Appendix C


Clinical Evaluation Tools

CONCUSION ASSESMENT TOOLS

Glasgow Coma Scale

Originally developed by Teasdale and Jennett (1974), the Glasgow Coma Scale (GCS) (see Table C-1) is a scoring scale for eye opening, motor, and verbal responses that can be administered to athletes on the field to objectively measure their level of consciousness. A score is assigned to each response type for a combined total score of 3 to 15 (with 15 being normal). An initial score of less than 5 is associated with an 80 percent chance of a lasting vegetative state or death. An initial score of greater than 11 is associated with a 90 percent chance of complete recovery (Teasdale and Jennett, 1974). Because most concussed individuals score 14 or 15 on the 15-point scale, its primary use in evaluating individuals for sports-related concussions is to rule out more severe brain injury and to help determine which athletes need immediate medical attention (Dziemianowicz et al., 2012).

Standardized Assessment of Concussion

The Standardized Assessment of Concussion (SAC) (see Figure C-1) provides immediate sideline mental status assessment of athletes who may have incurred a concussion (Barr and McCrea, 2001; McCrea et al., 1998, 2000). The test contains questions designed to assess athletes’ orientation, immediate memory, concentration, and delayed memory. It also includes an exertion test and brief neurological evaluation. The SAC takes approxi-



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Appendix C Clinical Evaluation Tools Concussion Assessment Tools Glasgow Coma Scale Originally developed by Teasdale and Jennett (1974), the Glasgow Coma Scale (GCS) (see Table C-1) is a scoring scale for eye opening, motor, and verbal responses that can be administered to athletes on the field to objectively measure their level of consciousness. A score is assigned to each response type for a combined total score of 3 to 15 (with 15 being normal). An initial score of less than 5 is associated with an 80 percent chance of a lasting vegetative state or death. An initial score of greater than 11 is associ- ated with a 90 percent chance of complete recovery (Teasdale and Jennett, 1974). Because most concussed individuals score 14 or 15 on the 15-point scale, its primary use in evaluating individuals for sports-related concus- sions is to rule out more severe brain injury and to help determine which athletes need immediate medical attention (Dziemianowicz et al., 2012). Standardized Assessment of Concussion The Standardized Assessment of Concussion (SAC) (see Figure C-1) provides immediate sideline mental status assessment of athletes who may have incurred a concussion (Barr and McCrea, 2001; McCrea et al., 1998, 2000). The test contains questions designed to assess athletes’ orientation, immediate memory, concentration, and delayed memory. It also includes an exertion test and brief neurological evaluation. The SAC takes approxi- 309

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310 SPORTS-RELATED CONCUSSIONS IN YOUTH TABLE C-1 Glasgow Coma Scale Response Type Response Points Eye Opening Spontaneous: Eyes open, not necessarily aware 4 To speech: Nonspecific response, not necessarily to 3 command To pain: Pain from sternum/limb/supraorbital pressure 2 None: Even to supraorbital pressure 1 Motor Response Obeys commands: Follows simple commands 6 Localizes pain: Arm attempts to remove supraorbital/ 5 chest pressure Withdrawal: Arm withdraws to pain, shoulder abducts 4 Flexor response: Withdrawal response or assumption 3 of hemiplegic posture Extension: Shoulder adducted and shoulder and 2 forearm internally rotated None: To any pain; limbs remain flaccid 1 Verbal Response Oriented: Converses and oriented 5 Confused: Converses but confused, disoriented 4 Inappropriate: Intelligible, no sustained sentences 3 Incomprehensible: Moans/groans, no speech 2 None: No verbalization of any type 1 mately 5 minutes to administer and does not require a neuropsychologist to evaluate test scores. The test is scored out of 30 with a mean score of 26.6 (McCrea et al., 1996). Studies have found the SAC to have good sensitivity and specificity (McCrea, 2001; McCrea et al., 2003), making it a useful tool for identify- ing the presence of concussion (Giza et al., 2013). Significant differences in scores have been reported for males and females in healthy young athletes (9 to 14 years of age), suggesting the need for separate norms for males and females in this age group (Valovich McLeod et al., 2006) as well as in high school athletes (Barr, 2003). Sport Concussion Assessment Tool 3 The Sport Concussion Assessment Tool 3 (SCAT3) is a concussion evaluation tool designed for individuals 13 years and older. Due to its dem- onstrated utility, the SAC has been incorporated into this tool, which also includes the GCS, modified Maddocks questions (Maddocks et al., 1995), a neck evaluation and balance assessment, and a yes/no symptom checklist as well as information on the mechanism of injury and background informa- tion, including learning disabilities, attention deficit hyperactivity disorder,

