Population-based normative data and language effects of the Immediate Post-Concussion Assessmentand Cognitive Testing (ImPACT)

OBJECTIVE

When test results are interpreted based on the norms of the U.S. population, misdiagnoses of neurocognitive impairment could occur with subgroups of individuals whose demographic characteristics differ from the overall population. The present study compared locally-based normative test data of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) of high school athletes in Hawaii, where diverse ethnicity and bilingualism are prominent, versus published test norms.

METHOD

8637 high school athletes in Hawaii underwent ImPACT baseline testing. Non-parametric group comparisons of age, sex, and language groups were performed. Classification ranges for the ImPACT Composite scores and Total Symptom of the Hawaii sample were presented in percentile ranks that corresponded to the published ImPACT normative tables.

RESULTS

Mann-Whitney U Test indicated significant differences in ImPACT Verbal Memory, Visual Memory, Visual Motor Speed, and Reaction Time Composite scores between age groups and sexes, although the effect sizes were small. Kruskal-Wallis H Test indicated no differences among the language groups. Percentile ranks of the Hawaii scores were predominantly similar to the ImPACT norms, except for Visual Motor Speed in the Impaired and Borderline ranges.

CONCLUSION

The findings suggest that locally based normative data should be considered for sub-populations that may differ from the general population. Language factors, such as bilingualism, did not have significant effect on the ImPACT scores.

Quantifying the Diagnostic Utility of Baseline Testing in Concussion Management: An Analysis of Collegiate Athletes From the NCAA-DoD CARE Consortium Dataset

BACKGROUND

Although preseason baseline testing is a commonly recommended part of the concussion management process, its "value-added" contribution to the diagnosis of acute concussion compared with normative reference values remains in question.

PURPOSE

This research aimed to evaluate the diagnostic benefits of baseline testing in acute concussion assessment compared with normative reference values and characterize the athletes who receive the most diagnostic utility from baseline testing.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 2.

METHODS

The investigators selected athletes from the National Collegiate Athletic Association-Department of Defense (NCAA-DoD) Concussion Assessment, Research, and Education (CARE) Consortium with at least 2 baseline assessments and 1 concussion. Two predictive models were developed that mimic acute concussion assessment using multivariate logistic regression based on a battery of postural control, neurocognitive status, and symptom assessments. The first predictive model gives a concussion status prediction based on change scores computed using individualized baseline testing information, whereas the second model uses normative reference values. The investigators defined and computed a novel metric called the Diagnostic Utility of Baseline Testing by comparing the concussion status predicted by each of these predictive models. The Diagnostic Utility of Baseline distribution was analyzed across athlete demographic characteristics and medical history.

RESULTS

The study included 1081 collegiate athletes (43.9% female) with 1279 acute concussion assessments (24- to 48-hour postinjury assessments) and 1551 reference assessments (baseline and 6-month assessments). Both the baseline and normative models exhibited notably high area under the curve values of .89 and .90, respectively. Most athletes (86.7%) did not gain additional diagnostic benefits from baseline testing versus normative values. Those with Hispanic ethnicity (P = .038) or a history of psychiatric disorders (P < .001) or depression (P = .002) were more likely to be correctly identified as having acute concussion when change scores were derived from normative values instead of individualized baseline values.

CONCLUSION

This study highlights that the additional diagnostic benefit of preseason baseline testing over normative data is limited for most collegiate student-athletes. Thus, normative data can be used for most collegiate student-athletes in the absence of baseline testing. Moreover, these results can inform decisions on the allocation of baseline tests in resource-limited athletic settings, emphasizing the need for targeted concussion assessment strategies based on individual characteristics.

Language Matters: Comparisons of Concussion Assessments Among English- and Spanish-Speaking Middle School Athletes

CONTEXT

The Child Sport Concussion Assessment Tool, fifth edition (Child SCAT5), is among the most widely used international pediatric concussion evaluation tools. However, the tool's English-only aspect may limit its use for patients who speak different languages. Prior researchers have suggested one's preferred language (ie, home language) could be associated with concussion assessments in adults, yet how this might affect pediatric athletes is not well understood.

OBJECTIVE

To compare baseline Child SCAT5 assessment outcomes between middle school athletes whose home language was Spanish and matched control athletes whose home language was English.

DESIGN

Case-control study.

SETTING

Middle school athletics.

PATIENTS OR OTHER PARTICIPANTS

Athletes self-reported their home language (ie, language spoken at home). Those indicating their home language was Spanish were individually matched to athletes who spoke English at home on age, sex, sport, school, and pertinent comorbidities (eg, concussion history). The final sample consisted of 144 athletes (Spanish home language = 72, English home language = 72).

