(Note: Be sure to click on the PDF to the right for a graphic display of sample ImPACT test questions.)
Penn State quarterback Rob Bolden tweeted at 8 p.m. Saturday - about six hours after getting pulled from a game at Minnesota with a concussion - then he sent seven more tweets in a 24-minute span a couple of hours later.
Based solely on him being able to tweet, some Nittany Lion fans on Internet message boards and call-in shows were discussing how Bolden must be OK and would be able to play this week against Michigan.
We've made big strides with regards to concussion awareness in sports, but when people think tweeting means a person is healthy enough to play football, then the education process clearly has a ways to go.
Bolden looked alert as he walked off the field at Minnesota - there's a video of it at altoonamirror.com - but that, too, is no way to judge the health of a concussed player.
The best way to do that is with a standardized computer test called ImPACT, which analyzes different parts of the brain through a series of memory and speed tasks. ImPACT, which stands for Immediate Post-Concussion Assessment and Cognitive Testing, was developed by two Pittsburgh doctors and is used by thousands of teams across the country.
The test tells doctors what the athletes cannot - or sometimes will not - after they have suffered a concussion.
"Young kids and athletes don't always tell you the truth," Dr. Eric Kephart, a head injury specialist with Blair Orthopedics in Altoona, said about concussed players. "They want to get back to football and playing. ImPACT is an objective way of saying, 'You're still concussed, you have this problem.'"
About the test
High school, college and professional athletes in all sorts of sports - ranging from football to volleyball, soccer to wrestling - take the ImPACT test when they are healthy to get a baseline score for their performance. At Penn State and most other universities, all incoming freshmen take the ImPACT.
It is an unusual test, to say the least.
"They're very strange," Penn State senior guard Stefen Wisniewski said of the questions. "You're definitely thinking, 'What the heck does this, what is this gonna help? But I know it was designed by some very smart people who understand the brain pretty well."
Once a player suffers a concussion, he or she takes the ImPACT test again 24 to 48 hours later. It takes about 20-22 minutes to complete, and the results show doctors which areas of the brain may still be injured.
If a player fails the test, it is strongly recommended he or she be withheld from participation for at least a couple of days.
"There's usually a little bit of a range that's an acceptable number," said Ivan Mulligan, assistant professor of physical therapy at St. Francis University. "If you score below that, it tells you that section of the brain has been affected a little bit more."
Bolden failed his ImPACT follow-up test Sunday and was held out of practice Monday and Tuesday. He was tested again Wednesday and passed, according to his father, Robert Bolden Sr.
Still, that doesn't mean Bolden will be allowed to start or even play Saturday against Michigan. Penn State coach Joe Paterno said Tuesday, "I'd guess he's not going to make it," in part for his own protection and also because he will have missed so much practice.
"It's very difficult to get the player back the next week after a concussion," Mulligan said.
Many factors go into an athletes' recovery time, with two of the most important being age and gender.
"Adolescents take longer to heal," Mulligan said. "If you look at a high school athlete versus a collegiate athlete, high school athletes take longer. And If it's a female athlete, they take longer."
There are six phases, or "modules," of the ImPACT test, and examples can be found above. The phases, and what they measure, according to the ImPACT website, are:
1. Word discrimination: Evaluates attentional processes and verbal recognition memory utilizing a word discrimination paradigm.
2. Design memory: Evaluates attentional processes and visual recognition memory utilizing a design discrimination paradigm.
3. X's and O's: Measures visual working memory as well as visual processing speed and consists of a visual memory paradigm and with a distractor track.
4. Symbol matching: Evaluates visual processing speed, learning and memory.
5. Color match: Represents a choice reaction time task and also measures impulse control and response inhibition.
6. Three letter memory: Measures working memory and visual-motor response speed.
"All the squiggly lines, the colors, the memory recall ... it's generating a map of how your brain is functioning," Kephart said. "It's hard to imagine bruising your brain, but that's essentially what a concussion is."
