title: The “Value Added” of Neurocognitive Testing after Sports-Related Concussion Sensitivity and specificity of the ImPACT Test Battery for concussion in athletes. Test-retest reliability of four computerized neurocognitive assessment tools in an active duty military population. Identification and Validation of Prognostic Criteria for Persistence of Mild Traumatic Brain Injury–Related Impairment in the Pediatric Patient Examining Concussion Rates and Return to Play in High School Football Players Wearing Newer Helmet Technology: A Three-Year Prospective Cohort Study Evaluation of Neuropsychological Domain Scores and Postural Stability Following Cerebral Concussion in Sports Is neuropsychological testing useful in the management of sport-related concussion? Depression and neurocognitive performance after concussion among male and female high school and collegiate athletes. Exploring differences in computerized neurocognitive concussion testing between African American and White athletes. Long-term outcomes after uncomplicated mild traumatic brain injury: a comparison with trauma controls. Grade 1 or “Ding” Concussions in High School Athletes HISTORY OF MULTIPLE SELF‐REPORTED CONCUSSIONS IS NOT ASSOCIATED WITH REDUCED COGNITIVE ABILITIES Symptom severity predicts prolonged recovery after sport-related concussion, but age and amnesia do not. Relationship between Postconcussion Headache and Neuropsychological Test Performance in High School Athletes Predicting Slow Recovery From Sport-Related Concussion: The New Simple-Complex Distinction Cognitive effects of one season of head impacts in a cohort of collegiate contact sport athletes Relationship of soccer heading to computerized neurocognitive performance and symptoms among female and male youth soccer players Return to play after an initial or recurrent concussion in a prospective study of physician-observed junior ice hockey concussions: implications for return to play after a concussion. A prospective study of physician-observed concussions during junior ice hockey: implications for incidence rates. Prevalence of neurocognitive and balance deficits in collegiate aged football players without clinically diagnosed concussion. Predictors of postconcussive symptoms 3 months after mild traumatic brain injury.
abstract: Background Neurocognitive testing has been endorsed as a “ cornerstone ’ of concussion management by recent Vienna and Prague meetings of the Concussion in Sport Group . Neurocognitive testing is important given the potential unreliability of athlete self-report after injury . Relying only on athletes'ormalities after injury . Study Design Case control study ; Level of evidence , 3 . Methods High school and college athletes with a diagnosed concussion were tested 2 days after injury . Postinjury neurocognitive performance ( Immediate Postconcussion Assessment and Cognitive Testing ) and symptom ( postconcussion symptom ) scores were compared with preinjury ( baseline ) scores and with those of an agex and education-matched noninjured athlete control group . “ Abnormal ” test performance was determined statistically with Reliable Change Index scores . Results Sixty-four percent of concussed athletes reported a significant increase in symptoms , as judged by postconcussion symptom scores , compared with preinjury baseline at 2 days after injury . Eighty-three percent of the concussed sample demonstrated significantly poorer neurocognitive test results relative to their own baseline performance . The addition of neurocognitive testing result ed in a net increase in sensitivity of 19 % . Ninety-three percent of the sample had either abnormal neurocognitive test results or a significant increase in symptoms , relative to their own baseline ; 30 % of a control group demonstrated either abnormalities in neurocognitive testing or elevated symptoms , as judged by postconcussion symptom scores . For the concussed group , use of symptom and neurocognitive test results result ed in an increased yield of 29 % overreliance on symptoms alone . In contrast , 0 % of the control group had both symptoms and abnormal neurocognitive testing . Conclusion Reliance on patients ’ self-reported symptoms after concussion is likely to result in underdiagnosis of concussion and may result in premature return to play . Neurocognitive testing increases diagnostic accuracy when used in conjunction with self-reported symptoms This study explored the diagnostic utility of the composite scores of Immediate Post-Concussion Assessment and Cognitive Testing ( ImPACT ) and Post Concussion Symptom Scale scores ( PCSS ) . Recently concussed high school athletes ( N=72 ) were tested within 72 h of sustaining a concussion , and data were compared to non-concussed high school athletes with no history of concussion ( N=66 ) . Between-groups MANOVA revealed a significant multivariate effect of concussion on test performance ( p<.001 ) ; univariate ANOVAS revealed all six measures contributed to the between-groups differences . A discriminant function analyses was conducted to measure the ability of the five ImPACT composite scores , as well as the PCSS to classify concussion status . One discriminant function was identified that consisted of the Visual