FAQ (Frequently Asked Questions)

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ORDERING THE SOFTWARE

• Can I get a demo of the ImPACT program?

  Yes, simply send an email to Doug Tauchen . Please note that you can not view your test results from the demo. If you would like to see your demo test results, please request it from Doug after you take the demo.

• Who do I call for more information?

  Please Call (877) 646- 7991, type in the proper extension.

• How do I obtain a W9 for ImPACT?

  Please send an email request to our administrative assistant and she can fax or email you a copy.

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ImPACT TEST: Administering the Test

• Who can administer ImPACT?

  An Athletic Trainer, Physician, Nurse, Neuropsychologist, Sports Medicine Clinician, Psychologist, Coach, Athletic Director. The administrator needs to have taken the test and be familiar with the testing protocol.

• Do you have forms to introduce the program to the parents and also get permission from the parents on testing their kid?

  Yes, Please download these forms:
  http://www.impacttest.com/pdf/PermissionForm.doc
  http://www.impacttest.com/pdf/PermissionForm2.doc
  

• Do we need to use a Social Security Number as the identification number when we take the test or can we use a different number?

  Online ImPACT does not require a Social Security Numer or other identification number. Name and date of birth are the only identifiers required.

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TECHNICAL SUPPORT: Online

• What are the computer requirements for online ImPACT?

  Please paste the following link into your browser. https://www.impacttestonline.com/customercenter/pdfs/ImPACT_Applications_Tech_Facts.pdf

• How do I switch to Online ImPACT?

  If you would like to switch to Online ImPACT or you have any questions about the product, simply give us a call, 1.877.646.7991.

• I am already using ImPACT. What will is cost to switch to Online ImPACT?

  Online ImPACT is sold on an annual subscription basis. If you’re already an ImPACT annual subscription client you can make the switch for free and your annual renewal date will remain the same. Consult the price sheet to find your Online ImPACT annual subscription rate.

• What are the advantages of Online ImPACT?

  Online ImPACT offers the advantage of not having to install software to your PC before testing. It only requires Macromedia Flash Player 7.0 or later and an active internet connection to take the test and view results. The program functions on PC’s and MAC’s.

• What happens to my desktop ImPACT data if I switch to online?

  The online and desktop databases are not compatible. You would need to keep the desktop system active until everyone was tested on the Online ImPACT platform.

• I have a baseline in Desktop ImPACT and just did the follow up using Online ImPACT. Can I compare them?

  Yes, the data can be directly compared. Within this context, there are slight variations in the data when comparing the online to desktop versions. More specifically, the reaction time scores are slightly different between the two systems, whereas the other composite scores (Verbal Memory, Visual Memory, Visual-Motor Speed scores) are nearly equivalent. The best way to directly compare data between the two systems is to use the normative data and percentile scores for comparison, rather than the raw scores. In this fashion, the data is identical as you are using the same metric for comparison. As norms are based upon comparisons to a normal population, the data are similarly converted to this common metric and percentile. Thus, for example, if someone scored .52 on the desktop version and is at the 51st percentile, this would be equivalent to someone scoring at .56 and at the 51st percentile for the online system. Using percentile scores rather than raw scores allow for a direct comparison of these data.

• What does it mean if the 'Saving Data' screen doesn't go away?

  It means the internet connection was lost during the testing procedure. Unfortunately the test has been lost and you will need to retest the athlete. To help limit this possiblity, don't login to Online ImPACT until the athlete is ready to start testing.

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ImPACT TEST: Baseline Testing

• What is the best way to test large numbers of athletes?

  1) Schedule groups of athletes in the computer lab. We suggest only using every other computer (more space means better baseline results). The test is 20 minutes long and you can schedule athletes every half hour to take the test. Athletes should be supervised by someone familiar with the program. 2) Schedule the test to be taken during your annual physicals. Install the program on the computers where you conduct your physicals and have the athletes take the test as part of their physical. Test athletes twice in high school (freshman & junior yrs.) and once in college (freshman yr.). 3. Online ImPACT users can provide students with a website where they can take the test.

• How often should athletes be given a baseline test?

  Although each athlete can be tested only once in high school, we recommend testing 2 times - freshman and junior years (in high school the brain is still developing). In college, the athlete should be tested during his or her freshman year. At the professional level, each athlete should be tested once.

• What if I don't have a baseline on an athlete?

  ImPACT performance following a concussion can be compared to our large normative database to assist in determination of recovery.

• Who should I baseline?