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APPENDIX C 311 1) ORIENTATION: 3) CONCENTRATION: Month: 0 1 Digits Backward (If correct, go to next string length. If incorrect, read trial 2. Stop after incorrect on both trials.) Date: 0 1 4-9-3 6-2-9 0 1 Day of week: 0 1 3-8-1-4 3-2-7-9 0 1 Year: 0 1 6-2-9-7-1 1-5-2-8-6 0 1 Time (within 1 hr): 0 1 7-1-8-4-6-2 5-3-9-1-4-8 0 1 Orientation Total Score / 5 Months in Reverse Order: (entire sequence correct for 1 point) Dec-Nov-Oct-Sep-Aug-Jul 2) IMMEDIATE MEMORY: (all 3 trials are completed regardless of score Jun-May-Apr-Mar-Feb-Jan 0 1 on trial 1 & 2; total score equals sum across all 3 trials) Concentration Total Score / 5 List Trial 1 Trial 2 Trial 3 EXERTIONAL MANEUVERS Word 1 0 1 0 1 0 1 (when appropriate): Word 2 0 1 0 1 0 1 5 jumping jacks 5 push-ups 5 sit-ups 5 knee bends Word 3 0 1 0 1 0 1 Word 4 0 1 0 1 0 1 4) DELAYED RECALL: Word 5 0 1 0 1 0 1 Word 1 0 1 Total Word 2 0 1 Immediate Memory Total Score / 15 Word 3 0 1 (Note: Subject is not informed of delayed recall testing of memory) Word 4 0 1 Word 5 0 1 NEUROLOGIC SCREENING: Delayed Recall Total Score / 5 Loss of Consciousness: (occurrence, duration) SUMMARY OF TOTAL SCORES: Retrograde & Posttraumatic Amnesia: (recollection of events pre- and post-injury) ORIENTATION / 5 Strength: IMMEDIATE MEMORY / 15 Sensation: CONCENTRATION / 5 DELAYED RECALL / 5 Coordination: OVERALL TOTAL SCORE / 30 FIGURE C-1 Standardized assessment of concussion. SOURCE: McCrea, 2001, Table 2, p. 2276. and history of concussion, headaches, migraines, depression, and anxiety (McCrory et al., 2013c). The precursor SCAT2 had been standardized as an easy-to-use tool with adequate psychometric properties for identifying concussions within the first 7 days (Barr and McCrea, 2001). The SCAT3 was developed from the original SCAT to help in making return-to-play de- cisions (McCrory et al., 2009, 2013b). This concussion evaluation tool can be used on the sideline or in the health care provider’s office. The SCAT3 takes approximately 15 to 20 minutes to complete. Because the SCAT3 was recently published (McCrory et al., 2013a), normative data and concussion cutoff scores are not yet available. However, a recent study to determine baseline values of the SCAT2 in normal male and female high school athletes found a high error rate on the concentration portion of the assessment in non-concussed athletes, suggesting the need for baseline testing in order to understand post-injury results (Jinguji et al., 2012). The study also showed significant sex differences, with females scoring higher on the balance, immediate memory, and concentration com- ponents of the assessment.

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312 SPORTS-RELATED CONCUSSIONS IN YOUTH Findings similar to those of Jinguji and colleagues (2012) were reported in a study of youth ice hockey players who demonstrated an average total score of 86.9 out of 100 points (Blake et al., 2012). In the largest assess- ment of the SAC/SCAT2, Valovich McLeod and colleagues (2012) assessed 1,134 high school students. Male high school athletes and male and female ninth graders were found to have significantly lower SAC and total SCAT2 scores than did female athletes and upperclassmen, respectively (Valovich McLeod et al., 2012). A self-reported history of previous concussion1 did not have a significant effect on SAC scores, but it did affect the symptom and total SCAT2 scores. The authors recommended baseline assessments in order to understand post-injury results for individual athletes. Schneider and colleagues (2010) tested more than 4,000 youth hockey players with the original SCAT and reported baseline scores showing absolute differ- ences with age and sex. However, because no parametric statistics were provided, the significance of the observed differences is not known. The Child SCAT3 is a newly developed concussion evaluation tool de- signed for children ages 5 to 12 years (McCrory et al., 2013a). It is similar to the SCAT3 except that tests such as the SAC and Maddocks questions are age appropriate for younger children. The Child SCAT3 includes ver- sions of the SAC and Maddocks questions, the GCS, a medical history completed by the parent, child and parent concussion symptom scales, neck evaluation, and balance assessment. As is the case with the SCAT3 for adults, the Child SCAT3 has yet to be validated, so no normative data are available, nor are there concussion cutoff scores. Military Acute Concussion Evaluation The military currently employs the Military Acute Concussion Evalua- tion (MACE) tool for concussion screening and initial evaluation (DVBIC, 2012). The first section of the MACE collects data regarding the nature of the concussive event and the signs and symptoms of concussion. The second “examination” portion of the MACE is a version of the SAC. The MACE was first employed in Iraq for determining concussions in theater (French et al., 2008). Coldren and colleagues (2010) examined concussed and control U.S. Army soldiers who were administered the MACE 12 hours after their injury. The researchers concluded that the MACE lacks the sensitivity and specificity necessary to determine a concussive event 12 hours post injury. However, a recent study by Kennedy and colleagues (2012) indicated that the MACE can be effective in serial concussion evaluation if originally ad- ministered within 6 hours of the injury. 1  Information on the time elapsed since the previous concussions was not reported.