Memory , Processing Speed , and Impulse Control composite scores PCSS , which correctly classified 85.5 % of the cases . Approximately 82 % of participants in the concussion group and 89 % of participants in the control group were correctly classified . Using these data , the sensitivity of ImPACT was 81.9 % , and the specificity was 89.4 % . As part of a formal concussion management program , ImPACT is a useful tool for the assessment of the neurocognitive and neurobehavioral sequelae of concussion , and can also provide post-injury cognitive and symptom data that can assist a practitioner in making safer return to play decisions Computerized neurocognitive assessment tools ( NCATs ) are increasingly used for baseline and post-concussion assessment s. To date , NCATs have not demonstrated strong test-retest reliabilities . Most studies have used non-military population s and different method ologies , complicating the determination of the utility of NCATs in military population s. The test-retest reliability of four NCATs ( Automated Neuropsychological Assessment Metrics 4 [ ANAM4 ]  ,  CNS-Vital Signs , CogState  , and Immediate Post-Concussion Assessment and Cognitive Test [ ImPACT ] ) was investigated in a healthy active duty military sample . Four hundred and nineteen Service Members were r and omly assigned to take one NCAT and 215 returned after approximately 30 days for retest . Participants deemed to have inadequate effort during one or both testing sessions , according to the NCATs scoring algorithms , were removed from analyses . Each NCAT had at least one reliability score ( intraclass correlation ) in the " adequate " range ( .70-.79 ) , only ImPACT had one score considered " high " ( .80-.89 ) , and no scores met " very high " criteria ( .90-.99 ) . However , overall test-retest reliabilities in four NCATs in a military sample are consistent with reliabilities reported in the literature and are lower than desired for clinical decision-making Objectives This study aim ed to develop and vali date prognostic criteria to identify children at risk for persistence of mild traumatic brain injury ( MTBI ) impairment . Methods A prospect i ve cohort study was conducted among 11- to 17-year-old emergency department ( ED ) patients admitted for MTBI . The Immediate Postconcussion Assessment and Cognitive Testing neurocognitive test was administered during hospitalization and at routine clinic follow-up ( ImPACT © ) . Logistic regression and receiver operating characteristic ( ROC ) analyses were used to develop prognostic criteria for MTBI-related impairment in 1 group and vali date the criteria in a second group . Mild traumatic brain injury – related impairment was defined as any impairment ( symptom score > 8 or < 25th percentile on at least 1 of 4 neurocognitive composite domains ) or severe impairment ( symptom score > 12 or < 25th percentile on at least 2 of 4 neurocognitive composite domains ) present on follow-up . Results The derivation and validation cohorts were 42 and 21 patients ( median age , 14 years ; 71.4 % male ) . Using the mean of the validation cohort patients ’ 4 neurocognitive deficit composite percentiles at baseline , a cut point of less than 39 percentile had high sensitivity ( 0.89 ) and specificity ( 0.80 ) and an area under the ROC curve of 0.85 in predicting the presence of any impairment at follow-up ; it discriminated equally well in the validation cohort . A cut point of less than 27 percentile had good sensitivity ( 0.67 ) and specificity ( 0.67 ) and area under the ROC curve of 0.67 in predicting the presence of severe impairment in the derivation cohort at follow-up ; it discriminated equally well in the validation cohort . Conclusions This is the first study demonstrating prognostic criteria that may greatly help physicians identify patients who would benefit from structured follow-up care after MTBI OBJECTIVE : The purpose of this study was to compare concussion rates and recovery times for athletes wearing newer helmet technology compared to traditional helmet design . METHODS : This was a three-year , prospect i ve , naturalistic , cohort study . Participants were 2,141 high school athletes from Western Pennsylvania . Approximately half of the sample wore the Revolution helmet manufactured by Riddell , Inc.  ( n = 1,173 ) and the remainder of the sample used  st and ard helmets ( n = 968 ) . Athletes underwent computerized neurocognitive testing through the use of ImPACT at the beginning of the study . Following a concussion , players were reevaluated at various time intervals until recovery was complete . RESULTS : In the total sample , the concussion rate in athletes wearing the Revolution was 5.3 % and in athletes wearing st and ard helmets was 7.6 % [ & khgr;2 ( 1 , 2 , 141 ) = 4.96 , P < 0.027 ] . The relative risk estimate was 0.69 ( 95 % confidence interval = 0.499– 0.958 ) . Wearing the Revolution helmet was associated with approximately a 31 % decreased relative risk and 2.3 % decreased absolute risk for sustaining a concussion in this cohort study . The athletes wearing the Revolution did not differ from athletes wearing st and ard helmets on the mechanism of injury ( e.g. , head-to-head strike ) , on-field concussion