  We suggest baselines for all athletes. Some schools only test contact sports based on the American Academy of Pediatrics guidelines. Visit this link to view the American Academy of Pediatrics recomendations: www.impacttest.com/pdf/MedicalConditionsAffectingSportsParticipation.pdf

• What is the recommendation in respect to yearly or one time baseline testing?

  Test at the beginning of an athlete's 7th grade year, 9th grade year and 11th grade year.

• Can an athlete who is color blind be tested?

  Color blindness can be accounted for after the patient takes the ImPACT test. First, it should be stated that it is VERY rare to have achromatic color blindness and minimal color blindness will not affect the test in any way shape or form. If achromatic color blindness does truly exist in the patient, the only test this condition will affect is the Color Match test (module 5), as all other tests do not depend on color recognition. On the Color Match test, there is a sample prior to taking the test. If the patient cannot complete this, they will skip that test and zeros will be entered in the raw data of the report (Page 3 under Module 5). If this does occur (again, this is a very infrequent condition), the only composite score that will be affected is the Reaction Time score. This score will be artificially lowered (and hence improved). Any test administrator who reviews the data and see that this error has occurred can also readjust the scores using the attached file (see attached handout under Color Match Error). No other composite score or test should be affected by true color blindness. Even if the patient is truly color blind, it is recommended that baseline testing be completed per usual protocol and these raw score adjustments occur after collection of the data. If this condition is not recognized in the patient, post injury data will also be affected in the same fashion and scores should theoretically be the same across both testing sessions.

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DOCTORS: Billing

• What code is recommended for billing for baseline test for athletes and a what is a reasonable cost?

  I do not use a billing code for baseline testing where there has never been a concussion. It is not reimbursable thus no need for the code. I give a billing statement to the patient with procedure code (96118 if I do the testing myself) charge amount, etc. If there was a previous recent concussion sometimes you can make a connection and submit the baseline testing to the insurance company. In this case you can use a dx of concussion (850's with date of previous concussion) or post-concussion syndrome (310.2).

• What is the best way to bill so that the insurance company will reimburse?

  Insurance companies vary in how they will reimburse. A physician may use the typical exam/consult code and then a testing code such as 96118. These codes can be used on the same day or separate days. More commonly, the 96116 neuropsych exam code (can only be used once per medical problem/incident) is paired with the 96118 testing code, instead of the physician’s typical consult/exam code. These codes require a medical diagnosis such as CONCUSSION. With these codes there is an expectation of a report. Testing on a followup visit should also be 96118, a code that can be used repeatedly. But you cannot use the 96116 exam code again on the next visit. If a technician performs the testing, then use 96119. If the patient is not in the company of the doctor and is being tested by a computer, then use the computer testing code 96120, but this is a one time use code. Currently, the APA, NAN and other agencies are working with AMA/CMS and others because of the misinterpretation and problematic way the codes are being defined and reimbursed by insurers. Thus, we are all working with insurers to find out what will be reimbursed and by whom. WHAT IS MOST IMPORTANT is to document the time and activity of the doctor that justifies the code that was used, and then bill the proper codes to match the time and activity. Remember 96116 and 96120 are one time per incident codes. 96118 and 96119 can be used repeatedly on a per hour basis. Physician’s may also use their exam and consultation codes in conjunction with the 96119, 96118, 96120 codes.

• In addition to the E&M codes, would MDs use CPT codes 96118 and/or 96120, or should they just use a higher E&M code? Should they use modifiers?

  ImPACT has found that its best to use the appropriated E&M or consult code witha -25 modifier and use CPT 96120. The -25 modifier indicates that there was work the same day that occurred in addition to the procedure (testing) performed. ImPACT does not recommend upcoding.

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HELPFUL FORMS

• Our school has purchased the ImPACT software and now we would like to send information to the parents. Do you have any suggestions?

  Yes, Please download these forms:
  http://www.impacttest.com/pdf/PermissionForm.doc
  http://www.impacttest.com/pdf/PermissionForm2.doc

• Do you have any consent forms that parents can sign?

  Yes, Please download these forms:
  http://www.impacttest.com/pdf/PermissionForm.doc
  http://www.impacttest.com/pdf/PermissionForm2.doc
  

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Consultation Assistance

• Who should our doctors and athletic trainers call for Medical and Clinical Report Questions?

  Mark Lovell, PhD Director, UPMC Sports Concussion (412) 432-3670 or Micky Collins, PhD Asst. Director, UPMC Sports Concussion Program (412) 432-3668

• Is there any way to get a copy of an patient's baseline test from another school/clinic to compare to the athlete's post-injury test?

  The only way to get a copy is to have the school/clinic give it to you. You may need to have the patient submit a written request to the school/clinic to give you a copy of the report.

