Does Frequency of Baseline Testing Influence Concussion Diagnostic Decision Making Among College Athletes.

OBJECTIVE: Concussion is a growing public health concern given the large number of youth and collegiate athletes participating in collision sports. Sport-related concussions can have an adverse impact on student-athletes' health and academic performance. Athletic programs within academic organizations are motivated to employ the most effective and efficient diagnostic and recovery procedures to minimize the duration and impact of these symptoms on student-athletes' functioning. The present study sought to further our understanding regarding the value and frequency of conducting baseline assessments when evaluating sport-related concussions. METHOD: A total of 41 athletes (24 men, 17 women) between the ages of 18 and 22 were evaluated following suspected concussive injury between 2015 and 2018. Post-injury test results were compared to baselines that had been collected either 1 or 2 years prior, and to normative data, to determine consistency in diagnostic outcomes. RESULTS: Baseline test/retest reliability using Pearson's bivariate correlations revealed modest correlations on measures of verbal and visual memory (0.437-0.569) and very strong correlations on measures of reaction time and visual-motor speed (0.811-0.821). Meanwhile, minimal if any differences in clinical decision-making regarding the diagnostic outcome was observed when comparing post-injury test results to different baselines and to normative data. CONCLUSIONS: Findings indicate that yearly baseline testing may not improve diagnostic accuracy, and in many cases, normative data may be adequate for decision-making. Additional research should evaluate the potential benefit of baseline testing in return-to-play decision-making among broader athletic populations.

The general ability measure for adults underrepresents true IQ in a high-functioning aviation population.

The General Ability Measure for Adults (GAMA) is a brief nonverbal assessment of general intellectual ability. Presently, there is a lack of research involving the use of the GAMA in a high-functioning population. Aviation pilots (n = 59) were referred for a neuropsychological evaluation and were concluded to be cognitively intact. They were administered a battery that included the GAMA and Wechsler Adult Intelligence Scale - 4th edition (WAIS-IV). A paired samples t-test revealed that IQ scores on the GAMA were significantly lower than IQ scores on the WAIS-IV, with WAIS-IV IQ being 7.54 points higher on average. Fisher's exact test determined there was significant disagreement in score classification between the tests, with individuals classified as Above Average on the WAIS-IV often being classified as Average on the GAMA. The GAMA appears to significantly underrepresent true IQ in both score and classification when compared to a more robust measure of intellectual assessment. Clinically, this suggests that IQ screeners, such as the GAMA, may not be appropriate for assessing patients who are suspected to be of higher premorbid functioning. Future research should expand on these results to assess the validity of verbal-based IQ screening measures in high-functioning populations.

Comparison of the PHQ9 and ImPACT symptom cluster scores in measuring depression among college athletes.

Accurate identification of athletes in need of mental health services is essential. The clinical utility of the Patient Health Questionnaire - 9 (PHQ-9), a stand-alone measure of depression, was explored among Division II college athletes (n = 1,209) completing pre-participation concussion baseline assessments (mean age = 19.28), which also included Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). ImPACT's symptom inventory can be divided into four clusters: affective, cognitive, physical/somatic, and sleep. Most athletes (81.9%) did not endorse any items on the affective symptom cluster; however, 90 athletes (7.4%) fell above the cutoff of 5 for depression on the PHQ-9, and approximately half of all athletes endorsed one or more PHQ-9 items. Simple linear regressions revealed ImPACT's sleep symptom cluster as the best predictor of PHQ-9 total score; however, affective, cognitive, and physical symptom clusters significantly predicted PHQ-9 total score as well. Due to relative under-endorsement of items on ImPACT's affective symptom cluster compared to the PHQ-9, the clinical utility of incorporating a stand-alone measure of depression such as the PHQ-9 during baseline testing is supported.

The Rey Dot Counting Test as a Tool for Detecting Suboptimal Performance in Athlete Baseline Testing.

