEASURE(S)

Participants completed the StART, computerized reaction time (Stroop task via CNS Vital Signs), and laboratory-based jump landing and cutting reaction time under single-task and dual-task (subtracting by 6s or 7s) cognitive conditions at 2 testing sessions a median of 7 days apart. We used intraclass correlation coefficients (ICCs), repeated-measure analysis of variance, and Pearson r correlations to address our aims.

RESULTS

Overall, good to strong interrater (ICC [2,k] range = 0.83-0.97), intrarater (ICC [3,k] range = 0.91-0.98), and test-retest (ICC [3,k] range = 0.69-0.89) reliability were observed. A significant reaction time assessment-by-cognitive condition interaction was present (P = .018, ηp2 = 0.14), with StART having the largest dual-task effect. Main time effects for dual-task conditions were seen across all reaction time assessments (mean difference = -25 milliseconds, P = .026, ηp2 = 0.08) with improved performance at the second testing session. No StART outcomes correlated with computerized reaction time (P > .05), although some correlated with single-task (r range = 0.42-0.65) and dual-task (r range = 0.19-0.50) laboratory cutting reaction time.

CONCLUSIONS

The StART demonstrated overall reliable performance relative to other reaction time measures. Reliability coupled with a strong dual-task effect indicates that StART is a valid measure for examining functional reaction time and may have future utility for sport-related concussion return-to-play decision-making.

A comparison of clinical assessment with common diagnostic tools for monitoring concussion recovery in adolescent rugby union players

OBJECTIVES

To characterise the incidence, severity and recovery of sport-related concussion (SRC) in schoolboy rugby players and explore whether the Sports Concussion Assessment Tool (SCAT), Cogstate Brief Battery (CBB) and the King-Devick test (K-D test) can be used to monitor concussion status through to full recovery.

DESIGN

Prospective cohort study.

SETTING

Rugby union has a high rate of SRC; however, there is little research investigating how concussion affects adolescent rugby players.

PARTICIPANTS

Schoolboy rugby players.

MAIN OUTCOME MEASURES

Participants completed baseline tests in the preseason. Participants diagnosed with SRC during the season attended for post-concussion testing on a weekly basis until recovered.

RESULTS

135 schoolboy rugby players (16.7 ± 0.82y) participated in the study. There were 18 SRCs in 16 participants. Concussion incidence was 9/1000 player hours. CBB and K-D tests were poorly associated with clinical assessment and produced high false negative rates (0.58 and 0.52 respectively).

CONCLUSIONS

This study reports a relatively high match SRC incidence for an adolescent population. Analysis of clinical recovery with CBB and K-D test revealed a relatively poor ability to accurately monitor concussion status compared to clinical assessment suggesting that these tools should not be used in isolation for monitoring SRC recovery in adolescents.

The Effects of Attention-Deficit/Hyperactivity Disorder Symptoms on the Association between Head Impacts and Post-Season Neurocognitive and Behavioral Outcomes

OBJECTIVE

Having attention-deficit/hyperactivity disorder (ADHD) is a risk factor for concussion that impacts concussion diagnosis and recovery. The relationship between ADHD and repetitive subconcussive head impacts on neurocognitive and behavioral outcomes is less well known. This study evaluated the role of ADHD as a moderator of the association between repetitive head impacts on neurocognitive test performance and behavioral concussion symptoms over the course of an athletic season.

METHOD

Study participants included 284 male athletes aged 13-18 years who participated in high school football. Parents completed the Strengths and Weaknesses of ADHD Symptoms and Normal Behavior (SWAN) ratings about their teen athlete before the season began. Head impacts were measured using an accelerometer worn during all practices and games. Athletes and parents completed behavioral ratings of concussion symptoms and the Attention Network Task (ANT), Digital Trail Making Task (dTMT), and Cued Task Switching Task at pre- and post-season.

RESULTS

Mixed model analyses indicated that neither head impacts nor ADHD symptoms were associated with post-season athlete- or parent-reported concussion symptom ratings or neurocognitive task performance. Moreover, no relationships between head impact exposure and neurocognitive or behavioral outcomes emerged when severity of pre-season ADHD symptoms was included as a moderator.

CONCLUSION

Athletes' pre-season ADHD symptoms do not appear to influence behavioral or neurocognitive outcomes following a single season of competitive football competition. Results are interpreted in light of several study limitations (e.g., single season, assessment of constructs) that may have impacted this study's pattern of largely null results.

Protocol for a living systematic review for the management of concussion in adults

INTRODUCTION

Concussion/mild traumatic brain injury (mTBI) often presents initially with disabling symptoms that resolve, but for an unfortunate minority some of these symptoms may become prolonged. Although research into diagnosis and interventions for concussion is increasing, study quality overall remains low. A living systematic review that is updated as evidence becomes available is the ideal research activity to inform a living guideline targeting clinicians and patients. The purpose of this paper is to present the protocol of an ongoing living systematic review for the management of adult concussion that will inform living guidelines building off the Guideline for Concussion/Mild Traumatic Brain Injury and Persistent Symptoms: third Edition.

METHODS AND ANALYSIS

The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol guidelines were followed in the reporting of this systematic review protocol. We are including English peer-reviewed observational studies, trials, qualitative studies, systematic reviews and clinical practice guidelines related to diagnosis/assessment or treatment of adult concussion. Future searches will be conducted at minimum every 6 months using the following databases: MEDLINE ALL, EMBASE, Cochrane, PsycInfo and CINAHL. The data are managed in the Covidence website. Screening, data extraction and risk-of-bias assessments are being done through multiple raters working independently. Multiple validated tools are being used to assess risk of bias, and the tool applied matches the document or study design (eg, Downs and Black Scale for healthcare interventions). Many concussion experts in various clinical disciplines from across North America have volunteered to examine the evidence in order to make recommendations for the living guidelines.

