Measurement Tools

The table below summarizes traditional pencil-and-paper neurocognitive tests frequently included in various batteries. For a comprehensive review, see Randolph, McCrea, and Barr (2005) .

Pencil-and-Paper Neurocognitive Tests
Test Age range (norms) Domain Measured Time
Brief Visuospatial Memory Test (BVMT)

18-62

Visual Memory

25 min (including delay)

Controlled Oral Word Association Test (COWAT)

 

Processing Speed, Executive Functioning

5 min

Digit Span (from the Wechsler Adult Intelligence Scale - IV)

16-90

Working Memory

<10 min

Digit Symbol (from the Wechsler Adult Intelligence Scale - IV)

16-90

Processing Speed

3 min

Hopkins Verbal Learning Test Revised (HVLT -R)

16-92

Verbal Memory

25 min (including delay)

Paced Auditory Serial Addition Test (PASAT)

18-75

Working Memory, Processing Speed

10-15 min

Stroop Color Word

15-90

Processing Speed, Executive Functioning (Inhibition)

3-5 min

Symbol Digit Modalities Test (SDMT)

8-74

Processing Speed

3 min

Trail Making Test (Trails A & B)

15-89

Processing Speed, Executive Functioning

<10 min

Symptom Reports

Scale Name Description Age Group Reliability/Validity/Factors Sensitivity/Specificity
Acute Concussion Evaluation (ACE) (Gioia & Collins, 2006)*

Presence of concussion characteristics (i.e., loss of consciousness, amnesia), concussion symptoms, and risk factors

3-18

 

 

Graded symptom checklist/Scale (GSS/GCS) (Mailer et al., 2008 ; Piland et al., 2006 )*

Self-report measures of concussion symptoms derived from the longer Head Injury Scale

13+

Three factor model = somatic, neurocognitive, cognitive

Time of Injury: Sensitivity = 89%
Specificity = 100%

Concussion Symptom Inventory (CSI) (Randolph, 2009 )*

Derived symptom scale designed specifically for tracking recovery; 9 items

High school to college

Day 1 post injury ROC =0.87

 

SCAT Post Concussion Symptom Scale (SCAT-PCSS)*

 

13+

 

 

The Post-Concussion Symptom Inventory (PCSI)*

Age appropriate checklists, vary by age group

5-7
8-12
13-18
Parent
Teacher

Inter-rater reliability = .62 to .84

 

The Rivermead Post-Concussion Symptoms Questionnaire (King et al., 1995 )

13-items scale developed for assessment of mild to moderate TBI

Adults

Two factor model = somatic/emotional & cognitive
Test-retest reliability = .87-.91 (King, Crawford, Wenden, Moss, & Wade, 1995 )

 

Head Injury Scale (HIS) (2003)

Symptom report grouped into brief/long duration

 

Internal Consistency  = .78-.84

 

The table below lists some computerized neurocognitive tests frequently used. For a comprehensive review, see: Resch, McCrea & Cullum, 2013 .

Computerized Test Battery Description
ANAM
www.vistalifesciences.com/index.php/anam-intro.html

Subtests:
Simple Reaction Time
Continuous Performance Test
Mathematical Processing
Sternberg Procedure
Matching to Sample
Code Substitution/
Delayed Memory

Axon Sports
www.axonsports.com/

Outcome Variables:
Psychomotor Speed
Decision Making Speed
Problem Solving Speed
Memory Speed

ImPACT
www.impacttest.com

Test Modules:
X’s and O’s
Symbol Match
Color Match
Three Letters
Word Memory
Design Memory
Post-Concussion Symptom Scale (PCSS)
Composite Scores:
Reaction Time
Processing Speed
Impulse Control
Verbal Memory
Visual Memory

Neurocognitive Testing

Brief cognitive screening tools, such as the SAC or SCAT2 are not substitutes for neurocognitive testing, and should be limited to use on the sideline (Echemendia et al., 2013 ). Typically, more comprehensive neurocognitive testing is completed in an office setting, and has been shown to be sensitive to deficits acutely (e.g., <24 hours following injury) and may detect deficits after an athlete is symptom free (Iverson, Brooks, Lovell, & Collins, 2006 ; Lovell et al., 2007 ; McClincy, Lovell, Pardini, Collins, & Spore, 2006 ). It is important to recognize that neurocognitive deficits are occasionally absent following concussion.

Throughout the past decade, computerized testing has been favored over conventional paper and pencil assessment. However, the table below outlines some of the strengths and weaknesses of both approaches.

