According to the clinical marketing and media, ImPACT testing (Immediate Post Concussion Assessment and Cognitive Testing) or neuropsychological testing has become the answer to concussion diagnosis and management concerning the injured athlete, but is it? A very positive aspect is that the marketing has exponentially increased the awareness of concussion as ImPACT or most computerized testing has been pushed to the patient. Exemplified by a recent study showing computerized neuropsychological testing being used to assess fully 41.2% of concussions at schools with at least one athletic trainer on staff in the 2019-20 year, an increase of 15.5% from the 25.7% of concussions in which such testing was used in assessing concussions during the 2018-2019 school year.
But does it test all aspects of the brain? All aspects of cortical integration? Is it missing anything? As it is ever apparent on any search engine of all the clinics and groups providing this for concussion management, does it truly evaluate all parts of the brain that integrate to form the mind? Well, let’s take a look.
From a concussion or mTBI (mild traumatic brain injury) many signs and symptoms can develop. The main clinical symptoms we see, besides signs such as headache and nausea, are thinking, reasoning, concentration and focus issues, as well as visual disturbances, balance issues, coordination issues, and sleep disturbances. All of these pieces come from different lobes of the brain. Now, if we look at the brain as the map of the United States, the individual states become the lobes, and the lobes/states comprise the country or brain in this scenario. Each lobe or state carries out a different task in the brain. These tasks need to smoothly integrate together to allow proper efficiency and neural activity, thus comprising the brain/country. If these lobes or states do not integrate or work together, then patient reported signs/discomfort/issues ensue…or chaos. Now we come back to ImPACT or neuropsychological testing. This form of testing ONLY measures the thinking and reasoning parts of the brain (medial temporal lobe and frontal lobe). It does NOT measure other parts of the brain such as vision, balance, or coordination represented by the calcarine cortex and cerebellum respectively. It is also vitally important to recognize that computerized testing DOES NOT DIAGNOSE CONCUSSION nor is to be used on-field. Computerized testing is great at providing rapid scoring, consistent testing, and as financial generators. Unfortunately, this computerized test CAN BE CHEATED ON. Athletes have become smart enough to understand that ‘sandbagging’ their baseline will help them get released sooner.
According to Dr. Robert Cantu in his 2012 book “Concussions and our Kids,” he said “…ImPACT [Immediate Post-Concussion Assessment and Cognitive Testing] and other cognitive testing wouldn't establish a baseline or reveal deficits in all the areas of the brain [so] more and different evaluations are needed...” We may remember Dr. Cantu as the forefront of concussion before it became a household name. That being said, it definitely should not be the ONLY tool used.
As a clinician, it is imperative to utilize multiple tools to properly assess the athlete. We first need to fully understand the individual signs and symptoms, then examine the cognition, balance, and coordination. We also utilize multiple tools from basic to complex neuro testing, to Sports Concussion Assessment Tool (SCAT5) forms to Acute Concussion Evaluation (ACE) forms to the Neck Disability Index. As all concussions are individually based, it is important to understand the injury and patient’s goals.
Concussion is an evolving injury and the seriousness of this injury has been horribly underestimated, causing early neurodegeneration in the athlete years after play. We need to utilize clinicians who examine all aspects, and have accomplished educational hours and certifications on the concussion injury. As the ImPACT test may be the easiest to use, it does not appear to provide the standard of care that a clinician should provide.