Introduction to ImPACT
Immediate Post Concussion
Assessment and Cognitive Testing
Gary Solomon, Ph.D.
Associate Professor of Neurological Surgery, Orthopaedic
Surgery and Rehabilitation, and Psychiatry,
Co-Director, Vanderbilt Sports Concussion Center
Vanderbilt University School of Medicine
Team Neuropsychologist, Nashville Predators
Consulting Neuropsychologist, Tennessee Titans
• ImPACT is a neuropsychological screening tool designed specifically
for sport-related concussion. Norms are available for male and
female athletes ages 10-59. ImPACT is computer administered and
takes about 30 minutes.
• ImPACT is not a substitute for neuropsychological testing.
Neuropsychological testing is a much more in-depth assessment of
cerebral functioning, and can take 2-8 hours to complete (paper and
pencil and/or computer based tests). Norms for formal
neuropsychological testing are available for children through 90+
years.
What does ImPACT Measure?
Demographic/Concussion History Questionnaire
Concussion Symptom Scale
- 21 Item, 0-6 Likert scale (e.g., headache, dizziness,
nausea, etc.)
Neurocognitive Measures
- Measures domains of Visual and Verbal Memory,
Reaction Time, & Visual Motor (Processing) Speed –
yields Composite Scores
Detailed Clinical Report
- Automatically computer scored
- Outlines demographic, symptom,
neurocognitive data
What does ImPACT enable us to do?
• Provides objective data to help
determine an athlete’s status
• Protects the student-athlete
and the professional athlete
• Helps determine safe RTP
• Helps prevent the potential
effects of repeat concussions
Clinical Protocol
ImPACT Testing
24-72 Hours
Day 5-10
Concussion
Baseline Testing
(Ideal, but not
necessary for
decision making;
VSCC uses the
baseline model)
Beyond if necessary
There have been several iterations of ImPACT since 2001; current
version is 2.1
First major change was the separation of the Memory Composite into
Verbal Memory and Visual Memory
Initial version of ImPACT was a disk & desktop version with local
storage
Current version is on-line, with HIPPA compliant on-line storage at
ImPACT (but test results are printable and downloadable)
Current slides show old and new versions of ImPACT
https://www.impacttestonline.com/customercenter
You will log in with your email and password. Your will have access to
baseline/follow-up testing and review of results for your team(s).
Demographics
► First Name
► Last Name
► Organization
► Height
► Weight
► Gender
► Handedness
Identifying Data
Country/Language (18 languages)
Demographics/Modifying Factors/Sport
(Years of education completed: college freshman = 12; 9th grader = 8)
- Years in North America
► Years of education completed
► Check any of the following that apply
- Received speech therapy
- Attended special education classes
- Repeated one or more years of school
- Diagnosed ADD or Hyperactive
- Diagnosed learning disability
► Current sport
- Current position/event/class
- Current Level
► Years experience
Medical History/Modifying Factors
Recent demographic additions
Ethnicity
Concussion History
Post Concussion Symptom Scale
0= Not having the symptom
1-6 rating scale if the athlete is having the
symptom
1 = Minor, 6 = Severe
How they are feeling past 24 hrs.
Symptom Checklist (PCS; n=22)
Module 1: Word Discrimination
Verbal learning and recognition memory
Module 1 (Word Discrimination)
Evaluates attentional processes/verbal recognition memory
Utilizes a word discrimination paradigm.
Twelve target words are presented for 750 milliseconds (twice to facilitate learning of the list)
The subject is then tested for recall via the presentation of the 24-word list that is:
comprised of 12 target words and 12 non-target words
Words chosen from the same semantic category as the target word.
EX: the word “ice” is a target word, while the word “snow” represents the
non-target word.
The subject responds by mouse-clicking the “yes” or “no” buttons
Individual scores are provided both for correct “yes” and “no” responses -In addition, a
total percent correct score is provided.