MAIN OUTCOME MEASURE(S)

We used Mann-Whitney U tests to compare the Child SCAT5 component scores of the home language groups (ie, Spanish versus English).

RESULTS

Athletes in the Spanish home language group scored lower on the Standardized Assessment of Concussion-Child version (P < .01, r = -0.25), Immediate Memory (P < .01, r = -0.45), and total modified Balance Error Scoring System scores (P < .01, r = -0.25) than the English home language group.

CONCLUSIONS

Matched athletes whose home language was Spanish versus English scored differently on baseline Child SCAT5 assessment components. Those with the home language of Spanish scored lower on cognitive and balance tasks than those whose home language was English. These findings may serve as a rationale for the development of future concussion assessment tools to properly capture clinically relevant data regarding language differences among pediatric athletes.

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.

Preseason Baseline Neurocognitive Performances and Symptom Reporting on Immediate Post-Concussion Assessment and Cognitive Testing: A Comparison of Adolescent Student-Athletes Tested in Spanish and English

CONTEXT

Student-athletes are commonly administered the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) battery at preseason baseline and postconcussion. The ImPACT is available in many languages, but few researchers have examined differences in cognitive performances and symptom ratings based on the language of administration.

OBJECTIVE

To examine differences in ImPACT neurocognitive composites and symptom reporting at preseason baseline testing between student-athletes who completed ImPACT in Spanish versus English.

DESIGN

Cross-sectional study.

SETTING

Preseason baseline testing for a high school concussion-management program in Maine.

PATIENTS OR OTHER PARTICIPANTS

Adolescent student-athletes who completed testing in Spanish (n = 169) and English (n = 169) were matched on age, gender, and health and academic history. Language groups were compared on each outcome for the full sample and for gender-stratified subsamples.

MAIN OUTCOME MEASURE(S)

Neurocognitive composite scores and individual and total symptom severity ratings from the ImPACT battery.

RESULTS

Athletes tested in Spanish displayed lower levels of neurocognitive performance on 2 of 5 composite scores (visual motor speed: P < .001, d = 0.51; reaction time: P = .004, d = 0.33) and reported greater symptom severity (P < .001, r = 0.21). When the analyses were stratified by gender, similar visual motor speed differences were observed between language groups among boys (P = .001, d = 0.49) and girls (P = .001, d = 0.49), whereas reaction time showed a larger group difference for boys (P = .012, d = 0.42) than for girls (P = .128, d = 0.21). Language-group differences in symptom reporting were similar for boys (P = .003, r = 0.22) and girls (P = .008, r = 0.21), with more frequent endorsement of physical and affective symptoms by athletes tested in Spanish.

CONCLUSIONS

Language-group differences in total symptom severity were small (r = 0.21) and in neurocognitive performances were small to medium (d = 0.05-0.51). Versus previous authors who compared athletes tested in Spanish and English with ImPACT, we observed smaller effects, which may be attributable to close matching on variables related to neurocognitive performances and symptom reporting.

Testing measurement equivalence of neurocognitive assessments across language in the Hispanic Community Health Study/Study of Latinos

OBJECTIVE

Neuropsychological instruments are often developed in English and translated to other languages to facilitate the clinical evaluation of diverse populations or to utilize in research environments. However, the psychometric equivalence of these assessments across language must be demonstrated before populations can validly be compared.

METHOD

To test this equivalence, we applied measurement invariance procedures to a subsample (N = 1,708) of the Hispanic Community Health Survey/Study of Latinos (HCHS/SOL) across English and Spanish versions of a neurocognitive battery. Using cardinality matching, 854 English-speaking and 854 Spanish-speaking subsamples were matched on age, education, sex, immigration status (U.S. born, including territories, or foreign-born), and Hispanic/Latino heritage background. Neurocognitive measures included the Six-Item Screener (SIS), Brief-Spanish English Verbal Learning Test (B-SEVLT), Word Fluency (WF), and Digit Symbol Substitution (DSS). Confirmatory factor analysis was utilized to test item-level invariance of the SIS, B-SEVLT, and WF, as well as factor-level invariance of a higher-order neurocognitive functioning latent variable.

RESULTS

One item of both the SIS and WF were more difficult in Spanish than English, as was the DSS test. After accounting for partial invariance, Spanish-speakers performed worse on each of the subtests and the second-order neurocognitive functioning latent variable.