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APPENDIX C 313 King-Devick Test The King-Devick test is designed to assess saccadic eye movements, measuring the speed of rapid number naming as well as errors made by the athlete, with the goal of detecting impairments of eye movement, attention, and language as well as impairments in other areas that would be indica- tive of suboptimal brain function (Galetta et al., 2011a). The King-Devick test includes a demonstration and three test cards with rows of single-digit numbers that are read aloud from left to right (see Figure C-2). The par- ticipant is asked to read the numbers as quickly as possible without making any errors. The administrator records the total time to complete the three cards and the total number of errors made during the test. The results are compared to a personal baseline. The King-Devick test usually takes ap- proximately 2 minutes to complete (King-Devick, 2013). Studies of the King-Devick test involve 10 or fewer concussed athletes (Galetta et al., 2011a,b, 2013; King et al., 2012, 2013), which is too small FIGURE C-2 Demonstration and test cards for King-Devick (K-D) test. SOURCE: King-Devick, 2013.

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314 SPORTS-RELATED CONCUSSIONS IN YOUTH a sample size to determine the test’s effectiveness in evaluating a concus- sion. Currently, there is not enough evidence to determine whether the test is effective in diagnosing or monitoring a concussion (Giza et al., 2013). Clinical Reaction Time Test Eckner and colleagues (2010) have developed a simple tool for measur- ing clinical reaction time (RT clin). The test involves a systematic approach to dropping a weighted stick that is calibrated to reflect speed of reaction for catching it. The athlete holds his or her hand around, but not touching, a rubber piece at the bottom of the stick, then the test administrator drops the stick, and the athlete catches it on the way down. Several studies docu- ment the initial development of this tool and demonstrate its concurrent and predictive validity (Eckner et al., 2010, 2011a,b). A 2010 pilot study established convergent validity of RT clin with the CogSport simple reaction time measure (Eckner et al., 2010). The Pearson correlation for 68 of the 94 athletes who completed both RT clin and Cog- Sport was .445 (p < .001). The other 26 athletes did not meet the validity criteria on CogSport. For those individuals, the correlations between the two tests were nonsignificant. A 2011 study looked at the test-retest reli- ability of RT clin at a 1-year interval as well as the same reliability statistic for CogSport reaction time (Eckner et al., 2011a). The researchers used a two-way random effects analysis of variance model for intraclass correla- tion coefficient analysis for each test. This means that each subject was assessed by each rater, and the raters were randomly selected. The RT clin intraclass correlation coefficient was above .60. One might argue that a two-way mixed effects analysis should be used, which would actually increase the coefficient. There was also significant improvement in the absolute reaction times from time one to time two for the RT clin but not for CogSport (here the CogSport analysis only included valid responders). Eckner and colleagues (2013) have also assessed the diagnostic utility of the RT clin. They compared 28 concussed athletes to 28 controls. Concussed athletes were tested within 48 hours of injury and a control was selected at the same time interval. Post-injury tests were compared to baseline scores and reliable change indices were calculated using the control group means and standard error of difference from the two time-points. Using a 60 percent confidence interval (one-tailed significance), the authors calculated sensitivity at 79 percent and specificity at 61 percent for a score difference of –3. Thirty-three of the 56 athletes obtained this score; of the 33, 22 were concussed and 11 were not, and therefore were misidentified. The sensitivity and specificity were improved somewhat by adjusting the cutoff score to a difference of zero seconds (75 percent sensitivity; 68 percent specificity). This correlated with a 68 percent (one-sided) confidence interval. Of note,

