Test-Retest Reliability of Remote ImPACT Administration.

OBJECTIVE: To evaluate the performance and test-retest reliability obtained when administering a computerized baseline neurocognitive exam to NCAA Division I student-athletes in a controlled laboratory setting versus an uncontrolled remote location. METHOD: A sample of 129 (female = 100) Division I student-athletes completed Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) pre-season assessments for two distinct and respective sports seasons in a controlled laboratory environment and an uncontrolled remote environment. Depending on the environment, participants were given verbal (controlled) or written (uncontrolled) guidelines for taking the test. RESULTS: Multivariate repeated-measures ANOVA's determined that there were no within-subject differences between testing environments on ImPACT composite scores and cognitive efficiency index (CEI). The Chi-square test did not find any significant differences in impulse control or the number of invalid test scores, as determined by ImPACT, between environments. Intraclass correlations found the ImPACT subtest scores to range in test-retest reliability across testing environments, demonstrating moderate (verbal memory composite, r = 0.46; visual memory composite, r = 0.64; reaction time, r = 0.61; impulse control, r = 0.52; and CEI, r = 0.61) and good (visual motor composite, r = 0.77) test-retest reliability. CONCLUSIONS: Results indicate that ImPACT is reliable between controlled and uncontrolled testing environments. This further suggests that ImPACT can be administered in a remote environment, pending specific adherence to testing instructions, or in the event of social distancing or isolation policies.

Concussions: Activity Avoidance and Rest Recommendation.

Research surrounding rest recommendations for the concussed population is discussed. Rest is compared with activity avoidance, which is common in several chronic disease and traumatic injury types. The case is made for rest recommendations tailored to each head-injured individual. Research is presented which suggests that activity in the initial stages of concussion recovery may be beneficial in reducing postconcussion symptom duration and severity. Furthermore, a gradual increase in activity may potentially aid in returning to normal daily activity sooner than those who avoid both physical and cognitive activity during the acute stage of a traumatic brain injury. Finally, the current state of rest recommendations is reviewed and anticipated future directions are discussed.

Impact of Sports-Related Subconcussive Injuries in Soccer Players.

Sports-related subconcussive impacts to the head are receiving increased interest. Recent evidence indicates that subconcussive impacts will have greater relevance across time because of the number of repetitive impacts. Soccer players are at risk of receiving at least one impact during a soccer game. The authors review the cognitive-communication functioning following subconcussive head injuries in youth and recommendations for baseline assessments and cognitive-communication dysfunctions after subconcussive impacts in youth. The review is followed by a description and discussion of a study that assessed the cognitive-communicative dysfunction in young soccer players prior to and following a series of soccer matches and recommendations for monitoring recovery of cognitive-communication.

The frequency of post-traumatic stress disorder symptoms in athletes with and without sports related concussion.

BACKGROUND: Purpose of this study is to investigate the presence and frequency of post-traumatic stress disorder (PTSD) symptoms in post-concussed (PC) athletes compared to a group of healthy control (HC) athletes. RESEARCH DESIGN AND METHOD: A pre and post-test group design was used to compare a post-concussed group to a matched healthy control group of athletes. An archival database which included PC (n = 62) and HC (n = 62) participants matched on age, years of education and gender who completed a test battery at baseline and post injury, The test battery was comprised of a neurocognitive assessment, self-reported symptom inventory and PTSD symptom questionnaire. Post-concussion assessment was obtained within 0-13 days post-injury. RESULTS: PTSD symptom scores were greater in PC post injury group (Mdn = 0) than for the HC group (Mdn = 0.0), U = 1282.0, p = 0.000, r = 0.34. A Wilcoxon Signed-ranks test indicated that PTSD symptom scores post-injury (Mdn = 0) were significantly higher than pre-injury (Mdn = 0), Z = - 2.75, p = 0.000, r = 0.35. Within the PC post injury group athletes having "difficulty sleeping" was the highest reported symptom an average of 25.8% followed by "avoiding similar situations" at an average of 19.4%. "Having trouble keeping thoughts of incident out of your head" was reported at an average of 17.7% and "flashbacks" were reported at an average of 12.9%. "Nightmares" and "feeling numb and detached" were reported at an average of 8.1 and 6.5% respectively. CONCLUSION: Athletes who reported no PTSD symptoms prior to sports related concussion do exhibit symptoms of PTSD. Providing a PTSD symptom questionnaire may provide a more comprehensive treatment plan for PC post injury athletes who may be at risk of chronic PTSD symptoms.

