What is Baseline Testing?
Baseline is a set of evaluations performed at Highmark Health that are designed to evaluate brain function from multiple perspectives. The diagnosis of concussion continues to be based on clinical assessment. There is no definitive medical “test” that diagnoses concussion, rather there are a variety of abnormalities that can be observed, and as a sum of the parts suggest the diagnoses of concussion probable.
In view of the above, Highmark does not ascribe to any one test or set of observations that evaluate brain function. A singular perspective on function will be less able to pick up the diagnoses (lower sensitivity), and at the same time be less accurate in the diagnoses (specificity).
Highmark looks at brain function from four different perspectives: patient reported symptoms, balance and vestibular function, visual motor function, and neurocognitive ability. In so doing, Highmark brings the highest currently available sensitivity to making the diagnoses of concussion as well as the highest degree of specificity. This is of critical importance in all Highmark patients, however, it is of greatest importance when making return to play decisions for athletes of all levels, where failure to “pick up” persisting dysfunction due to concussion could lead to significantly negative outcomes.
Baseline function is most effective if it has been completed before injury, in which case the comparison after injury is invaluable. However, establishing a baseline in patients post injury remains critical since as discussed, it markedly improves the validity of diagnoses while at the same time providing performance data on which to assess the progress of healing.
The Highmark baseline consists of the following:
Balance System Assessment:
The ability to assess balance in both a static and dynamic manner is of great importance to the diagnoses and management of concussion. The Balance Error Scoring System (BESS) enables clinicians to obtain a data-centric view of a patient’s ability to perform a number of balance exercises. Critical in assisting clinicians in diagnoses, the BESS system also provides objective patient performance data with which patients and practitioners can utilize to evaluate progress following injury.
Dynamic Balance Testing:
There have been a number of papers published in the medical literature that have demonstrated the increased incidence of lower extremity injuries occurring in post concussion patients who have recently returned to play. Highmark believes that this risk must be evaluated before agreeing to return to play. As such, Highmark also employs an assessment of dynamic balance in all of its return to play protocols.
King- Devick Visual Motor Assessment:
It is increasingly evident in medical literature that visual motor abnormalities are key indicators of brain injury, and in fact may be soon accepted as a biomarker definitive diagnosis of injury. Increasingly visual motor testing is forming a basis for sideline testing in athletics to make “play” or “no play” decisions. The King-Devick visual motor test is an excellent visual motor testing tool available as it objectively evaluates performance as related to binocular eye movements and visual information processing speed. The objective data captured in this assessment enables clinicians to assist in diagnoses as well as assist in rehabilitation as it can lead to focused visual exercise designed to improve dysfunction based on concepts of brain plasticity.
Automated Neuropsychological Assessment Metrics ( ANAM ):
The most-widely used scientifically validated computerized neurocognitive evaluation system, ANAM, provides trained clinicians with neurocognitive assessment tools and services that have heretofore been in the hands of the very limited, difficult to access, pool of neuropsychologists with pencil and paper testing. Increasingly computer based neurocognitive testing is being medically accepted as state-of-the-art best practices, and for concussion, appears to be superior to traditional pencil and paper testing, as it is more readily available. The neurocognitive assessment, via ANAM, provides an important piece of the overall concussion evaluation and management process. It is a sophisticated test of cognitive abilities and represents a well researched and peer reviewed concussion management tool that can assist health care professionals in tracking the recovery of cognitive processes following concussion. It is also a tool to help communicate post-concussion status as well as assist health care professionals, educators, and payers to make decisions about return to play/learn/work following concussion.
Sport and Concussion Assessment Tool (5th edition) (SCAT5):
The SCAT5 is a screening evaluation tool designed for evaluating concussion using memory, delayed recall, coordination and concentration tests for use by qualified first responders or medical professionals. The SCAT5 score does not independently determine the diagnosis of a concussion, nor does it independently determine the injured patient’s recovery or return to play, work or learn status. At HighMark, the SCAT5 is utilized as a basic assessment of the patient post concussion to further codify the current state of the patient’s performance.
Buffalo Concussion Treadmill Testing ( BCTT ):
Clinicians have long understood that there is dysfunction of the brain’s tolerance of exertion after concussion, and that this can in fact linger long after injury has resolved at the cellular level. As the science behind concussion medicine has accumulated, it has become clear that there is a degree of dysfunction in the automatic nervous system.
The University of Buffalo has developed a treadmill testing protocol, and published extensively regarding its effectiveness in safely making return to play or work decisions. At Highmark, all patients who are returning to play or work will have to undergo and pass the BCTT.