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CONSULTATION SERVICES 
Personal Consultation Services
For Student-Athletes With
A Sport-Related Concussion

Unique Rehabilitation Program 
Designed to Help Your Child 
Return to School

School and Home Rehabilitation Plan Will Be Worked Out With Classroom Teachers

Specific Strategies Designed to Reduce The Risk of Repeat Concussions

Contact Robert Kirwan For More Information About These Services
(705) 969-7215 or 
(705) 586-PURE (7873)
or email

rkirwan@infocomcanada.com
 

HOPE FOR TOMORROW
Concussion Management
Program Development
Workshop 
For School Boards
& Minor Sports

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Concussion Management Consultation Services
For School Boards

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Concussion Management Consultation Services
For Minor Sports

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CMP Program Development Guide
Click for a free PDF copy of the Book

Program Development Guide 
Excerpts
What is a Concussion?
Signs, Symptoms & Behaviours
A Partner Approach
Understanding The Brain
Essential Elements
Baseline Assessment
Concussions & The Law

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012
British Journal of Sport Medicine with Links to Related Reference Articles
PDF Download Copy
Review of Statement by CMP
SCAT3
Child SCAT 3
SCAT3 - Pocket Version
Sport Concussion Library
ImPACT Test Web Site
Other Links and Articles
 

BASELINE & POST-INJURY ASSESSMENT
(An excerpt from Chapter Ten of the CMP Program Development Guide which is provided to all people who participate in one of the Training & Development Workshops Sponsored by CMP Concussion Management Partners Inc.)

 

WHAT IS BASELINE ASSESSMENT?

The first thing we would like to make perfectly clear is that when we refer to “baseline” assessment, we are not simply talking about computerized neurocognitive testing. Unfortunately, the media has focused on the growing popularity of some of the high-profile baseline tests on the market and most people use “baseline test” as a general term to describe the tests.

A baseline is a starting point. It is what one would consider normal for a particular individual. This is another very important point. Everybody has a different baseline. Everybody also has a number of baselines to consider when it comes to skill development, intellectual ability, physical ability, etc..

When it comes to the identification and rehabilitation of a person who has a concussion it is critical that we know their baseline levels in a number of areas in order for us to determine, first of all if any change has occurred that would signify a traumatic brain injury and secondly to determine the rate of recovery. We consider recovery to have been successful if the person has “returned to baseline levels”.

WHAT BASELINE ASSESSMENTS SHOULD BE PERFORMED?

In order to have an effective concussion management program for student-athletes, it is important for a number of different baseline assessments to be completed. These baseline assessments will provide reference points against which we can check post-injury assessments when we are attempting to identify a concussion and will also give us a target to work towards while we are helping a person recover from such an injury.

The following five baseline assessments are recommended:

1.      A medical doctor already has a structural baseline in that he/she knows what is normal with respect to the condition of a skull, intracranial pressure, blood vessel structure, and muscle structure in the neck;

2.      A parent can establish a baseline assessment of activities and functioning levels at home;

3.      A teacher can establish a baseline assessment of performance in the classroom;

4.      The coach can establish a baseline assessment of basic sport-related skills;

5.      A computerized neuropsychological assessment of cognitive abilities can be obtained;

Whereas we have been recommending a partner approach to concussion management, it stands to reason that each of the partners should be able to have a baseline against which they can compare when it comes to identifying possible concussions. Without the baseline, you really don’t have a valid reference point. We will spend a little bit of time reviewing what each of the partners may consider when establishing their own baseline assessment for the student-athlete. When a school board, post-secondary institution or minor sports association develops a customized student-athlete concussion management program, this is something that should be given a great deal of attention. The program should include specific guides for each of the partners so that they can perform their baseline assessments and have information on hand to be used at a later date if necessary.