ETHICS AND DISSEMINATION

No ethical approval is necessary because primary data are not collected. The results will be disseminated through peer-reviewed publications and on the living guidelines website once built.

PROSPERO REGISTRATION NUMBER

CRD42022301786.

Assessment of the Relevance and Reliability of Reaction Time Tests Performed in Immersive Virtual Reality by Mixed Martial Arts Fighters

Immersive virtual reality (VR) is increasingly applied in various areas of life. The potential of this technology has also been noticed in recreational physical activity and sports. It appears that a virtual environment can also be used in diagnosing certain psychomotor abilities. The main aim of this study consisted of assessing the relevance and reliability of VR-implemented tests of simple and complex reaction time (RT) performed by mixed martial arts (MMA) fighters. Thirty-two professional MMA fighters were tested. The original test developed in the virtual environment was applied for RT assessment. The fighters’ task consisted of reacting to the lighting up of a virtual disc situated in front of them by pushing a controller button. The relevance of the test task was estimated by juxtaposing the obtained results with the classic computer test used for measuring simple and complex reactions, while its reliability was assessed with the intraclass correlation procedure. Significant relationships found between the results of VR-implemented tests and computer-based tests confirmed the relevance of the new tool for the assessment of simple and complex RT. In the context of their reliability, RT tests in VR do not differ from tests conducted with the use of standard computer-based tools. VR technology enables the creation of tools that are useful in diagnosing psychomotor abilities. Reaction time tests performed by MMA fighters with the use of VR can be considered relevant, and their reliability is similar to the reliability obtained in computer-based tests.

Recovery of symptoms, neurocognitive and vestibular-ocular-motor function and academic ability after sports-related concussion (SRC) in university-aged student-athletes: a systematic review

BACKGROUND

Physiological differences between a maturing and matured brain alters how Sports-Related Concussion (SRC) affects different age groups; therefore, a review specific to university-aged student-athletes is needed.

OBJECTIVES

Determine time to recovery for symptom burden, neurocognitive and Vestibular-Ocular-Motor (VOM) function and academic impact in university-aged student-athletes.

METHODS

Searches were conducted in PubMed, SpringerLink, PsycINFO, Science Direct, Scopus, Cochrane, Web of Science and EMBASE. Articles were included if they contained original data collected within 30 days in university-aged student-athletes, analysed SRC associated symptoms, neurocognitive or VOM function or academic ability and published in English. Two reviewers independently reviewed sources, using the Oxford Classification of Evidence-Based Medicine (CEBM) and the Downs and Black checklist, and independently extracting data before achieving consensus.

RESULTS

58 articles met the inclusion criteria. Recovery of symptoms occurred by 7 and 3-5.3 days for neurocognition. The evidence base did not allow for a conclusion on recovery time for VOM function or academic ability. Few papers investigated recovery times at specified re-assessment time-points and have used vastly differing methodologies.

CONCLUSIONS

To fully understand the implication of SRC on the university-aged student-athlete' studies using a multi-faceted approach at specific re-assessments time points are required.Systematic review registration number: CRD42019130685.

Feasibility and Reliability of a Novel Game-Based Test of Neurological Function in Youth: The Equilibrium Test Battery

Background

An estimated 11% of Canadian adolescents will sustain a sport-related concussion each year. However, diagnostic tools to detect and monitor concussive outcomes are limited.

Purpose

To evaluate the feasibility and test-retest reliability of the Highmark Interactive Equilibrium (HIEQ) test battery in uninjured adolescents.

Study Design

Observational study with repeated measurements.

Methods

Participants completed the HIEQ test battery, a game-based platform on an iPad application, that assesses balance, cognitive function, and visual function, for up to 15 consecutive school days in a group classroom setting. Feasibility for use of the HIEQ was evaluated by (1) recruitment rates; (2) retention rates; (3) test completion without assistance; and (4) adverse events. Test-retest reliability was examined using Bland Altman 95% limits of agreement and intraclass correlation coefficients comparing the first and second and second and third obtained scores. Reliability across multiple baseline assessments was also analyzed using intraclass correlations for the second to sixth and seventh to eleventh obtained scores.

Results

Fifty-five uninjured high school students (31 females and 24 males, mean age = 16.24 [1.09]) from three high schools participated in the study. Three participants (5%) completed all 15 days of testing, and 73% completed at least 10 of 15 test days. No adverse events were reported. Although the test was feasible, all subtests showed wide limits of agreement from first to second and from second to third testing occasions. Results indicate poor-to-moderate reliability (<0.50 to 0.75) across those intervals, as well as across the second to sixth and seventh to eleventh testing occasions.

Conclusion

The HIEQ is feasible in high school students; however, performance was characterized by wide limits of agreement and poor-to-moderate reliability across test occasions. Future evaluation of the HIEQ in visual and auditory distraction free individual testing settings is warranted.

Level of Evidence

Level 3.

Test-Retest Reliability of Remote ImPACT Administration

OBJECTIVE

To evaluate the performance and test-retest reliability obtained when administering a computerized baseline neurocognitive exam to NCAA Division I student-athletes in a controlled laboratory setting versus an uncontrolled remote location.

METHOD

A sample of 129 (female = 100) Division I student-athletes completed Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) pre-season assessments for two distinct and respective sports seasons in a controlled laboratory environment and an uncontrolled remote environment. Depending on the environment, participants were given verbal (controlled) or written (uncontrolled) guidelines for taking the test.

RESULTS

Multivariate repeated-measures ANOVA's determined that there were no within-subject differences between testing environments on ImPACT composite scores and cognitive efficiency index (CEI). The Chi-square test did not find any significant differences in impulse control or the number of invalid test scores, as determined by ImPACT, between environments. Intraclass correlations found the ImPACT subtest scores to range in test-retest reliability across testing environments, demonstrating moderate (verbal memory composite, r = 0.46; visual memory composite, r = 0.64; reaction time, r = 0.61; impulse control, r = 0.52; and CEI, r = 0.61) and good (visual motor composite, r = 0.77) test-retest reliability.

