Clincal Utility of ImPACT: Mayers & Redick

19 Dec

A new article on the review of ImPACT and it utility of use in determining return-to-play status of a post concussed individual has been published in the Journal of Clinical and Experimental Psychology.  (Lester B. Mayers & Thomas S. Redick (2011): Clinical utility of ImPACT assessment for postconcussion return-to-play counseling: Psychometric issues, Journal of Clinical and Experimental Neuropsychology, DOI:10.1080/13803395.2011.630655)

The abstract reads; Computerized neuropsychological testing is commonly utilized in the management of sport-related concussion. In particular, the Immediate Postconcussion Assessment and Cognitive Testing 2.0 program (ImPACT) is widely used to assess the cognitive functioning of athletes before and after a concussion.We review the evidence for the clinical utility of this program in terms of validity, reliability, and use in return-to-play decisions. We conclude that the empirical evidence does not support the use of ImPACT testing for determining the time of postconcussion return to play.

The authors mention the other used computer tests, but chose to focus on ImPACT because of its wide use; from professional sports all the way down to youth sports.  The over all impression is that the current studies from independent sources (void of any conflict of interest) seem to be trending away from using this tool as a clearance device.

Granted that each company, including ImPACT, inform the users that is is not what the tool is intended for; the tone and layman seem to indicate otherwise.  You can simply interview athletes, coaches and parents and ask them this question: “Does passing ImPACT mean you can go back to play?”

The resounding answer would be “yes”.

I spend more time educating parents and kids about what the ImPACT does not do.  Parents and kids believe that because they have spent money on the baseline and follow-up test this is the mechanism for return-to-play.  When in fact it is merely a device that, I personally use, to a) educate and b) use as the frame of the entire picture.

Over the years using this tool and others like it, I have used it more as a clearance for return to school.  Why you ask?  Just like the article presents the cognition portion of the brain recovers at a different rate than other aspects of brain function.  ImPACT measures this portion, and a portion that is key to going to school, thinking and retaining.

The ImPACT (again using this one due to its focus in the above article) may not have a place in return to activity, per se, but in my opinion it has a purpose of getting the injured individual back to the classroom.

If you have been paying attention to the blog you will also note that my “Graded Return-to-Play” step 2 (after rest and before light activity) is return to school/classroom.  A high school athlete will spend way more time in school than they will on a filed/court/rink of play.  It would be more prudent to make sure the athlete is capable handling the stresses to the brain at school than playing a sport.

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22 Responses to “Clincal Utility of ImPACT: Mayers & Redick”

  1. Paul LaDuke, ATC December 19, 2011 at 09:17 #

    Question for you Brandon: When do you perform a post-concussion ImPACT test?

    I to use the ImPACT as a tool in my toolbox and it gives me valuable information in the middle or towards the end of the recovery process. I typically have been giving the test to athletes post-concussion once their sx have cleared and they have begun the graded exercise protocol.

    • Dustin Fink December 19, 2011 at 16:01 #

      I am not Brandon, but I will tell you what we do.

      We give the post ImPACT after all symptoms are reported as resolved. Why give the test and give the false hope that they are going to be back to activity if they pass. I have seen the test passed by kids who have many symptoms (I understand that symptom reporting is key to making a decisions and should be the automatic DQ’er), but why even expose the brain to high level of function if it is not healed?

      ImPACT post tests are given at Step 5 of our RTP protocol, often by that time clinically they have been cleared by health care providers (including myself) and is part of the last confirmation that MD’s use to write the note.

  2. Joe Bloggs December 19, 2011 at 10:37 #

    A few takeaways from the article:

    1) It is not a long-term longitudinal instrument;
    2) 2 year baselining intervals are a problem (my note: true especially for high schools);
    3) Impact has issues with concurrent validity; and
    4) ImPact has issues with divergent validity.

    What is not in the article are representation regarding at home testing and use of ImPact without a baseline which only paints worse picture.

    No one should use ImPact on a two year baseline for high school, home baselined or without a baseline regardless of what ImPact states. It makes it an easier sell but undermines its utility.

    Passing ImPact or any Neuropsych (NP) test only implies the subject has normal cognitive function not that a concussion has resolved (Crosby and Pronger should never have seen ice time based on these results). Concussion has resolved when a complete work-up is taken and that often involves a complete NP work-up with a licensed NP.