OBJECTIVE: The limitations of Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)'s embedded validity measures (EVMs) are well-documented, as estimates suggest up to 35% of invalid baseline performances go undetected. Few studies have examined standalone performance validity tests (PVT) as a supplement to ImPACT's EVMs. METHOD: College athletes (n = 1,213) were administered a preseason baseline assessment that included ImPACT and the Rey Dot Counting Test (DCT), a standalone PVT, among other measures. RESULTS: Sixty-nine athletes (5.69%) met criteria for suboptimal effort on either ImPACT or the DCT. The DCT detected more cases of suboptimal effort (n = 50) than ImPACT (n = 21). A χ2 test of independence detected significant disagreement between the two measures, as only two individuals produced suboptimal effort on both (χ2(2) = 1.568, p = .210). Despite this disagreement, there were significant differences between the suboptimal effort DCT group and the adequate effort DCT group across all four ImPACT neurocognitive domains (U = 19,225.000, p < .001; U = 17,859.000, p < .001; U = 13,854.000, p < .001; U = 17,850.500, p < .001). CONCLUSIONS: The DCT appears to detect suboptimal effort otherwise undetected by ImPACT's EVMs.

AD8 patient-informant discrepancy predicts insight and cognitive impairment in Alzheimer's disease.

This study aimed to improve understanding of insight among individuals with Alzheimer's disease using patient and informant ratings of impairment on the AD8. Retrospective cohort data were used from 540 patients with a mean age of 81.1 (SD = 6.57). Informant AD8s were inversely related to patients' Montreal Cognitive Assessment (MoCA) scores (r = -.20, p < .001), while patient AD8s were not. Meanwhile, those with greater patient-informant AD8 discrepancies (suggesting low insight) endorsed fewer cognitive items on the Geriatric Depression Scale (GDS). Those with greater AD8 discrepancies also had significantly lower MoCA scores. Ultimately, the informant AD8 alone appears useful for identifying patients' degree of cognitive decline. However, when used in combination with the patient AD8 to calculate a discrepancy score, patients' degree of cognitive decline and level of insight can be better ascertained.

Change in Balance Performance Predicts Neurocognitive Dysfunction and Symptom Endorsement in Concussed College Athletes.

OBJECTIVE: Following concussion, there is an array of sequelae including symptom burden, neurocognitive dysfunction, and balance impairment. However, the magnitude of change in balance performance has yet to be explored fully regarding its relationship with neurocognitive functioning or symptom endorsement. The present study hypothesized that the magnitude of change in balance performance from baseline to post-trauma would have unique predictive power in identifying acute clinical outcomes. METHOD: Sixty-eight college athletes completed annual preparticipation baseline testing and were later diagnosed with a concussion. RESULTS: Linear regressions determined that the magnitude of change in balance performance was a better predictor of neurocognitive dysfunction and endorsement of "balance problems" than post-trauma balance performance alone. CONCLUSIONS: These findings highlight the importance of incorporating balance measurements during preparticipation baseline assessment.

Normative values of the Rey Word Recognition Test in college athletes.

Improved detection of sport-related concussions can be enhanced by performance validity tests, such as the Rey Word Recognition Test (WRT). The WRT is brief and in the public domain but no norms exist for healthy college-athletes. The present study identified such normative values in a large college-athlete sample. Participants included 1,147 college-athletes, and four measures were collected: total words correct, words correct of the first 8, total number of intrusions, and combination score. The WRT was administered individually during baseline evaluations. Means and standard deviations were as follows: total correct words recognized, 10.47 (SD = 2.12); number of correct words out of the first eight words presented, 6.01 (SD = 1.41); number of intrusions, 0.89 (SD = 1.09); combination score, 15.59 (SD = 3.55). Females scored significantly higher than males in total words correct, number correct of the first eight, and combination score, and significantly lower in intrusions. The WRT proved to be a quick, easily administer test in the baseline testing setting. Only 22 athletes recognized all 15 words, and close to a normal distribution of scores was obtained, suggesting that an expectation of optimum performance by college-athletes as an inference of effortful performance would be misplaced.

Performance of college athletes on the 10-item word list of SCAT5.

OBJECTIVES: The Sport Concussion Assessment Tool-5 (SCAT5) was published in 2017; however, normative performance within the college athlete population on the optional 10-item word list has not been described. This study reports normative values for immediate memory trials, total immediate memory score and delayed recall of the 10-item word list. METHODS: The SCAT5 was administered as part of the preparticipation medical testing to 514 collegiate student-athletes, aged 17-23 (M=19.65, SD=1.40; 64% male) prior to the 2017-2018 athletic season. RESULTS: On the SCAT5's optional 10-item word list, with a total possible immediate memory score of 30, participants recalled an average of 20.57 (SD=3.22) words over three learning trials, with an average for trial 3 of 8.13 (SD=1.32). The average delayed memory score was 6.59 (SD=1.85). Small but significant demographic comparisons were found. Women scored higher on both immediate and delayed recall, non-native speakers scored higher on delayed recall, and Black/African-American athletes scored lower than White athletes on immediate, and lower than White and Hispanic/Latino athletes on delayed recall. CONCLUSION: The 10-item word list on the SCAT5 eliminates the ceiling effect observed on the five-item word list of the SCAT3, therefore, increasing its clinical utility in the diagnosis of sports-related concussions. Significant demographic differences suggest use of category-specific norms for sex, native language and race/ethnicity.