CONCLUSIONS

Results indicate that ImPACT is reliable between controlled and uncontrolled testing environments. This further suggests that ImPACT can be administered in a remote environment, pending specific adherence to testing instructions, or in the event of social distancing or isolation policies.

The Frequency of Low Scores on ImPACT in Adolescent Student-Athletes: Stratification by Race and Socioeconomic Status Using Multivariate Base Rates

This study examined the associations between the frequency of low scores on the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) by race and socioeconomic status (SES), using the proxy of Title I school status, among adolescent student-athletes and calculated multivariate base rates. There were 753 participants assigned to groups based on race (White: n = 430, 59.8%; Black: n = 289, 40.2%) and SES. Black student-athletes obtained more low neurocognitive test scores, which was associated with lower SES. The current study offers a resource to clinicians involved in concussion management who may wish to consider race and SES when interpreting ImPACT test performances.

Prospective study with specific Re-Assessment time points to determine time to recovery following a Sports-Related Concussion in university-aged student-athletes

BACKGROUND

Time to recovery for symptom burden and neurocognition following a Sports-Related Concussion (SRC) has previously been determined by consolidating varying re-assessment time points into a singular point, and has not been established for Vestibular-Ocular-Motor (VOM) function or academic ability.

OBJECTIVES

Establish when recovery of symptom burden, neurocognition, VOM function, and academic ability occurs in university-aged student-athletes.

METHODS

Student-athletes completed an assessment battery (Post-Concussion Symptom Scale (PCSS), Immediate Post-Concussion Assessment and Cognitive Test (ImPACT), Vestibular Ocular-Motor Screening (VOMS), Perceived Academic Impairment Tool (PAIT)) during pre-season (n = 140), within 48 hours, 4, 8 and 14 days post-SRC and prior to Return To Play (RTP) and were managed according to the Rugby Football Union' community pathway (n = 42). Student-athletes were deemed recovered or impaired according to Reliable Change Index' (RCI) or compared to their individual baseline.

RESULTS

Symptom burden recovers by four days post-SRC on RCI and to baseline by eight days. VOM function and academic ability recovers by 8 days. Some student-athletes demonstrated worse performance at RTP on all tests by RCI and to baseline, except for on VOMS score and near point convergence by RCI change.

CONCLUSIONS

Variation in individual university-aged student-athletes requires a multi-faceted approach to establish what dysfunctions post-SRC exist and when recovery occurs.

Test-retest reliability and practice effects of the virtual environment grocery store (VEGS)

INTRODUCTION

The use of virtual reality (VR) technology has been suggested as a method to increase ecological validity in neuropsychological assessments. Although validity has been a focus in VR research, little attention has been paid to other psychometric properties such as test-retest reliability and practice effects. Practice effects are common on traditional neuropsychological tests and can be impacted by novelty. Because VR is not widely used it was expected that participants would demonstrate higher practice effects on VR as compared to paper-and-pencil testing.

METHOD

To compare test-retest reliability and practice effects in VR and traditional paper-and-pencil testing, the Virtual Environment Grocery Store (VEGS) and California Verbal Learning Test - Second Edition (CVLT-II) were used in healthy adults (n = 44). Participants received follow-up testing approximately 2 weeks after the initial visit.

RESULTS

Significant practice effects of similar magnitude were seen on memory scores (i.e., total learning, long-delay free recall, and long-delay cued recall) on the VEGS and the CVLT-II. The VEGS and CVLT-II memory scores also demonstrated strong test-retest reliability (r's > .71). Lastly, total learning scores (d = .32) and long-delay cued recall (d = .70) scores were significantly higher on the CVLT-II compared to the VEGS (p's < .01).

CONCLUSIONS

Results suggested similar test-retest reliability and practice effects of the VEGS and CVLT-II, although the VEGS has the benefit of being an immersive technology that simulates an everyday activity. The study replicated past findings that the VEGS is more difficult than the CVLT-II which may be a useful property for clinical assessment.

Multivariate Base Rates and Concussion Detection: A Comparative Study

Recent research has yielded multivariate base rates (MBRs) of low scores in healthy populations using a widely adopted concussion screening measure, Immediate Postconcussion and Cognitive Testing (ImPACT). However, the extent to which individuals with concussion obtain reliable changes at divergent frequencies relative to healthy individuals is largely unknown. The present study examined whether MBRs of reliable change accurately discriminated between those with and without concussion. This archival review consisted of 129 healthy individuals and 81 individuals with concussion. MBRs of reliable change scores were examined at varying cutoffs and frequencies between those with and without concussion. Composites showed small to medium effect sizes in differentiating between those with and without concussion. MBRs of reliable change scores on ImPACT provided limited discriminative utility in isolation. Computations of posttest probabilities using Bayes' Theorem yielded evidence for incremental gains when utilizing MBRs of reliable change under certain constraints.

Immediate Post-concussion and Cognitive Testing: Ceiling Effects, Reliability, and Implications for Interpretation

OBJECTIVE

The most commonly used computerized neurocognitive test in concussion assessment and management, Immediate Post-concussion and Cognitive Testing (ImPACT), has demonstrated varying and sometimes concerning levels of test-retest reliability. This study aimed to further examine ImPACT's psychometric qualities and whether ceiling effects may suppress its reliability.

METHOD

A total of 300 consecutively selected ImPACT score reports for students attending a secondary school between 2010 and 2015 were reviewed. Test-retest reliabilities for composite scores and subscales were computed using Pearson product moment correlations (r) and intraclass correlation coefficients. To examine the potential influence of ceiling effects, we conducted frequency analyses of scores falling at, or near, the maximum possible score.

RESULTS

A total of 92 score reports met inclusion criteria. Test-retest reliabilities ranged from 0.42 to 0.69 for composite scores and 0.19 to 0.71 for subscales. Subscales comprising the Verbal and Visual Memory composites evidenced the most prominent ceiling effects.