STRUCTURAL BASELINE

A doctor doesn’t need to perform a “structural baseline assessment” on a student-athlete. When a doctor examines an injured student-athlete he/she knows what a normal skull looks like. It does not have any cracks. He/she knows what the normal intracranial pressure should be, therefore, if the pressure is increased it is easy to diagnose swelling of the brain or internal bleeding. An MRI or CT scan will show if there are any abnormalities with respect to broken blood vessels in the brain or muscle damage in the neck area. This is why we recommend that a visit to the doctor should be the first step in the identification process. Any change in basic physical structure could be serious and even life-threatening. When it comes to any kind of injury, the first treatment of the patient is to make sure that the person’s life is not in danger. Once that has been determined, then you can deal with the non-life-threatening matters.

HOME BASELINE

Parent/guardians should be encouraged to create a “baseline” assessment of normal activities that their child is involved with at home. There are many simple home baseline assessments you can do with your child that involve balance, memory recall speed, etc. If you look at some of the signs and symptoms of concussion we are sure you can come up with some simple tests you can do right at home so that when you do a post-injury assessment you will be able to compare to help you identify a concussion.

CLASSROOM BASELINE

Classroom teachers are also a very important part of the concussion management program, therefore we recommend that they should be encouraged to create a “baseline” assessment of classroom performance for student-athletes who are participating on high-risk teams.

SPORT-SPECIFIC PERFORMANCE BASELINE

The coach plays a huge role in all aspects of the concussion management program. Therefore, we recommend that a “performance baseline” assessment be given to each of the student-athletes at the beginning of the season and repeated several times during practice sessions. This would require an assessment of the basic sport-related skill level for each player and would also include attitudinal, emotional and behavioural assessments. 

NEUROCOGNITIVE ASSESSMENT

When it comes to baseline and post-injury assessments, it is always desirable to rely on objective measurements. Parents/guardians, coaches and classroom teachers will be able to include some objective assessments into their baselines, but in many cases they are making subjective observations of behaviours and functions that are measured along a spectrum which is often hard to pin-point.

However, the structural assessment done by a medical doctor is very specific and objective. You know when a skull is fractured. You know when the intracranial pressure is elevated. You know when a blood vessel is broken. You know when there is muscle damage in the neck.

So too, when it comes to computerized neurocognitive assessment, everything is pretty much objective. The performance is measured and a baseline score is established.

We strongly recommend that all Student-Athlete Concussion Management Programs include the use of a neuropsychological, or as it is often referred to, a neurocognitive test as one of the methods of identifying a concussion and tracking the recovery of student-athletes who have suffered a brain injury.

Experts contend that each student-athlete who is injured must be managed on an individual basis, therefore by incorporating neurocognitive assessment as part of our program we can help to objectively evaluate a concussed student-athlete’s post-injury condition, keep track of the rate of recovery during the rehabilitation period, and ensure a safer return to play. Our goal is to prevent the cumulative effects of concussion from returning to play too early and risking subsequent injuries.

There are a number of neurocognitive assessment options available to school boards. We recommend ImPACT. Dr. Michael Czarnota, Ph. D., the consulting neuropsychologist for CMP Concussion Management Partners Inc., is a credentialed ImPACT consultant who has been working with athletes since 1998. It is his opinion that ImPACT is one of the best and most recognized of all neurocognitive tests available for student-athletes.

COMPLIANCE WITH PHYSICAL EDUCATION SAFETY GUIDELINES

The Physical Education Safety Guidelines developed by the Ontario Physical and Health Education Association (OPHEA) in partnership with the Ontario School Boards’ Insurance Exchange (OSBIE), the Ontario Association for the Supervision of Physical and Health Education (OASPHE), the Canadian Intramural Recreation Association – Ontario (CIRA), and the Ontario Federation of School Athletic Associations (OFSAA) recognizes the importance of using neuropsychological testing.

The OPHEA guideline states that “A concussion is more successfully evaluated if the student/athlete completes a neuropsychological baseline evaluation prior to beginning the sport season.”

