A NEW SEASON IS HERE!
PLAY PREPARED WITH A
BASELINE TEST
Baseline testing, together with a preseason evaluation, is an essential part of the concussion management process. The Axon Sports online Baseline test captures a snapshot of an Athlete’s brain speed and accuracy. In the event of a concussion, results are used by qualified Medical Providers to help determine when it’s safe for Athletes to return to the classroom, practice, or competitive play.
We encourage all Athletes to create their individual Baseline at the start of the playing season. The Axon Sports CCAT may be supervised by responsible adults who can help ensure an environment free from distractions and an Athlete’s “best effort.” Test results are available immediately and stored for future use. Preseason Baseline tests: an important step toward keeping our Athletes safe. Register or Log In
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Axon Sports Canada web site is now live! |
AXON SPORTS EXPANDS; LAUNCHES NEW WEB SITE
Welcome our newest addition! Axon Sports recently launched a web site for its Canadian customers, axonsports.ca.
The new e-commerce site integrates the successful Baseline test for concussion management—the Axon Sports Computerized Cognitive Assessment Tool (CCAT)—with proven educational materials related to concussion symptoms, evaluation, after injury care, and return-to-play decisions.
“The site incorporates feedback from our current customers,” said Polly James, Axon Sports president and CEO. “The end result reflects their insight and I’m pleased we took the time to include their suggestions on both the content and the user experience.”
This web site is designed to conveniently purchase affordable Baseline and After Injury tests for concussion management; take and store tests; share access to test results; and download educational materials. Athletes, Parents, Coaches, Athletic Directors, Athletic Trainers, and Healthcare Providers will have access to current, best-practice materials as they seek to better understand and recognize sports-related concussions. Always on the cutting edge of technology in regard to cognitive testing, Axon Sports provides all stakeholders—from Athletes to the Healthcare community—with a helpful and easy way to get the information they need.
The launch coincides with a popular time period for preseason Baseline tests—the month before school starts for high school Athletes. As part of a proactive concussion management program, an Athlete takes a Baseline test before the sports season begins (or when uninjured). After creating an account at axonsports.ca, they can take a Baseline test in eight to 10 minutes.
NEW WEB SITE FUNCTIONALITY FOR
MEDICAL PROVIDERS AND TEAM PHYSICIANS
Using the Axon Sports “Extract” Link for Concussion Research
There is a lot of research still required to understand the mechanisms underlying injury in concussion, as well as risk factors, most useful investigations, treatments and optimal management. The Axon Sports Computerized Cognitive Assessment Tool (CCAT) is but one tool in a well-stocked concussion management toolkit. It has several roles in aiding medical decision-making after concussion, particularly for measuring change in cognitive performance after injury in comparison to the Athlete’s own Baseline performance, and it can also be used for independent research. It is ideal for providing objective sensitive measurement of cognitive performance and can be repeated even at high frequency intervals to measure changes or stability in cognitive performance.
To facilitate your research, Medical accounts have a new tool to extract Axon Sports CCAT data in a format suitable for research studies. This is accessible in the Tests section under View Test Results, using the Download Summary Data button. Clicking this button will generate an Excel-compatible spreadsheet containing a row entry for each task taken by each Athlete linked to that account. This is a tab-delimited spreadsheet that can be downloaded to your computer and then opened in Excel (or other spreadsheet program). On this same page you will find an Extract Parameter Descriptions button that will open a PDF containing explanations for all the abbreviations used in the spreadsheet columns and rows.
Athletes
AXON POTENTIAL TO DEVELOP AN ENTIRELY NEW CATEGORY OF PRODUCTS AND TRAINING SYSTEMS
 Designed to enhance your skill acquisition and develop the cognitive skills required for peak performance
In May, a new venture called Axon Potential was launched. Axon Potential is an affiliate of Axon Sports, dedicated to creating cognitive training programs for competitive Athletes. Axon Potential’s initial products will train Athletes to recognize complex sport-specific information and improve both the speed and accuracy of their cognitive responses.