    If one is testing the long-term change meaning is one developing a neuro-degenerative disease neither ImPact nor any sports concussion instrument is designed for that purpose.

    The issues of concurrent and divergent validity are of even greater concern. Headminder has published extensive validity studies and I believe Cogstate/Axon has done as well. It is a standard process when developing NP instruments. It has long been known ImPact does tend to cut such corners.

    Nonetheless, caveat emptor and please follow the proper procedures propagated by reasonable people.

  3. BryanATC December 19, 2011 at 13:46 #

    I’m confused about the “not using ImPACT as a return-to-play” criteria. Is this any neuropsych test or just ImPACT? What if an athlete has been found by clinical evaluation to be “ok”, but their neuropsych scores are still below baseline? Wouldn’t a “passing” of that test then give the “ok” to return to activity or is there some other secret step I’m missing?

    Or is the “not using ImPACT as a return-to-play” focus more on the difference between “activity” and “play”. Returning to baseline neuropsych scores and being found clinically “ok” means you can then begin a graduated return to activity, not that you can walk out the door and play in a game?

    If that’s the case then that blame falls on who ever is administering the ImPACT (or other neurospych test) in the first place for not explaining what proper “return-to-play” protocol actually entails (i.e. it’s not “you are finally cleared, have fun in your game”).

    Is that the discussion going on here about ImPACT and neuropsych tests?

    • Dustin Fink December 19, 2011 at 15:58 #

      Bryan,
      I think the issue surrounds the use of this test or others like it as a “clearance” device for return to play. Basing the “well-being” of an athlete on a screen would be a kin to a health care provider saying you are “heart-healthy” after a blood screen that did not take into account all the factors.
      I think what you presented in your first paragraph is more where my line of thinking is. ImPACT or other NP tests are just one part of the puzzle, and not even the top of the list for me. I personally feel that because of the test-retest and divergent validity issues that are present this test is mainly a confirmation process. And like I mentioned a more suitable test for return to school.
      The general feeling amongst laypeople and athletes is that this test is the gold standard and is the only criteria for clearance. More often I find that kids can pass the ImPACT but still present with clinical symptoms/issues, the most troubling are behavioral or academic.

      Does that help or muddy the water more?

      • BryanATC December 19, 2011 at 18:37 #

        Dustin,

        I agree that ImPACT or NP should only be a part of the puzzle, which is why I put blame on those practitioners who are not adequately explaining that fact when the initially give a baseline. Unless a parent has their child take an ImPACT baseline on their own and then shows up saying “here, they can play”, it’s our jobs as ATCs (or who ever administers the baselines) to properly explain what the role NP tests will play in the return to activity.

        As a point of clarification, you say that that you utilize ImPACT post tests, but list both Step 2 (blog post) and Step 5 (comment above) as when you administer it. Do you do both?

        We’ve had discussions here in PA about how our new legislation pertains to the RTP protocols we use and where exactly a physicians clearance should be required. The two possibilities are progressing from Step 1 to 2 (Rest to light activity) or Step 4 to 5 (going from non contact to contact activities). Those are the same two instances you mention above, so should it be before Step 2 or Step 5? My personal view should be it has to be before Step 2. If you wait until Step 5 the athlete has been back in the classroom and potentially could be still cognitively impaired and subsequently slowing their healing process.

        I think the reason ImPACT has become the “go to” test (on the high school level) is because it is the cheapest and easiest to implement logistically. It adds more information than just the post-injury clinical evaluation. I also think trying to evaluate behavioral or academic changes in high school athletes that are only slight in nature is like trying to catch the proverbial greased pig. Those things change on healthy high school students let alone ones recovering from a concussion. Some athletes might never make it back onto the field/court if some external test isn’t utilized.

      • Dustin Fink December 20, 2011 at 06:55 #

        Clarification: Administer Step 2 if there is a question about returning to classroom… Everyone gets it Step 5 for return to play…

        Good comments… I tend to side with Joe and Don on this… Joe makes valid points, I do remember when it was promoted as a clearance device and the fact that according to them you don’t need a baseline makes me weary… I have my serious doubts about its “normalized” database…

  4. Joe Bloggs December 19, 2011 at 19:14 #

    I think ImPact became the go to product for many reasons.