Therefore, whereas school boards are committed to providing the highest standard of care possible for its student-athletes, it stands to reason that the policies and guidelines will include neuropsychological testing of some kind since this has been identified by the OPHEA as being something that will help with the identification of concussions among student-athletes. A program that does not include neuropsychological testing is not going to be as successful as one that does include this form of cognitive assessment.

ImPACT BASELINE AND POST-INJURY ASSESSMENT

We have done our research and have determined that by far the most reliable form of such a test is a computer based test done by ImPACT.

ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) was created in the early 1990's and has become the most-widely used and most scientifically validated computerized concussion evaluation system.

At the present time it is being used for concussion management services at more than 7000 high schools, colleges, amateur sports teams and professional clubs around the world and has become a standard tool used in comprehensive clinical management of concussions for athletes from as young as ten (10) to adulthood.

It is also available in 17 different languages. It is also being used by professional teams in the National Hockey League, the National Football League, The National Basketball League, the Major Baseball Leagues, among others. This is also the test that was being used by Sidney Crosby, who has become the “poster boy” for sport-related concussions.

ImPACT is a computer-based battery of tests developed specifically for assessing sport-related concussion. The computer program measures multiple aspects of cognitive functioning, including attention span, working memory, sustained and selective attention time, response variability, and several facets of verbal/visual memory. This will register a “baseline” record of abilities of student-athlete with which to test against should they suffer a possible brain injury during the season.

It is important to note that this test was developed to provide useful information to assist qualified practitioners in making return to play decisions for people who have suffered from concussions. It was never intended to be used as the sole criteria for making these decisions, but was always understood to be a tool that could help ensure that the best decision possible was going to be made.

In fact, CMP recommends that there is no one single source that should ever be relied upon to make the decision about the identification or the recovery of a student-athlete when it comes to concussions. This is even true of a medical practitioner who is examining an injured student-athlete.

The decision to return to play should not be based solely on the results of an examination by a medical practitioner. Rather, one must take into consideration the recommendations of the doctor, the results of the ImPACT test, the observations of the parents/guardians, classroom teachers, coaches and the self-declarations of the student-athlete him/herself.

Only when you factor into consideration all of the partners will you be confident that the decision you make is the right one.

MAIN FEATURES OF ImPACT TESTING

1.      ImPACT provides an evidence-based measurement of player symptoms;

2.      It measures verbal and visual memory, processing speed and reaction time;

3.      ImPACT measures reaction time to 1/100th of a second;

4.      It produces a comprehensive report of test results that can only be accessed by the CMP Consulting Neuropsychologist or one of his trained assistants;

5.      The results are presented in a PDF file which can be emailed if necessary to a treating physician who is treating the student-athlete;

6.      ImPACT automatically stores data from repeat testing so that all results are kept in the same safe and secure storage area;

7.      The test is administered online individually so that it can be done virtually anywhere;

8.      It is compatible with both PC and MAC computer systems;

9.      ImPACT testing procedures are non-invasive and pose no risks to the student-athlete.

10.  The test is now available in over 15 different languages, with the results being produced in English in order for our consulting neuropsychologists to be able to do a proper assessment.

RELIABILITY

Neurocognitive testing has come under a great deal of scrutiny in recent years by researchers who are attempting to discover more information about concussions and brain function in general. Because ImPACT is a comparison of post-injury test results with a baseline, or pre-injury test result, there is bound to be some variability in the results. This is why it is so important for us to ensure that all assessments of tests submitted through the Student-Athlete Concussion Management Program are done under the supervision of a consulting neuropsychologist.

Even the baseline test is examined to see that it falls within the normal range for a person the age and sex of the student-athlete. If it is outside of this normal expectation, then we find out why and if necessary have the test done over again. When the results return to or near baseline levels, we have Dr. Michael Czarnota or another licensed neuropsychologist examine the results to see if the student-athlete has returned to acceptable levels.