Updating the Rey Dot Counting Test for Use in Collegiate Baseline Concussion Testing.

Athletes occasionally attempt to lower their baseline scores to mask the effects of a concussion during post-trauma assessment, a phenomenon known as sandbagging. In order to help prevent this from occurring, the Rey Dot Counting Test (DCT) was examined as a potential measure to be added to a Division II university screening battery. Investigators utilized samples of athletes at baseline and non-athlete students instructed to provide honest effort or suppressed effort, either naïvely or coached. The results support the use of the DCT as a valid measure of suboptimal performance when using modified norms established from collegiate populations.

The role of executive functioning in quality of life in pediatric intractable epilepsy.

OBJECTIVE: Children with epilepsy are vulnerable to executive dysfunction, but the relationship between executive functioning (EF) and quality of life (QOL) in children with epilepsy is not fully delineated. This exploratory study elucidated the relationship between ecological EF and QOL in pediatric intractable epilepsy. METHOD: Fifty-four consecutively referred pediatric epilepsy surgery candidates and their parents were administered IQ measures, the Behavior Rating Inventory of Executive Function (BRIEF), and the Quality of Life in Childhood Epilepsy (QOLCE) as part of a comprehensive neuropsychological evaluation. RESULTS: A significant difference was found in QOL between those with and without clinical impairments on the BRIEF [t(52)=3.93; p<.001]. That is, children with executive dysfunction had lower overall QOL. All seizure variables and BRIEF scales were associated with overall QOL [F(12, 40)=6.508; p=.001; R2=.661]. Working memory from the BRIEF was the most frequently elevated scale in our sample (57%). Those with executive dysfunction had 9.7 times the risk of having poor QOL. CONCLUSIONS: Poor EF control according to behavior ratings is significantly related to QOL in intractable pediatric epilepsy. Identification of executive dysfunction in home environments is an essential component of presurgical evaluations and target for intervention, which may improve QOL.

Attention-Deficit Hyperactivity Disorder Status and Baseline Neurocognitive Performance in High School Athletes.

Approximately 136,000 concussions occur annually in American high school sports. Neuropsychological data indicate that children with preexisting cognitive difficulties, such as attention-deficit hyperactivity disorder (ADHD), may have protracted recovery from concussion. ADHD, with an estimated prevalence of 11% in youth, may increase an athlete's vulnerability to sustaining sports-related traumatic brain injury (TBI). The preponderance of evidence focusing on TBI and ADHD has derived from motor vehicle accidents rather than sports-related incidents. Thus, it is paramount to explore how ADHD may relate to injury in the sports concussion context, as well as to assess how ADHD may affect baseline neurocognitive testing. Adolescent athletes with ADHD (n = 256) demonstrated significantly reduced Verbal Memory, Visual Motor, and Impulse Control index scores compared with their peers without ADHD (n = 256). Athletes with ADHD were nearly twice as likely to have sustained a prior concussion (ADHD, 14.1%; non-ADHD, 7.8%). Knowledge regarding the unique neurocognitive profile of athletes with ADHD may enhance clinical management decisions.

History of neuropsychological study of sport-related concussion.

Although the medical literature has a long history of description and comment on concussion, the occurrence of concussion within the context of sports other than boxing was not judged to be problematic until the 1980s. Neuropsychological assessment played a critical and integral role in identifying the cognitive sequelae of concussion and mapping out the short- and long-term vagaries in recovery. This paper captures that history and expands upon current applications of neuropsychological assessment in the diagnosis and management of sport-related concussion.

Normative values of major SCAT2 and SCAT3 components for a college athlete population.