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APPENDIX C 315 more stringent cutoff values lowered sensitivity but increased specificity, meaning that improvements in scores beyond 11 points increased the probability that the athlete did not have a concussion, which can be useful clinical information. The RT clin is a simple-to-use and low-cost test of reaction time. The initial test of reliability at 1-year intervals is promising, and the diagnostic statistics indicate adequate utility. Further independent validation is needed, and it would be valuable to determine the increase in diagnostic efficiency if the test were combined with other tools because multimodal diagnostic test batteries have been recommended in the literature. BALANCE TESTS Balance Error Scoring System The Balance Error Scoring System (BESS) is a quantifiable version of a modified Romberg test for balance (Guskiewicz, 2001; Riemann et al., 1999). It measures postural stability or balance and consists of six stances, three on a firm surface and the same three stances on an unstable (medium density foam) surface (Guskiewicz, 2001; Riemann et al., 1999). All stances are done with the athlete’s eyes closed and with his or her hands on the iliac crests for 20 seconds. The three stances are: feet shoulder width apart, a tandem stance (one foot in front of the other), and a single-leg stance on the person’s nondominant leg (Guskiewicz, 2001; Riemann et al., 1999). For every error made—lifting hands off the iliac crests, opening the eyes, stepping, stumbling, or falling, moving the hip into more than a 30 degree of flexion or abduction, lifting the forefoot or heel, or remaining out of the testing position for more than 5 seconds—1 point is assessed. The higher the score, the worse the athlete has performed. The BESS test has very good test-retest reliability (0.87 to 0.97 intra- class correlations) (Riemann et al., 1999). The test’s sensitivity for diagnosis was 0.34 to 0.64, which is considered low to moderate, while specificity is high (0.91) (Giza et al., 2013). Using the BESS test in conjunction with the SAC and a graded symptom checklist increases the sensitivity (Giza et al., 2013). The BESS has only been found to be useful within the first 2 days following injury (Giza et al., 2013; McCrea et al., 2003). Sensory Organization Test The Sensory Organization Test (SOT) uses six sensory conditions to objectively identify abnormalities in the patient’s use of somatosensory, visual, and vestibular systems to maintain postural control. The test condi- tions systematically eliminate useful visual and proprioceptive information

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316 SPORTS-RELATED CONCUSSIONS IN YOUTH in order to assess the patient’s vestibular balance control and adaptive responses of the central nervous system (NeuroCom, 2013). Broglio and colleagues (2008) examined the sensitivity and specificity of the SOT using the reliable change technique. A baseline and one follow-up assessment were performed on healthy and concussed young adults. Post-injury as- sessment in the concussed group occurred within 24 hours of diagnosis. An evaluation for change on one or more SOT variables resulted in the highest combined sensitivity (57 percent) and specificity (80 percent) at the 75 per- cent confidence interval. The low sensitivity of the SOT suggests the need to use additional evaluation tools to improve identification of individuals with concussion. SYMPTOM SCALES Acute Concussion Evaluation The Acute Concussion Evaluation (ACE) tool is a physician/clinician form used to evaluate individuals for a concussion (see Figure C-3; Gioia and Collins, 2006; Gioia et al., 2008a). The form consists of questions about the presence of concussion characteristics (i.e., loss of consciousness, amnesia), 22 concussion symptoms, and risk factors that might predict prolonged recovery (i.e., a history of concussion) (Gioia et al., 2008a). The ACE can be used serially to track symptom recovery over time to help inform clinical management decisions (Gioia et al., 2008a). Concussion Symptom Inventory The Concussion Symptom Inventory (CSI) (see Figure C-4) is a derived symptom scale designed specifically for tracking recovery. Randolph and colleagues (2009) analyzed a large set of data from existing scales obtained from three separate case-control studies. Through a series of analyses they eliminated overlapping items that were found to be insensitive to concus- sion. They collected baseline data from symptom checklists, including a total of 27 symptom variables from a total of 16,350 high school and college athletes. Follow-up data were obtained from 641 athletes who sub- sequently incurred a concussion. Symptom checklists were administered at baseline (pre-season), immediately post concussion, postgame, and at 1, 3, and 5 days following injury. Effect-size analyses resulted in the retention of only 12 of the 27 variables. Receiver-operating characteristic analyses (non-parametric approach) were used to confirm that the reduction in items did not reduce sensitivity or specificity (area under the curve at day 1 post injury=0.867). Because the inventory has a limited set of symptoms,