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DOCTORS: Working with your Local Schools

• I am presenting a lecture on concussion and would like to include pictures of the tests and test report. Where can I get these?

  The ImPACT POWERPOINT PRESENTATION can be downlaoded at www.impacttestoffice.com. It contains screen captures.

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IMPACT TEST: Baseline Testing - INVALID?

• When should I begin to question if a student did not understand some of the test, or if they tried to sandbag it? What is an unacceptable impulse score?

  Typically, at baseline, any impulse control score above 30 indicates that something went wrong with the test. Typically, this would indicate that they did not read the directions correctly for the x’s and o’s interference test (left/right click), the three letters test (they may have counted forward instead of backwards) or the color match test. Below is a link to a form highlighting the most common errors on ImPACT, how to create the composite scores, and how to recalculate their scores if these errors do occur. Again, a score of greater than 30 indicates something went wrong with baseline. Post concussion, however, this score may be highlighted simply due to the concussion and not that it is invalid. Also, the check the validity of a baseline test, be sure their normative data is commensurate or equal to where you might expect that student/athlete to be. For example, an Average to Above Average student should be at least 50th percentile or higher across the composite scores, etc. ImPACT Test Invalidity Composite Score Formulas

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ImPACT TEST: Interpretation

• What are the three additional graphs in ImPACT 2006?

  These are supplemental research scores. These graphs can be turned off if desired.

• If any given athlete did not have baseline testing, and then clearly had a concussion or symptomology during competition, what, if anything, would repeat testing tell the training staff. I presume that there are norms by age, sex, etc?

  Yes, the program can, and should, be used even without a baseline. In the report summary scores (composite scores), the norms are printed out and automatically tabulated. The raw score is accompanied by a percentile which indicates where they fall relative to healthy age and gender-matched controls. For example, if the composite score falls at the 5th percentile…that would indicate 95 out of 100 non-concussed individuals would perform better than the athlete that is being tested. By understanding their pre-injury status, this data can be extremely informative and helpful. For example, a typical A/B student should be around the 60th percentile or higher on all composite scores, those that are C students should typically fall around the 40th percentile or higher and those with learning disability or very poor students could fall as low as the 20th percentile or so and be considered within normal limits. We use the program all the time without baselines and the data is very helpful for clinical management.

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ImPACT TEST: Post Injury Testing

• What do we do after a concussion? Who should interpret the test results?

  Once taken, ImPACT generates a 6-page clinical report. The ImPACT Clinical Team will train you, your staff, and your team doctors on reading and interpreting the test results. 1) 24-48 hours post injury, have the athlete sit down to take the Post-Concussion Test. 2) Ask your athletic trainer / team physicians / medical staff to get involved. We have found that MANY clinicians want to be involved. We find that many sports medicine clinicians want to learn to interpret the test results AND WE WILL TRAIN THEM ON USING THE INSTRUMENT. We can also provide names of specialists (e.g. neuropsychologists) in your area who are trained in proper interpretation. 3) If you don't have anyone at your school to do the interpretation, consult our website (DOCTOR LOCATOR) to find a specialist in your area. Consultation can be established through one of our specialists at the University of Pittsburgh Medical Center. ImPACT test results should be used as only one source of information regarding the athlete's level of functioning. Diagnostic or return to play decisions should be based on an evaluation by medical personnel in accordance with usual and standard medical practices. Post Injury testing consultation may be charged to athlete's insurance

• When should ImPACT be given following a concussion?

  We suggest initial evaluation 24-72 hours after injury. Consult an physician for interpretation of ImPACT test results. If ImPACT results are abnormal continue to refrain from practice and competition. The second ImPACT test should be administered once the athlete is asymptomatic. Once scores have returned to baseline level and symptoms have resolved an exertion test should be performed. Please attend an ImPACT workshop for contact Dr. Collins for a detailed return to play protocol.

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DOCTORS: Return-to-Play Issues

• When should I return an athlete to play following a known skull fracture with additional complexities including expressive dysphasia, a stable traumatic subarachnoid hemmorhage and frontotemporoparietal bone fracture along with a small acute SDH?

  The return to play decision can be controversial. The first step is to have the neurosurgeon assess whether the player is at any increased risk for re-injury, based on the player's skull fracture. The next step is to determine whether an athlete with a known structural injury, such as a hemorrhage, is at increased risk for tearing of ht brain tissue in that area. The final step is to ensure that the athlete is neuropsychologically normal prior to return to play. Until the dysphasia and any memory problems subside, the athlete should not return to play.

• How close to the Baseline scores must the Post-Injury scores be before the athlete can return to play?