This launch included a new web site axonpotential.com that highlights recent research in the world of sports and neuroscience and provides interviews with leaders in the fields of cognitive neuroscience, skill acquisition and performance training. Additionally, this site will offer updates on Axon Potential’s research and insights into the product development process. Recent posts include: “Rory McIlroy and the Quiet Brain”, “Meditation for Athletic Performance” and “Exercise and the Brain”.
Take a look at its newest blog entry
In addition to establishing relationships with the world’s top researchers and scientists in the fields of neuroscience and cognitive psychology, Axon Potential has partnered with Athletes’ Performance, a global leader in integrated performance training. These relationships will focus on the development of products and programs that help Athletes accelerate and optimize the acquisition of the cognitive skills needed for success on the field.
Axon Potential’s initial product development is a suite of four research-supported software training products: Baseball Pitch Recognition, Football IQ, Football High-Speed Decision Making, and Soccer Anticipation/Situational Assessment.
Schools, Leagues, and Clubs
CONCUSSION MANAGEMENT TOOLKIT
DESIGNED TO KEEP YOU AHEAD OF THE GAME
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| Sample page from Axon Sports new online toolkit, Ahead of the Game. |
Planning a fall sports meeting for Parents and Athletes? Check out our new online toolkit, Ahead of the Game. You’ll find educational materials—tips, videos, customizable forms, locker room posters, return-to-play permission slips and other items to assist you in getting started with a concussion management program or adding some energy to your current program. It’s available free to registered account holders under Account Tools.
Register or Log In
It’s important that all stakeholders—Athletes, Parents, Coaches, Athletic Trainers, School Nurses, Athletic Directors, Officials, EMT Staff—understand concussions, including the cause, effects and recommended recovery guidelines.
Medical Providers
INSURANCE REIMBURSEMENT FOR THE AXON SPORTS CCAT
- CPT codes are available for reimbursement for use of the Axon Sports CCAT performed in a medical practice. The simplest is unsupervised self-administered testing using 96120 at a flat rate. Supervised testing is billable per hour either by a Doctor (or PhD level psychologist) for all time spent providing the service using 96118, or by a technician where only face-to-face time is billable by hour using 96119.
- Baseline and After Injury testing requires a valid ICD-9 code meeting medical necessity. Baseline testing is not separately reimbursable without an ICD-9 diagnosis code. After Injury testing is reimbursable using a specific diagnosis code. The CPT and ICD-9 diagnosis codes need to match each other.
- Use mental health ICD-9 codes (290-319) for insurance companies which consider neuropsychological testing as a mental health service, e.g. post-concussion syndrome is 310.2. Use medical ICD-9 codes (320-389.9) for insurance companies which consider neuropsychological testing to be part of a medical service, e.g. concussion diagnosis is 850.X.
- Prior authorization is recommended. Some insurance companies require pre-authorization for some codes or policies. These determinations may differ depending upon the individual patient’s plan and policy. Federal law states that all carriers must acknowledge these codes (i.e. they are reimbursable).
For more information, see the Axon Sports Insurance Reimbursement flyer
Parents and Guardians
KIDS AND SPORTS-RELATED CONCUSSIONS:
THE ROLE OF BASELINE TESTING
The following article is a version originally appearing in State of the Sport. It underscores the value of playing prepared with an annual, pre-season Baseline test.
If you’re an avid sports fan and a regular consumer of popular media, you’ve heard, seen, and read about sports-related concussions. Nearly four million young Athletes--one in 10--will suffer concussions this year, according to the Centers for Disease Control. The actual number is likely much higher as concussions go unrecognized and underreported.
Concussions are injuries that don’t play favorites--they can occur in any sport, at any level, at any age. And, whether they’re occurring more frequently or we’re getting better at recognizing them, data continues to underscore the seriousness and potential for long-term consequences.
What is a concussion?
A concussion is a brain injury. It is caused by traumatic force–either a direct hit to the head or an indirect blow to the body.