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APPENDIX C 317 Acute concussion evAluAtion (Ace) Patient Name: PhysiciAn/cliniciAn office version DOB: Age: Gerard Gioia, PhD & Micky Collins, PhD 1 2 1 Children’s National Medical Center Date: ID/MR# 2 University of Pittsburgh Medical Center A. Injury Characteristics Date/Time of Injury Reporter: __Patient __Parent __Spouse __Other________ 1. Injury Description 1a. Is there evidence of a forcible blow to the head (direct or indirect)? __Yes __No __Unknown 1b. Is there evidence of intracranial injury or skull fracture? __Yes __No __Unknown 1c. Location of Impact: __Frontal __Lft Temporal __Rt Temporal __Lft Parietal __Rt Parietal __Occipital __Neck __Indirect Force 2. Cause: __MVC __Pedestrian-MVC __Fall __Assault __Sports (specify) Other 3. Amnesia Before (Retrograde) Are there any events just BEFORE the injury that you/ person has no memory of (even brief)? __ Yes __No Duration 4. Amnesia After (Anterograde) Are there any events just AFTER the injury that you/ person has no memory of (even brief)? __ Yes __No Duration 5. Loss of Consciousness: Did you/ person lose consciousness? __ Yes __No Duration 6. EARLY SIGNS: __Appears dazed or stunned __Is confused about events __Answers questions slowly __Repeats Questions __Forgetful (recent info) 7. Seizures: Were seizures observed? No__ Yes___ Detail _____ B. Symptom Check List* Since the injury, has the person experienced any of these symptoms any more than usual today or in the past day? Indicate presence of each symptom (0=No, 1=Yes). *Lovell & Collins, 1998 JHTR PHYSICAL (10) COGNITIvE (4) SLEEP (4) Headache 0 1 Feeling mentally foggy 0 1 Drowsiness 0 1 Nausea 0 1 Feeling slowed down 0 1 Sleeping less than usual 0 1 N/A Vomiting 0 1 Difficulty concentrating 0 1 Sleeping more than usual 0 1 N/A Balance problems 0 1 Difficulty remembering 0 1 Trouble falling asleep 0 1 N/A Dizziness 0 1 COGNITIvE Total (0-4) _____ SLEEP Total (0-4) _____ Visual problems 0 1 EMOTIONAL (4) Exertion: Do these symptoms worsen with: Fatigue 0 1 Irritability 0 1 Physical Activity __Yes __No __N/A Sensitivity to light 0 1 Sadness 0 1 Cognitive Activity __Yes __No __N/A Sensitivity to noise 0 1 More emotional 0 1 Overall Rating: How different is the person acting Numbness/Tingling 0 1 Nervousness 0 1 compared to his/her usual self? (circle) PHYSICAL Total (0-10) _____ EMOTIONAL Total (0-4) _____ Normal 0 1 2 3 4 5 6 Very Different (Add Physical, Cognitive, Emotion, Sleep totals) Total Symptom Score (0-22) _____ C. Risk Factors for Protracted Recovery (check all that apply) Concussion History? Y ___ N___ √ Headache History? Y ___ N___ √ Developmental History √ Psychiatric History Previous # 1 2 3 4 5 6+ Prior treatment for headache Learning disabilities Anxiety Longest symptom duration History of migraine headache Attention-Deficit/ Depression Days__ Weeks__ Months__ Years__ __ Personal Hyperactivity Disorder Sleep disorder __ Family___________________ If multiple concussions, less force ____________________ Other developmental Other psychiatric disorder caused reinjury? Yes__ No__ disorder_____________ _____________ List other comorbid medical disorders or medication usage (e.g., hypothyroid, seizures) D. RED FLAGS for acute emergency management: Refer to the emergency department with sudden onset of any of the following: * Headaches that worsen * Looks very drowsy/ can’t be awakened * Can’t recognize people or places * Neck pain * Seizures * Repeated vomiting * Increasing confusion or irritability * Unusual behavioral change * Focal neurologic signs * Slurred speech * Weakness or numbness in arms/legs * Change in state of consciousness E. Diagnosis (ICD): __Concussion w/o LOC 850.0 __Concussion w/ LOC 850.1 __Concussion (Unspecified) 850.9 __ Other (854) ______________ __No diagnosis F. Follow-Up Action Plan Complete ACE Care Plan and provide copy to patient/family. ___ No Follow-Up Needed ___ Physician/Clinician Office Monitoring: Date of next follow-up ___ Referral: ___ Neuropsychological Testing ___ Physician: Neurosurgery____ Neurology____ Sports Medicine____ Physiatrist____ Psychiatrist____ Other ___ Emergency Department ACE Completed by:______________________________ © Copyright G. Gioia & M. Collins, 2006 This form is part of the “Heads Up: Brain Injury in Your Practice” tool kit developed by the Centers for Disease Control and Prevention (CDC). FIGURE C-3 Page one of the acute concussion evaluation form. SOURCE: Gioia and Collins, 2006, p. 1.

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318 SPORTS-RELATED CONCUSSIONS IN YOUTH Concussion Symptom Inventory (CSI) Randolph, Millis, Barr, McCrea, Guskiewicz, & Kelly (2008) Player Name:____________________________________________________ Date of Injury:__________________ Date of Exam:____________________ absent mild moderate severe Score 0 1 2 3 4 5 6 Headache Nausea Balance Problems/Dizziness Fatigue Drowsiness Feeling like “in a fog” Difficulty concentrating Difficulty remembering Sensitivity to light Sensitivity to noise Blurred vision Feeling slowed down TOTAL: Other symptoms evident since injury?: FIGURE C-4 Concussion symptom inventory. SOURCE: Randolph et al., 2009, Appendix, p. 227. Randolph and colleagues note the need for a complete symptom inventory for other problems associated with concussion. Graded Symptom Checklist and Graded Symptom Scale The Graded Symptom Checklist (GSC) (see Figure C-5) and Graded Symptom Scale (GSS) are self-report measures of concussion symptoms derived from the longer Head Injury Scale (Janusz et al., 2012). The symp- toms are rated on their severity. The evidence is much stronger to support the use of such self-report symptom measures in youth ages 13 and older. Test-retest reliability has not been reported, but a three factor solution (cognitive, somatic, neurobehavioral) has been reported, although a bet-