CONCLUSIONS

We found some evidence of bias at both item and factor levels, contributing to the poorer neurocognitive performance of Spanish test-takers. While these results explain the underperformance of Spanish-speakers to some extent, more work is needed to determine whether such bias is reflective of true cognitive differences or additional variables unaccounted for in this study. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Cross-cultural exploration of baseline ImPACT Quick Test performance among football athletes in Zambia

OBJECTIVE

Concussion is a global sport injury; however, this public health issue has yet to be studied across Africa. It is unknown if tests such as the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) Quick Test (QT) are culturally appropriate for implementation as part of a concussion screening protocol in Zambia or other African nations. Study objectives included: 1) establish that Zambian athletes are able to complete the iPad-based ImPACT QT with respect to language or cultural barriers that may exist, and 2) document baseline neurocognitive percentile ranks among Zambian football athletes on the ImPACT QT.

METHODS

This study was completed with adult premiere league football athletes in Zambia (n = 125) aged 24.48 ± 5.41. Participants completed the ImPACT QT neurocognitive assessment prior to a preseason practice. Outcome measures were average performance on 3 factor scores: Motor Speed, Memory, and Attention Tracker, presented as percentile ranks using normative data built-into the ImPACT QT.

RESULTS

Zambian athletes scored nearly two standard deviations below the mean on Motor Speed (7^th percentile), using North American normative data. However, performance on Attention Tracker (44^th percentile) and Memory (56^th percentile) was within the average range.

CONCLUSION

Results of the current study show that Zambian athletes are able to complete the ImPACT QT, despite any language or cultural differences that may exist. In addition, preliminary percentile ranks suggest Zambian football athletes have average scores on Attention and Memory and below average scores on Motor Speed. These data are the first to explore Zambian athletes' performance on a cognitive concussion measure.

Baseline preseason ImPACT® testing in Mandarin with adolescent student-athletes in the United States

Researchers have examined differences on ImPACT^® in baseline symptom reporting and neurocognitive performances based on the language of administration and racial/ethnic identity. This is the first study to examine differences between student-athletes tested in Mandarin versus English on ImPACT^® during preseason baseline assessments conducted in high schools in the United States. Participants included 252 adolescent student-athletes who completed ImPACT^® testing in the state of Maine in Mandarin and 252 participants who completed testing in English, matched on age, gender, and health and academic history. Participants were compared on neurocognitive composite scores and symptom ratings. Boys tested in Mandarin, but not girls, had modestly better neurocognitive performance on one of four composite scores (i.e., Visual Motor Speed, p < .001, d = .45). Although language groups did not differ in total symptom severity, boys tested in Mandarin endorsed multiple physical symptoms at higher rates than boys tested in English. These results suggest that the current ImPACT^® neurocognitive normative data are reasonably appropriate for use with adolescents evaluated in Mandarin. There were some differences in the reporting of physical symptoms, with greater rates of symptom endorsement by boys tested in Mandarin than boys tested in English; but overall symptom severity ratings were comparable between the language groups.

Effect of Diagnosed Sleep Disorders on Baseline Concussion Symptom, Cognitive, and Balance Assessments in Collegiate Athletes

BACKGROUND

Symptoms, cognition, balance, and other domains are commonly assessed at baseline testing as part of comprehensive preseason evaluations among collegiate student-athletes. Although approximately 27% of college students have at least 1 sleep disorder, researchers have yet to examine the role of a preexisting sleep disorder on preinjury baseline performance.

PURPOSE

To compare athletes with and without a reported history of diagnosed sleep disorders on commonly used baseline concussion assessments.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 666 National Collegiate Athletic Association student-athletes completed baseline measures including the Balance Error Scoring System (BESS), Brief Symptom Inventory-18 (BSI-18), Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), Post-Concussion Symptom Scale (PCSS), Sport Concussion Assessment Tool-5th Edition (SCAT5), and Standardized Assessment of Concussion (SAC). There were 333 athletes with a history of diagnosed sleep disorders who were matched on age, sex, sport, and concussion history to 333 athletes with no history of diagnosed sleep disorders. Participants in both groups had a mean age of 19.89 ± 1.36 years and included 182 (54.7%) male athletes, and 126 (37.8%) reported a history of ≥1 concussions.

