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Webinar: C-3 (Advanced)Title: Keys to Interpretation: Special
Focus on Sand Bagging
Speaker: Mark Lovell, Ph.D., FACPN, D. Sci. (Hon)
Description:
This 45 minute course will review the role of
neurocognitive assessment in concussion management,
brief review of interpretation strategy and review atimely issue while focusing if the someone can Sandbag
the test.. This course is 45 minutes of presentation and
followed by 30 minutes of Q & A.
Table of Contents for Handouts
Section 1: Speaker Biography
Section 2: Slides (Presentation Handouts)
Section 3: Other Helpful HandoutsSection 4: FAQ from Workshop Attendees
Certificate of Completion Issued to All Registered.
BOC Credits available for Athletic Trainers
C-3 Keys to InterpretaSpecial Focus on Sand B
Info
Table of Contents
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Keys to Interpretation: Special Focus on Sand Bagging
Speaker: Mark Lovell, Ph.D., FACPN, D. Sci. (Hon.)
Biography
Mark R. Lovell, Ph.D., is internationally recognized as a concussion
expert for his development of innovative neurocognitive testing
programs and ground breaking research. Currently Dr. Lovell
serves as the chairman and chief executive officer of ImPACTApplications. In the early 1990s he developed the ImPACT test
which is the first, most-widely used and most scientifically validated
computerized concussion evaluation system. The ImPACT test has
become an internationally tool used in the comprehensive clinical
management of concussions. Dr. Lovells expertise led to his
development and direction of the first league wide
neuropsychological testing programs for the National Football
League (NFL) and National Hockey League (NHL). Dr. Lovell
remains a neuropsychological consultant for several organizations
throughout the world including, but not limited to, the NFL, NHL,Irish Rugby, USA Womens Olympic Hockey team, World Wrestling
Entertainment (WWE) and the US Ski and Snowboard team.
In 2000 Dr. Lovell became the founding director of the University ofPittsburgh Medical Centers (UPMC) Sports Medicine Concussion
Program. Dr. Lovells pioneering approach to concussion
management attracted professional athletes from around the world
to the UPMC Concussion Program. Until his retirement from clinical
practice in 2011 Dr. Lovell directed the UPMC program, which has
been regarded as the first and largest program of its kind.
C-3 Keys to InterpretSpecial Focus on Sa
Bagging
1: Bio
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Dr. Lovell is a leader in concussion research, publishing over 100peer-reviewed articles, authoring or co-authoring nine textbooks
and writing over 40 book chapters. He is an instrumental force in
spreading concussion education and awareness among the public
and medical community. Dr. Lovell served as a panel member for
the Center for Disease Controls Coaches Toolkitand has trained
thousands of medical professionals on neurocognitive testing and
concussion management.
Dr. Lovells contributions to the neuropsychological community
have allowed him to be a frequent presenter at professionalmeetings internationally and serve as a member of the Vienna and
Prague International Consensus Conference on Sports-Related
Concussion.
His vast accomplishments have been recognized by the Council of
Brain Injury award for excellence in research, National Concussion
Summit Excellence in Safety Award, USA Hockey Excellence in
Safety Award,American Board of Professional Neuropsychology
Distinguished Clinical Neuropsychologist Award and most recently
his alma mater, Northern Michigan University, awarded him with anHonorary Doctor of Science degree for his pioneering work in
managing sports concussions.
Dr. Lovell is a member of various professional and scientific
organizations including the International Neuropsychological
Society, American Psychological Association and North American
Brain Injury Association. In addition to being a member of several
prestigious organizations Dr. Lovell has been a reviewer for over 15
professional journals and is currently serving as an editorial board
member for several different journals.
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hout the prior written permission of ImPACT Applications, Inc. For information regarding permission, please write to ImPACT
Mark Lovell PhD, FACPN, D.Sci.
Chairman and CEO
ImPACT Applications, Inc.
Keys to InterpretationAdvanced Workshop Q and A
Special Focus-Sandbagging
Copyright 2013 by ImPACT
Applications, Inc.
