In the JournalsPerspective

Half of patients with concussions fail at least one validity indicator

More than 50% of patients who completed baseline neurocognitive testing in sports-related concussion testing did not pass at least one of four validity indicators, according to findings recently published in JAMA Neurology.

“Baseline testing was implemented to reduce the inherent error in estimating premorbid functioning. Theoretically, this practice increases the validity of decision making because individuals serve as their own healthy controls. However, the utility of baseline testing compared with the use of normative data in postinjury evaluations has long been debated,” Christopher A. Abeare, PhD, of the department of psychology at the University of Windsor in Ontario, Canada, and colleagues wrote. “The most recent Consensus Statement on Concussion in Sport concluded that baseline testing can be useful in the management of concussion, but there is not enough evidence to suggest that baseline testing should be mandatory."

Abeare and colleagues conducted assessments of 7,897 participants (mean age, 14.71 years) using the Immediate Postconcussion Assessment and Cognitive Testing (ImPACT) to determine baseline failure rates of the test’s validity indicators.

Researchers found that 55.7% of participants failed at least one of the four validity indicators Across each separate indicator, the base rate of failure ranged from 6.4% to 47.6%, with this failure showing considerable changes across age groups: 83.6% of those aged 10 years to 29.2% for those aged 21 years (RR = 2.86; 95% CI, 2.6-3.16).

“The results for base rate of failure were surprisingly high overall,” Abeare and colleagues wrote. “The strong age association, with three of four participants aged 10 to 12 years failing validity indicators, suggests that the clinical interpretation and utility of baseline testing in this age group is questionable. These findings underscore the need for close scrutiny of performance validity indicators on baseline testing across age groups.”– by Janel Miller

More than 50% of patients who completed baseline neurocognitive testing in sports-related concussion testing did not pass at least one of four validity indicators, according to findings recently published in JAMA Neurology.

“Baseline testing was implemented to reduce the inherent error in estimating premorbid functioning. Theoretically, this practice increases the validity of decision making because individuals serve as their own healthy controls. However, the utility of baseline testing compared with the use of normative data in postinjury evaluations has long been debated,” Christopher A. Abeare, PhD, of the department of psychology at the University of Windsor in Ontario, Canada, and colleagues wrote. “The most recent Consensus Statement on Concussion in Sport concluded that baseline testing can be useful in the management of concussion, but there is not enough evidence to suggest that baseline testing should be mandatory."

Abeare and colleagues conducted assessments of 7,897 participants (mean age, 14.71 years) using the Immediate Postconcussion Assessment and Cognitive Testing (ImPACT) to determine baseline failure rates of the test’s validity indicators.

Researchers found that 55.7% of participants failed at least one of the four validity indicators Across each separate indicator, the base rate of failure ranged from 6.4% to 47.6%, with this failure showing considerable changes across age groups: 83.6% of those aged 10 years to 29.2% for those aged 21 years (RR = 2.86; 95% CI, 2.6-3.16).

“The results for base rate of failure were surprisingly high overall,” Abeare and colleagues wrote. “The strong age association, with three of four participants aged 10 to 12 years failing validity indicators, suggests that the clinical interpretation and utility of baseline testing in this age group is questionable. These findings underscore the need for close scrutiny of performance validity indicators on baseline testing across age groups.”– by Janel Miller

    Perspective
    Douglas Comeau

    Douglas Comeau

    We have known for some time that the ImPACT test is more accurate the older that a patient gets, primarily because the brain is still maturing and developing at younger ages. Consequently, Abeare and colleagues’ findings are not surprising, and provide a nice retrospective analysis of the data of failures among age groups and the validity indicators.

    There are other tools that primary care physicians can use besides ImPACT to evaluate patients who have concussions to determine their ability to resume physical activity.  These tools include return-to-play and return-to-school guidelines that some school districts have that PCPs can follow.  PCPs can perform physical exams such as balance testing, vestibular and ocular responses to different challenges in addition to checking the cervical spine to see if muscular spasms are causing concussion-related symptoms.

    PCPs can also put patients through a return-to-physical activity progression, which is part of the international return-to-play guidelines. This progression typically takes 5 to 6 days, for example, in daily sequential order for 20 minutes: biking, running, performing a sports-specific activity, weightlifting, noncontact practice, and then, finally, a contact practice if it’s a contact-collision athlete. If an athlete can perform all of these steps without exhibiting concussion symptoms, he or she can return to play. There is the neurocognitive testing as well, but PCPs need to know that the younger a patient is, the less valid the results may be.  

    • Douglas Comeau, DO, CAQSM, FAAFP
    • Assistant professor, family medicine at Boston University School of Medicine,
      Medical director, Boston University and Boston Medical Center Sports Medicine
      Director, Boston University Sports Medicine Fellowship

    Disclosures: Comeau reports no relevant financial disclosures.