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By Zack Ward
ANNAPOLIS -- This fall, about 10,250 student-athletes had baseline concussion testing in Montgomery County, where mandatory testing was introduced this year, continuing a trend of Maryland school systems taking youth concussions more seriously.
The test being used, Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), began at the suggestion of the Pittsburgh Steelers’ front office in 2002 and has spread across the entire NFL, as well as the NHL, MLB and much of the NCAA.
Now, it has even spread to lower levels of competition. In addition to Montgomery County, Anne Arundel and Charles Counties are in their second years of ImPACT testing, while Howard County has been doing it since 2007.
Amy Knappen, Chief Creative Officer at Righttime Medical Care headquartered in Crofton, said that many high schools around the country are using ImPACT. Knappen is also the program advisor of Righttime affiliated HeadFirst Sports Injury and Concussion Care, which has eight locations in Maryland that offer ImPACT testing.
Knappen said ImPACT was created because the Steelers wanted to “prove in black and white what was actually measurable for a concussion,” so they turned to the University of Pittsburgh Medical Center, which came up with the test.
Dr. Gerard Gioia, director of the Safe Concussion Outcome Recovery & Education (SCORE) Program at the Children’s National Medical Center in Washington, D.C., said the model of baseline testing has been around for about 20 or 25 years.
The ImPACT tests have come with their fair share of complications, but to Knappen, Howard County is the most on top of its game.
“It is mandated [in Howard County] before you try out for a sport that you have to have your pre-participation sports physical and the ImPACT test.” Knappen said.
“For Montgomery County, they just brought trainers in this year. They did a line item in their budget to accommodate for ImPACT testing. That first year is always historically very tumultuous, trying to get it up and running,” she said.
Montgomery County is spending $99,140 to give the ImPACT test to student-athletes, according to Dana Tofig, the director of public information for Montgomery County Public Schools.
ImPACT is designed to test memory skills, both verbal and visual, as well as reaction time and attentional skills. The first section shows the athlete words on a computer screen and then later asks them to look at a new set of words and determine which ones were in the original set and which were not. The same process is then followed for shapes, to account for the visual memory portion. Later in the test, athletes are asked to press a key if they see one color and another key for a different color to test reaction times.
For all of these sections, it’s not a red flag if an athlete’s score isn’t perfect. Knappen said sometimes results that are extremely good correlate to the type of sport or position the athlete plays. For example, a hockey goalie might score above average in the reaction section.
The point of the baseline test is to see where an athlete stands under perfectly normal conditions, when they have not been impaired by a concussion. Student-athletes then take a follow up test if they sustain a head injury. Doctors compare the results to the baseline to determine when the athlete is safe to return to competition.
In Montgomery County, about 60 retests have been given this fall, a figure that accounts for some athletes who have taken the test more than twice, according to Tofig.
“I definitely think there is a benefit to baseline testing as long as the testing is done well,” said Dr. Stacy Suskauer, director of Brain Rehabilitation Programs at the Kennedy Krieger Institute in Baltimore. “It is not always done well. We’ve been told about student-athletes who have taken the test at home while they’re watching TV and not really paying attention.”
It is for that reason that HeadFirst strives to provide athletes with a quiet test-taking space, free of distraction. While the assessment may not be perfect, Knappen said the test is smarter than any student trying to sandbag it.
“There was anecdotally a lot of talk about athletes coming in and deliberately trying to do poorly on the test so that they would have a lower baseline,” Knappen said. “And therefore, if and when they sustained a concussion, they would not have to try as hard to get back to baseline.
“But the test is like playing chess on a computer … It knows when you’re trying to throw it and it will kick out an invalid response,” Knappen said. “We get those from time to time, there’s no doubt about it.”
More imperfections include the fact that taking the test too many times can can create what Knappen calls a “familiarization process,” where it becomes too easy for the athlete, and the fact that it is difficult to mandate for every sport.
Although all athletes were tested in Montgomery County this fall, other school systems might test football players, but not other athletes. For example, girl’s soccer players in Anne Arundel County weren’t tested last year, despite their sport being the second leading cause of sports-related head injuries in the United States.
In addition, Dr. Kevin Crutchfield, who works for LifeBridge Health and is the independent neurological consultant for the Baltimore Ravens, stressed that ImPACT tests do not diagnose concussions.
“It’s good to know some type of baseline function, but it has extreme limits as well,” Crutchfield said. “You’re only looking at certain functions that the brain does and see if they become dysfunctional after some type of event. But there are other things that cause dysfunction of those functions other than a brain injury.
“The test is sensitive in picking up that there might be some kind of problem after the initial test was taken. But is it a concussion? And that’s where the issue comes up. It is not specific enough,” Crutchfield said.
However, Gioia remains hopeful that working to improve baseline testing is worth the effort.
“If the information is made available to clinicians who know how to use it, it can be one of the more important tools that we use,” Gioia said.