C-3 Keys to Interpretation: Special Focus on Sand Bagging Info Table of Contents

Webinar: Title: Speaker:

C-3 (Advanced) Keys to Interpretation: Focus on Sand Bagging

Special

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 a timely 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: Section 2: Section 3: Section 4: Speaker Biography Slides (Presentation Handouts) Other Helpful Handouts FAQ from Workshop Attendees

Certificate of Completion Issued to All Registered. BOC Credits available for Athletic Trainers

C-3 Keys to Interpretation: Special Focus on Sand Bagging 1: Bio

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 ImPACT Applications. 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 of Pittsburgh 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.

Dr. Lovell is a leader in concussion research, publishing over 100 peer-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 Toolkit and 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 professional meetings 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 an Honorary 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.

Keys to Interpretation Advanced: Sandbagging

Keys to Interpretation Advanced Workshop Q and A Special Focus-Sandbagging

Mark Lovell PhD, FACPN, D.Sci. Chairman and CEO ImPACT Applications, Inc.

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., copyright@impacttest.com ImPACT and associated logos are trademarks of ImPACT Applications, Inc.

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., copyright@impacttest.com ImPACT and associated logos are trademarks of ImPACT Applications, Inc.

Keys to Interpretation Advanced: Sandbagging

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 not be 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.

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., copyright@impacttest.com ImPACT and associated logos are trademarks of ImPACT Applications, Inc.

Keys to Interpretation Advanced: Sandbagging

GOALS OF WEBINAR
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

Neurocognitive Testing: What it is and Isnt

IS a tool to help determine recovery from
injury.

IS a tool to help manage concussion (e.g.

return to academics, return to exertion return to play).

IS a tool to help communicate postconcussion status to coaches, parents, clinicians.

IS NOT a substitute for medical evaluation/

treatment or more formal NP assessment

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., copyright@impacttest.com ImPACT and associated logos are trademarks of ImPACT Applications, Inc.

Keys to Interpretation Advanced: Sandbagging

Interpretation Guidelines

ImPACTs Best Practices for Concussion Management for Schools and Teams
STEP 1 Pre Season Baseline Testing & Education
Educate Athletes, Parents, Coaches, Teachers on Concussions Take an ImPACT Training Webinar or Workshop to Learn about Baseline Test Administration Have a Concussion Management Protocol On-hand and Have Your Team of Key Professionals (listed below) Ready to Treat Athlete - Roles/Duties Should be Established for: - ATC -Concussion Specialist (MD/DO/PhD) -Rehabilitaion Have Parents Sign High School Permission Slip Schedule Supervised Baselines in School's Computer Lab Test Administrator Confirms All Baselines are Valid (if Invalid retest Athlete)

STEP 2 Concussion is Suspected

Sideline Assessment

STEP 3 Post Injury Testing & Treatment Plan

Athlete to Take Supervised Post Injury Test 24-48 Hours After Injury Supervised ATC Continues to Coordinate Concussion Specialist (MD/DO/PhD) Referral

STEP 4 Is Athlete Ready for Non Contact Activity?

CRITERIA: A: Symptom Free @ Rest & With Cognitive Exertion B. Post ImPACT Test: Within Normal Range of Baseline C: Written Clearance for Progression to Activity by Supervising Doctor (non-ER Doctor)

STEP 5 Determining Safe Return-to-Play

Return-to-Play Decisions Should Always be Made by a Concussion Specialist (MD/DO/PhD)

If Concussion is Suspected Immediate Removal from Play/Activity

ATC Sets Up Referral for Concussion Specialist (MD/DO/PhD)

No Recurring Symptoms at Rest or Following Physical or Cognitive Exertion

Team Coordinates Care between Athlete, Parent, MD/DO/PhD, ATC, Teachers, Coaches

Normal Vestibular Evaluation

ImPACT Test Scores Back to Baseline

Vestibular Screening Does the athlete need additional and more extensive neuropsychological Testing ? If so, Refer to Neuropsychologist IF NOT: Return to STEP 3 After Return to Play Athlete's Final ImPACT Score is Set as their New Baseline

At the discretion of trained medical personnel... Optional Brain imaging if needed

IF YES: Stepwise Return-to-Play Progression Beginning with Light Non-Contact Activity Progressing to Full Non-Contact Exertion

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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., copyright@impacttest.com ImPACT and associated logos are trademarks of ImPACT Applications, Inc.

Keys to Interpretation Advanced: Sandbagging

Interpretation Guidelines: Analysis of Composite Scores
1. Was baseline valid (Check Validity Index) 2. Comparison to baseline and RCIS? 3. Percentile score analysis

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

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., copyright@impacttest.com ImPACT and associated logos are trademarks of ImPACT Applications, Inc.