There are five different forms of the word list.
Delay Condition: Following the
administration of all other test
modules (approximately
20 minutes), the subject is
again tested for recall via the
same method described above.
The same scores that are
described above are provided
for the delay condition.
Module 2: Design Memory
Visual learning and recognition memory
Module 2 (Design Memory)
Evaluates attentional processes and visual recognition memory
Utilizes a design discrimination paradigm.
Twelve target designs are presented for 750 milliseconds (twice to facilitate learning)
The subject is then tested for recall via the presentation of the 24-designs
comprised of 12 target
designs and 12 non-target
designs
EX: target designs that
have been rotated in space
The subject responds by
mouse-clicking the “yes” or
“no” buttons
Individual scores are
provided both for correct
“yes” and “no” responses
In addition, a total
percent correct score is
provided
There are five different forms of this task
Module 3: X’s and O’s
Visuospatial memory and
processing speed
Module 3 (X ’ s and O ’s)
Measures visual working memory, visual processing speed, and visual memory paradigm
Incorporates a distractor task.
The subject can practice the distractor task prior to presentation of the memory task
The distractor is a choice reaction time test: the subject is asked to click the left mouse
button if a blue square is presented and the right mouse button if a red circle is presented.
Once the subject has completed this task, the memory task is presented.
Memory task: a random assortment of X’s and O’s is displayed for 1.5 seconds
For each trial: three of the X’s or O’s are illuminated in YELLOW (the subject has to
remember the location of the illuminated objects).
Immediately after the presentation
of the 3 X’s or O’s, the distractor task
re-appears on the screen.
Following the distractor task, the
memory screen (X’s and O’s)
re-appears and the subject is asked
to click on the previously illuminated
X’s and O’s.
Scores are provided for correct
identification of the X’s and O’s
(memory), reaction time for the
distractor task, and number of
errors on the distractor task.
For each administration of ImPACT, the subject completes 4 trials.
Replaced by “p” for red dot and “q” for blue square
Click the three that were yellow
Module 4: Symbol Matching
Processing speed and memory
Module 4 (Symbol Matching)
Evaluates visual processing speed, learning and memory
Initially, the subject is presented with a screen that displays 9 common symbols
(triangle, square, arrow, etc).
Directly under each symbol is a number button from 1 to 9
.Below this grid, a symbol is presented.
The subject is required to click the matching
number as quickly as possible and to
remember the symbol/number pairings
Correct performance is reinforced
through the illumination of a correctly
clicked number in GREEN. Incorrect
performance illuminates the
number button in RED.
Following the completion
of 27 trials, the symbols disappear
from the top grid.
The symbols again appear below the
grid and the subject is asked to recall
the correct symbol/number pairing by
clicking the appropriate number button.
This module provides an average reaction time score and a score for the
memory condition.
After a period of time, the numbers disappear and the athlete has
to remember which symbol corresponds with which number
Module 5: Color Match
Reaction time and impulse control
Module 5 (Color Match)
Represents a choice reaction time task and measures impulse
control/response inhibition
First, the subject is required to respond by clicking a red, blue or green button as
they are presented on the screen. This procedure is completed to assure that
subsequent trials would not be affected by color blindness
Next, a word is displayed on the screen in the same colored ink as the word
(e.g. RED), or in a different colored ink (GREEN or BLUE)
The subject is
instructed to click
in the box as
quickly as
possible only
if the word is
presented in the
matching ink.
In addition to
providing a
reaction time
score, this task
also provides
an error score.
Module 6: Three Letters
Working memory and processing speed
Module 6 (Three letters)
Measures working memory and visual-motor response speed
First, the subject is allowed to practice a distractor task
Consists of 25 numbered buttons (5 x 5 grid).
The subject is instructed to click as quickly as possible on the numbered buttons in
backward order starting with “25.” (has an initial practice task)
Then they are presented with three consonant letters displayed on the screen.