Type Advantages Disadvantages
Paper and Pencil Neurocognitive Testing
  • Larger normative data bases
  • Flexible battery
  • Can assess auditory (non-visual) abilities
  • Time intensive
  • Labor intensive
  • Variation in administration and scoring
  • Domains (e.g., reaction time) not assessed
  • Shorter time range for sensitivity
  • Sensitivity is questionable (inconsistencies among research studies)
Computerized Neurocognitive Testing (CNT)
  • Brief
  • Standardized administration and scoring
  • Can detect subtle differences on speeded measures that would be subject to human error
  • Practical for use in sports settings without full time neuropsychologist
  • Ease of baseline assessment
  • Research supporting prognostic cutoffs for recovery and reliable change indices
  • Typically include symptom scale
  • Alternative forms to reduce practice effects
  • Centralized data repositories that are easily assessable

 

  • Concerns with psychometric properties (e.g., large standard deviations)
  • Increased likelihood of misuse (e.g., poor control of environment, interpretation by under-qualified individuals)

 

Neuromotor/Neurosensory Evaluation

Assessment of balance and postural stability is most sensitive one day post-concussion, although the duration and persistence of balance deficits is debatable, and largely depends on assessment tool used (Covassin, Elbin, Harris, Parker, & Kontos, 2012 ). Balance assessment may be useful on the sideline and the clinical setting.

Gait & Dynamic Stability Assessment

Postconcussive impairments in dynamic stability are evidenced by slowed walking speed, shorter steps, and increased medio-lateral motion of the body (to allow more time for sensory information processing), and are present as long as 28 days post injury (Parker, Osternig, van Donkelaar, & Chou, 2008 ).

  1. Dual-Task Paradigm: Deficits in dynamic stability are most often assessed with a secondary, cognitive task. Examples include walking while spelling a five-letter word backwards, serial 7s subtraction, or reciting the months of a the year in reverse.

Balance/Postural Stability Assessment

  1. Balance Error Scoring System (BESS): developed by researchers at the University of North Carolina, is a widely utilized balance/postural stability system in SRC due to its rapid use and low cost. The BESS is available without purchase, with administration instructions, score card, and normative data for controls and concussed. Following concussion, athletes typically return to baseline BESS within 3-7 days (Guskiewicz, Ross, & Marshall, 2001 ; McLeod et al., 2004 ; Riemann & Guskiewicz, 2000 ).
  2. Romberg test: Requires the athlete to stand with feet together, eyes open and hands by the sides. The athlete then closes their eyes while the examiner observes for a 30 seconds.
  3. Sensory Organization Test (SOT): The SOT uses computerized dynamic posturography, quantifying how much a person sways under various sensory-isolating conditions using a force plate. Athletes with sports concussions tend to sway more than healthy athletes 1 day after injury using the SOT, and balance problems have been shown to persist up to 30 days after a concussion (Guskiewicz, 2001 ; Guskiewicz et al., 2001 ).

Vestibular/Ocular Assessment

  1. King-Devick (K-D) Oculomotor Test: The K-D is a one-minute test where the athlete is asked to read, fast and accurately, several pages of single-digit numbers that are arrayed left to right in columns that don't vertically align. The test requires smooth and steady eye movement across and down the page, as well as concentration, the rapid recognition of numbers and fast language production
  2. Vestibular/Oculomotor Screening (VOMS): Recently developed as a brief and practical screening tool for clinicians to assist with concussion diagnosis and determine if more comprehensive evaluation and treatment is necessitated.

Additionally, the following empirically validated measures are available and have been previously recommended for use following concussion (Gurley, Hujsak, & Kelly, 2013 ):

  1. Dizziness Handicap Inventory (DHI)
  2. Activities-specific Balance Confidence Scale (ABC)
  3. Visual Vertigo Scale (VVS)

Emotional Assessment

Emotional symptoms are typically viewed as transient symptoms following sports related concussion. It is not uncommon for an athlete to report increased irritability, anxiety, or sadness the hours to days following an injury, and symptoms most often dissipate with the physical and cognitive symptoms within 1-2 weeks, as measured by concussion symptom scales (Iverson et al., 2006 ; McClincy et al., 2006 ). Emotional symptoms persist in a subset of athletes, and can be conceptualized as the culmination of acute neurochemical changes perpetuated and maintained by environmental stressors associated with the injury. For the student athlete, day to day life may be dramatically altered with restricted sports participation, difficulty completing school work, and social isolation during a the recovery period.

General Assessments for Consideration

  1. Beck Depression Inventory, 2nd edition (BDI-II)
  2. Beck Anxiety Inventory
  3. Sport Anxiety Scale -2nd edition (SAS-2)
  4. Athletic Coping Skills Inventory (ACSI)

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