Knowlton-Key writes on the latest in baseline concussion testing and treatment
The chiropractic office and the latest in baseline concussion testing and treatment
Jordan Knowlton-Key for Chiropractic Economics
The examination and management of concussions and related conditions is constantly improving. If a health care provider doesn’t continue to track the changes or hasn’t taken an updated continuing education course that summarizes recent research in baseline concussion testing , they will likely be operating by old standards.
A prime example of this is how often patients with concussions are told to wait in a dark room without stimulation until their signs and symptoms recede. Research in the past few years has challenged this treatment model, and experts agree that this is no longer the proper method for treating these conditions, and may cause future complications when returning individuals to academics, sports, work or recreational activities. With significant discrepancies in patients’ signs, symptoms, recovery rates and the activities they need to return to, every patient needs an individualized treatment plan.
Standardized baseline concussion testing and care
The gold standard in managing these cases is to have a standardized, performance-based test that can be used to help determine when an individual has recovered fully and is ready to return to their respective activities.
Various testing methods exist including the Sport Concussion Assessment Tool 5 (SCAT 5), ImPACT Version 4 neurocognitive testing, and the vestibular-ocular motor screening (VOMS). Testing, while providing an objective data point regarding the patient’s performance, is never a substitute for a thorough clinical examination. These tests are often a key part in the decision process for returning individuals to their activities, but should not be used alone for decision-making.
Concussion in Sport Group is responsible for creating the SCAT examinations, with the SCAT 5 and the Child SCAT5 being the most recent renditions of their suggested examination released after their 2016 conference. These tests take approximately 10-20 minutes to complete and are composed of patient demographics, a symptom severity scale, brief neuropsychological test batteries assessing attention and short-/long-term memory, neurological screening and balance testing.
The test is available as a free-to-use PDF that can be transcribed into EHRs or an electronic system for ease of use. Since there are no normative values for these tests, a baseline should be obtained to use this test properly in the Return-to-Learn/Activity protocol. However, in the absence of a baseline SCAT test, you may still use portions of the examination (such as the symptom severity score, which has high clinical utility and can be implemented into any head injury examination) to help monitor and guide clinical treatment and Return-to-Learn/Activity protocols. The SCAT 5 test is one of the most common assessments used by sideline providers for baseline concussion testing immediately after injury.
ImPACT Version 4 is an FDA-cleared, computerized neurocognitive test composed of demographics, symptom scale, and six neurocognitive test modules (Word Memory, Design Memory, X’s and O’s, Symbol Match, Color Match, and Three Letters) that generate four composite scores (Memory, Visual Motor Speed, Reaction Time and Impulse Control). There is also an option to use a Two-Factor (Speed and Memory) scoring approach. Upon completion of the test, results are all summarized in an automated clinical report which can be used to compare an individual’s post-injury test to their baseline test or normative data.
While several computerized neurocognitive tests are on the market, ImPACT Version 4 is supported by over 600 peer-reviewed articles, systematic reviews and book chapters since 2000. Contrary to SCAT5, ImPACT does have a normative database that allows you to compare results even if you don’t have an individual’s baseline concussion testing data. The most recent version of the test has over 72,000 cases in the normative database and there have been over 21,000,000 administrations of the test.
Similar to the SCAT, ImPACT has utility as part of the post-injury assessment and in the Return-to-Learn/Activity protocol. One real advantage of utilizing ImPACT Version 4 is that, in a world affected by COVID-19, the ability to have patients take ImPACT from a quiet home environment is beneficial. ImPACT can be administered in approximately 20 minutes. In addition, a shortened version called ImPACT Quick Test, which takes 5-7 minutes to administer, can be used on the sidelines as part of an accelerated examination and a decision on removing the athlete from competition. You do need to have an appropriate electronic device on the sideline to administer the test.
The VOMS is an examination cluster that includes accommodation, smooth pursuits, horizontal and vertical saccades, horizontal and vertical vestibular-ocular reflexes, and vestibular-motor sensitivity, and is utilized to examine a variety of vestibular-ocular symptoms.
Research demonstrates the importance of examining head injury/concussion patients who are experiencing common conditions such as headaches, dizziness, gait instability, neck pain, etc., for vestibular-ocular conditions. VOMS has been utilized by many providers for its high reliability, low false positive, and high internal consistency at baseline compared to post-injury. However, patients may have abnormal findings according to the tests that are considered their normative value.
Including VOMS in a patient’s baseline concussion testing helps find these abnormal findings, treat them if necessary, and record these findings as a comparison to post-injury reports resulting in higher specificity and fewer false positives.