Immediately following display of the 3 letters, the numbered grid re-appears and the
subject is instructed to click the numbered buttons in backward order, again
After a period of 18 seconds, the numbered grid disappears and the subject is asked to
recall the three letters by typing them from the keyboard.
Both the number placement on the grid and letters displayed are randomized for each
trial.
Yields a memory score
(total number of correctly
identified letters) and a
score for the average
number of correctly clicked
numbers per trial from the
distractor test.
Five trials of this task
are presented for each
administration of the test.
C
S
W
What were the 3 letters?
Type them in order
Delayed Recall
Word Discrimination (Module 1; stimuli and distractors)
Delayed Recall
Design Memory (Module 2; stimuli and distractors)
Test is now completed and
is automatically scored & saved
Athlete is automatically logged out
and cannot access the results
Results will be interpreted according
to Team Physician’s preference
ImPACT’s Composite Scores
•
•
•
•
Verbal Memory
Visual Memory
Reaction Time
Visual-Motor Speed
(Processing Speed)
__________________
• Impulse Control
• Total Symptoms
Report: Composite Scores
Red = raw scores; Green = percentile scores (age/gender)
Report: Raw Scores
Report: Raw Scores
ImPACT subscales and Loadings on
Composite Scores
Verbal Memory Composite
Average of:
(Word Memory- Total Percent Correct)
(Symbol Match- Total Correct/Hidden)/9*100
(Three Letters- Total Sequence Correct)/5*100
Visual Memory Composite
Average of:
(Design Memory- Total Percent Correct)
(X’s and O’s- Total Correct/Memory)/12*100
Visual-Motor Speed Composite (Processing Speed)
Average of:
(X’s and O’s- Total Correct/Interference)/4
(Three Letters-Average Counted Correctly)*3
ImPACT subscales and Loadings on
Composite Scores
Reaction Time Composite
Average of:
(X’s and O’s- Average Correct Reaction Time Interference)
(Symbol Match- Average Correct Reaction Time/Visible)/3
(Color Match- Average Correct Reaction Time)
Impulse Control Composite
Average of:
(X’s and O’s- Total Incorrect/Interference)
(Color Match- Total Commissions)
Symptom Total Score
Sum of: All symptoms reported by athlete on the Post-Concussion Symptom Scale
Report: Symptom Scores
Report: Graph of Composite Scores
Recent and Forthcoming additions to ImPACT
ImPACT Symptom Increase Score
Performed for post concussion assessments
Athlete completes the symptom scale again (how he/she feels now after taking
the test), assessing whether the cognitive exertion of taking the test provoked
symptoms
Cognitive Efficiency Index
Speed and Memory Scores (Forthcoming)
Symptom Increase Score in Red
Cognitive Efficiency Index
The Cognitive efficiency Index measures the interaction between
accuracy (percentage correct) and speed (reaction time) in seconds on
the Symbol Match test
Determines the extent to which the athlete tried to work very fast on
symbol match (decreasing accuracy) or attempted to improve their
accuracy by taking a more deliberate and slow approach (jeopardizing
speed)
The range of scores is from approximately zero to approximately .70 with
a mean of .34. A higher score indicates that the athlete did well in both
the speed and memory domains on the symbol match test.
A low score (below .20) means that they performed poorly on both the
speed and accuracy component. If this score is a negative number, the
test taker performed very poorly on the reaction time component.
Two-Factor Theory (Schatz, UPMC, 2013)
Archives of Clinical Neuropsychology, in press
Factor analysis results
Baseline Group (N=22,000)
Concussion Group (N=560)
ImPACT is a screening tool that is extremely useful in
assessing the neurobehavioral and cognitive symptoms of
concussive injury.
When used appropriately, it is a valuable piece of the
concussion puzzle.
Having a baseline is ideal, but not necessary.
ImPACT is not a “concussion test”; No such test exists
There is no “pregnancy test” for concussion
Thanks!