While concussion reports may be a reoccurring topic, what is reported less often are the steps Parents, Coaches, Medical Providers, and Team Administrators can take to help protect the health and safety of young Athletes.
A Three-Point Plan of Action:
- Learn to recognize concussion signs and symptoms. The CDC has an entire library of current materials for youth sports coaches and parents as does MomsTeam. Plus, youth concussion laws are sweeping the country and interscholastic associations are tightening guidelines. Be aware of specific requirements in your state regarding education, informed consent, removal from play, and return to play.
- Be sure to follow the fundamentals of the sport being played--wear proper fitting equipment in good condition, teach proper techniques, have water available at all times, follow the rules of the game, practice good sportsmanship, etc.
- In addition to getting a pre-sport physical exam, add a cognitive Baseline test to your pre-season check list.
How it works
A Baseline test is a term for any test used before a treatment or activity. A cognitive Baseline test is one tool in an effective concussion plan because it measures what we can’t see-- brain function. Baseline testing has been used for many years by professional and college-level sports programs. It is a best practice and recommended by both the National Collegiate Athletic Association (NCAA) and the American Academy of Pediatrics (AAP).
As part of their pre-season prep, an Athlete takes a Baseline test before the sports season begins (or when uninjured). This establishes a “snapshot” of their brain’s speed and accuracy. If an Athlete becomes concussed, they should seek appropriate medical attention. When physical symptoms have resolved, under the care of their qualified Medical Provider, an Athlete can perform another test. The tests are identical because repeating the same tasks after the injury identifies any cognitive changes from the Baseline. This ability to compare results helps indicate whether the brain has fully recovered. It is an important, objective tool for qualified Medical Providers making decisions about when it is safe for Athletes to return to the classroom, practice or play—whether that’s bike riding, snowboarding, cheerleading, or football.
Why computerized cognitive testing?
Concussion causes subtle changes in the speed and accuracy of cognition (thinking). These changes are usually the last symptoms to go away after a concussion and they can be very slight. While not diagnostic, computerized testing does help identify change in cognition. In fact, it is very difficult to detect these changes without a computerized test which compares an individual to themselves pre-injury. This means that a Baseline test in the pre-season, before any injury occurs, is essential.
An Athlete can complete the Baseline test in about eight to 10 minutes. The test features four tasks with playing cards and is designed to be easy to use and fair for Athletes from very diverse backgrounds. “The brain likes making sense of new things,” said David Darby, M.D., co-creator of the Axon Sports CCAT, “and kids are easily bored. Concealing and revealing cards allows for anticipation and curiosity–which both brains and kids thoroughly enjoy.”
The test results are available immediately and stored in the Athlete’s secure account. This allows an Athlete to confidently play for multiple schools, clubs and leagues throughout their childhood, all while having access to their account and their aggregated testing history. It allows Parents to share test results at the click of a mouse with Coaches, Team Managers, and Medical Providers.
“Because the changes that occur in cognition with head injuries are often subtle and can occur within the normal ranges of population norms, evaluation of cognitive performance (i.e. how impaired is the individual) can benefit from the addition of sensitive tools like the Axon Sports CCAT,” said Darby.
Is it Valid?
For the past decade, validation studies have repeatedly proven the advantages of the Axon Sports CCAT for detecting cognitive change (see related article). The four tasks measure an Athlete’s processing speed, attention, learning and working memory. The validation efforts began in 2000 by establishing the properties necessary to detect change in cognitive function under a variety of comparisons and conditions. Several publications have reviewed the rationale behind using computerized cognitive testing by Medical Providers and have addressed validity issues. These studies showed the Axon Sports CCAT has minimal practice effects, good criterion, construct, test-retest and ecological validity.
So even though the Axon Sports test looks like a game and is motivating for the test-taker, the tasks are based on sound and well-established science. “The paradigms used are long-known psychological techniques regarding learning, memory, processing speed, and accuracy,” added Darby.
A winning sports team requires everyone to play a role. Play your part by educating yourself about concussions and the role Baseline tests can play in the health and safety of young Athletes.