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APPENDIX C 319 Graded Symptom Checklist (GSC) Time of 2-3 Hours 24 Hours 48 Hours 72 Hours Symptom injury postinjury postinjury postinjury postinjury Blurred vision Dizziness Drowsiness Excess sleep Easily distracted Fatigue Feel “in a fog” Feel “slowed down” Headache Inappropriate emotions Irritability Loss of consciousness Loss of orientation Memory problems Nausea Nervousness Personality change Poor balance/ coordination Poor concentration Ringing in ears Sadness Seeing stars Sensitivity to light Sensitivity to noise Sleep disturbance Vacant stare/glassy eyed Vomiting NOTE: The GSC should be used not only for the initial evaluation but for each subsequent follow-up assessment until all signs and symptoms have cleared at rest and during physical exertion. In lieu of simply checking each symptom present, the [certified athletic trainer] ATC can ask the athlete to grade or score the severity of the symptom on a scale of 0-6, where 0=not present, 1=mild, 3=moderate, and 6=most severe. FIGURE C-5 Graded symptom checklist. SOURCE: Guskiewicz et al., 2004, Appendix A, p. 296.

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326 SPORTS-RELATED CONCUSSIONS IN YOUTH day 45 were compared, the highest intraclass correlation was observed for working memory (0.65), followed by reaction time (0.60), decision mak- ing (0.56), attention (0.43), and matching (0.23). When days 45 and 50 were compared, the highest correlation was reported for matching (0.66), followed by working memory (0.64), decision making (0.62), reaction time (0.55), and attention (0.39). However, the effect on the participants’ performance of successively administering three neuropsychological test- ing batteries was identified as a possible methodological flaw, potentially contributing to the low intraclass correlation scores. Makdissi and colleagues (2010) conducted a prospective study that tracked the recovery of 78 concussed male Australian football players us- ing the Axon Sport CCAT and traditional paper-and-pencil tests (the Digit Symbol Substitution Test and the Trail Making Test Part B). Although concussion-associated symptoms lasted an average of 48.6 hours (95 per- cent CI, 39.5-57.7 hours), and cognitive deficits on the traditional paper- and-pencil test had for the most part resolved at 7 days post injury, 17.9 percent of the athletes still demonstrated significant cognitive decline on the Axon sport CCAT. This study implied that the Axon sport CCAT has greater sensitivity to cognitive impairment following concussion than the Digit Symbol Substitution test and the Trail Making Test Part B. Because Axon Sport is a new computerized neuropsychological test battery, more research is warranted on this test battery to determine whether it is effective in assessing concussion outcomes. Concussion Resolution Index The CRI, developed by HeadMinder, Inc., is a Web-based computerized neuropsychological assessment battery composed of six subtests: reaction time, cued reaction time, visual recognition 1 and 2, animal decoding, and symbol scanning (Erlanger et al., 2003). Symbol scanning measures simple and complex reaction time, visual scanning, and psychomotor speed. These six subtests form three CRI indices: Psychomotor, Speed Index, Simple Reaction Time (Erlanger et al., 2003). In addition to cognitive testing, the CRI collects demographic information, medical history, concussion history, and symptom report. Concurrent validity was established using traditional neuropsychologi- cal paper-and-pencil tests. Correlations for CRI Psychomotor Speed Index were 0.66 for the Single Digit Modality Test, 0.60 and 0.57 for the Grooved Pegboard Test dominant and nondominant hand respectively, and 0.58 for the WAIS-III Symbol Search subtest (Erlanger et al., 2001). Correlations for CRI Complex Reaction Time Index were 0.59 and 0.70 for the Grooved Pegboard test for dominant and nondominant hand, respectively (Erlanger et al., 2001). Correlations for the CRI Simple Reaction Time Index were