CONCLUSIONS

Obtained test-retest reliabilities were consistent with a large segment of the literature and add to concerns about ImPACT's reliability. Furthermore, at least in a select sample, this study identified sizeable ceiling effects that likely diminish the reliability of some composite scores. To mitigate the risk of false-negative errors on post-injury testing, ImPACT users should be cognizant of such ceiling effects. Supplemental, or alternative, approaches to protect against underestimating baseline functioning also warrant consideration.

Evaluation of CogSport for acute concussion diagnosis in cricket

Objective

The diagnosis of sport-related concussion is a challenge for practitioners given the variable presentation and lack of a universal clinical indicator. The aim of this study was to describe the CogSport findings associated with concussion in elite Australian cricket players, and to evaluate the diagnostic ability of CogSport for this cohort.

Methods

A retrospective study design was used to evaluate CogSport performance of 45 concussed (male n=27, mean age 24.5±4.5 years; female n=18, 23.5±3.5 years) compared with 45 matched non-concussed (male n=27, mean age 27.3±4.5 years; female n=18, 24.1±4.5 years) elite Australian cricket players who sustained a head impact during cricket specific activity between July 2015 and December 2019.

Results

Median number of reported symptoms on the day of injury for concussed players was 7 out of 24, with a median symptom severity of 10 out of 120. CogSport performance deteriorated significantly in concussed cricket players’ Detection speed (p<0.001), Identification speed (p<0.001), One Back speed (p=0.001) and One Back accuracy (p=0.022) components. These components, when considered independently and together, had good diagnostic utility.

Conclusion

This study demonstrated good clinical utility of CogSport for identifying concussed cricket players, particularly symptoms and Detection, Identification and One Back components. Therefore, CogSport may be considered a useful tool to assist concussion diagnosis in this cohort, and the clinician may place greater weight on the components associated with concussion diagnosis.

Examination of Reaction Time Deficits Following Concussion: A Systematic Review and Meta-analysis

BACKGROUND

Reaction time (RT) deficits are reported following concussion, but it is unknown when these deficits normalize to pre-injury status. It is also unclear how factors such as RT measurement technique and participant characteristics influence post-concussion RT.

OBJECTIVE

The purpose of this systematic review and meta-analysis was to (1) characterize acute post-concussion (0-3 days) RT impairments, (2) examine RT recovery over time, and (3) explore moderating factors related to acute RT impairment following concussion.

METHODS

Database searches (PubMed, CINAHL, EBSCOhost) were conducted according to PRISMA guidelines for articles published in English from January 2002 to March 2019. Studies compared baseline-to-post-injury RT within individuals (within-subject) and/or RT in concussed individuals to non-concussed controls (between-subject). Sixty studies met inclusion criteria, reporting on a total of 9688 participants with 214 discrete RT effects (Hedges' d; between-subject: N = 29, k = 129; within-subject: N = 42, k = 85). Of the 214 effects, 93 occurred in the acute (0-3 days) post-injury timeframe (k = 47 between-subject). Numerous demographic [sex, age, concussion history, population type (athlete, military, and general population), athlete level (high school, college), and sport], and method-based (RT test and measure type, computerized neurocognitive testing platform, concussion definition, and time post-injury) moderators were examined for mean effect influence. Mixed-effects multi-level modeling with restricted-maximum-likelihood estimation was used to account for nested effects and high heterogeneity for the pooled effect size (D+).

RESULTS

Significant medium-magnitude RT deficits were observed acutely for between- (D+ = - 0.7279, 95% CI - 0.9919, - 0.4639, I² = 88.66, p < 0.0001) and within-subject (D+ = - 0.7472, 95% CI - 0.9089, - 0.5855, I² = 89.21, p < 0.0001) effect models. RT deficits were present at the sub-acute and intermediate-term timeframes for between-subject effects (sub-acute: D+ = - 0.5655, 95% CI - 0.6958, - 0.4352, p < 0.0001; intermediate-term: D+ = - 0.3219, 95% CI - 0.5988, - 0.0450, p = 0.0245). No significant RT mean effect was observed for the between-subject model at the long-term timeframe, indicating RT recovery among concussed participants relative to controls (D+ = 0.3505, 95% CI - 0.4787, 1.1797, p = 0.3639). Sex was a significant moderator for between-subject effects, with every 1% male sample size increase demonstrating - 0.0171 (95% CI - 0.0312, - 0.0029, p = 0.0193) larger RT deficits. Within-subject effect models resulted in RT measure type (simple: [D+ = - 0.9826] vs. mixed: [D+ = - 0.6557], p = 0.0438) and computerized neurocognitive testing platforms (ANAM: [D+ = - 0.3735] vs. HeadMinder CRI: [D+ = - 1.4799] vs. ImPACT: [D+ = - 0.6749], p = 0.0004) having significantly different RT-deficit magnitudes. No other moderators produced significantly different RT-deficit magnitudes (between-subject: [p ≥ 0.0763], within-subject: [p ≥ 0.1723]).

CONCLUSIONS

Robust RT deficits were observed acutely following concussion. Minimal magnitude differences were noted when comparing between- and within-subject effects, suggesting that pre-injury baselines may not add clinical value in determining post-injury RT impairment. RT deficits persisted up till the intermediate-term (21-59 days post-injury) timeframe and indicate lingering deficits exist. Mean effect size differences were observed between RT measure types and computerized neurocognitive testing platforms; however, all categories displayed negative effects consistent with impaired RT following concussion. Clinical interpretation suggests that measuring RT post-concussion is more important than considering the RT method employed so long as reliable and valid tools are used. PROSPERO Registration #CRD42019119323.