ASK THE EXPERT
Q: I’ve heard that once you’ve had one concussion, the likelihood of having a second is significantly greater. Is this true? What is Second Impact Syndrome?
Dr. Moriarity:
Generally speaking, it is true that Athletes who have suffered a concussion are at a statistically greater risk for developing a future concussion than those who have never suffered a concussive head injury. This was first noted in a study published in 1986 by Gerberich looking at injury rates in Minnesota high school Athletes, and subsequent investigations have supported this observation. However, like most generalities, the devil is in the details. What is not clear is if this increased risk is due to:
- Genetic pre-disposition to concussive injury,
- A lowered threshold for concussion as a result of damage from the initial concussion, or
- Patient awareness of concussive symptoms as a result of sustaining a concussive head injury that make them more likely to report concussive symptoms in the future.
One should be aware that the above observation applies only to the long-term statistical risk of suffering a concussion as a result of participation in athletic activity. It has nothing to do with the short-term risks associated with returning to activity too soon after sustaining a concussive head injury. In the short-term setting, the risk of experiencing prolonged post-injury symptoms and delayed recovery, or the development of further concussive injury, is far greater in those who return to activity and competition prematurely when the recovering brain is still in a vulnerable state. The combination of attentive, knowledgeable medical care, cognitive testing utilizing the Axon Sport Computerized Cognitive Assessment Tool (CCAT) and a graded return to activity and competition is currently the best defense we have of preventing prolonged and recurrent concussion injury.
Second Impact Syndrome (SIS) is a very rare medical catastrophe. It is classified as a secondary brain injury which means that even though the injury was caused by an initial head trauma, the trauma was not sufficient to cause immediate and severe disability. It is only later when another seemingly minor head injury occurs (hence, “second impact”) that the catastrophic process begins. In short, SIS is characterized by a sudden, massive swelling of fluid (not blood) inside the brain with nowhere for the fluid to expand because of the confines of the bony skull. The pressure in the brain rises very quickly and in a short time stops all blood circulation and oxygen delivery. Death follows rapidly unless the pressure is released. No one really knows what causes SIS although it has been associated with relatively minor head trauma (including concussion) causing brain bruising or small subdural hematomas (TADD syndrome). Sudden death due to SIS differs from sudden death caused from the acute head trauma of epidural and subdural hematomas. In those injuries, large amounts of bleeding in the brain displace and compress brain tissue resulting in cell death, abnormally high pressures, and circulation loss.
As stated earlier, SIS is exceedingly rare in comparison to the number of concussions sustained yearly by Athletes, and it should not be invoked as a cause of death in cases of acute epidural and subdural hematomas. Nevertheless, it is a serious cause for concern in the management of sports-related head injury and reinforces the concept that “there is no such thing as a minor head injury.” Appropriate Physician care, Baseline and after injury testing with the Axon Sports CCAT, and graded return to activity are the mainstays of concussion management.
BIODEX AND AXON SPORTS TACKLE BEST PRACTICE BASELINE TESTING FOR CONCUSSION MANAGEMENT
Biodex Medical Systems, a leader in sports medicine and rehabilitation, has teamed up with 360° Balance to develop the PLAY IT SAFE® Concussion Management Program. PLAY IT SAFE brings together Baseline best practices: Cognitive (Axon Sports) and balance (Biodex). Learn more at www.biodex.com/concussion
TOYOTA ANNOUNCES SPONSORSHIP OF THE
AXON SPORTS ROLL-OUT IN AUSTRALIA
Offers Baseline Tests to 130 Australian Rules Football Clubs through its Good for Footy Program
Toyota has announced it will sponsor a new initiative that will lead the way in making Australian Rules football safer for players at a grassroots level. Toyota will provide the same CogState concussion testing used by the Australian Football League (AFL) clubs to more than 25,000 grassroots footballers as part of the Toyota Good for Footy program. Toyota will be working closely with Axon Sports—now the exclusive concussion management system of the AFL—to roll-out Baseline testing to more than 130 clubs in the Toyota Good for Footy program.
