ImPACT® Test Interpretation
ImPACT Interpretive Strategy
As with the interpretation of any neurocognitive test or test battery, test data often requires analysis at multiple levels. Any program that claims to diagnose all concussions through a "yes-no" or "red light-green light" decision-making process is overly simplistic and may miss subtle difficulties. This could expose the athlete to further injury.
Therefore, ImPACT does not yield one summary score, but rather a series of indicators that have been demonstrated to be sensitive to concussion (see reference section of website). Not every athlete will demonstrate poor performance on all indices and the individual test performance of the athlete may depend on a number of factors that include type of blow to the head, site of the blow, and the patient's individual history.
In addition, ImPACT team members have developed a symptom scale that has been adopted by most professional sports organizations as well as by the International Olympic Committee, FIFA and the International Ice Hockey Foundation.
The interpretation of ImPACT should ideally follow a multi-level path of analysis. Of course, it should be stressed that as a brief screening battery, ImPACT does not purport to represent a comprehensive evaluation of neuropsychological functioning nor should it be used to diagnose a concussion. Some athletes may require more involved evaluation, which should always be accomplished by a qualified neuropsychologist.
As a first step in the clinical interpretation of ImPACT, an evaluation of the five composite scores is recommended. You may find it helpful to view a sample clinical report or our Clinical Interpretation Manual. Even a cursory review of the composite scores often reveals subtle deficits in the core areas of attention and memory (as evidenced by decreased performance on the Verbal and Visual Memory composites) or cognitive speed (as evidenced by increased reaction time or a decreased score on the Visual-Motor Processing composite).
The magnitude of changes from baseline testing is assessed via the use of Reliable Change Index (RCI) scores for the ImPACT composites. If an athlete demonstrates a change in scores that falls outside of the range of normal score variation, the ImPACT report notes these changes in test performance.
However, even subtle changes in performance that fail to reach the level of the RCI score may be significant if they are different from baseline performance. If baseline performance has not been completed, a comparison of ImPACT scores to established age and gender stratified normative scores is recommended. These scores can be very helpful in establishing the overall level of performance in comparison to the athlete's peer group for each composite score.
The second step of test analysis should involve a more specific analysis of the individual scores that comprise the composite scores. This type of pattern analysis involves a thorough analysis of each of the module scores as well as an analysis of patterns or strengths and weaknesses in various areas of performance. For instance, does the athlete display relatively intact performance on tests measuring memory but deficits on tests that tap cognitive speed? In addition, it is important to evaluate the dimension of speed and memory accuracy on specific tests, examining what individual scores may have lead to the drop in overall performance measured by the composite scores.
Since several of the ImPACT modules are multi-dimensional and measure both speed and memory, the injured athlete may sacrifice performance in one dimension for performance in another. This is often seen on the Symbol Match subtest. In an apparent attempt to increase memory accuracy, an athlete may slow down considerably with regard to the speed element of the test. The astute clinician will recognize this as abnormal performance.
It is important to emphasize that not all concussed athletes demonstrate clear evidence of cognitive dysfunction on neurocognitive testing. Non-cognitive symptoms such as headache, nausea, balance problems and dizziness are common and should be thoroughly assessed. Although athletes at all levels of competition are notorious for minimizing symptoms, particularly later in the recovery process when they are being considered for return to play, the tracking of symptoms still represents an important and necessary element of the concussion management process. Although as noted earlier, every concussion may present differently, there are often symptom constellations that may suggest specific clinical syndromes.
For example, migraine-type headaches are relatively common following concussion and often present with the characteristic symptoms of headache (often unilateral and described as throbbing or pulsating), dizziness, photophobia or phonophobia, and nausea. A recent study utilizing ImPACT has demonstrated that this type of post-traumatic migraine syndrome is associated with reduced neurocognitive performance (Collins et al., 2003), although this is not always the case.
Post-traumatic migraine is particularly common in individuals with a prior history or family history of headache and this history adds an additional level of complexity to the return to play decision-making process. To complicate matters further, these athletes often receive pharmacologic treatment of their headaches, which may help with regard to the headache but not treat the underlying neurocognitive dysfunction. In this case, the clinician should be especially careful to assure that the athlete is indeed recovered with regard to their level of cognitive functioning, prior to consideration of return to play.
The ImPACT symptom scale has become standard throughout amateur and professional sports and promotes the quantification of the severity of symptoms. This symptom scale also allows for the accurate tracking of recovery from each of the individual symptoms throughout the recovery process. Finally, the symptom scale serves as an educational tool, alerting the athlete, team staff and parents regarding potential post-concussive symptoms.
Normative Data on the Clinical Report
Online ImPACT Testing System incorporates normative data into the report that is presented as percentile scores for specific age and gender groups. Consult the ImPACT Clinical Interpretation Manual for more details.
When looking at the composite scores, you will notice a smaller number to the right of the composite score. This is the percentile rank of the athlete for their gender and age at the time of testing.
Reliable Change Index
Scores in bold type indicate composites that exceed the Reliable Change Index (RCI) when compared to the baseline test. However, scores that do not exceed the RCI index may still be clinically significant.
Become an ImPACT® Client:
One of the keys to ImPACT's approach to concussion management is to compare an athlete's post-concussive performance and symptoms to a baseline (pre-concussion) level for that athlete. In order to do this, athletes must take a baseline ImPACT measurement prior to sustaining a concussion.
Typically, this can be done with a 20-minute online test at the beginning of preseason training or even a few months prior to season training. This user-friendly computer program can be administered by a coach, athletic trainer or physician with minimal training. It is important to have athletes complete the ImPACT test before they start any type of contact that might result in a concussion (e.g., drills, scrimmages, etc.). The online test is designed to measure cognitive functions, including: attention span, working memory, non-verbal problem solving and reaction time.
More About ImPACT®
Headquartered in Pittsburgh, Pennsylvania, ImPACT Applications, Inc., is a provider of computerized neurocognitive assessment tools and services that are used by medical professionals to assist them in determining an athlete's fitness to return to play after suffering a concussion. At the current time, ImPACT is being used for concussion management services at more than 1,000 high schools, colleges, sports medicine centers, and professional teams throughout the world.