As you can see from the examples above, some portions of the test appear easy, while others are more difficult. St. Francis allowed this writer to take the test Monday at its DiSepio Institute for Rural Health and Wellness facility, and the most struggles occurred during Phase 2, which involves a bunch of squiggly lines.
"I love the squiggly lines. I'm great at that," said Wisniewski, an Academic All-American.
There is no pass or fail the first time an athlete takes the ImPACT test because the results are used merely to find a baseline for a normal, healthy brain. Wisniewski, however, didn't see it that way.
"I look at it like a challenge," he said. "I'm like excited. Being me, I'm like, 'Ah, test, I've got to get 100. I've got to get 'em all right.' But that's not actually the goal."
Origin of ImPACT
The test was developed by Pittsburgh Steelers neurosurgeon Dr. Joseph Maroon and a colleague, neuropsychologist Mark Lovell. Maroon has been working with the Steelers for more than 20 years, back to Chuck Noll's coaching tenure, and explained how the idea for ImPACT came about in 1990.
"I told Chuck Noll, 'Your starting quarterback couldn't play against the Dallas Cowboys the following week,'" Maroon recalled. 'He said, 'Why not?' I said, 'Because he had a concussion.'"
That quarterback was the late David Woodley, who died in 2003, and Noll didn't want to hear about him not being able to play.
"I said, 'The guidelines say you have to stay out two weeks,'" Maroon told Noll. "And he said, 'Well, who wrote the guidelines? And what criteria did they use? And is this scientifically based?'
"He challenged me very directly. I said, 'You know, Coach, you're exactly right.' He said, 'If you want me to keep a guy out of play, I want scientific data you can show me that something's wrong.'"
Maroon and Lovell set out to establish such data, first using a pencil and paper test before fine-tuning and updating what eventually became the ImPACT test.
"I went back to Coach Noll and Dan Rooney and said, 'Coach, Dan, we need to baseline the whole team if you want objective data so we know what we're dealing with,'" Maroon said. "They both were very happy to do that."
The Philadelphia Eagles adopted the system shortly thereafter, more and more teams did, as well, and in 1995 the NHL started relying on ImPACT to gauge its players.
"This is a purely preventive measure," Maroon said. "It prevents kids from returning too soon and really damaging their brains."
Last week, ImPACT reached the 1.5 million mark in baseline tests. His development in 1990 has become what Maroon proudly calls "the standard of care."
All eight Blair County school districts use ImPACT for their athletes. Others in the Mirror's 24-team coverage area that use it are: Bishop Carroll, Cambria Heights, Huntingdon, Juniata Valley, Northern Bedford, Portage and Tussey Mountain.
"The key thing is it gives you a definitive analysis or measuring device to try to determine if a kid has recovered or if he's ready to play," Hollidaysburg football coach John Barton said. "There are symptoms that we all are familiar with like headache and stuff like that, but this gives you a better assessment of where the kid is and how safe it is for him to return."
Area schools that don't use ImPACT, according to its website, are: Bedford, Central Cambria, Chestnut Ridge, Everett, Glendale, Moshannon Valley, Northern Cambria, Penn Cambria and Philipsburg-Osceola.
"A neuropsychological test costs anything from $750 to $1,500 for one test," Maroon said. "ImPACT costs almost nothing for high schools, like $500 or $600 per high school for all sports."
The test is so cheap, Maroon added, that "we've basically made nothing on this over the course of 15 years. It's almost been given away because it's such an effective tool for preventing brain damage."
Caution is best
The most important contribution of the ImPACT test is that it helps keep injured athletes sidelined during a time in which they are susceptible to getting hurt again.
"What you don't want to have is a concussion on top of a concussion," Kephart said. "That can lead to very serious effects for these young kids.
"We're talking about their brains, which is much more important than their sporting activity. But it's hard for them to realize that."
ImPACT offers scientific evidence to help them realize it.
"You can have long-term damage if you don't properly diagnose and then treat a concussion the first time," Kephart said. "If you have multiple hits or multiple concussions, you're at risk for further damage, even death."
Cory Giger can be reached at 949-7031 and firstname.lastname@example.org.