The Sports Concussion Assessment Tool-2 (SCAT2) is a posttrauma evaluative screener for concussion. Although a revised version (SCAT3) recently was released, the SCAT2 continues in use. Moreover, there have been no reports of normative values with college athletes with the SCAT2 or SCAT3. Similar to the SCAT3, the SCAT2 includes a 22-item self-report symptom scale, the Standardized Assessment of Concussion (SAC), and a hard surface-only version of the Balance Error Scoring System (BESS). The SCAT3 does not employ a total score and adds an optional gait component. The purpose of this study was to develop normative values for collegiate athletes on the SCAT2 and its subparts with respect to sex, collision risk by sport, and concussion history. In preseason, 477 college athletes (332 male, 145 female) completed the SCAT2. The average total score was 91.08 (SD = 5.60). The average number of symptoms endorsed was 1.75. Average SAC and BESS scores were 27.17 (SD = 2.01) and 25.64 (SD = 4.07), respectively. Little or no difference was found in total and component scores due to sex, sport type, or concussion history. When baseline measurement is lacking, these data provide a good benchmark for interpreting SCAT2 and SCAT3 performance.

Sport and team differences on baseline measures of sport-related concussion.

CONTEXT: With the advent of the National Collegiate Athletic Association's (NCAA's) mandating the presence and practice of concussion-management plans in collegiate athletic programs, institutions will consider potential approaches for concussion management, including both baseline and normative comparison approaches. OBJECTIVE: To examine sport and team differences in baseline performance on a computer-based neurocognitive measure and 2 standard sideline measures of cognition and balance and to determine the potential effect of premorbid factors sex and height on baseline performance. DESIGN: Cross-sectional study. SETTING: University laboratory. PATIENTS OR OTHER PARTICIPANTS: A total of 437 NCAA Division II student-athletes (males = 273, females = 164; age = 19.61 ± 1.64 years, height = 69.89 ± 4.04 inches [177.52 ± 10.26 cm]) were recruited during mandatory preseason testing conducted in a concussion-management program. MAIN OUTCOME MEASURE(S): The computerized Concussion Resolution Index (CRI), the Standardized Assessment of Concussion (Form A; SAC), and the Balance Error Scoring System (BESS). RESULTS: Players on the men's basketball team tended to perform worse on the baseline measures, whereas soccer players tended to perform better. We found a difference in total BESS scores between these sports (P = .002). We saw a difference between sports on the hard-surface portion of the BESS (F6,347 = 3.33, P = .003, ηp(2) = 0.05). No sport, team, or sex differences were found with SAC scores (P > .05). We noted differences between sports and teams in the CRI indices, with basketball, particularly the men's team, performing worse than soccer (P < .001) and softball/baseball (P = .03). When sex and height were considered as possible sources of variation in BESS and CRI team or sport differences, height was a covariate for the team (F1,385 = 5.109, P = .02, ηp(2) = 0.013) and sport (F1,326 = 11.212, P = .001, ηp(2) = 0.033) analyses, but the interaction of sex and sport on CRI indices was not significant in any test (P > .05). CONCLUSIONS: Given that differences in neurocognitive functioning and performance among sports and teams exist, the comparison of posttraumatic and baseline assessment may lead to more accurate diagnoses of concussion and safer return-to-participation decision making than the use of normative comparisons.

Vibrotactile pattern perception as a method for the assessment of brain dysfunction.

An immediate need exists for a portable diagnostic device for the assessment of cortical function, and diagnosis of mTBI. This paper presents initial results using a vibrotactile acuity test for the objective and quantitative diagnosis of acute mTBI suspects. mTBI is hypothesized to involve derangement or damage to the underlying cortical network. In particular, fundamental building blocks of the cortex are changed in such a way as to limit the functional connectivity within and between cortical columns. Our approach is based on sensory illusions that are configured as a test of neural connectivity. Pilot clinical test data showed differences between a small healthy normal group and a concussion group using a sports concussion model.

Status of computerized cognitive testing in aging: a systematic review.