Test-Retest Reliability of Concussion Baseline Assessments in United States Service Academy Cadets: A Report from the National Collegiate Athletic Association (NCAA)-Department of Defense (DoD) CARE Consortium

OBJECTIVE

In response to advancing clinical practice guidelines regarding concussion management, service members, like athletes, complete a baseline assessment prior to participating in high-risk activities. While several studies have established test stability in athletes, no investigation to date has examined the stability of baseline assessment scores in military cadets. The objective of this study was to assess the test-retest reliability of a baseline concussion test battery in cadets at U.S. Service Academies.

METHODS

All cadets participating in the Concussion Assessment, Research, and Education (CARE) Consortium investigation completed a standard baseline battery that included memory, balance, symptom, and neurocognitive assessments. Annual baseline testing was completed during the first 3 years of the study. A two-way mixed-model analysis of variance (intraclass correlation coefficent (ICC)3,1) and Kappa statistics were used to assess the stability of the metrics at 1-year and 2-year time intervals.

RESULTS

ICC values for the 1-year test interval ranged from 0.28 to 0.67 and from 0.15 to 0.57 for the 2-year interval. Kappa values ranged from 0.16 to 0.21 for the 1-year interval and from 0.29 to 0.31 for the 2-year test interval. Across all measures, the observed effects were small, ranging from 0.01 to 0.44.

CONCLUSIONS

This investigation noted less than optimal reliability for the most common concussion baseline assessments. While none of the assessments met or exceeded the accepted clinical threshold, the effect sizes were relatively small suggesting an overlap in performance from year-to-year. As such, baseline assessments beyond the initial evaluation in cadets are not essential but could aid concussion diagnosis.

The use of inertial measurement units to assess gait and postural control following concussion

BACKGROUND

Impairments in gait and balance function are typical after concussion. There is evidence that these neuromuscular deficits persist past the typical time of symptom resolution. The ability to quantify these changes in gait and balance may provide useful information when making return to play decisions in clinical settings.

RESEARCH QUESTION

Are changes in gait function and postural control evident across the course of a concussion management program?

METHODS

A retrospective analysis of a convenience sample of 38 patients who were seen for concussion between October 2017 and May 2019 was performed. Gait and balance measures were assessed at their initial clinic visit post-injury and at their clearance visit using inertial measurement units. During dual-task walking trials, the medial-lateral motion of the center of mass and gait velocity were measured. Postural sway complexity and jerk index were measured during both eyes-open and eyes-closed balance trials.

RESULTS

Paired samples t-tests and Wilcoxon signed rank tests were used to determine whether statistically significant changes occurred for the gait and balance variables, respectively. Medial-lateral sway decreased (4.4 ± 1.3 cm to 4.0 ± 1.2 cm, p = 0.018) and gait velocity increased (0.78 ± 0.23 m/s to 0.91 ± 0.18 m/s, p <  0.001) from initial to clearance testing. Jerk index decreased (6.41 ± 11.06 m²/s⁵ to 5.73 ± 4.28 m²/s⁵, p = 0.031) and (11.87 ± 26.42 m²/s⁵ to 7.87 ± 8.38 m²/s⁵, p = 0.003) from initial to clearance testing for the eyes-open and eyes-closed conditions, respectively. Complexity index increased (2.38 ± 1.08-2.86 ± 0.72, p = 0.010) from initial to clearance testing for the eyes-closed condition. There was no change in complexity index for the eyes-open condition.

SIGNIFICANCE

These preliminary results support the potential use of measures of gait and postural control to assess recovery following a concussion in a clinical setting.

Outpatient Management of Sport-Related Concussion, Return to Learn, Return to Play

Outpatient sports-related concussion (SRC) management continues to evolve as evidence emerges supporting a multidisciplinary approach to the clinical assessment of SRC. Early active rehabilitation has replaced strict cognitive and physical rest. With this paradigm shift in management, pragmatic approaches are highly sought by busy clinicians that provide direction to individualized treatment, which can potentially expedite symptom resolution. Treatment strategies that address domain-based symptom constellations continue to be developed by clinician researchers. Although the optimal timing and dose of these domain-specific therapies has yet to be determined, future directions of SRC treatment will answer these and other questions regarding SRC management.

Neurocognitive changes associated with concussion in elite cricket players are distinct from changes due to post-match with no head impact

OBJECTIVES

Determine intra-individual changes in CogSport performance in elite cricket players diagnosed with concussion, and differentiate this from changes which may be attributed to post-match with no head impact.

DESIGN

Retrospective observational study of elite Australian male and female cricket players with diagnosed concussion and prospective cohort study of cricket players with no head impact post-match.

METHODS

CogSport performance relative to an individual's baseline was compared between 46 cricket players diagnosed with concussion following a head impact sustained during a match, and 84 cricket players who played a match during which they had no head impact.

RESULTS

CogSport performance post-match for players diagnosed with concussion was slower for detection speed (p < 0.001), identification speed (p = 0.007), and one back speed (p = 0.011). No changes in one card learning speed or any accuracy measures were observed. CogSport performance post-match with no head impact was faster but less accurate for one card learning (both p < 0.001). No changes in the other three test components were observed.

CONCLUSIONS

Slower performance in three of four CogSport tasks (detection, identification, one back) may be indicative of concussion, as these intra-individual changes were not observed in players post-match with no head impact. The fourth task, one card learning, may not be a useful indicator of concussion as it was not observed to change with concussion yet was susceptible to change post-match with no head impact. CogSport may have clinical utility in assisting the clinical diagnosis of concussion in elite male and female cricket players.

An examination of reliable change methods for measuring cognitive change with the Cogstate Computerized Battery: Research and clinical implications

Objective

To compare the performance of four reliable change (RC) methods with respect to measuring cognitive change on the Cogstate Computerized Battery (CCB).

Method

We assessed cognitive change in 57 healthy, urban, well-educated males on the CCB at baseline and 6 months (Median age = 50, 65% university-educated). The study CCB version comprised seven measures covering attention, processing speed, verbal learning, and memory. Raw scores were z-score transformed using age-corrected Cogstate norms (CN) or the sample mean and standard deviation (internal standardization [IS]), and then averaged to create composite z-scores. Composite scores were entered into four RC formulae. RC was defined based on a 90% two-tailed confidence interval. Change scores were compared as continuous (z-scores) and ordinal variables (RC outcomes).