    1) The NFL, NHL, NBA use it (mostly because results will fall in line with owners desires because ImPact selects to read the results – player needs to on the field or ice they are);
    2) The sold it for many years by saying, if you pass ImPact the player is good-to-go;
    3) A willingness to bend reality like using it without a baseline, testing at home and baseline every two years (to accomodate people who don’t believe concussion is serious);
    4) ImPact took advantage of people unqualified to discern technical and medical difference in products; and
    5) Years of obscuring the fact ImPact was a for-profit enterprise promoted by its owners while claiming independence as UPMC researchers.

  5. Don Brady, PhD, PsyD, Licensed Psychologist December 20, 2011 at 00:10 #

    Some pertinent excerpts from my 2004 Dissertation and 2011 Sport-Related Concussions article written by Don Brady PhD, PsyD and Flo Brady, BSW seem to apply to the above comments. The Dissertation is entitled:
    A Preliminary Investigation of Active and Retired NFL
    Players’ Knowledge of Concussions
    ==============================================
    2004 Dissertation excerpts:
    1- In order to avoid false negative findings, continued efforts need to be sustained for developing more sensitive and precise neurocognitive evaluative instrumentation and medical techniques to assist with this process [of accurately assessing concussions].
    Comment:
    Furthermore, a ‘passing score’ obtained in a screening may be grossly misleading; the newly obtained score may be influenced by practice effects and it may have required ‘more brain effort’ to obtain similar score…
    =========================================================

    2- In neuropsychological-related research pertaining to brain injury, cognitive functions have received more attention than physical and emotional/behavioral effects (Lezak, 1995, p. 21). Lezak further noted that brain damage rarely affects just one of these systems as the disruptive effects of most brain lesions usually involve all three categories.

    3- In an extensive review of research pertaining to mild brain injury, Reitan & Wolfson (2000) strongly cautioned that many researchers who have examined mild brain injury have typically not employed comprehensive neuropsychological test batteries in their methodology. The authors perceive this as a MAJOR FLAW in evaluating the impact of mild brain injury, because they firmly believe that standard neuropsychological test batteries have frequently been shown to be sensitive to both focal and diffuse brain damage. They also pointed out that researchers typically have limited their assessment and focus due to
    a premature presumption that neuropsychological impairment is limited to a rather narrow range of deficits, and that a restricted range of tests is all that is required for adequate neuropsychological assessment. Our clinical experience suggests that mild brain injury produces diversified and even widespread neuropsychological losses in some patients (p.97).

    Comment:
    Thus why are not thorough assessments being completed on all 3 brain functions: physical, cognitive and emotional? From my perspective, any screening/assessment that does not include all three areas of brain functioning constitutes negligence.
    If all 3 components were consistently assessed…then it should have come to no surprise that significant personality changes were possible…and perhaps some emerging concussion- related suicides could have been averted?
    And keep in mind that policy is now in place re concussion management laws. Thus I anticipate that concussion-related lawsuits will be growing exponentially…
    =======================================================
    4- Given the extensive number of potential concussion effects, preconcussion baseline and postconcussion data should be obtained beyond the generally assessed cognitive functions to more precisely determine the multiple effects of a concussion (Brady, 1989, 1999, 2002). For example, since concussions may affect an athlete’s visual information processing skills, baseline and postconcussion data pertaining to vision should be obtained, as players are at risk for the occurrence of ocular and visual dysfunctions as a result of brain injury (Heitger, Anderson, Jones, Dalrymple-Alford, Framptom, & Ardagh, 2004; Suchoff, Kapoor, Waxman, & Ference, 1999). Concussions may adversely impact visual functioning by significantly reducing the efficiency of a person’s visual system (L. Savedoff, personal communication, May 12, 1999). Moreover, routine optometric assessments of persons who experience a brain injury have also been advocated (Cohen & Rein, 1992). Pre- and post- concussion personality testing should also be considered in order to compare data for potential psychosocial changes (Prigatano, 1992; Putukian & Echemendia, 2003; Brady, 2002) and the possible emergence of psychotic and psychotic-like disorders (Fujii & Ahmed, 2002; Sachdev & Smith, 2001; Zhang & Sachdev, 2003), which may occur after a person sustains a traumatic brain injury.

