Introduction to ImPACT

Immediate Post Concussion Assessment and Cognitive Testing

Gary Solomon, Ph.D.

Associate Professor of Neurological Surgery, Orthopaedic

Surgery and Rehabilitation, and Psychiatry,

Co-Director, Vanderbilt Sports Concussion Center

Vanderbilt University School of Medicine

Team Neuropsychologist, Nashville Predators

Consulting Neuropsychologist, Tennessee Titans

• ImPACT is a neuropsychological screening tool designed specifically for sport-related concussion. Norms are available for male and female athletes ages 10-59. ImPACT is computer administered and takes about 30 minutes.

• ImPACT is not a substitute for neuropsychological testing. Neuropsychological testing is a much more in-depth assessment of cerebral functioning, and can take 2-8 hours to complete (paper and pencil and/or computer based tests). Norms for formal neuropsychological testing are available for children through 90+ years.

What does ImPACT Measure?

���� Demographic/Concussion History Questionnaire

���� Concussion Symptom Scale

- 21 Item, 0-6 Likert scale (e.g., headache, dizziness, nausea, etc.)

���� Neurocognitive Measures

- Measures domains of Visual and Verbal Memory, Reaction Time, & Visual Motor (Processing) Speed –

yields Composite Scores

���� Detailed Clinical Report

- Automatically computer scored- Outlines demographic, symptom,

neurocognitive data

What does ImPACT enable us to do?

• Provides objective data to help determine an athlete’s status

• Protects the student-athlete and the professional athlete

• Helps determine safe RTP

• Helps prevent the potential

effects of repeat concussions

24-72 Hours Day 5-10

Concussion

Beyond if necessaryBaseline Testing

(Ideal, but not

necessary for

decision making;

VSCC uses the

baseline model)

Clinical ProtocolImPACT TestingClinical ProtocolImPACT Testing

There have been several iterations of ImPACT since 2001; current version is 2.1

First major change was the separation of the Memory Composite into Verbal Memory and Visual Memory

Initial version of ImPACT was a disk & desktop version with local storage

Current version is on-line, with HIPPA compliant on-line storage at ImPACT (but test results are printable and downloadable)

Current slides show old and new versions of ImPACT

https://www.impacttestonline.com/customercenter

You will log in with your email and password. Your will have access to baseline/follow-up testing and review of results for your team(s).

Demographics

► Handedness

► Gender

► Weight

► Height

► Organization

► Last Name

► First Name

► Handedness

► Gender

► Weight

► Height

► Organization

► Last Name

► First Name

Identifying Data

Country/Language (18 languages)

Demographics/Modifying Factors/Sport

(Years of education completed: college freshman = 12; 9th grader = 8)

► Years experience

- Current Level

- Current position/event/class

► Current sport

- Diagnosed learning disability

- Diagnosed ADD or Hyperactive

- Repeated one or more years of school

- Attended special education classes

- Received speech therapy

► Check any of the following that apply

► Years of education completed

- Years in North America

► Years experience

- Current Level

- Current position/event/class

► Current sport

- Diagnosed learning disability

- Diagnosed ADD or Hyperactive

- Repeated one or more years of school

- Attended special education classes

- Received speech therapy

► Check any of the following that apply

► Years of education completed

- Years in North America

Medical History/Modifying Factors

Recent demographic additions

Ethnicity

Concussion History

Post Concussion Symptom Scale

0= Not having the symptom

1-6 rating scale if the athlete is having the symptom

1 = Minor, 6 = Severe

How they are feeling past 24 hrs.

Symptom Checklist (PCS; n=22)

Module 1: Word Discrimination

Verbal learning and recognition memory

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

� Evaluates attentional processes/verbal recognition memory

� Utilizes a word discrimination paradigm.

� 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 semantic category as the target word.

� EX: the word “ice” is a target word, while the word “snow” represents the

non-target word.

� The subject responds by mouse-clicking the “yes” or “no” buttons

� Individual scores are provided both for correct “yes” and “no” responses -In addition, a

total percent correct score is provided.

� There are five different forms of the word list.

Delay Condition: Following the

administration of all other test

modules (approximately

20 minutes), the subject is

again tested for recall via the

same method described above.

The same scores that are

described above are provided

for the delay condition.

Module 2: Design Memory

Visual learning and recognition memory

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

� Evaluates attentional 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

����comprised of 12 target designs and 12 non-target designs

�EX: target designs that have been rotated in space

�The subject responds by mouse-clicking the “yes” or “no” buttons

�Individual scores are provided both for correct

“yes” and “no” responses

�In addition, a total percent correct score is provided

�There are five different forms of this task

Module 3: X’s and O’s

Visuospatial memory and

processing speed

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

� Measures visual working memory, visual processing speed, and visual memory paradigm � Incorporates a distractor task. � The subject can practice the distractor task prior to presentation of the memory task� The distractor is a choice reaction time test: the subject is asked to click the left mouse

button if a blue square is presented and the right mouse button if a red circle is presented. � Once the subject has completed this task, the memory task is presented.

� Memory task: a random assortment of X’s and O’s is displayed for 1.5 seconds� For each trial: three of the X’s or O’s are illuminated in YELLOW (the subject has to

remember the location of the illuminated objects). � Immediately after the presentation

of the 3 X’s or O’s, the distractor task re-appears on the screen.

