ImPACT: Beyond the Numbers Elizabeth M. Pieroth, PsyD, ABPP NorthShore University HealthSystem

COGNITIVE Fogginess Concentration Memory deficits Cognitive fatigue MOOD DISRUPTION Irritability Sadness Anxiety SLEEP DYSREGULATION Falling asleep Fragmented sleep Too much/too little sleep SOMATIC Headaches Dizziness Light/noise sensitivity Tinnitus Adapted from Camiolo Reddy, Collins & Gioia, 2008

“Horseplay” Failure to Understand Directions “Sandbagging” or Faking Not Using Mouse/Malfunctioning Mouse Incentive different at baseline/post-injury

PERCENTILE RANGES Superior/Very Superior 90 – 99 th %ileSuperior/Very Superior 90 – 99 th %ile High Average 75 – 89 th %ileHigh Average 75 – 89 th %ile Average 26 – 74 th %ileAverage 26 – 74 th %ile Low Average 16 – 25 th %leLow Average 16 – 25 th %le Poor 6 – 15 th %ilePoor 6 – 15 th %ile Impaired < 5 th %ileImpaired < 5 th %ile Average High average Low average Superior Poor Impaired Very superior

VALID | RELIABLE | SAFE Computerized Neurocognitive Testing To Test or Not to Test When Symptomatic? Computerized Neurocognitive Testing To Test or Not to Test When Symptomatic? - Is there “added value” in completing neurocognitive testing during symptomatic phase of recovery? - What is prognostic value of doing testing? - What is sensitivity/specificity of subacute testing in predicting protracted recovery?

VALID | RELIABLE | SAFE ImPACT Summary Scores

VALID | RELIABLE | SAFE At three days post-injury, if athlete exhibit three or more RCI changes on ImPACT composite scores (relative to baseline), there is a 94% chance that recovery will require >10 days. Exhibiting a high symptom score did not improve classification accuracy over neurocognitive test scores in isolation. Athletes with prior history of concussion were not statistically more likely to have “protracted” recovery from concussion. Iverson G. CJSM; 2008 Predicting Simple versus Complex Concussion

VALID | RELIABLE | SAFE - Neurocognitive and symptom evaluation during symptomatic phase of recovery “adds value” in prognosis and determining severity of injury - Migraine symptom cluster and ImPACT cognitive composite scores most predictive of outcome - Migraine= headache, photo/phonophobia, dizziness, nausea, vomiting, vision - ImPACT= Reaction Time, Verbal Memory, Visual Memory - Testing while symptomatic allows for understanding of severity of injury, prognosis of outcome, considerations for academic accommodations, and consideration of physical exertion recommendations Predicting Outcomes Following Sports Concussion: Evidence Summary Lau B, Collins MW, Lovell M. American J Sports Med, In Press

VALID | RELIABLE | SAFE Copyright © 2011 Exam TypeBaseline Date Tested9/21/2004 Word MemoryWG = 1 Hits (immediate)12 Correct distractors (immed.)12 Learning percent correct100% Hits (delay)11 Correct distractors (delay)8 Delayed memory pct. Correct79% Total percent correct90% Design Memory Hits (immediate)8 Correct distractors (immed.)9 Learning percent correct71% Hits (delay)9 Correct distractors (delay)9 Delayed memory pct. Correct75% Total percent correct73% X's and O's Total correct (memory)8 Total correct (interference)115 Avg. correct RT (interference)0.45 Total incorrect (interference)7 Avg. incorrect RT (interfer.)0.37 Symbol Match Total correct (visible)27 Avg. correct RT (visible)1.19 Total correct (hidden)8 Avg. correct RT (hidden)1.06 Color Match Total correct9 Avg. correct RT0.78 Total commissions1 Avg commissions RT0.57 Three Letters Total sequence correct5 Total letters correct15 Pct. Of total letters correct100% Avg. time to first click1.95 Avg. counted21.2 Avg. counted correctly21 Average: Word Memory – Total Percent Correct Symbol Match – (Total correct/Hidden)/9*100 Three Letters – Percent Total Letters Correct

VALID | RELIABLE | SAFE Copyright © 2011 Exam TypeBaseline Date Tested9/21/2004 Word MemoryWG = 1 Hits (immediate)12 Correct distractors (immed.)12 Learning percent correct100% Hits (delay)11 Correct distractors (delay)8 Delayed memory pct. Correct79% Total percent correct90% Design Memory Hits (immediate)8 Correct distractors (immed.)9 Learning percent correct71% Hits (delay)9 Correct distractors (delay)9 Delayed memory pct. Correct75% Total percent correct73% X's and O's Total correct (memory) 8 Total correct (interference)115 Avg. correct RT (interference)0.45 Total incorrect (interference)7 Avg. incorrect RT (interfer.)0.37 Symbol Match Total correct (visible)27 Avg. correct RT (visible)1.19 Total correct (hidden)8 Avg. correct RT (hidden)1.06 Color Match Total correct9 Avg. correct RT0.78 Total commissions1 Avg commissions RT0.57 Three Letters Total sequence correct5 Total letters correct15 Pct. Of total letters correct100% Avg. time to first click1.95 Avg. counted21.2 Avg. counted correctly21 Average of: (Design Memory- Total Percent Correct) (X’s and O’s- Total Correct/Memory)/12