markers ( e.g. , amnesia or loss of consciousness ) , or on-field presentation of symptoms ( e.g. , headaches , dizziness , or balance problems ) . CONCLUSION : Recent sophisticated laboratory research has better eluci date d injury biomechanics associated with concussion in professional football players . This data has led to changes in helmet design and new helmet technology , which appears to have beneficial effects in reducing the incidence of cerebral concussion in high school football players Context With increasing knowledge and research about concussion , there have been few objective studies that have used neuropsychological domain scores and postural stability to assess concussion . Objective To evaluate the recovery curve of athletes who incur sport-related concussion from repeated serial testing of neuropsychological and posturography testing . Design A prospect i ve epidemiological model was used for the course of the study . Setting Division I intercollegiate athletics . Participants Athletes participating in football , soccer , basketball , softball , and cheerleading . Main Outcome Measures  Neuropsychological scores and posturography measures  were obtained preseason and serially at day 1 , day 2 , day 3 , and day 10 postconcussion .  Control participants  were tested at the same intervals .  Neuropsychological scores were converted to st and ards score and then into domains of attention , learning , speed of information processing , concentration , memory , and verbal fluency . Analysis of covariance with the baseline test as the covariate was used to analyze the data with univariate post hoc tests performed . Results Significant group differences were found for self reported symptoms ( P = 0.001 ) , speed of information processing ( P = 0.005 ) , mean stability ( P = 0.002 ) , and vestibular function ( P = 0.003 ) between injured and control participants . A group , by day , planned comparison found that speed of information processing and composite balance measures demonstrated significant differences through day 10 postinjury , while symptoms and the vestibular ratio remained significant only through day 3 . Conclusions The concussion recovery curve demonstrated short-term neuropsychological and posturography deficits following injury . A comprehensive approach to concussion management should be used to assess the injury and make return-to-play decisions OBJECTIVE Neuropsychological ( NP ) testing has been used for several years as a way of detecting the effects of sport-related concussion in order to aid in return-to-play determinations . In addition to st and ard pencil- and -paper tests , computerized NP tests are being commercially marketed for this purpose to professional , collegiate , high school , and elementary school programs . However , a number of important questions regarding the clinical validity and utility of these tests remain unanswered , and these questions present serious challenges to the applicability of NP testing for the management of sport-related concussion . Our purpose is to outline the criteria that should be met in order to establish the utility of NP instruments as a tool in the management of sport-related concussion and to review the degree to which existing tests have met these criteria . DATA SOURCES A comprehensive literature review of MEDLINE and PsychLit from 1990 to 2004 , including all prospect i ve , controlled studies of NP testing in sport-related concussion . DATA SYNTHESIS The effects of concussion on NP test performance are so subtle even during the acute phase of injury ( 1 - 3 days postinjury ) that they often fail to reach statistical significance in group studies . Thus , this method may lack utility in individual decision making because of a lack of sensitivity . In addition , most of these tests fail to meet other psychometric criteria ( eg , adequate reliability ) necessary for this purpose . Finally , it is unclear that NP testing can detect impairment in players once concussion-related symptoms ( eg , headache ) have resolved . Because no current guideline for the management of sport-related concussion allows a symptomatic player to return to sport , the incremental utility of NP testing remains question able . CONCLUSIONS / RECOMMENDATIONS Despite the theoretic rationale for the use of NP testing in the management of sport-related concussion , no NP tests have met the necessary criteria to support a clinical application at this time . Additional research is necessary to establish the utility of these tests before they can be considered part of a routine st and ard of care , and concussion recovery should be monitored via the st and ard clinical examination and subjective symptom checklists until NP testing or other methods are proven effective for this purpose OBJECTIVES To prospect ively examine the relationship of sport-related concussion with depression and neurocognitive performance and symptoms among male and female high school and college athletes . A secondary objective was to explore age and sex differences . DESIGN Pretest , multiple posttest , repeated- measures design . SETTING Laboratory . PARTICIPANTS High school and collegiate athletes ( N=75 ) with a diagnosed concussion . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES  Beck Depression Inventory-II and computerized neurocognitive test battery ( Immediate Post-concussion Assessment and Cognitive Test )  , which includes concussion symptoms ( Post-concussion Symptom Scale ) at baseline and at 2 , 7 , and 14 days postinjury . RESULTS Concussed athletes exhibited significantly higher levels of depression from baseline at 2 days ( P≤.001 ) , 7 days ( P=.006 ) , and 14 days postconcussion ( P=.04 ) . Collegiate athletes demonstrated a significant increase in depression at 14 days postconcussion than did high school athletes ( P=.03 ) . There were no sex differences in depression levels . Neurocognitive decrements at 14 days were supported for reaction time ( P=.001 ) and visual memory ( P=.001 ) . Somatic depression at 7 days postconcussion was related to slower reaction time at 7 days postconcussion . Somatic depression at 14 days postinjury was related to lower visual memory scores at 14 days postinjury . CONCLUSIONS Although not clinical ly significant , athletes experienced increased depression scores up to 14 days after concussion that coincided with neurocognitive decrements in reaction time and visual memory . Somatic depression appears to be most salient with regard to lower neurocognitive performance . Mood assessment s after concussion are warranted to help monitor and enhance recovery The purpose of the current study was to explore potential differences in pre- and post-concussion performance on a computerized neurocognitive concussion test between African American and White high-school and collegiate student-athletes . A prospect i ve case-control design was used to compare baseline and 2- and 7-day post-concussion computerized neurocognitive performance and symptoms between 48 White and 48 African American athletes matched for age , gender , and concussion history . The Immediate Post-Concussion Assessment Cognitive Test ( ImPACT ) version 2.0 ( NeuroHealth System , LLC , Pittsburgh , PA , USA ) computer software program was used to assess neurocognitive function ( i.e. , verbal and visual memory , motor processing speed , and reaction time ) and concussion symptoms . Regardless of race/ethnicity , there were significant decrements in computerized neurocognitive performance and increased symptoms following a concussion for the entire sample . African Americans and Whites did not differ significantly on baseline or post-concussion verbal memory , visual memory , reaction time , and total reported symptoms . However , African American participants were 2.4 × more likely to have at least one clinical ly significant cognitive decline on ImPACT at 7 days post-concussion and scored lower at 7 days post-concussion compared with baseline on processing speed than White participants . The authors concluded that the baseline ImPACT test was culturally equivalent and construct valid for use with these two racial/ethnic groups . However , in contrast , the findings support deleterious performance for the African American athletes compared with the White athletes on the ImPACT post-concussion evaluation that is of critical clinical relevance and warrants further research The question as to whether mild traumatic brain injury ( mTBI ) results in persisting sequelae over and above those experienced by individuals sustaining general trauma remains controversial . This prospect i ve study aim ed to document outcomes 1 week and 3 months post-injury following mTBI assessed in the emergency department ( ED ) of a major adult trauma center . One hundred and twenty-three patients presenting with uncomplicated mTBI and 100 matched trauma controls completed measures of post-concussive symptoms and cognitive performance ( Immediate Post-Concussion Assessment and Cognitive Testing battery ; ImPACT ) and  pre-injury health-related quality of life ( SF-36 ) in the ED . These measures together with measures of psychiatric status ( the Mini-International Neuropsychiatric Interview [ MINI ] ) pre- and post-injury , the Hospital Anxiety and Depression Scale , Visual Analogue Scale for Pain , Functional Assessment Question naire , and PTSD Checklist-Specific , were re-administered at follow-up . Participants with mTBI showed significantly more severe post-concussive symptoms in the ED and at 1 week post-injury . They performed more poorly than controls on the Visual Memory subtest of the ImPACT at 1 week and 3 months post-injury . Both the mTBI and control groups recovered well physically , and most were employed 3 months post-injury . There were no significant group differences in psychiatric function . However , the group with mild TBI was more likely to report ongoing memory and concentration problems in daily activities . Further investigation of factors associated with these ongoing problems is warranted Background Recent concussion management guidelines have suggested that athletes with mild ( grade 1 ) concussions may be returned to play if asymptomatic for 15 minutes . The purpose of this study was to assess the utility of a current concussion management guideline in classifying and managing mild concussion . Hypothesis High school athletes diagnosed with a grade 1 concussion will demonstrate measurable