2. Quantify the head injuries with a highly sensitive measure of brain function. Protect the student athlete Help determine safe return to play. Help prevent cumulative effects of multiple concussions. Provides objective data to help determine athletes injury status. Prevent lingering effects of concussion and potential catastrophic injury.

3. An athlete who sustains concussion is 4-6 times more likely to sustain a second concussion. Bell ringers or mild concussions account for 75% of all concussive injuries. Effects of concussion are cumulative in athletes who return to play prior to complete recovery. The best way to prevent problems with concussion is to manage them effectively when they occur. No athlete should return to play while experiencing symptoms of concussion.

4. Concussion Signs Appears dazed Confused about play Answers question slowly Personality/behavior change Forgets plays prior to hit Retrograde amnesia Forgets plays after hit Anterograde amnesia Loss of consciousness Concussion Symptoms Headache Nausea Balance problems Double vision Photosensitivity Feeling sluggish Feeling foggy Change in sleep pattern Cognitive changes

5. Decreased Processing Speed Short-Term Memory Impairment Concentration Deficit Irritability/Depression Fatigue/Sleep Disturbance General Feeling of Fogginess Academic Difficulties

6. Occurs in athletes with prior concussion following relatively minor second impact Second impact has been shown to occur up to 14 days post-injury Athlete returns to competition before resolution of symptoms Catastrophic increase in intracranial pressure Vasomotor paralysis, edema, massive swelling, herniation, death Most often occurs in athletes <21 years old Neurochemical processes appear to differ in developing brain

7. Return to Play Current guidelines are not data driven. CT and MRI insensitive to subtleties of injury CAT scans & the standard MRI Scans do not indicate if there are physiological changes in the concussed brain – since these instruments study structure and not FUNCTION. Self-report determines management directives Variability in physician recommendations

8. No athlete should return to play with symptoms of concussion. All athletes should be properly evaluated after concussion. Football has greatest risk Soccer, wrestling, hockey, lacrosse, girls/boys basketball, cheerleading also carries significant risk ImPACT is currently available as an effective clinical tool for all levels of contact sport participation. Proper management of concussion is the best form of prevention.

9. Computerized test developed by clinical researchers at the University of Pittsburgh Medical Center (UPMC) Developed to allow for a more objective assessment of concussion and recovery. Accounts for individual differences in cognitive ability and symptom reporting through the use of baseline testing. Provides a common metric which allows for effective collaboration between athletic trainers, coaches, physicians, and neuropsychologists in concussion management. Utilized throughout professional and amateur sports across the country and internationally.

10. Demographic/Concussion History Questionnaire Concussion Symptom Scale 21 Item Likert scale (e.g. headache, dizziness, nausea, etc) Eight Neurocognitive Measures Measures domains of Memory, Working Memory, Attention, Mental Speed, Verbal Memory, Visual Memory, Reaction Time, Processing Speed - Summary Scores Detailed Clinical Report Automatically computer scored Outlines demographic, symptom, neurocognitive data

11. ImPACT is easy to implement Athletic trainer usually coordinates Athletic trainer usually coordinates Baselines obtained as part of pre-season physical Baselines obtained as part of pre-season physical Follow up post injury with credentialed physician Follow up post injury with credentialed physician Refer to www.IndianaSportsConcussionNetwork.com for a list of physicians Refer to www.IndianaSportsConcussionNetwork.com for a list of physicianswww.IndianaSportsConcussionNetwork.com

12. Concussions are one of the most serious medical problems at the High School level. Proper management of concussion is the best form of prevention of serious injury. An increasing number of schools are being sued each year for concussion mismanagement. Parents appreciate the information provided by ImPACT about their injured child.

13. Help determine severity of concussion. Provide valuable information to the athlete, parents, athletic trainers, physicians. Provide information on academic deficits associated with concussion. Promote safe return to play. Reduce liability for school districts.

14. Prevent a concussion from occurring. Nothing prevents a concussion, but there are measure that can reduce the number and severity of concussions. Eliminate the risk of concussion.

15. NOT a substitute for medical evaluation/treatment or more extensive neuropyschological testing. NOT a stand-alone assessment program. NOT effective if clinician is naïve to specifics and complexities of data.

16. The ImPACT software package consists a Self-Report Symptom Questionnaire, a Concussion-History Form that precedes the neuropsychological measures, and seven cognitive tests of cognitive functioning: Attention Span Working Memory Sustained Attention Selective Attention Non-verbal Problem Solving Reaction Time Visual Memory & Verbal Memory Response Variability

17. Minimum interval between baseline tests is 2 years. All examinations must be monitored by an athletic trainer, doctor, or other qualified medical professional who is familiar with the software. Test administrators should take the test a minimum of three times to become familiar with the test www.impacttestonline.com/impactdemo Pass code: KJZB2X8FHG Should understand the importance of obtaining a quality baseline test

18. Group administration is encouraged to expedite baseline testing. Groups of 10-15 optimal Optimal performance is critical to establish true baseline. Encourage athletes to be honest and give a good effort. Close proctoring to minimize horseplay. Empty terminal between tester takers if possible. Must use external mouse (invalid without). Cannot use laptop touch-pad

19. Follow instructions provided for launching baseline tests. Will be provided after completion of this course Pull up website prior to athletes arriving to take test. Explain the test: Not intelligence test Want to complete as fast and accurately as possible Difficult – not going to get everything right

20. The following slides: Sample screens of information gathered including demographics and concussion history. Symptom inventory and neuropsychological tests. Examples of the modules and descriptions of each.