VALID | RELIABLE | SAFE Copyright © 2011 Average of: (X’s and O’s- Total Correct/Interference) /4 (Three Letters-Average Counted Correctly) X 3 Exam TypeBaseline Date Tested9/21/2004 Word MemoryWG = 1 Hits (immediate)12 Correct distractors (immed.)12 Learning percent correct100% Hits (delay)11 Correct distractors (delay)8 Delayed memory pct. Correct79% Total percent correct90% Design Memory Hits (immediate)8 Correct distractors (immed.)9 Learning percent correct71% Hits (delay)9 Correct distractors (delay)9 Delayed memory pct. Correct75% Total percent correct73% X's and O's Total correct (memory) 8 Total correct (interference)115 Avg. correct RT (interference)0.45 Total incorrect (interference)7 Avg. incorrect RT (interfer.)0.37 Symbol Match Total correct (visible)27 Avg. correct RT (visible)1.19 Total correct (hidden)8 Avg. correct RT (hidden)1.06 Color Match Total correct9 Avg. correct RT0.78 Total commissions1 Avg commissions RT0.57 Three Letters Total sequence correct5 Total letters correct15 Pct. Of total letters correct100% Avg. time to first click1.95 Avg. counted21.2 Avg. counted correctly21

VALID | RELIABLE | SAFE Copyright © 2011 Exam TypeBaseline Date Tested9/21/2004 Word MemoryWG = 1 Hits (immediate)12 Correct distractors (immed.)12 Learning percent correct100% Hits (delay)11 Correct distractors (delay)8 Delayed memory pct. Correct79% Total percent correct90% Design Memory Hits (immediate)8 Correct distractors (immed.)9 Learning percent correct71% Hits (delay)9 Correct distractors (delay)9 Delayed memory pct. Correct75% Total percent correct73% X's and O's Total correct (memory)8 Total correct (interference)115 Avg. correct RT (interference)0.45 Total incorrect (interference)7 Avg. incorrect RT (interfer.)0.37 Symbol Match Total correct (visible)27 Avg. correct RT (visible)1.19 Total correct (hidden)8 Avg. correct RT (hidden)1.06 Color Match Total correct9 Avg. correct RT0.78 Total commissions1 Avg commissions RT0.57 Three Letters Total sequence correct5 Total letters correct15 Pct. Of total letters correct100% Avg. time to first click1.95 Avg. counted21.2 Avg. counted correctly21 Average of: X’s and O’s - Average Correct RT Interference (Symbol Match - Average Correct RT/Visible) / 3 Color Match - Average Correct Reaction Time

VALID | RELIABLE | SAFE Copyright © 2011 Total of: X’s and O’s - Total Incorrect/Interference Color Match- Total Commissions Exam TypeBaseline Date Tested9/21/2004 Word MemoryWG = 1 Hits (immediate)12 Correct distractors (immed.)12 Learning percent correct100% Hits (delay)11 Correct distractors (delay)8 Delayed memory pct. Correct79% Total percent correct90% Design Memory Hits (immediate)8 Correct distractors (immed.)9 Learning percent correct71% Hits (delay)9 Correct distractors (delay)9 Delayed memory pct. Correct75% Total percent correct73% X's and O's Total correct (memory) 8 Total correct (interference)115 Avg. correct RT (interference)0.45 Total incorrect (interference)7 Avg. incorrect RT (interfer.)0.37 Symbol Match Total correct (visible)27 Avg. correct RT (visible)1.19 Total correct (hidden)8 Avg. correct RT (hidden)1.06 Color Match Total correct9 Avg. correct RT0.78 Total commissions1 Avg commissions RT0.57 Three Letters Total sequence correct5 Total letters correct15 Pct. Of total letters correct100% Avg. time to first click1.95 Avg. counted21.2 Avg. counted correctly21

The Cognitive efficiency Index measures the interaction between accuracy (percentage correct) and speed (reaction time) in seconds on the Symbol Match test. This score was not developed to make return to play decisions but can be helpful in determining 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.

“I just got an from one of my athletic trainers. Apparently, an athlete went to a pediatric neurologist with an ImPACT report. The doc took one look at it with the cognitive efficiency index and said that the kid was ‘mentally retarded’ and said that he was going to hold him out longer because of that.”