Systematic review of the balance error scoring system

Neuromuscular Control Deficits and the Risk of Subsequent Injury after a Concussion: A Scoping Review

An emerging area of research has identified that an increased risk of musculoskeletal injury may exist upon returning to sports after a sport-related concussion. The mechanisms underlying this recently discovered phenomenon, however, remain unknown. One theorized reason for this increased injury risk includes residual neuromuscular control deficits that remain impaired despite clinical recovery. Thus, the objectives of this review were: (1) to summarize the literature examining the relationship between concussion and risk of subsequent injury and (2) to summarize the literature for one mechanism with a theorized association with this increased injury risk, i.e., neuromuscular control deficits observed during gait after concussion under dual-task conditions. Two separate reviews were conducted consistent with both specified objectives. Studies published before 9 December, 2016 were identified using PubMed, Web of Science, and Academic Search Premier (EBSCOhost). Inclusion for the objective 1 search included dependent variables of quantitative measurements of musculoskeletal injury after concussion. Inclusion criteria for the objective 2 search included dependent variables pertaining to gait, dynamic balance control, and dual-task function. A total of 32 studies were included in the two reviews (objective 1 n = 10, objective 2 n = 22). According to a variety of study designs, athletes appear to have an increased risk of sustaining a musculoskeletal injury following a concussion. Furthermore, dual-task neuromuscular control deficits may continue to exist after patients report resolution of concussion symptoms, or perform normally on other clinical concussion tests. Therefore, musculoskeletal injury risk appears to increase following a concussion and persistent motor system and attentional deficits also seem to exist after a concussion. While not yet experimentally tested, these motor system and attentional deficits may contribute to the risk of sustaining a musculoskeletal injury upon returning to full athletic participation.

A Preliminary Report on Brain-Derived Extracellular Vesicle as Novel Blood Biomarkers for Sport-Related Concussions

The purpose of the study was to test the utility of unique panel of blood biomarkers as a means to reflect one’s recovery process after sport-related neurotrauma. We established a panel of biomarkers that reacted positive with CD81 (extracellular vesicle marker) and various neuron- and glia-specific antigens [e.g., neurofilament light polypeptide (NF-L), tau, synaptosome-associated protein 25 (SNAP25), glial fibrillary acidic protein, and myelin basic protein]. We first evaluated test–retest reliabilities of brain-derived exosome markers, followed by an application of these markers in eight professional ice hockey players to detect cumulative neuronal burden from a single ice hockey season. During the season, two players were diagnosed with concussions by team physician based on an exhibition of symptoms as well as abnormality in balance and ocular motor testing. One player reached symptom-free status 7 days after the concussion, while the other player required 36 days for symptoms to completely resolve. Blood samples and clinical assessments including balance error scoring system and near point of convergence throughout recovery process were obtained. Biomarkers indicative of axonal damage, neuronal inflammation, and glial activation showed excellent test–retest reliabilities (intraclass correlation coefficient: 0.713–0.998, p’s < 0.01). There was a statistically significant increase in the NF-L marker at post-season follow-up compared to pre-season baseline (Z = −2.100, P = 0.036); however the statistical significance did not withstand Bonferroni correction for multiple comparisons. In concussion cases, neuronal and microglia markers notably increased after concussions, with the unique expression patterns being similar to that of concussion recovery process. These longitudinal data coupled with excellent test–retest reliabilities of novel array of blood biomarkers potentially reflect the damage in neural cell structures and metabolic crisis due to concussion. However, future studies with larger sample size and appropriate control groups to evaluate sensitivity and specificity of these markers are needed. This preliminary case report suggests the potential utility of multimodal blood biomarkers for concussion prognosis and recovery assessment.

ASSESSING STATIC AND DYNAMIC POSTURAL CONTROL IN A HEALTHY POPULATION

Static postural control testing is often conducted by clinicians and athletic trainers for use with athletes who have sustained a concussion. Dynamic postural control involves the body's response to perturbation of the center of mass and may offer additional insight that static testing cannot capture. The objective of this study was to assess the reliability and feasibility of a balance protocol consisting of both static and dynamic postural control assessments with a healthy, adult population. Subjects stood in both unipedal and bipedal stances on a force plate to capture quantitative data regarding the center of pressure over time. Further, subjects completed the Balance Error Scoring System (BESS), a static measure, and a modified version of the Star Excursion Balance Test (SEBT), a dynamic measure. Reliability with the BESS was limited, while moderate to strong reliability was obtained for the modified SEBT. Unipedal stances were associated with a greater variance than bipedal stances for both the BESS and force plate protocol. These assessments will be applied within a pediatric populations to determine the validity of their use. Further postural control research is necessary to determine the most viable assessments for use within an active, pediatric population.