Keys to Interpretation Advanced: Sandbagging

Common question from clients

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?

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!!

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., copyright@impacttest.com ImPACT and associated logos are trademarks of ImPACT Applications, Inc.

Keys to Interpretation Advanced: Sandbagging

Research
Two Recent study with college athletes caught between
89 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 Neuropsychology

Sandbagging 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 to sandbag 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

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., copyright@impacttest.com ImPACT and associated logos are trademarks of ImPACT Applications, Inc.

Keys to Interpretation Advanced: Sandbagging

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 <7 Three letter total correct <8 Three letter average counted correctly <10 Impulse control >30

New ImPACT Invalidity Criteria, Summer 2013

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 <7 Three letter total correct <8 Three letter average counted correctly <10 Impulse control >30 Word Memory Correct Distractors (Immediate + Delayed)< 22

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., copyright@impacttest.com ImPACT and associated logos are trademarks of ImPACT Applications, Inc.

Keys to Interpretation Advanced: Sandbagging

Case 1

First Hint. Uniformly poor performance Across all composite scores

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Keys to Interpretation Advanced: Sandbagging

New for Summer of 2013 Word Memory Correct Distractors < 22 (actual score is 18) Word Memory below 69%

Design memory close to below 50%

Three letter total correct <9

Three letter average correctly counted <10

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Keys to Interpretation Advanced: Sandbagging

Case 2

All composite scores very poor

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Keys to Interpretation Advanced: Sandbagging

Poor performance but does not exceed criterion (<69%)

Very poor performance and exceeds criterion (<50%) Very poor performance and Exceeds criterion (>30)

Very poor performance and Exceeds criterion

No Symptoms

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Keys to Interpretation Advanced: Sandbagging

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

Be on Guard!!

Open Q and A

Copyright 2013 by ImPACT Applications, Inc.

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Keys to Interpretation Advanced: Sandbagging

ImPACT Training Questions:

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 multisport players? When do you test them?

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., copyright@impacttest.com ImPACT and associated logos are trademarks of ImPACT Applications, Inc.

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Keys to Interpretation Advanced: Sandbagging

ImPACT Training Questions:

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?
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., copyright@impacttest.com ImPACT and associated logos are trademarks of ImPACT Applications, Inc.

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Keys to Interpretation Advanced: Sandbagging

ImPACT Training Questions:

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)?
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., copyright@impacttest.com ImPACT and associated logos are trademarks of ImPACT Applications, Inc.

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Keys to Interpretation Advanced: Sandbagging

ImPACT Training Questions:

Does ImPACT send me a note 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?
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., copyright@impacttest.com ImPACT and associated logos are trademarks of ImPACT Applications, Inc.

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Keys to Interpretation Advanced: Sandbagging

ImPACT Training Questions:

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)

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., copyright@impacttest.com ImPACT and associated logos are trademarks of ImPACT Applications, Inc.

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Keys to Interpretation Advanced: Sandbagging

ImPACT Training Questions:

A low design memory score 53% with all other areas of the baseline being great IMPACT flagged this test as possible invalid. How would we handle this baseline?

ImPACT Training Questions:

Is there one area, in the post-injury test, that consistently reveals a low score?

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., copyright@impacttest.com ImPACT and associated logos are trademarks of ImPACT Applications, Inc.

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Keys to Interpretation Advanced: Sandbagging

ImPACT Training Questions:

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 at home?

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., copyright@impacttest.com ImPACT and associated logos are trademarks of ImPACT Applications, Inc.

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Keys to Interpretation Advanced: Sandbagging

ImPACT Training Questions:

An athletes baseline test showed a composite score in the <1-2 percentile, but was not flagged as an invalid test result. How is this possible?

ImPACT Training Questions:

What are the recommendations for using ImPACT and the RCI for middle-school students?

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., copyright@impacttest.com ImPACT and associated logos are trademarks of ImPACT Applications, Inc.

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Keys to Interpretation Advanced: Sandbagging

ImPACT Training Questions:

What are the guidelines for making return-toplay decisions? Are there official numbers used for making this decision?

ImPACT Training Questions:

Is it possible for a student with any colorvision deficiency to complete the Color Match Module of the test?
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., copyright@impacttest.com ImPACT and associated logos are trademarks of ImPACT Applications, Inc.

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Keys to Interpretation Advanced: Sandbagging

ImPACT Training Questions:

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?

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., copyright@impacttest.com ImPACT and associated logos are trademarks of ImPACT Applications, Inc.

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Keys to Interpretation Advanced: Sandbagging

Thank You

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., copyright@impacttest.com ImPACT and associated logos are trademarks of ImPACT Applications, Inc.

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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 and athletes. 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 gather additional information regarding concussions. http://www.cdc.gov/concussion/headsup/