Results

CCB composite score reliability (rXY = .78–.79) was replicated in an age- and sex-matched Cogstate database sample of similar size. There was good overall agreement between the four RC methods (Bland–Altman Mdiff = .00; 95% limits of agreement with the mean—CN: z = ± .90; IS: z = ± .93), with each model adhering closely to the 10% rate of RC expected by chance alone (largest χ2 = .86, p = .99). Initial norming strategy (CN or IS) did not affect these outcomes.

Conclusions

Norming strategy and RC method choice did not significantly impact cognitive change predictions on CCB composite scores. A series of example case data are provided to practically demonstrate the steps involved in applying the longitudinal norms generated in this study. Research in more diverse normative samples is warranted.

Performance on the DANA Brief Cognitive Test Correlates With MACE Cognitive Score and May Be a New Tool to Diagnose Concussion

Nearly 380,000 U.S. service members between 2000 and 2017 were, and at least 300,000 athletes annually are, diagnosed with concussion. It is imperative to establish a gold-standard diagnostic test to quickly and accurately diagnose concussion. In this non-randomized, prospective study, we examined the reliability and validity of a novel neurocognitive assessment tool, the Defense Automated Neurobehavioral Assessment (DANA), designed to be a more sensitive, yet efficient, measure of concussion symptomatology. In this study, the DANA Brief version was compared to an established measure of concussion screening, the Military Acute Concussion Evaluation (MACE), in a group of non-concussed service members. DANA Brief subtests demonstrated low to moderate reliability, as measured by intra-class correlation coefficient (ICC; values range: 0.28–0.58), which is comparable to other computerized neurocognitive tests that are widely-implemented to diagnose concussion. Statistically significant associations were found between learning and memory components of the DANA Brief and the diagnostic MACE cognitive test score (DANA Brief subtests: CDD: R² = 0.05, p = 0.023; CDS: R² = 0.10, p = 0.010). However, a more robust relationship was found between DANA Brief components involving attention and working memory, including immediate memory, and the MACE cognitive test score (DANA Brief subtests: GNG: R² = 0.08, p = 0.003; PRO: R² = 0.08, p = 0.002). These results provide evidence that the DANA Rapid version, a 5-min assessment self-administered on a hand-held portable device, based on the DANA Brief version, may serve as a clinically useful and improved neurocognitive concussion screen to minimize the time between injury and diagnosis in settings where professional medical evaluation may be unavailable or delayed. The DANA's portability, durability, shorter test time and lack of need for a medical professional to diagnose concussion overcome these critical limitations of the MACE.

Clinical versus Functional Reaction Time: Implications for Postconcussion Management

PURPOSE

This study aimed to examine the association between clinical and functional reaction time (RT) assessments with and without simultaneous cognitive tasks among healthy individuals.

METHODS

Participants (n = 41, 49% female; 22.5 ± 2.1 yr; 172.5 ± 11.9 cm; 71.0 ± 13.7 kg) completed clinical (drop stick, Stroop) and functional (gait, jump landing, single-leg hop, anticipated cut, unanticipated cut) RT assessments in random order. All RT assessments, except Stroop and unanticipated cut, were completed under single- (movement only) and dual-task conditions (movement and subtracting by 6s or 7s). Drop stick involved catching a randomly dropped rod embedded in a weighted disk. Stroop assessed RT via computerized neurocognitive testing. An instrumented walkway measured gait RT when center-of-pressure moved after random stimulus. All other functional RT assessments involved participants jumping forward and performing a vertical jump (jump landing), balancing on one leg (single-leg hop), or a 45° cut in a known (anticipated cut) or unknown (unanticipated cut) direction. RT was determined when the sacrum moved following random visual stimulus. Pearson correlation coefficients and a 5 × 2 repeated-measures ANOVA compared RT assessments and cognitive conditions.

RESULTS

Stroop RT outcomes did not significantly correlate with functional RT assessments (r range = -0.10 to 0.24). A significant assessment by cognitive task interaction (F4,160 = 14.01; P < 0.001) revealed faster single-task RT among all assessments compared with dual-task (mean differences, -0.11 to -0.09 s; P < 0.001), except drop stick (P = 0.195). Single-leg hop (0.58 ± 0.11 s) was significantly slower compared with jump landing (0.53 ± 0.10 s), anticipated cut (0.49 ± 0.09 s), gait (0.29 ± 0.07 s), and drop stick (0.21 ± 0.03 s; P values ≤ 0.001). Dual-task assessments were significantly slower than single-task assessments (mean difference, 0.08 s; P < 0.001).

CONCLUSIONS

Clinical and functional RT assessments were not correlated with each other, suggesting that sport-like RT is not being assessed after concussion. Functional and dual-task RT assessments may add clinical value and warrant further exploration after concussion.

Effect of a Concussion on Anterior Cruciate Ligament Injury Risk in a General Population

BACKGROUND

Recent studies indicate concussion increases risk of musculoskeletal injury in specific groups of patients. The purpose of this study was to determine the odds of anterior cruciate ligament (ACL) injury after concussion in a population-based cohort.

METHODS

International Classification of Diseases, 9th and 10th Revision (ICD-9, ICD-10) codes relevant to the diagnosis and treatment of a concussion and ACL tear were utilized to search the Rochester Epidemiology Project (REP) between 2000 and 2017. A total of 1653 unique patients with acute, isolated ACL tears were identified. Medical records for cases were reviewed to confirm ACL tear diagnosis and to determine history of concussion within 3 years prior to the ACL injury. Cases were matched by age, sex, and REP availability date to patients without an ACL tear (1:3 match), resulting in 4959 controls. The medical records of the matched control patients were reviewed to determine history of concussion.