The ImPACT test even consists of a near infinite number of alternate versions which randomly vary the stimulus array for each administration of a test. This is a special feature that was built into ImPACT in order to minimize the possibility of student-athletes producing a result that is affected by what is known as the “practice effect”. This is why ImPACT is more reliable than some other neuropsychological tests that are available on the market.

Even under the intense scrutiny of experts around the world, ImPACT is still considered among the best neuropsychological assessment tools available, which explains why it is used so widely.

WHAT DOES ImPACT MEASURE?

ImPACT only takes about 20 to 25 minutes to complete. It can be administered by one of the School Leaders or School Head Coaches. It tracks information such as memory, reaction time, speed, and concentration. However, we want to make it perfectly clear that ImPACT is not an IQ test.

The computer program measures multiple aspects of cognitive functioning, including:

  • attention span,
  • working memory,
  • sustained and selective attention time,
  • response variability, and
  • several facets of verbal/visual memory.

TEST SCORES REVEAL RECOVERY PROGRESSION

When a player records a score on ImPACT that is lower than his baseline score, it signals that recovery is incomplete. When recovery is incomplete one of more of the following three deficiencies are common:

·                     a player’s reaction time is longer;

·                     his ability to concentrate is diminished, and;

·                     more time is required for thought processing.

These three deficiencies alone would render a player at risk if he returns to play in this state.

SIGNIFICANT VARIABILITY FACTOR

One of the main reasons we recommend a pre-injury baseline test for student-athletes is due to the fact that there is significant variability in neurocognitive functioning among athletes at the best of times. Therefore without baseline assessments which are administered before the athlete is injured, it is difficult to determine if a low score on a post-injury test is the result of the trauma or just reflective of his/her normal capabilities.

IMPORTANCE OF AN ACCURATE BASELINE SCORE

We cannot emphasize enough how important it is for a student-athlete to put forth his/her best effort when completing the baseline ImPACT test. The School Leaders or School Coaches who administer the tests will be well-trained in how to make sure that the conditions are just right for taking the test.

BASELINE TESTS

Qualified First-Level Test Evaluators working for CMP, under the supervision of Dr. Michael Czarnota, are responsible for ensuring that all Baseline tests submitted are valid. If any Baseline tests are flagged as being significantly different from standard norms, those tests will be reviewed and if necessary, the student-athlete will be asked to retake the test.

Therefore, we have the administrator checking to make sure that the baseline test was in fact uploaded into the system, and then we have a qualified first-level test evaluator checking to see that the baseline test falls within a normal standard of expectation for similar student-athletes. We are doing everything possible to ensure that we have a valid baseline score just in case we need to do a post-injury comparison.

We recommend that any school board, post-secondary institution or minor sport association using neuropsychological testing ensure the same level of care from your test evaluators.

POST-INJURY TESTS

Post-Injury tests that are submitted will first of all be evaluated by Qualified First-Level Test Evaluators. If the results of the test indicate that there are still obvious concussion-like symptoms or that the neurocognitive portion of the test is significantly deviated from the baseline, then the School Leader will be informed of the results and advised that the student-athlete is not yet ready to resume physical activities or training according to our results.

If the results of the post-injury test are determined by the Qualified First-Level Test Evaluator to be close to or approaching the baseline level, then the results will be reviewed by Dr. Michael Czarnota or another Licensed Associate Neuropsychologist. When it comes to the moment when we may be confirming that the results are back to baseline levels, then we want to make sure that this determination is made by a neuropsychologist and not a first-level test evaluator.

If the test results are back to baseline levels, then Dr. Czarnota will send a letter to the School Leader indicating that the baseline has been achieved and the student-athlete is permitted to begin the physical training segment of the rehabilitation program.

TEST COMPONENTS

The ImPACT test is divided up into several different components. You can easily visit the main corporate web site at www.impacttest.com to view the sections. We will try to give you a brief overview in the paragraphs that follow.