decline in neuropsychological functioning that persists during the 1st week of recovery . Study Design Prospect i ve study design ed to evaluate neuropsychological functioning both prior to and following concussion . Methods Forty-three high school athletes completed  neuropsychological test performance  and  symptom ratings  prior to the season and at two times during the 1st week following  mild concussion . Results Thirty-six hours after injury , mildly concussed high school athletes demonstrated a decline in memory ( P < 0.003 ) and a dramatic increase in self-reported symptoms ( P < 0.00001 ) compared to baseline performance . Conclusions Athletes with grade 1 concussion demonstrated memory deficits and symptoms that persisted beyond the context in which they were injured . These data suggest that current grade 1 return-to-play recommendations that allow for immediate return to play may be too liberal . Clinical Relevance A reconsideration of current concussion grading systems appears to be warranted OBJECTIVE The long-term impact of sports-related concussion is uncertain . Several studies using traditional neuropsychological measures have found a relationship between a previous history of concussion and reduced cognitive abilities . In contrast , studies using computerized neuropsychological measures have typically found no relationship between concussion history and cognition . In the present study , we examined the association between a self-reported concussion history and cognition using traditional and computer-based neuropsychological tests . METHODS A computerized neuropsychological battery was administered to a sample of 858 collegiate male athletes . Of this sample , 298 athletes reported a history of concussion . A traditional neuropsychological battery was administered to a separate sample of 479 male collegiate athletes , 187 of whom reported a history of concussion . Finally , both a computerized and a traditional neuropsychological battery were administered to a third distinct sample of 175 male collegiate athletes , 57 of whom reported a history of concussion . Concussion history was assessed via self-report . None of the athletes had been concussed in the 6 months before testing . RESULTS No significant association was found between self-reported concussion history and performance on either  computerized or traditional neuropsychological tests .  CONCLUSION Findings suggest that athletes who report a distant history of concussion have minimal enduring neurocognitive deficits . Given conflicting findings in the literature , prospect i ve studies that attempt to identify moderating factors are necessary to help determine who is at risk for long-term cognitive difficulties after concussion OBJECTIVE To identify predictors of prolonged symptoms in athletes who sustain concussions . STUDY DESIGN This was a multicenter prospect i ve cohort study of patients in 2 sport concussion clinics . Possible predictors of prolonged symptoms from concussion were compared in 2 groups , those whose symptoms resolved within 28 days and those whose symptoms persisted beyond 28 days . C and i date predictor variables were entered into a logistic regression model that was used to generate aORs . RESULTS A total of 182 patients met the inclusion criteria during the study period . The mean patient age was 15.2 ± 3.04 years . More than one-third of the patients ( n = 65 ) underwent  computerized neurocognitive testing  on their initial visit . On univariate analyses , Post-Concussion Symptom Scale ( PCSS ) score and all composite scores on computerized neurocognitive testing were apparently associated with prolonged symptom duration . Sex , age , loss of consciousness at time of injury , and amnesia at time of injury were not associated with prolonged symptom duration . After adjusting for potential confounding , only total PCSS score was associated with the odds of suffering prolonged symptoms . CONCLUSION Further efforts to develop clinical tools for predicting which athletes will suffer prolonged recoveries after concussion should focus on initial symptom score Background : The relevance of headache to outcome after sports-related concussion is poorly understood . Hypotheses : High school athletes reporting headache approximately 1 week after injury will have significantly more other concussion symptoms and will perform more poorly on neuropsychological tests than athletes not experiencing headache . Study Design : Prospect i ve cohort study . Methods : Study participants included 109 high school athletes who had sustained concussion and who were divided into two groups : those reporting headache 7 days after injury and those reporting no headaches . The two groups were compared regarding on-field markers of concussion severity at the time of injury and symptoms and neurocognitive test results collected via ImPACT , a computerized neuropsychological test battery and postconcussion symptom scale , at a mean of 6.8 days after injury . Results : Athletes reporting posttraumatic headache demonstrated significantly worse performance on reaction time and memory ImPACT neurocognitive composite scores . These athletes also reported significantly more symptoms other than headache