RESULTS

39 patients with a concussion suffered an ACL injury up to 3 years after the concussion. The rate of prior concussion was higher in ACL-injured cases (2.4%) compared to matched controls with no ACL injury (1.5%). This corresponds to an odds ratio of 1.6 (95% CI 1.1-2.4; p = 0.015).

CONCLUSIONS

Although activity level could not be assessed, there are increased odds of ACL injury after concussion in a general population. Based on the evidence of increased odds of musculoskeletal injury after concussion, standard clinical assessments should consider concussion symptom resolution as well as assessment of neuromuscular factors associated with risk of injuries.

Methodology and Implementation of a Randomized Controlled Trial (RCT) for Early Post-concussion Rehabilitation: The Active Rehab Study

Background: Sports-related concussion (SRC) is a complex injury with heterogeneous presentation and management. There are few studies that provide guidance on the most effective and feasible strategies for recovery and return to sports participation. Furthermore, there have been no randomized studies of the feasibility, safety, and efficacy of early rehabilitation strategies across multiple sports and age groups. This international cluster-randomized pragmatic trial evaluates the effectiveness of early multi-dimensional rehabilitation integrated with the current return to sport strategy vs. the current return to sport strategy alone.

Methods: The study is a cluster-randomized pragmatic trial enrolling male and female athletes from 28 sites. The sites span three countries, and include multiple sports, levels of play (high school, college, and professional), and levels of contact. The two study arms are Enhanced Graded Exertion (EGE) and Multidimensional Rehabilitation (MDR). The EGE arm follows the current return to sport strategy and the MDR arm integrates early, MDR strategies in the context of the current return to sport strategy. Each arm employs a post-injury protocol that applies to all athletes from that site in the event they sustain a concussion during their study enrollment. Participants are enrolled at pre-season baseline. Assessment timepoints include pre-season baseline, time of injury (concussion), 24–48 h post-injury, asymptomatic, and 1-month post-injury. Symptoms and activity levels are tracked post injury through the return to play process and beyond. Injury and recovery characteristics are obtained for all participants. Primary endpoints include time to medical clearance for full return to sport and time to become asymptomatic. Secondary endpoints include symptom, neurocognitive, mental status, balance, convergence insufficiency, psychological distress, and quality of life trajectories post-injury.

Discussion: Outputs from the trial are expected to inform both research and clinical practice in post-concussion rehabilitation across all levels of sport and extend beyond civilian medicine to care for military personnel.

Ethics and Dissemination: The study is approved by the data coordinating center Institutional Review Board and registered at clinicaltrials.gov. Dissemination will include peer-reviewed publications, presentation to patients and public groups, as well as dissemination in other healthcare and public venues of interest.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT02988596

Trial Funding: National Football League.

The effects of socioeconomic status on baseline neurocognitive testing scores

Baseline neurocognitive testing has been recommended to provide a more accurate representation of the pre-concussion cognitive status of individual athletes. Socioeconomic status is not typically controlled for when obtaining baseline scores, which may lead to inaccurate findings if post-injury scores are compared to normative data. Understanding the role of socioeconomic status in baseline testing is important for the accurate analysis of test scores and proper evaluation of patients if individualized baseline data are not available. Our purpose was to investigate the effects of socioeconomic status, as determined by eligibility for free or reduced cost lunch on baseline neurocognitive test scores in secondary school athletes. 1,788 secondary school athletes (females = 778, males = 1,010, age = 14.96 ± 1.11 years, height = 171.25 ± 17.83 cm, mass = 66.82 ± 21.63 kg) completed the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) upon starting scholastic athletics. ImPACT components (symptom severity scores and composite scores of verbal memory, visual memory, visual motor speed, and reaction time) served as the dependent variables. School administration coded free or reduced cost lunch eligibility (N = 1255 not eligible, N = 563 eligible) for each participant (group), which served as the independent variable. Free or reduced cost lunch eligibility significantly altered the combined dependent variables (multivariate F_5,1780=14.41, p < .001, ɳ² = .04) when sex and age were controlled. Follow up ANOVAs showed that participants eligible for free or reduced cost lunch scored significantly worse on verbal memory (F_1,1784 = 24.81, p < .001, ɳ² = .01), visual memory (F_1,1784 = 24.90, p < .001, ɳ² = .01), and visual motor speed (F_1,1784 = 50.54, p < .001, ɳ² = .03). In addition, slower reaction times (F_1,1784 = 35.10, p < .001, ɳ² = .02) and higher symptom severity scores (F_1,1784 = 10.37, p < .01, ɳ² = .01) were observed in those eligible for free or reduced cost lunch. If normative data are used instead of individual baselines, potential modifiers such as socioeconomic status should be taken into account when analyzing concussion scores to provide accurate diagnoses.

Monitoring of Neurocognitive Function in the Care of Patients with Brain Tumors

PURPOSE OF REVIEW

A detailed characterization of the nature of neurocognitive impairment in patients with brain tumors is provided, as well as considerations for clinical practice regarding neuropsychological assessment throughout the disease course.

RECENT FINDINGS

Neurocognitive impairment is common in patients with brain tumors and may result from the tumor itself, as a consequence of treatment, including surgery, chemotherapy, and radiation, or in association with supportive care medications (e.g., anticonvulsant and pain medications). Serial surveillance of neurocognitive functioning in this population can facilitate medical decision-making and inform recommendations to improve patient daily functioning and quality of life. Neuropsychological assessment is increasingly recognized as a critical component of the multidisciplinary care of patients with brain tumors and has already had practice-changing effects. Further understanding of genetic risk factors for neurocognitive decline along with the development of novel assessment and intervention strategies may further enhance functioning and general well-being in this patient population.

Monitoring neurocognitive functioning in childhood cancer survivors: evaluation of CogState computerized assessment and the Behavior Rating Inventory of Executive Function (BRIEF)

BACKGROUND

Many childhood cancer survivors develop neurocognitive impairment, negatively affecting education and psychosocial functioning. Recommended comprehensive neuropsychological testing can be time- and cost- intensive for both institutions and patients and their families. It is important to find quick and easily administered surveillance measures to identify those in need of evaluation.