The test can be administered by a School Leader or School Coach who has successfully completed the training requirements of the Student-Athlete Concussion Management Program.

Post-injury tests should be administered by either a School Leader or a School Coach who is not associated with the student-athlete's current team. This policy is recommended in order to avoid the perception of any possible conflict of interest on the part of the coach who may be suspected of trying to help the student-athlete pass the test in order to return to play.

DEMOGRAPHIC BACKGROUND INFORMATION

The first section of the test asks the student-athlete to answer questions regarding height, weight, sport, position, concussion history, history of learning disabilities and other important descriptive information.

This information is extremely important and may be reviewed carefully when determining the validity of the test results. For example, it is important to know if the student-athlete has any learning disabilities that may affect the outcome of any part of the test.

CONCLUSION

We cannot emphasize enough the importance of “baseline assessment” as an integral component of an effective student-athlete concussion management program. A concussion changes the way the brain functions. In order to be able to identify and then provide proper rehabilitation, you must know how much change has occurred in order to know what kinds of accommodations and rehabilitation strategies should be employed. Without a baseline, you don’t know when you have returned to “normal conditions”.

Finally, we want to point out once again that it is not just enough to rely upon the “structural baseline assessment” of a medical doctor. Nor is it enough to rely upon the computerized baseline assessment of a program like ImPACT. You also need to have a baseline assessment done by the parent/guardian, the classroom teacher and the coach in order to be confident that you have provided your student-athletes with the highest standard of care possible.

  
OVERVIEW OF IMPACT TEST

ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) was created in the early 1990's and has become the most-widely used, and most scientifically validated computerized concussion evaluation system. It is used by schools, amateur sports teams and professional clubs around the world.

For some background information on the test CLICK HERE.

CLINICAL INTERPRETATION MANUAL

If you are a School Leader or School Coach, we would strongly recommend that you read the Clinical Interpretation Manual so that you have a better understanding of what it is that is being measured through the ImPACT Test. You do not need to understand all of the technical terms, but it will give you a better perspective on how comprehensive the test can be when administered properly and when interpreted by Dr. Michael Czarnota or one of his Associate Licensed Neuropsychologists. CLICK HERE FOR THE DOCUMENT

MAIN CORPORATE WEB SITE

We would also advise that anyone who is interested in finding out more about the ImPACT test should spend some time on the main company web site at www.impacttest.com There you will find answers to most of your questions as well as some relevant background information on the test itself.

CMP has tried to provide you with all of the information that we feel you need to know in order to understand the general purpose and administration of the test. We want to emphasize that the ImPACT test is a very useful tool in our Student-Athlete Concussion Management Program, but that is all it is. It is one useful tool that will assist in the identification and rehabilitation of a student-athlete who has suffered brain trauma resulting in concussion. It is not to be used as a "stand-alone" resource, but must be combined with the input of all of the "partners" of the CMP Concussion Management Program.

 
 
 

CMP CONCUSSION MANAGEMENT PARTNERS INC.
Serving Canada & the United States
Offices in the Province of Ontario and the State of Michigan
www.concussionmanagementpartners.ca
email: robertkirwan@concussionmanagementpartners.ca    Phone: (705) 969-7215

DISCLAIMER: All content found on this web site is provided for information and education purposes only and is intended to provide viewers, participants, and other injury prevention practitioners with information and guidance that may be used in helping them make informed decisions about concussion management. This web site is not intended to provide medical advice and should only be used to support, not to replace the advice of a physician or other qualified healthcare professionals. We have tried our best to include accurate information in all sections of the web site, but we do not guarantee that any information is in fact accurate and true in all respects. You should always consult a physician or other relevant healthcare professionals for specific information on personal health matters,  to ensure that your own circumstances are considered. You are responsible for obtaining appropriate medical advice from a physician or other qualified healthcare professional prior to acting upon any information available at or through our website.

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