Understanding ImPACT™ in Sports Medicine: Benefits, Usage & Applications

1. Introduction to ImPACT™ John Neidecker, D.O., ATC Sports Medicine Physician Cooper Bone and Joint Institute

2. COMPUTERIZED NEUROCOGNITIVE TESTING Why do we use it? Quantify the injury with a highly sensitive measure of brain function Provides objective data to help determine athlete’s injury status Help determine safe return to play.

3. Types of Testing • ImPACT • Cogsport • Headminders • CNS Vital Signs • ANAM

4. ImPACT™ Immediate Post-Concussion Assessment and Cognitive Testing Computerized test developed by clinical researchers at the University of Pittsburgh Medical Center (UPMC) Accounts for individual differences in cognitive ability and symptom reporting through the use of baseline testing Utilized throughout professional and amateur sports across the country and internationally

5. Who uses ImPACT™? - 2010 All NFL Teams All MLB Teams All NHL Teams MLS Major/Minor League Umpires Team USA (Winter Olympics) Cirque du Soleil WWE USA Rugby South African Rugby New Zealand Rugby US Military Academy US Air Force Academy Army Navy 3000+ High Schools 1000+ Colleges and Universities

6. WHAT DOES ImPACT MEASURE? • † Demographic/Concussion History Questionnaire • † Concussion Symptom Scale • - 22 Items (e.g. headache, dizziness, nausea, etc) • † Eight Neurocognitive Measures • - Measures domains of Memory, Working Memory, Attention, Reaction Time, Mental Speed, Verbal Memory, Visual Memory, Reaction Time, Processing Speed - Summary Scores • † Detailed Clinical Report • - Automatically computer scored • - Outlines demographic, symptom, neurocognitive data

7. How its done 24-72 Hours Day 5-10 Concussion Baseline Testing (Normative data available for decision making when baseline data not available) Beyond (if necessary)

8. IS ImPACT SENSITIVE? (2003 ImPACT Data) N=115 concussed N=49 controls Concussed Not Concussed + Test 93% 7% (107) (8) - Test12% 88% (6) (43) 95% Sensitivity 84% Specificity

9. UNIQUE CONTRIBUTION OF ImPACT TO CONCUSSION MANAGEMENT N=115 ImPACT reveals cognitive deficits in asymptomatic athletes within 4 days post-injury

10. UNIQUE CONTRIBUTION OF ImPACT TO CONCUSSION MANAGEMENT N=115

11. The Test

15. Module 1 (Word Discrimination) •  Evaluates attention processes/verbal recognition memory •  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 category as the target word. •  EX: the word “ice” is a target word, while the word “snow” represents the non-target word. •  There are five different forms of the word list.

16. Module 2 (Design Memory) • Evaluates attention 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 • There are five different forms of this task

17. Module 3 (X’s and O’s)

18. Module 3 (X’s and O’s) • Measures visual working memory, visual processing speed, and visual memory paradigm • Subject shown the yellow X’s and O’s • Subject is then asked click the left mouse/”Q” button for red circle as quick as possible • Subject is then asked click the right mouse/”P” button for blue square as quick as possible • X’s and O’s are then displayed again, Subject has to pick what ones were yellow • For each administration of ImPACT, the subject completes 4 trials.

19. Module 3 (X’s and O’s)

20. Module 3 (X’s and O’s)

21. 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. • Subject is asked to click on the matching number • After 27 symbols, the top symbols disappear

22. Module 5 (Color Match) •  Represents a choice reaction time task and measures impulse control/response inhibition • 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 orBLUE) • The subject is instructed to click in the box as quickly as possible only if the word is presented in the matching ink.

23. Module 6 (Three Letters) • Remember these three letters S T B

24. Module 6 (Three letters) • Measures working memory and visual-motor response speed • Subject shown the three letters • Subject is then asked to count backwards on grid, starting from 25 as quick as possible • 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. • Five trials of this task are presented for each administration of the test. • Both the number placement on the grid and letters displayed are randomized for each trial.

25. Module 6 (Three Letters) • Do you remember the three letters? S T B

26. Module 6 (Three Letters) • Do you remember the three letters? S T B

27. Back to the words… • Words are then asked again

28. So what do we get? • A print out consisting of • Demographic information • Symptom scores • Module scores • Composite scores • Scores displayed in both grid and bar graph format

29. Total Symptom Composite Is also displayed graphically. This score represents the total for all 22-symptom descriptors. Graphic Display of Total Symptom Composite over time

30. Numeric Display of all Composites over Time

31. Verbal Memory Composite • Is comprised of the average of the following scores: • Total percent correct score from Module 1 (Word Discrimination) • 2) Total correct hidden symbols from Module 4 (Symbol Matching) • 3) Percent of total letters correct from Module 6 (3 Letters)

32. Visual Memory Composite This score in its current form is comprised ofthe average of: 1) Total percent correct score from module 2 (Design Memory) 2) Total correct-memory score from module 3 (X’s & O’s)

33. Reaction Time Composite Is comprised of the average of the following scores: 1) Average Correct RT of interference stage of module 3 (X’s & O’s) 2) Average Correct RT /3 of module 4 (Symbol Match) 3) Average Correct RT of module 5 (Color Match)

34. Processing/Visual Motor Speed Composite Is comprised of the average of following scores: 1) Total number correct during interference of module 3 (X’s & O’s) 2) Average counted correctly x3 from countdown phase of module 6 (3 Letters)

35. Impulse Control Composite This score indicates the sum of errors committed during different phases of the test and while it clinical decisions should not be based on this composite, its inclusion may help in the interpretation of other composites.This score is obtained by adding: 1) Total errors on the interference phase of module 3 (X’s & O’s) 2) Total omissions from module 5 (Color Match) Graphic Display of Impulse Control Composite over time

36. Composite Scores • Also have an age related percentile score • Flag statistically significant change from baseline • These are the scores we consider when determining return to play

43. If Used Correctly, ImPACT will… • 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

44. ImPACT will NOT….. • Prevent a concussion from occurring • Eliminate the risk of concussion • Differentiate those with learning disabilities • Be the sole determining factor to RTP

45. For more information • www.impacttest.com