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APPENDIX C 327 0.56 for Trail Making Test Part A, and 0.46 and 0.60 for the Grooved Pegboard Test dominant and nondominant hand, respectively (Erlanger et al., 2001). In the previously mentioned study by Broglio and colleagues (2007), test-retest reliability was also examined for the CRI at baseline and at 45 and 50 days post baseline test. The CRI demonstrated extremely low intra- class correlations (0.03) for Simple Reaction Time Error score when days 45 and 50 were compared, and 0.15 for baseline to day 45. The correlations for simple reaction time were 0.65 (baseline to 45 days) and 0.36 (day 45 to 50) and for complex reaction time were 0.43 (baseline to 45 days) and 0.66 (day 45 to 50); the complex reaction time error score was 0.26 (baseline to 45 days) and 0.46 (day 45 to 50), and the processing speed index was 0.66 (baseline to 45 days) and 0.58 (day 45 to 50). These low correlations may be due to the three neuropsychological testing batteries being administered during one session and also to the lack of counterbalance of these three computerized test batteries. Erlanger and colleagues (2003) reported that test-retest reliability for a 2-week interval was 0.82 for psychomotor speed, 0.70 for simple reaction time, and 0.68 for complex reaction time. Another study also examined the sensitivity of the CRI in detecting changes between baseline and post-injury testing, and it found that the CRI had a sensitivity of 77 percent in identify- ing a concussion (Erlanger et al., 2001). Thus, the CRI was found to be a valid method of identifying changes in psychomotor speed, reaction time, and processing speed after a sports-related concussion. Immediate Post-Concussion Assessment and Cognitive Testing ImPACT is an online computerized neuropsychological test battery composed of three general sections. First, athletes input their demographic and descriptive information by following instructions on a series of screens. The demographic section includes sport participation history, history of alcohol and drug use, learning disabilities, attention deficit hyperactive disorders, major neurological disorders, and history of previous concus- sion. Next, the athletes self-report any of 22 listed concussion symptoms, which they rate using a 7-point Likert scale. The third section consists of six neuropsychological test modules that evaluate the subject’s attention processes, verbal recognition memory, visual working memory, visual pro- cessing speed, reaction time, numerical sequencing ability, and learning. Schatz and colleagues (2006) examined the diagnostic utility of the composite scores and the PCSS of the ImPACT in a group of 72 concussed athletes and 66 non-concussed athletes. All athletes were administered a baseline test and all concussed athletes were tested within 72 hours of in- curring a concussion. Approximately 82 percent of the participants in the

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328 SPORTS-RELATED CONCUSSIONS IN YOUTH concussion group and 89 percent of the participants in the control group were correctly classified. This indicates that the sensitivity of ImPACT was 81.9 percent and the specificity was 89.4 percent. To examine the construct validity of ImPACT, Maerlender and col- leagues (2010) compared the scores on the ImPACT test battery to a neuropsychological test battery and experimental cognitive measures in 54 healthy male athletes. The neuropsychological test battery included the California Verbal Learning test, the Brief Visual Memory Test, the Delis Kaplan Executive Function system, the Grooved Pegboard, the Paced Audi- tory Serial Attention Test, the Beck Depression Inventory, the Speilberger State-Trait Anxiety Questionnaire, and the Word Memory Test. The experi- mental cognitive measures included the N-back and the verbal continuous memory task. The following scores were generated: neuropsychological ver- bal memory score, neuropsychological working memory score, neuropsy- chological visual memory score, neuropsychological processing speed score, neuropsychological attention score, neuropsychological reaction time score, neuropsychological motor score, and neuropsychological impulse control score. The results indicated significant correlations between neuropsycho- logical domains and all ImPACT domain scores except the impulse control factor. The ImPACT verbal memory correlated with neuropsychological verbal (r=0.40, p=0.00) and visual memory (r=0.44, p=0.01); the ImPACT visual memory correlated with neuropsychological visual memory (r=0.59, p=0.00); and the ImPACT visual motor processing speed and reaction time score correlated with neuropsychological working memory (r=0.39, p=0.00 and r=–0.31, p=–.02), neuropsychological process speed (r=0.41, p=.00 and r=–0.37, p=0.01), and neuropsychological reaction time score (r=0.34, p=0.00 and r=–0.39, p=0.00). It must be noted that the neuropsychological domain scores for motor, attention, and impulse control were not correlated with any ImPACT composite scores. Overall the results suggest that the cognitive domains represented by ImPACT have good construct validity with standard neuropsychological tests that are sensitive to cognitive func- tions associated with mTBI. Allen and Gfeller (2011) also found good concurrent validity between ImPACT scores and a battery of paper-and-pencil neuropsychological tests. Specifically, 100 college students completed the traditional paper-and-pencil test battery used by the National Football League and the ImPACT test in a counterbalanced order. Five factors explained 69 percent of variance with the ImPACT test battery with the authors suggesting that ImPACT has good concurrent validity. Although ImPACT has been reported to have good sensitivity, speci- ficity, and construct validity, its test-retest reliability has been shown to be somewhat inconsistent. Iverson and colleagues (2003) examined the test-retest reliability over a 7-day time span using a sample of 56 non-