BACKGROUND: Early detection of cognitive decline in the elderly has become of heightened importance in parallel with the recent advances in therapeutics. Computerized assessment might be uniquely suited to early detection of changes in cognition in the elderly. We present here a systematic review of the status of computer-based cognitive testing, focusing on detection of cognitive decline in the aging population. METHODS: All studies purporting to assess or detect age-related changes in cognition or early dementia/mild cognitive impairment by means of computerized testing were included. Each test battery was rated on availability of normative data, level of evidence for test validity and reliability, comprehensiveness, and usability. All published studies relevant to a particular computerized test were read by a minimum of two reviewers, who completed rating forms containing the above mentioned criteria. RESULTS: Of the 18 test batteries identified from the initial search, 11 were appropriate to cognitive testing in the elderly and were subjected to systematic review. Of those 11, five were either developed specifically for application with the elderly or have been used extensively with that population. Even within the computerized testing genre, great variability existed in manner of administration, ranging from fully examiner-administered to fully self-administered. All tests had at least minimal reliability and validity data, commonly reported in peer-reviewed articles. However, level of rigor of validity testing varied widely. CONCLUSION: All test batteries exhibited some of the strengths of computerized cognitive testing: standardization of administration and stimulus presentation, accurate measures of response latencies, automated comparison in real time with an individual's prior performance as well as with age-related norms, and efficiencies of staffing and cost. Some, such as the Mild Cognitive Impairment Screen, adapted complicated scoring algorithms to enhance the information gathered from already existing tests. Others, such as CogState, used unique interfaces and subtests. We found that although basic indices of psychometric properties were typically addressed, sufficient variability exists that currently available computerized test batteries must be judged on a case-by-case basis.

Neuropsychological evaluation in the diagnosis and management of sports-related concussion.

A mild traumatic brain injury in sports is typically referred to as a concussion. This is a common injury in amateur and professional athletics, particularly in contact sports. This injury can be very distressing for the athlete, his or her family, coaches, and school personnel. Fortunately, most athletes recover quickly and fully from this injury. However, some athletes have a slow recovery, and there are reasons to be particularly concerned about re-injury during the acute recovery period. Moreover, some athletes who have experienced multiple concussions are at risk for long-term adverse effects. Neuropsychologists are uniquely qualified to assess the neurocognitive and psychological effects of concussion. The National Academy of Neuropsychology recommends neuropsychological evaluation for the diagnosis, treatment, and management of sports-related concussion at all levels of play.

In-home monitoring of persons with dementia: ethical guidelines for technology research and development.

Innovative technologies are rapidly emerging that offer caregivers the support and means to assist older adults with cognitive impairment to continue living "at home." Technology research and development efforts applied to older adults with dementia invoke special grant review and institutional review board concerns, to ensure not only safe but also ethically appropriate interventions. Evidence is emerging, however, that tensions are growing between innovators and reviewers. Reviewers with antitechnology biases are in a position to stifle needed innovation. Technology developers who fail to understand the clinical and caregiving aspects of dementia may design applications that are not in alignment with users' capabilities. To bridge this divide, we offer an analysis of the ethical issues surrounding home monitoring, a model framework, and ethical guidelines for technology research and development for persons with Alzheimer's disease and their caregivers.

Designing for older adult users of handheld technology.

There are few interface design guidelines for handheld devices used by adults sixty years and older. Yet, this growing user group would benefit from the portability offered by such technology in promoting health management and social interaction. In this paper, we describe a usability framework for conducting studies on the use of a PocketPC by older adult caregivers. The usability framework provides a basis for conducting studies taking into account the user profile of an older adult, environment factors, usability quality factors, and technology objectives.

Sex differences in outcome following sports-related concussion.

OBJECT: Females comprise an increasing percentage of the athlete population across all age groups, and analysis of recent literature reveals that they sustain more concussions in collegiate sports. Results of human and animal studies indicate that females may have poorer outcomes after traumatic brain injury; however, no return-to-play guideline takes sex or other individual differences into account. In the present study the authors evaluated the influence of patient sex on objective neurocognitive performance and subjective reporting of symptoms following sports-related concussion. METHODS: According to preseason baseline neurocognitive computerized testing in 2340 male and female high school and collegiate athletes, individuals who sustained sports-related concussions (155 persons) were reevaluated using an alternate form of the cognitive test. Sex differences in the magnitude of cognitive change from baseline levels and the subjective experience of symptoms were analyzed. To account for the possible protective effects of helmets, comparisons were performed among females, males with helmets, and males without helmets; none of the female athletes wore helmets. Female athletes had significantly greater declines in simple and complex reaction times relative to preseason baseline levels, and they reported more postconcussion symptoms compared with males. As a group, females were cognitively impaired approximately 1.7 times more frequently than males following concussions. Furthermore, females experienced more objective and subjective adverse effects from concussion even after adjusting for the use of helmets by some groups of male athletes (for example, in football). CONCLUSIONS: Return-to-play decisions and concussion management must be objective and made on an individual basis, including consideration of factors such as patient sex rather than relying on a one-size-fits-all guideline.