Suzanne Hecht, MD, FACSM University of Minnesota Team Physician: UM Athletics

DISCLOSURES

►DJ Global Primary Care Sports Medicine Advisory Panel

►NFL Charities Grant Assessing vascular reactivity in patients with

multiple concussions ►Chair: Big Ten-Ivy League TBI Research

Committee

OBJECTIVES

►List 3 limitations of NPT for RTP decisions ►Be aware of psychometric properties of

computerized NPT programs ►Recognize that NTP for RTP decisions is

best used as part of a multifaceted approach

►Appreciate that psychometric data on popular computerized NPT is lacking

3 QUESTIONS…..

1. What are the limitations of NPT & RTP? 2. Should we use it? Adults? Peds? 3. How much “stock” should we place in

the results?

CASE TO PONDER…

►18 yo freshman wide receiver ►Suffered his 1st concussion in practice Hit head on ground while catching a pass

►Initial: Dizzy, HA, hard to concentrate ►Symptoms resolved in 24 hours ►48 hrs: Light biking w/o symptoms ►PE & BESS testing: normal

NPT RESULTS

QUESTION #1: WHAT ARE THE

LIMITATIONS OF NPT? ►Randolph; JAT 2005 Review of traditional & computerized NPT

for Sports related concussions (SRC) Conclusion: “Computerized NPT for SRC

does not possess the psychometric properties necessary to support their use in the clinical management of concussions.”

BASELINE TESTING

►How is the baseline data obtained? Group testing (>20) resulted in lower scores

& more invalid test results Moser R; AJSM 2011

Group: Higher symptom scores & reaction times Schatz P; Arch Clin Neurpsych 2010

Computer equipment, connection speed, etc may influence the results Hinton-Bayre; CJSM 2012

Baseline data not stable in young athletes

RELIABLE CHANGE INDEX

►Usually employed in computerized NPT ►Helps the clinician to see what result

represents a significant change ►Different models of RCI ►No one model is superior ►Better to understand them all and see

how it applies clinically! Hinton Bayre; CJSM 2012

PROPERTIES OF A GOOD TEST

►Reliability ►Validity Sensitivity Specificity

►Clinical Utility

ANAM

►Reliability Most subscales did not meet minimal criteria

for clinical utility ►Validity Lack of discriminate validity between

constructs ►Sensitivity: 1-15% depending on subtest ►Specificity: 86-100% “ “

Resch; Neuropsych Rev 2013

COGSPORT-STATE

►Reliability Most subscales did not meet minimal criteria

for clinical utility ►Validity Correlation coefficients: 0.23-0.83

►Sensitivity: 70.8% overall ►Specificity Not calculated due to no control group

HEADMINDER CRI

►Reliability Most subscales did not meet minimal criteria

for clinical utility ►Validity Correlation coefficients: 0.37-0.70

►Sensitivity: 69-79% overall ►Specificity Not calculated due to no control groups

IMPACT

►Reliability Most subscales did not meet minimal criteria

for clinical utility ►Validity Correlation coefficients: 0.20-0.88

►Sensitivity: 79-95% overall & subtests ►Specificity: 89-97%

NPT INTERPRETATION

►~3-17% of NPT interpreted by a licensed neuropsychologist Majority done by ATC &/or Physician

Comstock RD; 2012, Covassin; JAT 2009, Meehan; Pediatrics 2012

►~50% of ATCs don’t review baselines for validity Covassin; JAT 2009

47% of HS baselines invalid per review by Neuropsychologist Resch; Neuropsych Rev 2013

►Of ATCs interpreting NTP, only 26% had formal training Covassin; JAT 2009

EFFORT

►~4-11% of NPT inadequate effort Hunt; Arch Neuropsych 2007, Schatz; JAT 2012

►Sandbagging is a concern 11-35% were told to give reduced effort on

baseline testing Erdal; Arch Neuropsych 2012, Schatz; AJSM 2013

PEDIATRIC ATHLETES

►Formal “paper & pencil” ►Sideline assessment SAC (Norms for middle & HS) SCAT or SCAT 2 or SCAT 3 Pediatric SCAT

►Computerized ImPACT (10 yo norms) CogSport Head Minders (10 yo)

PEDS & NEUROPSYCH

►Are they old enough & mature enough? ►Baseline testing is important ►Baseline probably not stable in kids Improves w/ brain maturation Kids between 8-15 yo may need q 6mo repeat

baseline testing (McCrory 2004)

►Consider expected baseline improvement over time when interpreting results.

QUESTION #2: SHOULD WE USE IT?

►We don’t know the answer There are lots of opinions Need more science NP results influenced by: effort, fatigue,

mood, exercise, etc. Consumer demand has increased

►NCAA mandates baseline & f/u testing for high risk sports

►Consensus documents recommend

HIGH SCHOOL & NPT

►HS Reporting Information Online Injury Surveillance System 2009-10 192 HS w/ ATCs reporting on 20 sports All concussions recorded 1056 concussions; 97% response rate (#178)

►40% use computer neuropsych testing 2008-09: 26% 93% ImPACT

HS & NPT

►78% interpretations: ATC &/or Doctor 17% Neuropsychologist

►Less likely to return to play < 10 days if using computer NP testing 38.5% vs 55.7%

Meehan; Pediatrics 2012

QUESTION #3: HOW MUCH “STOCK”

SHOULD WE PUT IN IT? ►No one knows! “It is just a tool” ►Get interpretation training ►Try to get good baselines ►Work w/ neuropsych for questions Some NPT are challenging to interpret

►Give the athletes a chance to do their best ►Use your clinical judgement