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APPENDIX C 329 concussed adolescent and young adults (29 males and 27 females with an average age of 17.6 years). The Pearson test-retest correlation coefficients and probable ranges of measurement effort for the composite scores were: verbal memory=0.70 (6.83 pts), visual memory=0.67 (10.59 pts), reaction time=0.79 (0.05 sec), processing speed=0.89 (3.89 pts), and post-concus- sion scale=0.65 (7.17 pts). There was a significant difference between the first and 7-day retest on the processing speed composite (p < 0.003) with 68 percent of the sample performing better on the 7-day retest than at the first test session. In the 2007 study by Broglio and colleagues, the ImPACT intraclass correlations ranged from 0.28 to 0.38 (baseline to day 45) and 0.39 to 0.61 (day 45 to day 50) (Broglio et al., 2007). The correlations for each composite score were: verbal memory (0.23 for baseline to day 45, and 0.40 for day 45 to day 50), visual memory (0.32 and 0.39, respectively), motor processing speed (0.38 and 0.61, respectively), and reaction time (0.39 and 0.51, respectively). However, it must be pointed out that this study was flawed by methodological errors which contributed to the low intraclass correlation values. Miller and colleagues (2007) conducted a test-retest study over a longer time period (4 months) with in-season athletes. The researchers adminis- tered a series of ImPACT tests to 58 non-concussed Division III football players during pre-season (before the first full-pads practice), at midseason (6 weeks into the season), and during post-season (within 2 weeks of the last game). The results indicated no significant differences in verbal memory (p=0.06) or in processing speed (p=0.05) over the three testing occasions. However, the scores for visual memory (p=0.04) and reaction time showed significant improvement as the season progressed (p=0.04). Even though the statistical difference was found at the P level of 0.05, when an 80 percent confidence interval was used, the ImPACT results could be interpreted as stable over a 4-month time period in football players. The test-retest reli- ability of ImPACT has been examined with even longer time periods. In response, Elbin and colleagues (2011) investigated a 1-year test- retest reliability of the online version of ImPACT using baseline data from 369 high school varsity athletes. The researchers administered the two ImPACT tests approximately 1 year apart, as required by the participants’ respective athletic programs. Results indicated that motor processing speed was the most stable composite score with an intraclass correlation of 0.85, followed by reaction time (0.76), visual memory (0.70), verbal memory (0.62), and PCSS (0.57). The test-retest study of ImPACT with the longest elapsed time was conducted by Schatz (2010), who tested 95 college athletes over a 2-year interval. Motor processing speed was the most stable composite score over those 2 years with an intraclass correlation of 0.74, followed by reaction

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330 SPORTS-RELATED CONCUSSIONS IN YOUTH time (0.68), visual memory (0.65), and verbal memory (0.46). Even though the correlation for verbal memory did not reach the “acceptable” threshold (0.60), with the use of regression-based methods none of the participants’ scores showed significant change. Furthermore, reliable change indices revealed that only a small percentage of participants (0 to 3 percent) showed significant change. This study suggests that college athletes’ cogni- tive performance remains stable over a 2-year time period. In addition, the ImPACT test battery has been shown to have good psychometric properties. In a small sample of non-athlete college students (n=30), Schatz and Putz (2006) administered three computerized batteries along with select paper-and-pencil tests, counterbalanced over three 40-minute testing ses- sions. The results showed shared correlations between all the computer- based tests in the domain of processing speed, and between select tests in the domains of simple and choice reaction time. Little shared variance was seen in the domain of memory, although external criterion measures were lacking in this area. Of the test measures used, ImPACT shared the most consistent correlations with the other two computer-based measures as well as with all external criteria except for internal correlations in the domain of memory. However, the authors were clear about the limitations in sample size and the lack of a clinical population as well as the other limitations of the study, and they cautioned against considering this a complete evaluative study. The study does, however, provide some framework for understanding the concurrent validity of these tools. Previous concurrent validity studies indicated good validity when com- pared to individual tests. The convergent construct validity of ImPACT was good compared to a full battery of neuropsychological tests (Maerlender et al., 2010). Using a factor analytic approach, Allen and Gfeller (2011) also found good concurrent validity between ImPACT scores and a battery of paper-and-pencil neuropsychological tests. However, there were differ- ences in factor structure between the paper-and-pencil battery and the Im- PACT battery, suggesting differences in “coverage” of neuropsychological constructs. REFERENCES Allen, B. J., and J. D. Gfeller. 2011. The Immediate Post-Concussion Assessment and Cognitive Testing battery and traditional neuropsychological measures: A construct and concurrent validity study. Brain Injury 25(2):179-191. Ayr, L. K., K. O. Yeates, H. G. Taylor, and M. Browne. 2009. Dimensions of postconcussive symptoms in children with mild traumatic brain injuries. Journal of the International Neuropsychological Society 15(1):19-30. Barr, W. B. 2003. Neuropsychological testing of high school athletes: Preliminary norms and test-retest indices. Archives of Clinical Neuropsychology 18:91-101.

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