All rights reserved. No part of this publication maybe
reproduced in whole or in part or transmitted in any form
or by any means without the prior written permission of
ImPACT Applications, Inc. For information regarding
permission, please write to ImPACT Applications, Inc.,
ImPACT and associated logos are trademarks
of ImPACT Applications, Inc.
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hout the prior written permission of ImPACT Applications, Inc. For information regarding permission, please write to ImPACT
ImPACT and the ImPACT logos are
trademarks of ImPACT Applications,Inc. and are used herein with the
express written permission of ImPACT
Applications, Inc. and may not be
duplicated, removed or altered
without ImPACT Applications, Inc.s
written consent.
The ImPACT Applications, Inc. software is a tool that provides
basic data related to neurocognitive functioning. The software
does not provide treatment recommendations or a specific
medical diagnosis with respect to any particular end user.
Training provided or facilitated by ImPACT Applications, Inc. on the use of its software
is intended to provide users with the ability to properly administer the tests
embedded in the software and to become familiar with the types of data generated by
the software. Treatment decisions that you and/or your organization make based on
the data generated by the software is in you and/or your organizations sole and
absolute discretion. By participating in the training, you and your organization
acknowledge and agree that ImPACT Applications, Inc., its officers, directors,
employees, or agents and affiliates and their respective successors and assigns will notbe held liable for claims of medical malpractice, practicing medicine without a license
or similar claims made by you, your organization or any third party. To the fullest
extent permitted by applicable law, you and your organization agree to hold ImPACT
Applications, Inc., its officers, directors, employees, agents, and affiliates and their
respective successors and assigns harmless and to indemnify ImPACT Applications Inc.
and its officers, directors, employees, agents, and affiliates and their respective
successors and assigns against any and all such claims.
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hout the prior written permission of ImPACT Applications, Inc. For information regarding permission, please write to ImPACT
1. Review of role of neurocognitive assessment
in concussion management
2. Brief review of interpretation strategy
3. Review a timely issue
Todays topic: Sandbagging
4. Q and A
GOALS OF WEBINAR
Neurocognitive Testing: What it is and IsntIS a tool to help determine recovery frominjury.
IS a tool to help manage concussion (e.g.return to academics, return to exertion returnto play).
ISa tool to help communicate post-concussion status to coaches, parents,clinicians.
IS NOT a substitute for medical evaluation/treatment or more formal NP assessment
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Interpretation Guidelines
STEP 1
Pre Season BaselineTesting & Education
Educate Athletes,Parents, Coaches,
Teachers onConcussions
Take an ImPACTTraining Webinar orWorkshop to Learnabout Baseline Test
Administration
Have a ConcussionManagement Protocol
On-hand and HaveYour Team of Key
Professionals (listedbelow) Ready to TreatAthlete - Roles/DutiesShould be Established
for:
- ATC
-Concussion Specialist(MD/DO/PhD)
-Rehabilitaion
Have Parents SignHigh School Permission
Slip
Schedule SupervisedBaselines in School's
Computer Lab
Test AdministratorConfirms All Baselines
are Valid
(if Invalid retest Athlete)
STEP 2
Concussion isSuspected
SidelineAssessment
If Concussion isSuspected Immediate
Removal fromPlay/Activity
ATC Sets Up Referral forConcussion Specialist
(MD/DO/PhD)
Vestibular Screening
At the discretion oftrained medical
personnel...
Optional Brain imagingif needed
STEP 3
Post Injury Testing &Treatment Plan
Athlete to TakeSupervised Post Injury
Test 24 -48 Hours AfterInjury Supervised
ATC Continues toCoordinate Concussion
Specialist(MD/DO/PhD)
Referral
Team Coordinates Carebetween Athlete,
Parent, MD/DO/PhD,ATC, Teachers, Coaches
Does the athlete needadditional and more
extensiveneuropsychological
Testing ?If so, Refer to
Neuropsychologist
STEP 4
Is Athlete Ready for NonContact Activity?
