Why No Single Concussion Test Is Enough: The Case for Multimodal Baseline Batteries

Here’s a fact that should change how you think about baseline testing: no single concussion test has sufficient sensitivity or specificity to reliably detect all concussions on its own. The science on this point is unambiguous.

The limits of each individual tool

ImPACT, the most widely used neurocognitive test, has sensitivity rates ranging from 79.2% to 91.4% depending on the study and the composite scores used, according to research published in the Archives of Clinical Neuropsychology and the American Journal of Sports Medicine. That means 9–21% of genuinely concussed athletes may produce normal-looking cognitive scores.

The BESS balance test is even more limited — research published in PMC (McCrea et al., 2003) showed that balance deficits often resolve within 3–5 days post-injury, making BESS useful only in the acute evaluation window.

Symptom checklists are compromised by underreporting; studies in the Clinical Journal of Sport Medicine have shown that up to 50% of athletes continue playing despite recognized symptoms.

What happens when you combine them

Research by Mucha et al. (2014) demonstrated that VOMS achieves approximately 90% accuracy when integrated with a clinical interview, symptom inventory, and neurocognitive testing. Each tool catches different deficits:

• Cognitive tests catch processing speed and memory problems.
• Balance tests catch postural instability.
• VOMS catches vestibular and oculomotor dysfunction.
• Symptom checklists capture the subjective experience.

Together, they create a comprehensive net.

Concussions are not a single syndrome

A concussion can affect any or all of these domains, and the affected domains vary from person to person. Research by the UPMC Sports Medicine Concussion Program has identified six distinct clinical trajectories for concussion (cognitive/fatigue, vestibular, ocular, post-traumatic migraine, cervical, and anxiety/mood) — each involving different domains. An athlete might have perfect cognitive test scores but severe vestibular dysfunction. Another might have normal balance but impaired visual memory. If you only test one domain, you’re rolling the dice on which deficits you’ll catch.

Consensus guidance

This is why the 6th International Consensus Statement on Concussion in Sport (published in the British Journal of Sports Medicine, 2023) emphasizes multimodal assessment. The National Athletic Trainers’ Association position statement similarly recommends baselines that evaluate symptoms, cognition, motor control, and ocular motor function. The era of relying on a single computer test to manage concussions is over.

At Headquarters, our baseline protocol covers four domains at minimum: symptoms, cognition, balance, and vestibular-ocular function. This approach gives clinicians the most complete picture of your athlete’s healthy brain function and maximizes the chances of detecting impairment post-injury. For a tool-by-tool comparison, see our ImPACT vs. SCAT6 vs. King-Devick vs. VOMS comparison.

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