METHODS

We evaluated, individually and in combination, the sensitivity and specificity of the 1) Behavior Rating Inventory of Executive Functioning-Metacognition Index (BRIEF-MCI), and 2) CogState Composite Index (computerized assessment of cognition) in identifying below grade-level performance on state-administered tests of reading and mathematics among childhood cancer survivors.

RESULTS

The 45 participants (39% female) were a mean age of 7.1 ± 4.4 years at diagnosis, 14.0 ± 3.0 at evaluation, with a history of leukemia (58%), lymphoma (9%), central nervous system tumors (20%), and other tumors (13%). Impairment on the BRIEF-MCI was associated with low sensitivity (26% reading, 41% mathematics) but stronger specificity (88% reading, 96% mathematics). We found similar associations for the CogState Composite Index with sensitivity of 26% for reading and 29% for mathematics and specificity of 92% for both reading and mathematics. Combining the two measures did not improve sensitivity appreciably (47% reading, 59% mathematics) while reducing specificity (84% reading, 88% mathematics).

CONCLUSIONS

While individuals identified from the BRIEF-MCI or CogState Composite would likely benefit from a full neuropsychological evaluation given the strong specificity, use of these measures as screening tools is limited. With poor sensitivity, they do not identify many patients with academic difficulties and in need of a full neuropsychological evaluation. Continued effort is required to find screening measures that have both strong sensitivity and specificity.

Preliminary normative study of ImPACT® in Finnish professional male ice hockey players

Assessment of cognition is an important part of concussion management. The common paradigm of baseline and postinjury evaluations is recommended but due to the often lacking baseline data, reliable normative values are needed. The Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT®) battery is a widely used method of cognitive assessment offering several language options. There are few comparative studies between language groups on this test battery. ImPACT was administered at baseline to 184 Finnish male Professional Ice Hockey league players. The performance of the Finnish sample differed from previously published English and Czech language samples on the Visual Motor Speed and Reaction Time composites with medium effect-sizes (d = 0.38-0.52). Age, but not education or prior concussions, was associated with ImPACT performance. ImPACT performance is not uniform across language and culture groups and the findings highlight the need for language-specific norms. Finnish reference values for ImPACT for ages <20, 20-26, and >26 are presented. A similar approach is encouraged for other languages.

An Evidence-Based Objective Study Protocol for Evaluating Cardiovascular and Cerebrovascular Indices Following Concussion: The Neary Protocol

Introduction: The prevalence and incidence of sport-related concussion have continued to increase over the past decade, and researchers from various backgrounds strive for evidenced-based clinical assessment and management. When diagnosing and managing a concussion, a battery of tests from several domains (e.g., symptom reporting, neurocognitive, physiology) must be used. In this study, we propose and develop an objective, evidence-based protocol to assess the pathophysiology of the brain by using non-invasive methods. Methods: Contact sport athletes (n = 300) will be assessed at the beginning of the season in a healthy state to establish baseline values, and then prospectively followed if a mild traumatic brain injury (mTBI) occurs on approximately days 1–2, 3–5, 7–10, 21, 30, and subsequently thereafter, depending on the severity of injury. The protocol includes spontaneous measurements at rest, during head postural change, controlled breathing maneuvers for cerebrovascular reactivity, a neurovascular coupling stimuli, and a baroreflex/autoregulation maneuver. Physiological data collection will include cerebral blood flow velocity, cerebral oxygenation, respiratory gases for end-tidal oxygen and carbon dioxide, finger photoplethysmography for blood pressure, seismocardiography for cardiac mechanics, and electrocardiography. Conclusion, Limitations, and Ethics: The protocol will provide an objective, physiological evidence-based approach in an attempt to better diagnose concussion to aid in return-to-play or -learn. Ethics approval has been granted by the University Research Ethics Board.

When Is It Safe to Drive after Mild Traumatic Brain Injury/Sports-related Concussion?

Driving an automobile has inherent danger, and driving after mild traumatic brain injury (mTBI)/sports-related concussion (SRC) can make this task even more hazardous. There is evidence to suggest that restriction from driving for the first 24 to 48 h after mTBI/SRC is probably reasonable. However, after the first 48 h have passed, there is insufficient evidence to make a recommendation regarding return to driving. Clinicians need to weigh the evidence and make decisions on how to advise their patients on a case by case basis. Further research is required to provide a standardized recommendation.

Digit Symbol Substitution Test: The Case for Sensitivity Over Specificity in Neuropsychological Testing

PURPOSE/BACKGROUND

Development of the Digit Symbol Substitution Test (DSST) was initiated over a century ago as an experimental tool to understand human associative learning. Its clinical utility, owing to its brevity and high discriminant validity, was first recognized in the 1940s, and now the DSST is among the most commonly used tests in clinical neuropsychology.

METHODS

Specific studies and articles were reviewed to illustrate what the test measures, to evaluate its sensitivity to change, and to discuss its use in clinical practice.

RESULTS

The DSST is a valid and sensitive measure of cognitive dysfunction impacted by many domains. Performance on the DSST correlates with real-world functional outcomes (eg, the ability to accomplish everyday tasks) and recovery from functional disability in a range of psychiatric conditions including schizophrenia and major depressive disorder. Importantly, the DSST has been demonstrated to be sensitive to changes in cognitive functioning in patients with major depressive disorder and offers promise as a clinical decision-making tool for monitoring treatment effects in this and other disorders affecting cognition.

IMPLICATIONS/CONCLUSIONS

The DSST is sensitive to the presence of cognitive dysfunction as well as to change in cognitive function across a wide range of clinical populations but has low specificity to determine exactly which cognitive domain has been affected. However, the DSST offers a practical and effective method to monitor cognitive functions over time in clinical practice.