    ============================================================================
    Excerpt from Sport-Related Concussions (NASP-2011)
    By Don Brady, PhD, PsyD, NCSP and Flo Brady, BSW

    A negative MRI or CAT scan finding does not mean an athlete did not sustain a concussion or have any brain injury. Neuroimaging techniques, neuropsychological testing, and computerized neurocognitive screenings are not always sensitive to detecting subtle brain injury. Thus, a false negative finding may be obtained due to the lack of sensitivity of the instrumentation employed. In order to avoid false negative findings, continued efforts need to be sustained for developing more sensitive and precise neurocognitive evaluative instrumentation and medical techniques to assist with this process.

    ============================================================================

    Finally, please help me understand while RTP grading standards are being used when there is NO scientific evidence to support these OPINIONS… yes OPINIONS and not evidence based research…

    Thanks for listening

  6. Don Brady, PhD, PsyD, Licensed Psychologist December 20, 2011 at 00:21 #

    typo corrected and one additional comment…

    Finally, please help me understand WHY RTP grading standards are being used when there is NO scientific evidence to support these OPINIONS… yes OPINIONS and not evidence based research…

    one additional comment:

    and whatever happened to Professional Ethics that was learned/taught in grad school and the obvious ongoing conflicts of interests (COIs) re concussion assessments…and management?

    • BryanATC December 20, 2011 at 12:58 #

      RTP grading standards? Do you mean grading, as in scores on NP tests? Or are you referring to “graduated” RTP guidelines which refer to the progressive return to activity?

      In terms of Professional Ethics, I surely don’t think there are those being un-ethical which would mean they are putting the health and safety of athletes at risk just to justify their position. I think it’s more that they steadfastly believe their position and have let their judgment become clouded. If they truly know that any of their recommendations or protocols are unsafe then that is truly deplorable, though I don’t believe that is the case currently.

      • Don Brady, PhD, PsyD, Licensed Psychologist December 20, 2011 at 21:05 #

        =====================================================

        Bryan,

        I. I use the terms ‘Grading’ and ‘guidelines’ interchangeably…

        ————————————————————————————–

        Below are excerpts from my Dissertation that hopefully will clarify my previous statements…re these terms:

        Harmon (1999) cited the existence of at least 16 different concussion management guidelines or models, while Johnston et al. (2001) acknowledged at least 25 sports-related concussion management and grading systems. The guidelines are designed to assist with the assessment and decision-making process relating to the following components: (a) grade (i.e., severity) of a concussion; (b) management and treatment recommendations; and (c) duration of time the athlete must abstain from participation in a sport after experiencing concussion.

        The numerous sets of concussion guidelines logically result in varying and differing perspectives pertaining to the assessment, management, and return-to-play of the athlete.

        Not surprisingly, critics have emerged regarding the various grading systems that have been developed to assist in the management and return-to-play decisions of a concussed athlete. The existence of various guidelines and resulting differing viewpoints may be attributed to the difficulty in accurately assessing the severity of a concussion, and the lack of a scientific basis for determining when an athlete has adequately recovered from the concussion (Roos, 1996). One of the significant criticisms of the various concussion grading systems is that they are not based on scientific evidence (McCrory, 2000; Johnston et al., 2001).
        —————————————————————————————
        Comment /question
        Am curious as to the scientific basis for the graduated return to play protocol that you use?
        —————————————————————————————

        Re Conflicts of Interest

        1—Sports team health care personnel also need to focus primarily on the athlete’s health and well being, and not minimize an injury (Huizenga, 1994) or primarily focus on the player’s capacity to perform (Matheson, 2001; Pipe, 1998). This is necessary in order to avoid any real or perceived conflicts of interests emerging in the return-to-play decision-making process (Pipe, 1998; Matheson, 2001). A review of the literature clearly indicated that the topic of conflict of interest (COI) has not only been inadequately addressed by various professions, but is also an ongoing and growing source of intense debate within the legal, health care, educational and research arena. (Alpert, 2002; Angell, 2000; Angell, 2002; Barnes, & Florencio, 2003; Davidoff, 1997; DeAngelis, 2000; DeAngelis, Fonanarosa, & Flanagin, 2001; Huizenga, 1994; International Committee of Medical Journal Editors, 1999; Jason, & Loewenstein, 2003; Kalb & Koehler, 2002; Krimsky & Rothenburg, 1998; Lemmens, Liclur, & Singer, 1998; McDonnell, 1999; Moore, 2001; Moore, 2003; Shortell, Waters, Clarke, & Burdette, 1998; Thompson, 1993; Tsai, 2003; Wager, Field, & Grossman, 2003). Unfortunately, effective policy and professional medical standards have not been devised to combat adequately the various significant ethical and legal issues that have emerged from this COI debate (Lemmens et al., 1998; Moore, 2001). Some of the core conflict of interest issues and proposed safeguards will be briefly addressed here and related to the emerging field of sports-related concussions. So to engender public trust in patient-care, research findings, and the overall practice of the art and science of sports-related concussion assessment and treatment, it is this writer’s desire that the field of sports-related concussion address fundamental COI issues and incorporate related safeguards into this emerging discipline.