21. First Name Last Name Organization Height Weight Gender Handedness Country Native language Second language - Years speaking - Years in North America Years of education completed Check any of the following that apply - Received speech therapy - Attended special education classes - Repeated one or more years of school - Diagnosed ADD or Hyperactive - Diagnosed learning disability Current sport - Current position/event/class - Current Level Years experience Complete demographic information screen by screen and as a group. Demographics

22. Number of times diagnosed with a concussion Total number of concussions that resulted in loss of consciousness Total number of concussions that resulted in confusion Total number of concussions that resulted in difficulty with memory for events occurring immediately after injury Total number of concussions that resulted in difficulty with memory for events occurring immediately before injury Total games were missed as a direct result of all concussions combined. List the 5 most recent concussions Indicate whether you have experienced the following Treatment for headaches by physician Treatments for migraine headaches Treatment for epilepsy/seizures History of brain surgery History of meningitis Treatment for substance/alcohol abuse Treatment for psychiatric condition (depression, anxiety, etc.) Questions that will be asked of athletes. Necessary to gain accurate information for comparison of baseline test to subsequent post injury exams. History

23. Sample Screens

24. CURRENT SYMPTOMS Headache Nausea Vomiting Balance Problems Dizziness Fatigue Trouble falling asleep Sleeping more than usual Sleeping less than usual Drowsiness Sensitivity to light Sensitivity to noise Irritability Sadness Nervousness Feeling more emotional Numbness or tingling Feeling slowed down Feeling mentally foggy Difficulty concentrating Difficulty remembering Visual problems (blurry or double vision) Allow athletes to complete symptom inventory and neuropsychological tests at their own pace. 6 pages Symptoms

25. The test will begin after the completion of the Current Symptoms screens. Encourage athlete to raise hand if they have questions. Relay the importance of understanding the directions of each module before proceeding. Stress that athletes must respond as quickly as possible on timed tests.

26. 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

27. Delay Condition: Following the administration of all other test modules (approximately 20 minutes), the subject is again tested for recall via the same method. Module 1 (Word Discrimination) 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.

28. 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

29. 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

30. Measures visual working memory, visual processing speed, and visual memory paradigm. Incorporates a distracter task. The subject can practice the distracter task prior to presentation of the memory task. The distracter 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.

31. Memory task: a random assortment of Xs and Os is displayed for 1.5 seconds For each trial: three of the Xs or Os are illuminated in YELLOW the subject has to remember the location of the illuminated objects Immediately after the presentation of the 3 Xs or Os, the distracter task reappears on the screen. Following the distracter task, the memory screen (Xs and Os) reappears and the subject is asked to click on the previously illuminated Xs and Os. Scores are provided for correct identification of the Xs and Os (memory), reaction time for the distracter task, and number of errors on the distracter task. Distracter test sample

32. 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. This module provides an average reaction time score and a score for the memory condition.

33. 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.

34. 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) In addition to providing a reaction time score, this task also provides an error score.

35. The subject is instructed to click in the box as quickly as possible only if the word is presented in the matching ink.

36. Measures working memory and visual-motor response speed First, the subject is allowed to practice a distracter task 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 distracter test. Five trials of this task are presented for each administration of the test.

37. 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. Then they are presented with three consonant letters displayed on the screen. Immediately following display of the 3 letters, the numbered grid reappears 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.

38. No athlete should return to play while experiencing symptoms of concussion. Release from concussion should include: Decrease of signs and symptoms ImPACT back to baseline Normal neurological exam Clinical judgment Experience Second Impact occurs in athletes with prior concussion following relatively minor second impact. Has been shown to occur up to 14 days post-injury Athlete returns to competition before resolution of symptoms CT and MRI insensitive to subtleties of injury. CAT scans & the standard MRI Scans do not indicate if there are physiological changes in the concussed brain – since these instruments study structure and not FUNCTION.

39. ImPACT Accounts for individual differences in cognitive ability and symptom reporting through the use of baseline testing Provides a common metric which allows for effective collaboration between athletic trainers, coaches, physicians, and neuropsychologists in concussion management All examinations must be monitored by an athletic trainer, doctor, or other qualified medical professional who is familiar with the software Test administrators should take the test a minimum of three times to become familiar with the test

40. Group administration is encouraged to expedite baseline testing Optimal performance is critical to establish true baseline Encourage athletes to be honest and give a good effort Pull up website prior to athletes arriving to take test Complete demographic information screen by screen and as a group. Explain the test: Not intelligence test Want to complete as fast and accurately as possible Difficult – not going to get everything right

41. Encourage athlete to raise hand if they have questions Relay the importance of understanding the directions of each module before proceeding Stress that athletes must respond as quickly as possible on timed tests

42. You have completed the online course for administering the ImPACT test. Please complete the attached document and return for administration instructions and access code. If there are any questions or problems please contact 317-571-8233 or concussion@methodistsports.com Conclusion