Sports Medicine Research: In the Lab & In the Field: Smaller Groups and More Supervision May Be Necessary for Baseline Testing in Younger Athletes (Sports Med Res)
Monday, March 3, 2014

Smaller Groups and More Supervision May Be Necessary for Baseline Testing in Younger Athletes

Age and test setting affect the prevalence of invalid baseline scores on neurocognitive tests

Lichtenstein J.D., Scolaro Moser R., Schatz P. Am J Sports Med. 2014;42(2):479-484.

Take Home Message: Younger athletes (10-12 year olds) have more invalid baseline ImPACT exams compared to older athletes (13-18 year olds). This is most pronounced when younger athletes are tested in large groups in a nonclinical setting.

For us to assess cognitive function following a concussion we often rely on a valid baseline test. Unfortunately, many factors may increase the risk of invalid baseline tests (e.g., fatigue/lack of sleep, testing environment).  While we’ve seen that 4 to 11% of individuals 13 years or older have invalid baseline testing results we have no data among younger athletes. Therefore, the authors reviewed previously collected baseline tests to examine the prevalence of invalid baseline tests between younger and older youth athletes that completed their testing in a small or large group test setting. Five hundred and two athletes (10 to 18 years old; 85% male) who participated in a nonscholastic sport completed the online version of ImPACT between 2010 and 2013. Most of the athletes participated in ice hockey (59%) or lacrosse (28%). Two hundred and seven athletes completed their baseline testing in a large group. The large group setting consisted of testing at an athletic facility, where ~10 athletes were taking the exam with 2 trained administrators present. Two hundred and ninety-five athletes completed baseline testing in a small group setting at a neuropsychology center. The small group consisted of testing with 1 to 3 athletes at a time with 3 trained administrators. The authors found that younger athletes (10-12 years old) had a greater proportion of invalid baseline tests (7%) compared with older athletes (13-18 years old; 2.7% invalid). Younger athletes who tested in a large group were more likely to provide an invalid test (12%) compared with younger athletes tested in a smaller group (5%), older athletes in a larger group (3%), or older athletes in a smaller group (3%).

The authors suggest that an athlete younger than 13 years should be tested in a smaller group environment under strict supervision to decrease the risk of an invalid baseline test. This suggests that younger athletes may need more attention or supervision and an environment with less distraction when they take their baseline test. The higher rate of invalid test results among younger athletes may indicate that they do not know the importance or the necessity of baseline testing. Additionally, they may not be able to read and understand the instructions for the exam, which would explain the higher rate of invalid tests compared with older athletes. It was interesting to note that the group setting did not influence the rate of invalid baseline tests among athletes older than 13 years. This indicates that a larger group setting may be reasonable for older athletes as long as the administrators maintain a well-supervised environment. While we know other factors such as amount of sleep, reading level, and previous history of concussions influence the rate of invalid results among older athletes we still need to gain a better understanding of what influences results among younger athletes. It will be interesting to see if future research can shed light on these issues and support the current findings, particularly if this research question is explored in a randomized trial. In conclusion, these findings support the need for younger athletes to take their standardized baseline-testing in a small group to decrease the rate of invalid baseline tests.
Questions for Discussion: How many athletes do you baseline test at a time? Do you have a standardized protocol or script that you use when baseline testing athletes? How many administrators do you believe are necessary for valid baseline testing?

Written by: Jane McDevitt, PhD
Reviewed by: Jeffrey Driban

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Lichtenstein JD, Moser RS, & Schatz P (2014). Age and test setting affect the prevalence of invalid baseline scores on neurocognitive tests. The American Journal of Sports Medicine, 42 (2), 479-84 PMID: 24243771

4 comments:

Jake Marshall said...

In the clinic I am currently employed at we usually test them individually. If we are doing a designated baseline day we still never have more than 3 people in a room at once taking the test. We always have some one sit with the athlete until they have completed the demographics and symptom screen. Once the test begins we leave them to them selves, but the treatment rooms do have windows so we can keep an eye on them.

For group testing we have 3-4 clinicians and 1-2 supports staff (front office staff to assure consent to treat and other paperwork is filled out correctly). One clinician runs the Impact testing, one runs BESS, one runs King Devick, and one runs the D2 light board.

Jane McDevitt said...

The way your clinic runs baseline testing seems like a very reliable method. Do you ever get any invalid results? Do you see a difference in the amount of assistance younger athletes need compared to older athletes?

Kaitlin Henderson said...

I think it's important to test athletes individually. In groups it's easier for them to distract one another or listen to test being given. Unfortunately, I think especially in a busy preseason it's sometimes difficult to keep testing environments and testers uniform; there were times in my experience when one person would run one athlete through the whole BESS and SAC test, and there would be other times when one person would do all BESS tests and another would do all SAC tests, etc. Ultimately I think the most important factor is a consistent, quiet environment that the athlete feels comfortable in and won't be easily distracted.

Jane McDevitt said...

Kaitlin,

I agree best case scenario is individually, but when you have 1 athletic trainer and upwards of 900 athletes the task of baseline testing seems virtually impossible. I think your recommendation of keeping the environment consistently quite as to not distracts the athletes during testing is right on point. I think it is also important to mention that a test can only be as good as the administration. If the environment is not adequate per the instructions then you are going to come up with more invalid tests that will not be beneficial after the athlete sustains a concussion; thus, all the time putting into baseline testing obsolete.

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