RESULTS

A series of 1-way analyses of covariance with Bonferroni corrections revealed significant group differences on the BESS (F_1,559 = 8.88; P < .01); BSI-18 somatization (F_1,640 = 18.48; P < .01), depression (F_1,640 = 18.78; P < .01), anxiety (F_1,640 = 19.42; P < .01), and global severity index (F_1,640 = 27.18; P < .01); PCSS (F_1,424 = 29.42; P < .01); SCAT5 symptom number (F_1,634 = 28.79; P < .01) and symptom severity (F_1,634 = 31.74; P < .01); and SAC (F_1,578 = 4.36; P = .037). Specifically, while the sleep disorder group did perform better on the BESS, they also reported higher symptoms on the BSI-18, PCSS, and SCAT5 and performed worse on the SAC. There were no group differences on ImPACT performance.

CONCLUSION

Collegiate student-athletes with diagnosed sleep disorders reported elevated affective and concussion symptoms at baseline that could affect the interpretation of postinjury impairments and symptoms. Based on the small effect sizes of our findings, however, the magnitude of these differences is of questionable clinical significance. Still, clinicians should consider diagnosed sleep disorders as reported during preparticipation sports physical examinations when interpreting baseline and postinjury concussion assessments.

ImPACT Normative Data of Ethnically Diverse Adolescent Athletes

OBJECTIVE

The aim of this research was to develop preliminary norms for the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) administered to a large sample of adolescent athletes from diverse ethnic backgrounds.

DESIGN

A retrospective records review.

SETTING

Middle and high school athletic departments.

PARTICIPANTS

A total of 5741 male and female adolescent athletes in Hawaii, aged 13 to 18 years, in grades 9 to 12 were included in the study.

INDEPENDENT VARIABLES

Age, sex, ethnicity, and sport.

MAIN OUTCOME MEASURES

ImPACT Composite scores (Verbal Memory, Visual Memory, Visual Motor Speed, Reaction Time, and Impulse Control) and Total Symptom score from baseline testing.

RESULTS

The results indicated statistically significant differences between age and sex groups, as well as between ethnic and sport groups.

CONCLUSIONS

The findings support the continued use of stratified norms for age and sex for ethnically diverse adolescent athletes. Comparisons of ethnic and sport groups deserve further investigation. When baseline scores are not available for postconcussion comparison, present observations tentatively support the cautious use of standard ImPACT norms with ethnically diverse athletes.

Factor structure models for the Post-Concussion Syndrome Scale with monolingual Spanish-speaking adults from Colombia

PRIMARY OBJECTIVE

The Post-Concussion Syndrome Scale (PCSS) is a self-report questionnaire that measures post-concussive symptom severity and has been primarily normed on young Caucasian samples. This study aims to explore the factor structure models of a Spanish translation of the PCSS at a chronic post-traumatic brain injury (TBI) time point.

RESEARCH DESIGN

Descriptive and exploratory research designs were utilized.

METHODS AND PROCEDURES

The study consisted of a monolingual sample of Spanish-speaking adults from Colombia, with 100 subjects in the control group and 70 subjects in the TBI group. A t-test, chi-square, and MANOVA were calculated to compare group differences. Cronbach's alpha was calculated to investigate reliability. Confirmatory factor analysis compared item loadings onto an existing four-factor model. Exploratory factor analysis sought to identify a new factor model if the loadings did not fit.

MAIN OUTCOMES AND RESULTS

There were no group differences in demographic variables. Internal consistency was acceptable. Model fit indices revealed a poor fit with the original four factors. Item loadings revealed a novel six-structure model.

CONCLUSIONS

While the PCSS appears to capture general post-TBI sequelae, the underlying factors may differ due to cultural and linguistic differences in Spanish-speaking individuals. Clinical implications and future directions are further discussed.

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.

Factors Contributing to Disparities in Baseline Neurocognitive Performance and Concussion Symptom Scores Between Black and White Collegiate Athletes

BACKGROUND

National Collegiate Athletic Association (NCAA) concussion guidelines state that all NCAA athletes must have a concussion baseline test prior to commencing their competitive season. To date, little research has examined potential racial differences on baseline neurocognitive performance among NCAA athletes. The purpose of this study was to investigate differences between Black and White collegiate athletes on baseline neurocognitive performance and self-reported symptoms.

METHODS

A total of 597 collegiate athletes (400 White, 197 Black) participated in this study. Athletes self-reported their race on the demographic section of their pre-participation physical examination and were administered the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) neurocognitive battery in a supervised, quiet room. Controlling for sex, data were analyzed using separate one-way analyses of covariance (ANCOVAs) on symptom score, verbal and visual memory, visual motor processing speed, and reaction time composite scores.