and were more likely to have demonstrated on-field antero grade amnesia . Conclusions : Findings suggest that any degree of postconcussion headache in high school athletes 7 days after injury is likely associated with an incomplete recovery after concussion Objective : Following the Second International Conference on Concussion in Sport in 2005 , a summary agreement statement was published that introduced new terminology for sport-related concussions . This new classification system is binary ( ie , “ simple ” versus “ complex ” concussions ) . Athletes who are slow to recover ( ie , > 10 days ) are classified as having complex concussions . The purpose of this study was to determine if high school football players , retrospectively classified as having a simple or a complex concussion , could be differentiated in the first 48 after injury on the basis of symptom reporting or neuropsychological testing . Design : Case-control study . Setting : Pennsylvania high school football programs . Participants : The total sample consisted of 114 concussed high school football players who were identified through a 3 year prospect i ve cohort study . Interventions : All completed a computerized neuropsychological screening evaluation within 72 hours of injury . They were followed clinical ly until they recovered and were cleared to return to play . They were classified retrospectively as having a simple ( n = 55 ) or complex ( n = 59 ) concussion based on their recovery times . Main Outcome Measurements : Neurocognitive test performance and symptom ratings . Results : Within 72 hours after injury , athletes with complex concussions performed more poorly on neuropsychological testing and reported more symptoms than those with simple concussions . Athletes with complex concussions who were slow to recover were 18 times more likely to have 3 unusually low neuropsychological test scores than those with simple concussions ( 95 % CI = 2.3 - 144.9 ) . Athletes with previous concussions did not recover more slowly . Conclusions : This study provides evidence that supports and refutes the clinical usefulness of the new simple-complex concussion classification system Objective : To determine whether exposure to repetitive head impacts over a single season negatively affects cognitive performance in collegiate contact sport athletes . Methods : This is a prospect i ve cohort study at 3 Division I National Collegiate Athletic Association athletic programs . Participants were 214 Division I college varsity football and ice hockey players who wore instrumented helmets that recorded the acceleration-time history of the head following impact , and 45 noncontact sport athletes . All athletes were assessed prior to and shortly after the season with a  cognitive screening battery ( ImPACT ) and a subgroup of athletes also were assessed with 7 measures from a neuropsychological test battery . Results : Few cognitive differences were found between the athlete groups at the preseason or postseason assessment s. However , a higher percentage of the contact sport athletes performed more poorly than predicted postseason on a measure of new learning ( California Verbal Learning Test ) compared to the noncontact athletes ( 24 % vs 3.6 % ; p < 0.006 ) . On 2 postseason cognitive measures ( ImPACT Reaction Time and Trails 4/B ) , poorer performance was significantly associated with higher scores on several head impact exposure metrics . Conclusion : Repetitive head impacts over the course of a single season may negatively impact learning in some collegiate athletes . Further work is needed to assess whether such effects are short term or persistent Primary objective : The purpose of this study was to investigate the relationship between soccer heading and computerized neurocognitive performance and symptoms in female and male youth soccer players . Research design : Cross-sectional and prospect i ve design . Methods and procedures : A total of 63 ( 27 females , 36 males ) youth soccer players aged 13–18 years ( M = 15.89 , SD = 1.17 ) participated in the study . Participants completed the Immediate Post-concussion Assessment and Cognitive Test ( ImPACT ) and symptom report . Main outcomes : Computerized neurocognitive performance ( e.g. , verbal and visual memory , motor processing , and reaction time ) and symptoms . Results : There were no differences in neurocognitive performance or symptoms among low- , moderate- , and high-exposure header groups . The current sample outperformed the 10th percentile norms for neurocognitive and symptom scores . Males headed the ball more frequently and reported lower verbal and visual memory and motor processing speed scores than females . Conclusion : The current findings did not support a relationship between soccer heading and computerized neurocognitive performance and symptoms . The research ers suggest that any purported effects of soccer heading in youth are subtle and may affect only a small number of athletes . The reported sex differences in heading exposure warrant further attention OBJECT The authors investigated return-to-play duration for initial and recurrent concussion in the same season in 2 teams of junior ( 16 - 21-year-old ) ice hockey players during