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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.
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NEUROCOGNITIVE ASSESSMENT
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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.
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ImPACT BASELINE AND
POST-INJURY ASSESSMENT
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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.
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