        2—It has been strongly suggested that the American Medical Association (AMA) has not adequately addressed the need for the existence of COI tenets within its members’ clinical and research practices (Moore, 2001; 2003). In the following statement, Moore (2001) noted that a significant shortcoming existed in the AMA’s Principles of Medical Ethics pertaining to COI:
        “Unlike the legal profession, the medical profession lacks a strong tradition of regulating conflicts of interests generally” (p. 3).

        3—… failure to provide acceptable health care services is also unethical. This particular concern has long been raised within the sports field and in particular by the National Football League Players Association (NFLPA) (Moore, 1982). In a 1982 article, the sports medicine coordinator for the NFLPA advocated for “improved medical care that he thinks is lacking in the injury world of professional football” (p.162). Moore (1982) also pointed out the existence of apparent COIs existing for team physicians and athletic trainers via conflicts in their dual roles of “allegiance to their team owners and the best interests of their patients”(p.162). Huizenga (1994), a former team physician for the Oakland Raiders, voiced similar perspectives pertaining to these two medically related concerns.

        4—It should be noted that the NFLPA advocated for a players’ physician over 20 years ago (Moore, 1982). Further input on this topic was provided by another player who responded to this writer’s survey. The athlete offered his unbridled perspective pertaining to COIs and some NFL team physicians when he opined that “they are soulless gatekeepers protecting the money, that’s why they are there” (anonymous NFL player, personal communication, September 16, 2003).

        Comment: Suggest you read some of the COI articles cited…if you have not previously been exposed to the various articles. Since my Dissertation was completed during 2004, additional articles have been written re COIs existing within Sport…

        =======================================================

        Miscellaneous comment/excerpt:

        A …view of significant sport injury risk was depicted in Dean and Hoerner’s (1981) findings that an individual has a 50% chance of being injured while actively involved in sports. Although the authors indicate many injuries are called “minor,” they also succinctly note, “all injury is damage.” These authors also posed an interesting question that they left unanswered: “What does society trade-off for these injuries and death” (p. 41).

  7. brokenbrilliant December 20, 2011 at 19:39 #

    One of the issues that concerns me with ImPACT testing for determining RTP readiness, is that if it’s a neuropsychological test, does it measure the physiological post-concussion symptoms, such as dizziness, balance issues, sensitivities to light and sound, chronic pain, etc. as well as the behavioral issues which can also affect readiness to play again? The most noticeable and dramatic after-effects of my own concussions have been physiological, which have also played into behavioral and psychological issues. ImPACT testing may gauge neurocognitive issues, which are certainly indicative of concussion, but as with the Colby Armstrong situation, there are other symptoms and indicators which the test can (and will by its very nature) miss.

    • Joe Bloggs December 20, 2011 at 20:43 #

      Neurocognitive Tests measure changes in brain function although one would expect to pick-up a lack of coordination and sensitivity to light secondary effects in the reaction time and working memory domains. It doesn’t appear ImPact is well-tuned.

      Nonetheless, any evidence of a broad range of symptoms should automatically sit a player regardless of positive cognitive results.

      It is unlcear how UPMC/ImPact instruct ATCs/NPs/Doc on RTP but as evidenced by the NHLs cases of Pronger, Crosby et al., and numerous NFL cases it seems to lack the same rigor as is demanded by this type of injury.

      • Don Brady, PhD, PsyD, Licensed Psychologist December 20, 2011 at 21:24 #

        Joe,

        I see an emerging concern that individuals may perceive that ImPact attempts to measure more areas of brain functioning/dysfunctioning than the screening tool is reportedly designed to evaluate.