The auditory comprehension changes over time after sport-related concussion can indicate multisensory processing dysfunctions.

Background: Although science findings and treatment approaches of a concussion have changed in recent years, there continue to be challenges in understanding the nature of the post-concussion behavior. There is growing a body of evidence that some deficits can be related to an impaired auditory processing. Purpose: To assess auditory comprehension changes over time following sport-related concussion (SRC) in young athletes. Methods: A prospective, repeated measures mixed-design was used. A sample of concussed athletes (n = 137) and the control group consisted of age-matched, non-concussed athletes (n = 143) were administered Subtest VIII of the Computerized-Revised Token Test (C-RTT). The 88 concussed athletes selected for final analysis (neither previous history of brain injury, neurological, psychiatric problems, nor auditory deficits) were evaluated after injury during three sessions (PC1, PC2, and PC3); controls were tested once. Between- and within-group comparisons using RMANOVA were performed on the C-RTT Efficiency Score (ES). Results: ES of the SRC athletes group improved over consecutive testing sessions (F = 14.7, p < .001), while post-hoc analysis showed that PC1 results differed from PC2 and PC3 (ts ≥ 4.0, ps < .001), but PC2 and PC3 C-RTT ES did not change statistically (t = 0.6, p = .557). The SRC athletes demonstrated lower ES for all test session when compared to the control group (ts > 2.0, Ps<.01). Conclusion: Dysfunctional auditory comprehension performance following a concussion improved over time, but after the second testing session improved performance slowed, especially in terms of its timing. Yet, not only auditory processing but also sensorimotor integration and/or motor execution can be compromised after a concussion.

Auditory comprehension performance of college students with and without sport concussion on Computerized-Revised Token Test Subtest VIII.

AIM: Auditory comprehension (AC) and visually assessed cognitive functions were compared in early stage postconcussed (PC) athletes and healthy controls using the Subtest VIII of the Computerized-Revised Token Test (C-RTT) and Immediate Postconcussion Assessment and Cognitive Test (ImPACT). RESULTS: As compared with healthy controls (n = 30), PC subjects (n = 30) had significantly lower C-RTT efficiency scores (p = 0.018), and lower ImPACT scores; total symptom score (p = 0.000.), verbal memory (p = 0.000), visual memory (p = 0.000), visual motor speed (p = 0.000) and reaction time (p = 0.004) in this post-test only matched subject design. Impulse Control was not significant (p = 0.613). Multiple regression and ANOVA indicated an association with reaction time only (p = 0.012) for the PC subjects. After controlling for reaction time, a significant difference in AC remained. CONCLUSION: The relationship between AC and other visually assessed cognitive functions was inconsistent suggesting that the C-RTT and ImPACT assessed different functional systems.

Assessment of the Wii Basic Balance Test in measuring postural deficits post-concussion.

Background and Aim: To evaluate the Wii Basic Balance Test (WBBT), as a tool for detecting postural instability in athletes with concussions. Methods: Seventy-nine healthy physically active controls (NORM) (mean age 21.23 ± 1.78), and fifty-six athletes with concussions (CONC) (mean age 19.39 ± 2.145) participated in this study. All participants performed the Wii Basic Balance Test, which requires the participants to shift weight mediolaterally to maintain a red bar within a blue area denoted on the screen for three seconds during set levels of difficulty. CONC were included in the study within 24-48 hours of the initial concussion injury. Seven one-way ANOVAs assessed differences for each (1) Mean total number of WBBT Levels completed (TL), (2) Mean total seconds to complete all WBBT Level (TT), (3) Time to complete Level 1 (LI), (4) Time to complete Level 2 (L2), (5) Time to complete Level 3 (L3), (6) Time to complete Level 4 (L4), (7) Time to complete Level 5 (L5). Results: CONC completed significantly fewer Levels of the WBBT (p=0.032) when compared to NORM. Athletes with Concussions took a significantly longer time to complete LI (p=0.002) when compared to CONC. Post-hoc Chi-Square analysis determined a significantly greater (p=0.015) proportion (39%) of CONC successfully completed WBBT L5 when compared to the proportion (19%) of CONC. Follow up ROC curves revealed an Sn = 0.392 and an Sp = 0.821 for TL with a cutoff value of 4 levels, Sn=0.875 and an Sp = 0.253 for LI with a cutoff value of 4.4 seconds, and Sn = 0.804 and an Sp = 0.392 for those who successfully completed the WBBT L5. Conclusions: WBBT could be a low cost object method of assessing postural instability within 24-48 hours post-concussion. Relevance for patients: This data could provide health providers with an alternative method to measure the presence of postural instability post-concussion injury.

