Concussion Tests in 22 Languages — but Are They Valid? The Cross-Cultural Testing Gap

ImPACT is available in 22 languages, which sounds impressive from an accessibility standpoint. But translation and linguistic validation are not the same thing — and the gap between them has real clinical consequences.

Cognitive testing is culture-bound

Cognitive testing is inherently culture-bound. Word lists used for verbal memory tasks may have different frequency, familiarity, and emotional valence in different languages. The speed of reading and number-naming varies across writing systems. Processing speed norms developed in English-speaking populations may not transfer directly to speakers of languages with different alphabetic structures or reading directions. Research by Tsushima et al. identified culture as a factor influencing baseline ImPACT performance, though the topic remains significantly understudied.

Symptom reporting varies across cultures

Symptom reporting patterns also differ culturally. Research in cross-cultural psychology has documented that some cultures are more likely to report somatic symptoms (headache, dizziness, nausea) while others emphasize cognitive or emotional complaints (difficulty concentrating, feeling “in a fog,” irritability). If a symptom checklist was developed and normed in one cultural context, it may not capture the full symptom experience of athletes from different backgrounds.

How many athletes does this affect?

According to U.S. Census data, approximately 22% of the U.S. population speaks a language other than English at home. In states with large immigrant populations, this percentage is significantly higher. Athletes and workers who test in their non-primary language — or whose first language is available but whose normative data was developed in a different cultural context — may produce baseline results that don’t accurately reflect their true cognitive function.

How we approach it

At Headquarters, we administer baseline tests in the athlete’s preferred language whenever possible and interpret results with awareness of cultural and linguistic factors that may affect performance. We believe equitable brain health assessment means meeting people where they are — linguistically and culturally. For related context, see our piece on the concussion gender gap.

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