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DISCLOSURES
►DJ Global Primary Care Sports Medicine Advisory Panel
►NFL Charities Grant Assessing vascular reactivity in patients with
multiple concussions ►Chair: Big Ten-Ivy League TBI Research
Committee
OBJECTIVES
►List 3 limitations of NPT for RTP decisions ►Be aware of psychometric properties of
computerized NPT programs ►Recognize that NTP for RTP decisions is
best used as part of a multifaceted approach
►Appreciate that psychometric data on popular computerized NPT is lacking
3 QUESTIONS…..
1. What are the limitations of NPT & RTP? 2. Should we use it? Adults? Peds? 3. How much “stock” should we place in
the results?
CASE TO PONDER…
►18 yo freshman wide receiver ►Suffered his 1st concussion in practice Hit head on ground while catching a pass
►Initial: Dizzy, HA, hard to concentrate ►Symptoms resolved in 24 hours ►48 hrs: Light biking w/o symptoms ►PE & BESS testing: normal
QUESTION #1: WHAT ARE THE
LIMITATIONS OF NPT? ►Randolph; JAT 2005 Review of traditional & computerized NPT
for Sports related concussions (SRC) Conclusion: “Computerized NPT for SRC
does not possess the psychometric properties necessary to support their use in the clinical management of concussions.”
BASELINE TESTING
►How is the baseline data obtained? Group testing (>20) resulted in lower scores
& more invalid test results Moser R; AJSM 2011
Group: Higher symptom scores & reaction times Schatz P; Arch Clin Neurpsych 2010
Computer equipment, connection speed, etc may influence the results Hinton-Bayre; CJSM 2012
Baseline data not stable in young athletes
RELIABLE CHANGE INDEX
►Usually employed in computerized NPT ►Helps the clinician to see what result
represents a significant change ►Different models of RCI ►No one model is superior ►Better to understand them all and see
how it applies clinically! Hinton Bayre; CJSM 2012
ANAM
►Reliability Most subscales did not meet minimal criteria
for clinical utility ►Validity Lack of discriminate validity between
constructs ►Sensitivity: 1-15% depending on subtest ►Specificity: 86-100% “ “
Resch; Neuropsych Rev 2013
COGSPORT-STATE
►Reliability Most subscales did not meet minimal criteria
for clinical utility ►Validity Correlation coefficients: 0.23-0.83
►Sensitivity: 70.8% overall ►Specificity Not calculated due to no control group
HEADMINDER CRI
►Reliability Most subscales did not meet minimal criteria
for clinical utility ►Validity Correlation coefficients: 0.37-0.70
►Sensitivity: 69-79% overall ►Specificity Not calculated due to no control groups
IMPACT
►Reliability Most subscales did not meet minimal criteria
for clinical utility ►Validity Correlation coefficients: 0.20-0.88
►Sensitivity: 79-95% overall & subtests ►Specificity: 89-97%
NPT INTERPRETATION
►~3-17% of NPT interpreted by a licensed neuropsychologist Majority done by ATC &/or Physician
Comstock RD; 2012, Covassin; JAT 2009, Meehan; Pediatrics 2012
►~50% of ATCs don’t review baselines for validity Covassin; JAT 2009
47% of HS baselines invalid per review by Neuropsychologist Resch; Neuropsych Rev 2013
►Of ATCs interpreting NTP, only 26% had formal training Covassin; JAT 2009
EFFORT
►~4-11% of NPT inadequate effort Hunt; Arch Neuropsych 2007, Schatz; JAT 2012
►Sandbagging is a concern 11-35% were told to give reduced effort on
baseline testing Erdal; Arch Neuropsych 2012, Schatz; AJSM 2013
PEDIATRIC ATHLETES
►Formal “paper & pencil” ►Sideline assessment SAC (Norms for middle & HS) SCAT or SCAT 2 or SCAT 3 Pediatric SCAT
►Computerized ImPACT (10 yo norms) CogSport Head Minders (10 yo)
PEDS & NEUROPSYCH
►Are they old enough & mature enough? ►Baseline testing is important ►Baseline probably not stable in kids Improves w/ brain maturation Kids between 8-15 yo may need q 6mo repeat
baseline testing (McCrory 2004)
►Consider expected baseline improvement over time when interpreting results.
QUESTION #2: SHOULD WE USE IT?
►We don’t know the answer There are lots of opinions Need more science NP results influenced by: effort, fatigue,
mood, exercise, etc. Consumer demand has increased
►NCAA mandates baseline & f/u testing for high risk sports
►Consensus documents recommend
HIGH SCHOOL & NPT
►HS Reporting Information Online Injury Surveillance System 2009-10 192 HS w/ ATCs reporting on 20 sports All concussions recorded 1056 concussions; 97% response rate (#178)
►40% use computer neuropsych testing 2008-09: 26% 93% ImPACT
HS & NPT
►78% interpretations: ATC &/or Doctor 17% Neuropsychologist
►Less likely to return to play < 10 days if using computer NP testing 38.5% vs 55.7%
Meehan; Pediatrics 2012