a regular season . METHODS The authors conducted a prospect i ve cohort study during 1 junior regular season ( 2009 - 2010 ) of 67 male fourth-tier ice hockey players ( mean age 18.2 ± 1.2 years [ SD ] , range 16 - 21 years ) from 2 teams . Prior to the start of the season , every player underwent baseline assessment s that were determined using the  Sideline Concussion Assessment Tool 2 ( SCAT2 ) and the Immediate Post-Concussion Assessment and Cognitive Test ( ImPACT ) . The study protocol also required players who entered the study during the season to complete a baseline SCAT2 and ImPACT . If the protocol was not followed , the postinjury test results of a player without true baseline test results were compared with previously established age- and sex-matched group normative levels . Each game was directly observed by a physician and at least 1 neutral nonphysician observer . Players suspected of suffering a concussion were evaluated by the physician during the game . If a concussion was diagnosed , the player underwent clinical evaluation at the physician 's office within 24 hours . The return-to-play decision was based on clinical evaluation guided by the Zurich return-to-play protocol ( contained in the consensus statement of international expert opinion at the 3rd International Conference on Concussion in Sport held in Zurich , November 2008 ) . This clinical evaluation and return-to-play protocol was augmented by the 2 tests ( SCAT2 and ImPACT ) also recommended by the Zurich consensus statement , for which baseline values had been obtained . RESULTS Seventeen players sustained a physician-observed or self-reported , physician-diagnosed concussion during a physician-observed ice hockey game . The mean clinical return-to-play duration ( in 15 cases ) was 12.8 ± 7.02 days ( median 10 days , range 7 - 29 days ) ; the mean number of physician office visits by players who suffered a concussion ( 15 cases ) was 2.1 ± 1.29 ( median 1.5 visits ) . Five of the 17 players who sustained a concussion also suffered a recurrent or second concussion . One of the 5 individuals who suffered a repeat concussion sustained his initial concussion in a regular season game that was not observed by a physician , and as a result this single case was not included in the total of 21 concussions . This initial concussion of the player was identified during baseline testing 2 days after the injury and was subsequently medically diagnosed and treated . The mean interval between the first and second concussions in these 5 players was 78.6 ± 39.8 days ( median 82 days ) , and the mean time between the return-to-play date of the first and second concussions was 61.8 ± 39.7 days ( median 60 days ) . CONCLUSIONS The mean rates of return to play for single and recurrent concussions were higher than rates cited in recent studies involving sport concussions . The time interval between the first and second concussions was also greater than previously cited . This difference may be the result of the methodology of direct independent physician observation , diagnosis , and adherence to the Zurich return-to-play protocol OBJECT The objective of this study was to measure the incidence of concussion ( scaled relative to number of athlete exposures ) and recurrent concussion within 2 teams of fourth-tier junior ice hockey players ( 16 - 21 years old ) during 1 regular season . METHODS A prospect i ve cohort study called the Hockey Concussion Education Project was conducted during 1 junior ice hockey regular season ( 2009 - 2010 ) involving 67 male fourth-tier ice hockey players ( mean age 18.2 ± 1.2 years , range 16 - 21 years ) from 2 teams . Prior to the start of the season , every player underwent baseline assessment s using the Sideline Concussion Assessment Tool 2 ( SCAT2 ) and the Immediate Post-Concussion Assessment and Cognitive Test ( ImPACT ) . The study protocol also required players who entered the study during the season to complete baseline SCAT2 and ImPACT testing . If the protocol was not followed , the postinjury test results of a player without true baseline test results would be compared against previously established age and gender group normative levels . Each regular season game was observed by a qualified physician and at least 1 other neutral nonphysician observer . Players who suffered a suspected concussion were evaluated at the game . If a concussion diagnosis was made , the player was subsequently examined in the physician 's office for a full clinical evaluation and the SCAT2 and ImPACT were repeated . Based on these evaluations , players were counseled on the decision of when to return to play . Athlete exposure was defined as 1 game played by 1 athlete . RESULTS Twenty-one concussions occurred during the 52 physician-observed games ( incidence 21.5 concussions per 1000 athlete exposures ) . Five players experienced repeat concussions . No concussions were reported during practice sessions . A concussion was diagnosed by the physician in 19 ( 36.5 % ) of the 52 observed games . One of the 5 individuals who suffered a repeat concussion sustained his initial concussion in a regular season game that was not observed by a physician , and as a result this single case was not