Toyota Senior Executive Director, Sales & Marketing, David Buttner said, “Supporting the game we all love is a priority for Toyota and Toyota Dealers across Victoria, Southern New South Wales and Tasmania. Supporting the game we love also means keeping it safe. Providing concussion management testing to young players along with much-needed financial support reflects our commitment to safety and continuous improvement in all that Toyota does.”
Read the full release
TEN YEARS OF RESEARCH UNDERSCORES
VALIDITY OF THE AXON SPORTS CCAT
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| David Darby, MB, BS, PhD FRACP |
There has been considerable media interest in the validity of computerized cognitive testing used to aid medical decision-making following concussion. Much of this interest has followed the publication of personal opinions expressed by a particular research neuropsychologist who has published several articles questioning the validity of such tests to both detect changes after concussion (Randolph 2005) and more recently to prevent concussion-related impairment (Randolph 2011). Although the Axon Sports Computerized Cognitive Assessment Tool (CCAT) has not been singled out for specific criticism, this issue is an important one to address since there has been a lot of scientific work done to support claims of scientific validity for the Axon Sports CCAT in detecting change in cognition and specifically as a tool in the medical management of athletes with concussion.
There are many forms of scientific validity that can be used to evaluate whether a test or technique is useful in assessing a particular ability. For concussion, it is important to show that a tool has the following forms of validity.
- Criterion validity: measures whether the test can detect abnormalities when the condition is present. In this case, it must show cognitive impairment when there is a concussion or traumatic brain injury on a single assessment, but in addition shows ongoing cognitive impairment on repeated testing if the condition persists and resolution of impairment when the condition recovers. Sensitivity to the impairment caused by the condition is also important, but specificity for the condition is not as important for a tool like the Axon Sports CCAT where testing is being used to document cognitive impairment, not diagnose the concussion (or other condition).
- Construct validity: evaluates the constructs or cognitive domains claimed to influence performance on the test. For example, if a test purports to measure memory, it has good construct validity if results on both the novel test and other standard tests of memory correlate highly.
- Test-retest validity: evaluates the similarity of results with repeated testing and includes reliability and stability. Reliability measures whether relative test results of individuals are similar with respect to each other, and will be high if individuals obtain scores that are equidistant from each other (and with the same individual performing better). Reliability can be high even if there are practice effects if individuals’ relative positions don’t alter. Stability measures the variability of scores with repeated testing, with high stability if scores change within a narrow range. For repeated testing where subtle changes are to be detected, high stability is essential. Tests with large practice effects have low stability.
Finally, although not strictly a type of statistical validity, tests are commonly compared to normative data. Most normative data is population-based using similar peers from testing on a single occasion, but for comparisons After Injury to Baseline, normative data for repeated testing is required to determine the usual intra-individual variability that occurs. By knowing what is normal with single and repeated testing, statistical thresholds for abnormal deviations from these can be set.
There have now been many studies using the technology that underlies the Axon Sports CCAT. Many of these studies have been done by CogState Ltd, which originally developed the testing system. As is common in science, these studies are published in many different journals so it can be hard to collate them together to gain a coherent picture of the breadth of research that supports the sensitivity of the Axon Sports CCAT in detecting change from Baseline. The next paragraph summarizes this research with several abstracts available from the Axon Sports Resource Center for those interested.