RESULTS

Results revealed significant differences between White and Black athletes on baseline symptom score (F (1,542) = 5.82, p = .01), visual motor processing speed (F (1,542) = 14.89, p < .001), and reaction time (F (1,542) = 11.50, p < .01). White athletes performed better than Black athletes on baseline visual motor processing speed and reaction time. Black athletes reported higher baseline symptom scores compared to Whites. There was no statistical difference between race on verbal memory (p = .08) and that on visual memory (p = .06).

CONCLUSIONS

Black athletes demonstrated disparities on some neurocognitive measures at baseline. These results suggest capturing an individual baseline on each athlete, as normative data comparisons may be inappropriate for athletes of a racial minority.

Validity of the Immediate Post Concussion Assessment and Cognitive Testing (ImPACT)

BACKGROUND

The immediate post concussion assessment and cognitive testing (ImPACT) is the most widely used concussion assessment tool. Despite its popularity, it is unclear if validation studies for the ImPACT test covered all aspects of validity to support its widespread use in research and clinical practice.

OBJECTIVE

The purpose of this report is to review literature surrounding the validity and the utility of the ImPACT test.

DATA SOURCES AND APPRAISAL

A systematic review of relevant studies in PubMed, CINAHL, and PsycINFO was carried out. Studies were evaluated using the STROBE (strengthening the reporting of observational studies in epidemiology) or the STARD (standards for reporting of diagnostic accuracy) criteria.

RESULTS

The literature search yielded 5968 studies. Sixty-nine studies met the inclusion criteria and were included in the qualitative review. Although the convergent validity of ImPACT was supported, evidence of discriminant and predictive validity, diagnostic accuracy and responsiveness was inconclusive. The utility of the ImPACT test after acute symptom resolution was sparse. The review found many factors influenced the validity and utility of ImPACT scores.

CONCLUSION

Clinicians must consider the benefit of ImPACT testing for their patients on a case-by-case scenario and must take the psychometric properties of the test into account when interpreting results.

A case matched study examining the reliability of using ImPACT to assess effects of multiple concussions

BACKGROUND

Approximately 3.8 million sport and recreational concussions occur per year, creating a need for accurate diagnosis and management of concussions. Researchers and clinicians are exploring the potential dose-response cumulative effects of concussive injuries using computerized neuropsychological exams, however, results have been mixed and/or contradictory. This study starts with a large adolescent population and applies strict inclusion criteria to examine how previous mild traumatic brain injuries affect symptom reports and neurocognitive performance on the Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) computerized tool.

METHODS

After applying exclusion criteria and case matching, 204 male and 99 female participants remained. These participants were grouped according to sex and the number of previous self-reported concussions and examined for overall differences on symptoms reported and scores obtained on the ImPACT neurocognitive battery composites. In an effort to further reduce confounding factors due to the varying group sizes, participants were then case matched on age, sex, and body mass index and analyzed for differences on symptoms reported and scores obtained on the ImPACT neurocognitive battery composites.

RESULTS

Case matched analysis demonstrated males with concussions experience significantly higher rates of dizziness (p = .027, η² = .035), fogginess (p = .038, η² = .032), memory problems (p = .003, η² = .055), and concentration problems (p = .009, η² = .046) than males with no reported previous concussions. No significant effects were found for females, although females reporting two concussions demonstrated a slight trend for experiencing higher numbers of symptoms than females reporting no previous concussions.

CONCLUSIONS

The results suggest that male adolescent athletes reporting multiple concussions have lingering concussive symptoms well after the last concussive event; however, these symptoms were found to be conflicting and better explained by complainer versus complacent attitudes in the population examined. Our results conflict with a significant portion of the current literature that uses relatively lenient inclusion and exclusion criteria, providing evidence of the importance of strict inclusion and exclusion criteria and examination of confounding factors when assessing the effects of concussions.

Influence of Language of Administration on ImPACT Performance by Bilingual Spanish-English College Students

Previous research has suggested that there are performance differences on the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) battery related to language of administration, such that scores are higher with the English than the Spanish version of the battery. This study extended those findings in a within-subjects design, evaluating neurocognitive performance of 58 bilingual English-Spanish-speaking individuals who completed ImPACT in both languages. Results revealed a significant multivariate effect of language of test administration, p < .01; partial η(2) = 0.23, with significantly better English language performance on Verbal Memory and Visual Motor Speed composite scores, but not Visual Memory, Reaction Time, or Total Symptom score. Results are discussed in relation to potential linguistic biases of the ImPACT and functional language dominance that may contribute to the lower scores. These results extend previous findings and suggest a need for separate normative data for Spanish-speaking individuals completing the ImPACT battery if baseline data are not present.