Science and Technology Move Concussion Assessment into the Modern Era
James S. Gyurke, Ph.D. - Chief Operating Officer at ImPACT Applications, Inc.
There has been a long history of man being concerned with injuries to the brain. As early as 800 B.C. the Hippocratic Corpus, a collection of medical works from ancient Greece, mentions concussion, later translated to commotio cerebri, and discusses loss of speech, hearing, and sight that can result from "commotion of the brain." While medical science over the years has wrestled with defining the concept of a traumatic brain injury, the term “concussion” did not come into use until the 16th century, as symptoms such as confusion, lethargy, and memory problems were described. In the 16th century physician Ambroise Paré used many terms to describe this condition including commotio cerebri, "shaking of the brain," "commotion," and "concussion."
Early conceptions of concussive injuries believed that they were primarily structural injuries. However more recently that conception has been refuted. Research on what actually transpires in the brain when there is a traumatic injury has found that a concussion is not a structural injury but rather a pathophysiological event (Giza and Hovda, 2014). Because a concussion is not a structural injury, scans (including CT, XRAY, MRI, and PET) are generally not useful in identifying this type of injury. The obvious question then is, “what is the best way to assess a concussion?”
While there currently are many ways to assess a patient for a concussion, not all methods are equally accurate, provide useful data to the clinician, or are practical from a cost or efficiency standpoint. By far, the most popular and longest used approach is clinical judgment. While widely utilized, this approach tends to have a high degree of subjectivity and the accuracy of this approach is highly dependent on the skill and experience of the healthcare provider.
Similar to clinical judgment in terms of its widespread use is symptom evaluation. While generally accepted as a key component in most diagnostic processes, symptom evaluation has been the focus of a number of research studies (e.g. Lau, Collins, and Lovell, 2011; Collins, Iverson, and Lovell, 2003). When focusing only on symptoms, the clinician is relying on the patient to be truthful about the nature and severity of the symptoms he or she is experiencing. More importantly, there is no universally accepted set of symptoms for the clinician to focus on when diagnosing a concussion.
Because of the subjectivity of the previously described methods, many healthcare providers depend on a more objective approach. Early efforts in this area involved using paper and pencil testing to assess functions such as memory, processing speed, and problem solving (Randolph, McCrea, and Barr, 2005). Though these tests tend to be accurate and provide the clinician with valuable data when diagnosing and treating a concussed patient, they tend to take a significant amount of time and are expensive. Most recently, Computerized Neurocognitive Testing (CNT) has been widely accepted as an economical, efficient alternative that can be used by clinicians to gather the data needed to make an accurate diagnosis (McCrory, Meeuwisse, Dvorak, et al, 2017).
Computerized Neurocognitive Testing allows for rapid assessment, is more cost effective than paper and pencil testing and clinical interviews, and is commonly used by psychologists, physicians, and other trained healthcare providers involved in diagnosing and treating patients. Within this category of tests, ImPACT (Lovell, 2016) is the most widely used and the most widely researched and supported for clinical evaluation. It is also the only tool approved by the FDA for aiding clinicians in the diagnostic process.
When utilizing a test such as ImPACT, the clinician can effectively work in a multidisciplinary setting to ensure that the patient is receiving the focal treatment best suited for the particular nature of his or her injury. A study by Collins, Kontos, et al (2014) demonstrated that ImPACT provides the clinician with data that can be used to categorize concussions into six recovery trajectories. Matching the appropriate therapy to the particular trajectory involved (i.e. cognitive, anxiety/mood, vestibular, etc.) enabled patients to return to normal activity more quick
Diagnosing and treating a concussion is a complicated endeavor. Patients depend on the clinician to accurately identify their concussion and devise a treatment approach that will enable them to return to their daily activities quickly and safely. For clinicians, the best approach to this problem is to utilize a CNT such as ImPACT which can provide valuable information in an efficient and cost-effective manner. Used in a multidisciplinary approach along with clinical, behavioral, and medical information, ImPACT is an important part of the diagnostic process.