Criterion validity studies have shown the Axon Sports CCAT tasks to be sensitive to the cognitive effects of mild head injury and concussion (Makdissi et al 2001; Collie et al 2003; Moriarity et al 2004; Collie et al 2006; Maruff et al 2009; Makdissi et al 2010; Straume-Naesheim et al 2009). Construct validity has also been shown in healthy volunteers with high correlations between specific Axon Sports CCAT tasks and conventional neuropsychological tests when performed on a single assessment (Collie et al 2001; Collie et al 2003c; Maruff et al 2009). In addition, the Axon Sports CCAT is sensitive to cognitive impairment in fatigue, alcohol and drug use (Falleti et al 2003; Snyder et al 2005a, b; Falleti et al 2006; Collie et al 2007), psychiatric (Pietrzak et al 2009a,b), and neurodegenerative disease (Darby et al 2002; Maruff et al 2004; Ellis et al 2009; Darby et al (in press)). Thus, the Axon Sports CCAT is highly sensitive to almost any cause of cognitive impairment, but not specific to concussion. This emphasizes the importance of use of the Axon Sports CCAT by informed medical attendants who understand the complete medical context of the athlete. It also allows comparisons between the magnitude of Axon Sports CCAT detected cognitive impairment and socially meaningful impairments caused by other conditions, e.g. a blood alcohol change of 0.08% is equivalent to the speed decline seen at the threshold level for a significant decline from Baseline of 1.65 standardized change units used in the Axon Sports CCAT report (Falleti et al 2003).
Reliability validity studies have also been evaluated showing moderate to high reliability on repeated testing (Collie et al 2003a; Falleti et al 2006; Broglio et al 2007), but more importantly very high stability and minimal practice effects when repeated within minutes, hours, weeks, months or years (Collie et al 2003c; Falleti et al 2006; Fredrickson et al 2010). Issues relating to important psychometric properties of computerized assessment tools used in concussed athletes have also been described (Collie et al 2003b) and were the basis for the unique game-like design of the Axon Sports CCAT. Axon Sports has evaluated high frequency testing specifically because the absence of practice effects makes evaluation of After Injury cognitive impairment (in comparison to the Athlete’s Baseline results) much simpler than if practice effects were present. It is therefore essential that tools that claim to be useful with repeated testing publish high frequency testing data so that the presence of practice effects can be appreciated. An article recently published by German neuropsychologists is one such study, showing large and continuing practice effects on all conventional tasks evaluated except where ceiling effects occurred (Bartels et al 2010).
The Axon Sports CCAT has been shown to be more sensitive to post-concussion cognitive impairment than reported symptoms or commonly used paper & pencil tests (Makdissi et al 2010). Impairments detected by the Axon Sports CCAT in comparison to an Athlete’s Baseline, tend to remain 2-3 days longer than other clinical features, such that at seven days up to 18 percent of Athletes have persistent CCAT abnormalities (and this is about 8 percent at 13 days). Therefore, as an indicator of persistent cerebral injury, the Axon Sports CCAT is more sensitive than reported symptoms or paper & pencil testing. The Axon Sports CCAT is also sensitive to possible sub-concussive cognitive impairment, even where this was not recognized by medical supervisors, as was shown recently in a study of amateur boxers where two boxers had persistent and evolving cognitive impairment first detected on the Axon Sports CCAT (Moriarity et al, in prep). Studies in professional boxers have also identified similar evolving cognitive impairment, particularly in speed measures despite no overt clinical features of concussion (Clausen, doctoral thesis, 2011).
Finally, the normative data used in the Axon Sports CCAT analyses uses more than 17,000 Athletes tested on a single and repeated occasions. This normative data extends from age 10 upward and has shown maturational improvements up to at least age 14 to 15 years of age (McCrory et al 2004). In addition, age-stratified normative data has been collected for children down to age 5 (McKay et al 2011) which will be gradually incorporated into the Axon Sports CCAT to allow Baseline and After Injury testing in Athletes of all ages.
About the Author: David Darby, MB, BS, PhD FRACP, is the co-founder of CogState, the co-creator of the Axon Sports CCAT; an Associate Professor at the University of Melbourne; and a Behavioral Neurologist at the Repatriation Campus, Austin Health and Eastern Cognitive Disorders Clinic, Boxhill, Melbourne, Australia.
RECENT EVENTS
American College of Sports Medicine Annual Meeting
National Athletic Trainers Association Annual Meeting
Texas High School Coaches Association Convention
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| Axon Sports booth at the 2011 National Athletic Trainers Association Annual Meeting |
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