        From my perspective, and regardless of the validity and reliability of the instrument, ImPact is merely a ‘screening instrument’ and not a comprehensive assessment instrument

    • Don Brady, PhD, PsyD, Licensed Psychologist December 20, 2011 at 21:12 #

      Broken…

      I think that a brief porion of an above comment of mine is an approrpiate response to your statements.

      1—- In neuropsychological-related research pertaining to brain injury, cognitive functions have received more attention than physical and emotional/behavioral effects (Lezak, 1995, p. 21). Lezak further noted that brain damage rarely affects just one of these systems as the disruptive effects of most brain lesions usually involve all three categories.

      2— In an extensive review of research pertaining to mild brain injury, Reitan & Wolfson (2000) strongly cautioned that many researchers who have examined mild brain injury have typically not employed comprehensive neuropsychological test batteries in their methodology. The authors perceive this as a MAJOR FLAW in evaluating the impact of mild brain injury, because they firmly believe that standard neuropsychological test batteries have frequently been shown to be sensitive to both focal and diffuse brain damage. They also pointed out that researchers typically have limited their assessment and focus due to
      a premature presumption that neuropsychological impairment is limited to a rather narrow range of deficits, and that a restricted range of tests is all that is required for adequate neuropsychological assessment. Our clinical experience suggests that mild brain injury produces diversified and even widespread neuropsychological losses in some patients (p.97).

      • Don Brady, PhD, PsyD, Licensed Psychologist December 20, 2011 at 21:14 #

        oops…typos in 1st sentence:

        I think that a brief portion of an above comment of mine is an appropriate response to your statements.

  8. Joe Bloggs December 20, 2011 at 22:47 #

    No computerized test can replace a complete work-up by a skilled or group of skilled clinicians. Regretably, most teams don’t even have ATCs. Many parts of the country don’t have NPs or Docs who undertsand m-TBI. This creates a quandary not easily resolved.

    The injury was not taken seriously in he face of overwhelming clinical evidence for fear of litigation by the NFL. So it proceeded to propagate nonsense for 15 years after the evidence was extant. Coaches, schools, players unions and insurers could feel safe as manifestions of severe damage oftern take years or decades to become evident and could argue inconclusive causation.

    For schools that lack an ATC, nurse or doctor; it may be time to pack in collision sports. Schools with and ATC, nurse or doctor, should be well-trained in both recognizing and treating concussion. In fact, I would argue that complex cases require a team of skilled clinicians that is seldom available outside areas lacking major academic medical centers.
    I am acquainted with a handful of practitioners who I would trust to treat the injury.

    While Barth and Hovda (murine models) suggest functional recovery in 3 to 10 days in the vast majority of cases, most programs should err towards conservatism as childrens brain development leads to unpredicatble resolution. Perhaps imposing AIBA boxing standard following concussion.

    Your own research strongly argues symptomology that is not part of many current protocols but is clearly valid in complex cases.

    It stands to reason, that protocols need to redrawn. At minimum an ATC should be present a games and practices of collision sports. SCAT-II while not validated is a good guideline, if a school can afford it, NP screening. Following injury a complete and rigorous protocol should be executed. In the event the patient does not resolve rapidly, the athlete should be refferred for a complete work-up and removed from play and in some cases school until his or her condition stabalizes.