� Following the distractor task, the memory screen (X’s and O’s) re-appears and the subject is asked to click on the previously illuminated X’s and O’s.

� Scores are provided for correct identification of the X’s and O’s (memory), reaction time for the distractor task, and number of errors on the distractor task.

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

Replaced by “p” for red dot and “q” for blue square

Click the three that were yellow

Module 4: Symbol Matching

Processing speed and memory

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.

�The subject is required to click the matching

number as quickly as possible and to

remember the symbol/number pairings

�Correct performance is reinforced

through the illumination of a correctly clicked number in GREEN. Incorrect

performance illuminates the number button in RED.

�Following the completion

of 27 trials, the symbols disappear

from the top grid.

�The symbols again appear below the

grid and the subject is asked to recall

the correct symbol/number pairing by clicking the appropriate number button.

� This module provides an average reaction time score and a score for the

memory condition.

After a period of time, the numbers disappear and the athlete hasto remember which symbol corresponds with which number

Module 5: Color Match

Reaction time and impulse control

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

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

� First, the subject is required to respond by clicking a red, blue or green button as

they are presented on the screen. This procedure is completed to assure that

subsequent trials would not be affected by color blindness

� Next, 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.

� In addition to

providing a

reaction timescore, this task

also provides

an error score.

Module 6: Three Letters

Working memory and processing speed

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

� Measures working memory and visual-motor response speed

� First, the subject is allowed to practice a distractor task

�Consists of 25 numbered buttons (5 x 5 grid).

�The subject is instructed to click as quickly as possible on the numbered buttons in

backward order starting with “25.” (has an initial practice task)

�Then they are presented with three consonant letters displayed on the screen.

� Immediately following display of the 3 letters, the numbered grid re-appears and the

subject is instructed to click the numbered buttons in backward order, again

�After 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.

�Both the number placement on the grid and letters displayed are randomized for each

trial.

�Yields a memory score

(total number of correctly

identified letters) and a

score for the average number of correctly clicked

numbers per trial from the

distractor test.

� Five trials of this task

are presented for each

administration of the test.

C S W

What were the 3 letters?Type them in order

Delayed Recall

Word Discrimination (Module 1; stimuli and distractors)

Delayed Recall

Design Memory (Module 2; stimuli and distractors)

Test is now completed and is automatically scored & saved

Athlete is automatically logged outand cannot access the results

Results will be interpreted accordingto Team Physician’s preference

ImPACT’s Composite Scores

• Verbal Memory

• Visual Memory

• Reaction Time

• Visual-Motor Speed(Processing Speed)

__________________

• Impulse Control

• Total Symptoms

Report: Composite Scores

Red = raw scores; Green = percentile scores (age/gender)

Report: Raw Scores

Report: Raw Scores

ImPACT subscales and Loadings onComposite Scores

Verbal Memory Composite

Average of: (Word Memory- Total Percent Correct)(Symbol Match- Total Correct/Hidden)/9*100(Three Letters- Total Sequence Correct)/5*100

Visual Memory Composite

Average of: (Design Memory- Total Percent Correct)(X’s and O’s- Total Correct/Memory)/12*100

Visual-Motor Speed Composite (Processing Speed)

Average of: (X’s and O’s- Total Correct/Interference)/4(Three Letters-Average Counted Correctly)*3

ImPACT subscales and Loadings on Composite Scores

Reaction Time Composite

Average of: (X’s and O’s- Average Correct Reaction Time Interference)(Symbol Match- Average Correct Reaction Time/Visible)/3(Color Match- Average Correct Reaction Time)

Impulse Control Composite

Average of: (X’s and O’s- Total Incorrect/Interference)(Color Match- Total Commissions)

Symptom Total Score

Sum of: All symptoms reported by athlete on the Post-Concussion Symptom Scale

Report: Symptom Scores

Report: Graph of Composite Scores

Recent and Forthcoming additions to ImPACT

ImPACT Symptom Increase Score

Performed for post concussion assessments

Athlete completes the symptom scale again (how he/she feels now after taking the test), assessing whether the cognitive exertion of taking the test provoked symptoms

Cognitive Efficiency Index

Speed and Memory Scores (Forthcoming)

Symptom Increase Score in Red

Cognitive Efficiency Index

The Cognitive efficiency Index measures the interaction between accuracy (percentage correct) and speed (reaction time) in seconds on the Symbol Match test

Determines the extent to which the athlete tried to work very fast on symbol match (decreasing accuracy) or attempted to improve their accuracy by taking a more deliberate and slow approach (jeopardizing speed)

The range of scores is from approximately zero to approximately .70 with a mean of .34. A higher score indicates that the athlete did well in both the speed and memory domains on the symbol match test.

A low score (below .20) means that they performed poorly on both the speed and accuracy component. If this score is a negative number, the test taker performed very poorly on the reaction time component.

Two-Factor Theory (Schatz, UPMC, 2013)Archives of Clinical Neuropsychology, in press

Factor analysis results

Baseline Group (N=22,000) Concussion Group (N=560)

ImPACT is a screening tool that is extremely useful in assessing the neurobehavioral and cognitive symptoms of concussive injury.

When used appropriately, it is a valuable piece of the concussion puzzle.

Having a baseline is ideal, but not necessary.

ImPACT is not a “concussion test”; No such test exists

There is no “pregnancy test” for concussion

Thanks!