CRITERIA:
A: Symptom Free @Rest & With Cognitive
Exertion
B. Post ImPACT Test:Within Normal Range
of Baseline
C: Written Clearancefor Progression to
Activity by SupervisingDoctor (non-ER Doctor)
NormalVestibularEvaluation
IF NOT:Return to STEP 3
IF YES: StepwiseReturn-to-Play
Progression Beginningwith Light Non-ContactActivity Progressing to
Full Non-ContactExertion
STEP 5
Determining SafeReturn-to-Play
Return-to-PlayDecisions Should
Always be Made by aConcussion Specialist
(MD/DO/PhD)
No Recurring Symptomsat Rest or FollowingPhysical or Cognitive
Exertion
ImPACT Test ScoresBack to Baseline
After Return to Play
Athlete's Final ImPACTScore is Set as theirNew Baseline
ImPACTs Best Practices for Concussion Management for Schools and Teams
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Speed vs. Memory
Look for low scores and variability Be mindful of role of exertion with post-injury variability
Different areas of deficit with different
biomechanics and affected systems
1. Was baseline valid (Check Validity Index)
2. Comparison to baseline and RCIS?
3. Percentile score analysis
Interpretation Guidelines:
Analysis of Composite Scores
Sandbagging
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We have recently heard a great deal in the media
about athletes sandbagging the baseline test
(trying to set a low baseline to make it easier to
return to play).
How can you detect this using ImPACT?
Common question from clients
Answer:
Athletes routinely try to hide concussion symptoms
Athletes are always looking for ways to get back on field
Studies suggest that 53 percent of FB players had symptoms
but didnt report them (McCrea et al., 2004).
Some athletes may attempt to fool ImPACT but it is difficult to do
Validity Index is set up to catch them
Best way to prevent is to tell them up front that they
will most likely be caught and need to take test again!
Always Check validity index!!
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Research
Two Recent study with college athletes caught between89 and 95 percent of athletes trying to sandbag.
(see Erdal,Archives of Clinical Neuropsychology, 2012
and Schatz et al., Archives of Clinical Neuropsychology,
in Press).
Schatz and Glatts, 2013, Archives of Clinical NeuropsychologySandbagging Baseline Test Performance on ImPACT, Without
Detection is More Difficult than it Appears.
Tested 60 college students assigned to three groups:
Do Best, Nave Malinger, Coached Malinger 95% if nave and 100% of coached sandbaggers were detected
The Balance Error Scoring System (BESS) did not detect sandbaggers
Why do athletes sometimes attempt tosandbag their Baseline test?
(estimated rate is under 5 percent in HS students)
People in general are often more focused on
Short term gain rather than long-term risk
(other example: weight loss and dieting)
Examples: recent ESPN survey, survey of
Olympic Athletes
Athletes are highly motivated to play
Athletes are well-known to deny symptoms
of concussion when they occur
Recent Quote from NFL Player: You need to protect us from ourselves
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ImPACT Invalidity Criteria (Current)
Not all invalid scores indicate sandbagging(failure to understand directions, LD, ADD,
other factors)
Word memory below 69
Design Memory below 50
Xs and Os incorrect interference >30
Color Match total correct
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Case 1
First Hint.
Uniformly poor performance
Across all composite scores
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Word Memory below 69%
Design memory close
to below 50%
Three letter total correct
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Case 2
All composite scores very poor
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Poor performance but does not
exceed criterion (
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Summary:
Athletes are strongly motivated to
compete
Hiding symptoms has been linked to
the death of a number of kids
A minority may attempt to sandbag
A proactive approach is best
Always check validity index after
baseline
Open Q and A
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What is your post
exertional time frame
for giving the ImPACT,
baseline or post injury?
Is it 24 hours or longer?
ImPACT Training Questions:
What about multi-
sport players? When
do you test them?
ImPACT Training Questions:
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What are your
thoughts on ImPACT
testing with athletes
that are
symptomatic?