  9. Tommy Dean December 21, 2011 at 10:47 #

    I guess my question here would be “What is the alternative?” if high schools did not utilize ImPACT (or any other NP testing for that matter). I agree 100% that schools that can not afford (or otherwise think it is not necessary to have) a certified athletic trainer at practice and events should not be allowed to field a collision sport. In Louisiana there are two legislative acts that were passed as early as this summer that address youth concussion and sports injury management (ACT 314 and ACT 352 respectively). The youth concussion act, in my opinion, is nothing more than a blanket “CYA” piece of legislation. It does not call for a true “management” program. It doesn’t “solve any problems”. It was a PR push by the NFL (to prove their innocence and soften the fire storm they’ve received as of late) just like 98% of the laws passed to date (with exception of states such as Washington and it’s unfortunate event that inspired their law). ACT 314 identifies who is “qualified” to clear these individuals for RTP and proposes other “guidelines” which most of us have been following for 10 years already. We fight the same battle here that I’m sure most of you out there fight. How do we (as certified athletic trainers) identify the physicians in our geographical area that are truly “qualified” in concussion management? And does it truly make sense to have a high school athlete that has had a concussion run off and make an appointment with a neuropsychologist to have an 8 hour work up done? What’s the cost associated with a potentially unnecessary test? ImPACT has at least been able to provide a credentialing process that gives physicians some of the knowledge to be able to interpret the data to a degree so that the “concussion management team” can make a better informed decision based on human clinical judgement and with the impact report in hand (along with the other test batteries that are recommended). Again, I pose the question. What is the alternative to concussion management at the high school level if you are not using NP testing (or don’t have a certified athletic trainer)? Is ImPACT or any other NP test out there the answer? I don’t know. I could tell you this much though. Without anything, we as certified athletic trainers aren’t any more valuable in injury management than mom, dad, the coach or the guy that serves us drinks at the bar (although everyone indeed does have their place). We have been asked to make tough decisions without any tools to do so. There was a problem and someone had the vision to provide a solution. Now that we have something that gives us more objective information than we had before to make these tough decisions it is being scrutinized as fraudulent marketing. So again. What’s the ultimate solution? Because although they may help in raising awareness these youth laws are not solving any problems. If anything, they are creating problems. In my opinion, if the NFL deems it necessary to put “injury observers” (and I’m glad they have decided to put certified AT’s) up high in the sky so that they may see if something is being missed on the field, why don’t they implement a program where they fund high schools (possibly through a grant) to have certified athletic trainers in high schools around the country? Just a thought.

    • BryanATC December 21, 2011 at 12:54 #

      Don, I’m still a little confused with some of your points.

      RTP protocols have zero to do with “grading”. Dustin had a post a short time ago about misleading terms, and while we disagreed with the use of some in terms of severity of injury, we all agreed that the injury protocols are exactly the same. Essentially, regardless of “grade” there is no change in the RTP guidelines.

      With that being said, there are two distinct sections when referring to concussion management guidelines. The first and longest section is the rest/healing/recovery stage that extends from when the athlete suffers a concussion to when they are allowed to begin activity. Simply put, as much rest (both physical and mental) as possible with the hopefull resolution of symptoms, cognitive changes and behavioral abnormalities. Once that level has been reached then begins a “graduated return to play” (which is different that “grading”) which progressive physical activity (usually one level per 24 hours) while remaining asymptomatic. The protocol ends when the athlete is released back to full contact activity with out restrictions.

      Yes clinical evaluation will be made at some point (Zurich report suggests before return to full activity, but most states are going with prior to going from rest to light activity), but it most often will not be more than a standard office visit. It will (by most state legislation) be with a physician who is “trained in current concussion evaluation and management protocols”.

      So if you disagree with “grading” concussions, fine (Zurich 2008 agrees with you), but if you disagree with the “graduated return to play” following a concussion please explain why?

      In terms of COI, I never said the NFL or NFLPA or any other non-medical group didn’t have huge COI’s . They most undoubtedly do which is why independent evaluators are needed on the sidelines (which appears to now be the case). My comment on believe conscious COI and unethical decisions were not rampant had to do with the release of studies supporting evaluative tools such as ImPACT.

      • Don Brady, PhD, PsyD, Licensed Psychologist December 25, 2011 at 22:47 #

        Bryan,

        Before I respond to comments of yours…

        1–again it would be helpful to know the evidence based research that supports

        “graduated return to play”

        and

        2– how you assess / determine:

        “when a player has obtained as much rest (both physical and mental) as possible…”

  10. Jason Viel December 21, 2011 at 15:10 #

    I agree with what most posters have said. No matter what people say about or their personal views of ImPACT (other NP tests) you cannot and should not have been using them as the sole RTP decision. I think that most AT’s (myself included) have been using NP tests as a tool in the box of RTP. While ImPACT has issues it has to resolve I think that for the most part their tool when used appropriately serves its purpose. We (AT’s) need to be on the forefront of concussion awareness with parents/athletes/coaches/admistrators/etc if we are going to change the culture. I compliment Dustin on his blog as being a “watchdog” and pointing out the deficiencies of fellow AT’s and other health care professionals on their mismanagement of concussion.

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