included in the total of 21 total concussions . This initial concussion of the player was identified during baseline testing 2 days after the injury and was subsequently medically diagnosed and treated . CONCLUSIONS The incidence of game-related concussions ( per 100 [ corrected ] athlete exposures ) in these fourth-tier junior [ corrected ] ice hockey players was 7 [ corrected ] times higher than [ corrected ] previously reported in the literature . This difference may be the result of the use of st and ardized direct physician observation , diagnosis , and subsequent treatment . The results of this study demonstrate the need for follow-up studies involving larger and more diverse sample groups to reflect generalizability of the findings . These follow-up studies should involve other contact sports ( for example football and rugby ) and also include the full spectrum of gender , age , and skill levels STUDY DESIGN Prospect i ve cohort . OBJECTIVES To identify the prevalence of neurocognitive and balance deficits in collegiate football players 48 hours following competition . BACKGROUND Neurocognitive testing , balance assessment s , and subjective report of symptoms are a commonly used test battery in examining athletes when concussion is suspected . Previous literature suggests many concussions go unreported . Little research exists examining the prevalence of neurocognitive or balance deficits in athletes who do not report concussion-like symptoms to a health care provider . METHODS Forty-five Division IA collegiate football players participated in this study . Preseason baseline scores using the  Balance Error Scoring System , the Immediate Post-Concussion Assessment and Cognitive Testing , and the Postconcussion Symptom Scale  were compared to posttest results obtained 48 hours following a game . Prevalence of symptoms was analyzed and reported . RESULTS Thirty-two ( 71 % ) of the 45 athletes tested demonstrated at least 1 deficit in either the Postconcussion Symptom Scale , Balance Error Scoring System , or at least 1 composite score of the Immediate Post-Concussion Assessment and Cognitive Testing . Nineteen of the 32 subjects demonstrated a change in 2 or more categories of neurocognitive and balance function . CONCLUSION In a cohort of football players tested 48 hours following their last game of the season , who did not seek medical attention related to a concussion , a significant number demonstrated limitations in neurocognitive and balance performance , suggesting that further research may need to be performed to improve recognition of an athlete 's deficits and to improve the ability to assess concussion . LEVEL OF EVIDENCE Differential diagnosis/symptom prevalence , level 3b OBJECTIVE There is continuing controversy regarding predictors of poor outcome following mild traumatic brain injury ( mTBI ) . This study aim ed to prospect ively examine the influence of preinjury factors , injury-related factors , and postinjury factors on outcome following mTBI . METHOD Participants were 123 patients with mTBI and 100 trauma patient controls recruited and assessed in the emergency department and followed up 1 week and 3 months postinjury . Outcome was measured in terms of reported postconcussional symptoms . Measures included the  ImPACT Post-Concussional Symptom Scale and cognitive concussion battery , including Attention , Verbal and Visual memory , Processing Speed and Reaction Time modules , pre- and postinjury SF-36 and MINI Psychiatric status ratings , VAS Pain Inventory , Hospital Anxiety and Depression Scale , PTSD Checklist-Specific , and Revised Social Readjustment Scale . RESULTS Presence of mTBI predicted postconcussional symptoms 1 week postinjury , along with being female and premorbid psychiatric history , with elevated HADS anxiety a concurrent indicator . However , at 3 months , preinjury physical or psychiatric problems but not mTBI most strongly predicted continuing symptoms , with concurrent indicators including HADS anxiety , PTSD symptoms , other life stressors and pain . HADS anxiety and age predicted 3-month PCS in the mTBI group , whereas PTSD symptoms and other life stressors were most significant for the controls . Cognitive measures were not predictive of PCS at 1 week or 3 months . CONCLUSIONS Given the evident influence of both premorbid and concurrent psychiatric problems , especially anxiety , on postinjury symptoms , managing the anxiety response in vulnerable individuals with mTBI may be important to minimize ongoing sequelae
target: Although the convergent validity of ImPACT was supported , evidence of discriminant and predictive validity , diagnostic accuracy and responsiveness was inconclusive .
  The review found many factors influenced the validity and utility of ImPACT scores .
background: Background The immediate post concussion assessment and cognitive testing ( ImPACT ) is the most widely used concussion assessment tool .
  Despite its popularity , it is unclear if validation studies for the ImPACT test covered all aspects of validity to support its widespread use in research and clinical practice .
  Objective The purpose of this report is to review literature surrounding the validity and the utility of the ImPACT test .