ImPACT Training Questions:
How many of the
invalidity criteria must
be met?
Is it just 1 or 2 or should
all?
ImPACT Training Questions:
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Where is the score of
18 on the
Word Memory test?
ImPACT Training Questions:
How would you interpret an athlete
with a normal baseline score but high
symptoms and 2 post injury scores
which are significantly diminished?
Also the last scores decreased in 3
areas but pt reporting no symptoms,normal saccades, gaze, no
convergence, and normal physical
exam/balance? she also was tested
too much (4 times in 4 days)?
ImPACT Training Questions:
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Does ImPACT send me anote if one of my
baseline tests is
potentially invalid?
(group testing of
athletes)
ImPACT Training Questions:
How many times would you
administer ImPACT, when
they are assymptomatic,
but they continue to fail
before you would have
them undergo more
thorough NP testing?
ImPACT Training Questions:
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Do you find that with an
"invalid" baseline in 1
composite area, that the
baseline can still be useful
with the other scores?
ImPACT Training Questions:
In a patient with dyslexia, he received normal
scores in his reaction time and his visual motor
speed composites.
His verbal and visual memory were below the
1st% both times we had him test.
(there was 10 days in between the test).
He was asymptomatic and no history of injury. We
accepted this second one as a baseline.
If he is injured I assume we would need to refer
him to a NP(I am a nurse practitioner and MD team)
ImPACT Training Questions:
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A low design memory score53% with all other areas of
the baseline being great
IMPACT flagged this test as
possible invalid.
How would we handle thisbaseline?
ImPACT Training Questions:
Is there one area, in the
post-injury test, that
consistently reveals a
low score?
ImPACT Training Questions:
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An athlete is symptom
free and able to handle
light exertion. How
frequently can he/she
be tested?
ImPACT Training Questions:
Is it possible for an
athlete to take the
baseline test athome?
ImPACT Training Questions:
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An athletes baseline test
showed a composite score
in the
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What are the guidelinesfor making return-to-
play decisions?
Are there official
numbers used for
making this decision?
ImPACT Training Questions:
Is it possible for a
student with any color-
vision deficiency to
complete theColor Match Module of
the test?
ImPACT Training Questions:
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Will using a touch
screen effect the
reaction time in
the ImPACT test?
ImPACT Training Questions:
For kids with learning
disabilities, how do I use
the normative data?
ImPACT Training Questions:
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Thank You
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Helpful Links
Peer Reference Articles
http://impacttest.com/uploads/resources/ImPACT_References_5-11-12.pdf
ImPACTs Client Resource Center
The resource center contains a wealth of information that is available to
you. In the center you will find fact sheets for parents, coaches andathletes. In addition there are training videos available as well as forms that
you are able to use and adopt and many other types of useful information
and forms.
http://impacttest.com/resources
password: ImClient2011
Free Apps
ImCATImPACT Concussion Awareness Tool was developed to educate
athletes, parents, teachers and coaches about common signs and symptoms
of concussions. For more information please click on the link below.
http://impacttest.com/imcat
ImPACTs Mobile Customer Center app for iPhone and iPad, ImPACTs
customers can access their Customer account from an iOS device. To
download your free ImPACT Mobile Customer Center please visit the app
store.
Centers for Disease Control and Prevention is a great resource to gatheradditional information regarding concussions.
http://www.cdc.gov/concussion/headsup/
http://impacttest.com/uploads/resources/ImPACT_References_5-11-12.pdfhttp://impacttest.com/uploads/resources/ImPACT_References_5-11-12.pdfhttp://impacttest.com/resourceshttp://impacttest.com/resourceshttp://impacttest.com/imcathttp://impacttest.com/imcathttp://www.cdc.gov/concussion/headsup/http://www.cdc.gov/concussion/headsup/http://www.cdc.gov/concussion/headsup/http://impacttest.com/imcathttp://impacttest.com/resourceshttp://impacttest.com/uploads/resources/ImPACT_References_5-11-12.pdf