Relationship between the Romberg test and the Wii Fit basic balance test and cognition in athletes with concussion.

BACKGROUND: Approximately 30% of individuals with a sport-related concussion present with postural instability. Multiple clinical balance tests exist to diagnose postural instability; yet little is known about the potential relationship between these type of postural assessments and cognition post-concussion. AIM: The purpose of the current study was to assess the relationship between the Romberg test, the Wii Fit basic balance test (WBBT), and the composite scores on the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) test in a sample of athletes with concussions. METHODS: Fifty five post-concussed athletes (40 males) completed the Romberg test (RT) (-/+), the WBBT, and ImPACT test. WBBT performance was operationalized as the number of successfully completed trials (of 5 trials of increasing difficulty) within 30 seconds. Pearson's and point-biserial correlations examined univariate associations among the variables. RESULTS: The RT and WBBT were not significantly related (r = - 0.029, p = 0.832). The RT weakly correlated with ImPACT impairment scores (r = 0.26, p = 0.041), whereas WBBT the number of trials did not (r = - 0.20, p = 0.155). The RT scores were significantly correlated with ImPACT Visual Processing Speed Score (r = 0.27, p = 0.036) and Reaction Time score (r = 0.34, p = 0.006). In contrast, WBBT trials were significantly correlated with the ImPACT Visual Memory Score (r = - 0.41, p = 0.003). CONCLUSIONS: These results suggest that the WBBT and RT assess unique aspects of postural control. The RT may relate directly to single sensory cognitive and motor processing, while the WBBT may relate to multi-sensory visually driven cognitive and motor processing. RELEVANCE FOR PATIENTS: Clinical balance tests could point to different cognitive impairments post-concussion.

Future of traumatic brain injury in adults.

The previous articles in this compendium reviewed the past, present, and future status of the diagnosis, prognosis, treatment, and prevention of mild traumatic brain injury in the adult population. This article will discuss the issue of when an individual should initiate the return-to-play (or class or work) protocol. The clinical criterion to initiate the return-to-play protocol consists of neuropsychological performance that returns to baseline and is stable, with no reported symptoms. Recent functional magnetic resonance imaging (fMRI) studies raise serious questions about these clinical criteria. fMRI results in individuals with concussion are different from those of normal controls. Does this difference represent cortical reorganization and/or cortical dysfunction? If the imaging results reflect neuroplastic reorganization, then the initiation of the return-to-play protocol is acceptable. However, if the imaging differences indicate cortical dysfunction, then initiation of the return-to-play protocol would not be advised. This article will describe the problem, the data available to address this problem, and future research needs.

Assessment of oculomotor control and balance post-concussion: a preliminary study for a novel approach to concussion management.

PRIMARY OBJECTIVE: Balance disturbances occur in ∼30% of concussion injuries, with vestibular dysfunction reported as the main contributor. However, few have studied oculomotor control post-concussion to assess vestibular dysfunction. RESEARCH DESIGN: The current research measured the differences in oculomotor control between athletes post-concussion (PC) and athletes without concussion (NC) during an active balance control task. METHODS: Nine PC and nine NC athletes wore a monocular eye tracking device, while balance tests were performed using the Nintendo WiiFit® soccer heading game. Average game scores, eye deviations from centre (Gaze Deviations) and gaze fixation (Percentage Time on Centre) were measured. RESULTS: PC made significantly greater Gaze Deviations from centre compared to NC (p < 0.001), however Percentage Time on Centre and game scores were not significantly different between groups. Correlations between gaze and balance within groups revealed a significant positive correlation in NC, while a significant negative correlation in PC. CONCLUSIONS: Results from this exploratory examination of oculomotor behaviour post-concussion revealed significant differences in gaze stability between athletes with a concussion and those without, suggesting vestibular involvement post-concussion. Assessment of oculomotor control during balance activities may provide further insight into dysfunction of the vestibular system following a concussion injury.