  Reliable change indices are a helpful tool for determining when an athlete's post-injury test has satisfactorily approached baseline levels. On newer versions of ImPACT, a composite score is BOLDED if the post-test composite exceeds the reliable change index, and is thus considered atypical and representative of cognitive impairment related to injury. Once the composite is within the reliable change index, it is no longer printed in bold text. The RCI should not be the only criteria in determining when an athlete's test scores are back to baseline. An examination of the athlete's performance on individual tests should happen as well. In addition, symptoms and exertional testing should be a part of the process. And, of course, the ATC would need to first determine that the baseline was valid and representative of the athlete's non-injured functioning.

• How often do you administer the ImPACT test during an athlete's injury?

  I evaluate the athlete within 72 hours of injury and then at weekly intervals, until they are asymptomatic at rest, asymptomatic with exertion, and all normal on ImPACT (return to play criteria). For those who take a long time to recover, this time interval can be extended. If the case is milder, I might evaluate them a few times within the first week. ou should never test more than twice in a week.

• Do you administer the test when an athlete has still has self reported symptoms?

  Yes, I do test athletes when they are symptomatic, to help monitor progress and help to determine school issues, return to exertion, etc.

• Have you found that athletes who perform the test have increased symptoms following the test because of increased cognitive function?

  Yes, I do find that athletes will complain of symptoms when taking ImPACT, this is actually very frequently reported.

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CONCUSSION

• As athletes return to play after sustaining a minor head injury, what is the best type of helmet in order to prevent more concussions?

  There is no data in soccer or hockey regarding helmet manufacturing and a reduction in the incidence or severity of concussion. In short, I personally do not endorse or recommend soccer headgear, etc. Obviously, the best way to prevent problems with concussion is to be certain the athlete has recovered fully prior to RTP. In football, we have done some research with the Revolution Helmet and found that to slightly reduce the incidence, though not the severity of concussion.

• In regards to athletes getting hit in certain areas of the brain and affecting different functions. Do you have some sort of list or general description blows to certain areas of the brain may cause; ie athlete gets a frontal hit look for visual, attentio

  By Micky Collins, PhD...Here are some general points of reference. Please consider these general points, as the injury and presentation is very complicated and may not always present as outlined below....though we often see 'subtypes' of concussive injury. The brain can be thought to be composed of different systems, and each system plays a different role in behavior (and symptom presentation). When examining concussion, two systems may be affected differently. The subcortical system, or deeper (and posterior) parts of the brain control attention, speed, sleep/wake cycles, balance, fine motor movements, visual functions, etc. The reticular activating system is also deeper in the brain (though pathways extend anteriorly towards the frontal regions), and controls arousal. Hence, if you have a blow to the posterior or back portion of the cranium, you may expect to have a loss of conscioussness, and acute symptoms will typically (not always) include brief visual changes, balance deficits, fatigue, slowness, and arousal difficulties. With posterior concussions, lingering symptoms may include include a lot of fatigue, distractibility, potential sleep/wake issues, and deficits on ImPACT may include reaction time and visual-motor speed deficits. The cortical (or frontal/temporal) functions include memory, multi-tasking, problem solving, mood/behavior, reasoning, and exective functioning. Thus, a cortical concussion will more likely involve amnesia (both retrograde, post-traumatic), deficits with memory, concentration, multi-tasking and potential emotional changes. On ImPACT, you will often see deficits with verbal memory, as well as visual memory. For more chronic symptoms, you may see a sense of 'fogginess' (which is an attentional deficit), academic difficulties characterized by concentration deficit/memory difficulties, and potential mood related changes (depression, anxiety, etc). Obviously, if you have a posterior blow, and have all of these symptoms (with amnesia, mood, etc, along with speed/arousal difficulties), it is a more serious concussion and vica versa with a frontal blow. That is why when all four scores on ImPACT are impaired, it is a more serious concusssion and you may expect a more protracted recovery. As an FYI, there are also vestibular or labyrynthine concussion (inner ear and not necessarily intracranial). With this type of injury, you will see positional dizziness, dysequilibrium, and similar symptoms. It is typical that you will have concussion symptoms, in addition to the vestibular deficits that you have to account for.

• What number of symptoms is considered significant?

  Any symptom that is not normally present or is normally present but elevated post concussion should be taken seriously.

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HELMET RECOMMENDATIONS

• Which football helmet company and style does the best job in preventing concussions and mild traumatic brain injuries?

  We hope to see more research before recommending any one helmet. Check with NOCSAE to see if they have any detailed information on available helmets. http://www.nocsae.org/about/history.html

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