EFFECTS OF A SEASON OF YOUTH FOOTBALL ON STATIC POSTURAL CONTROL

Concussions occur in youth football with lower frequency than observed at higher levels of play, though the effect of repetitive subconcussive head impacts resulting from participation in youth football is unknown at this point. One measure shown to be affected by concussions is athlete postural control. The objective of this study was to compare performance on the Balance Error Scoring System (BESS) and a force plate protocol at two time points within a cohort of healthy youth football players and healthy non-contact youth track or baseball athletes. In absence of a clinically-diagnosed concussion, the hypothesis was tested that a season of youth football would affect measures of static postural control and stability. Between time points, there were no significant differences observed between either BESS scores or force plate metrics. Between athlete groups, there were no significant differences observed for either the BESS or the force plate protocol. Particularly for pediatric males, postural control is still developing and current assessments may not be sensitive enough to detect changes. Continued research is necessary to determine what postural control testing may be most viable for use within an active, pediatric population.

Postural Control and Head Impact Exposure in Youth Football Players: Comparison of the Balance Error Scoring System and a Force Plate Protocol

Postural control testing is often used by clinicians and athletic trainers to assess the health of athletes during recovery from a concussion. Characterization of postural control as a clinical tool for use with youth athletes is limited though. The objective of this study was to compare performance on the Balance Error Scoring System (BESS) and a force plate protocol at the beginning and end of a season of football within a cohort of 34 healthy youth football players (average age of 9.9 ± 0.6 y). A secondary aim was to investigate if changes in measures of balance from the postseason to the preseason were correlated with head impact exposure. Players completed testing at the beginning and end of the youth football season. There were no significant differences between BESS scores before the season and after the season (P = .54). Performance on the BESS was not associated with any of the center of pressure metrics considered in this study. No correlation was observed between measures of balance and head impact exposure for the season. Further research is required to determine the viability of postural control testing with this population.

Neurological Manifestations Among US Government Personnel Reporting Directional Audible and Sensory Phenomena in Havana, Cuba

IMPORTANCE

From late 2016 through August 2017, US government personnel serving on diplomatic assignment in Havana, Cuba, reported neurological symptoms associated with exposure to auditory and sensory phenomena.

OBJECTIVE

To describe the neurological manifestations that followed exposure to an unknown energy source associated with auditory and sensory phenomena.

DESIGN, SETTING, AND PARTICIPANTS

Preliminary results from a retrospective case series of US government personnel in Havana, Cuba. Following reported exposure to auditory and sensory phenomena in their homes or hotel rooms, the individuals reported a similar constellation of neurological symptoms resembling brain injury. These individuals were referred to an academic brain injury center for multidisciplinary evaluation and treatment.

EXPOSURES

Report of experiencing audible and sensory phenomena emanating from a distinct direction (directional phenomena) associated with an undetermined source, while serving on US government assignments in Havana, Cuba, since 2016.

MAIN OUTCOMES AND MEASURES

Descriptions of the exposures and symptoms were obtained from medical record review of multidisciplinary clinical interviews and examinations. Additional objective assessments included clinical tests of vestibular (dynamic and static balance, vestibulo-ocular reflex testing, caloric testing), oculomotor (measurement of convergence, saccadic, and smooth pursuit eye movements), cognitive (comprehensive neuropsychological battery), and audiometric (pure tone and speech audiometry) functioning. Neuroimaging was also obtained.

RESULTS

Of 24 individuals with suspected exposure identified by the US Department of State, 21 completed multidisciplinary evaluation an average of 203 days after exposure. Persistent symptoms (>3 months after exposure) were reported by these individuals including cognitive (n = 17, 81%), balance (n = 15, 71%), visual (n = 18, 86%), and auditory (n = 15, 68%) dysfunction, sleep impairment (n = 18, 86%), and headaches (n = 16, 76%). Objective findings included cognitive (n = 16, 76%), vestibular (n = 17, 81%), and oculomotor (n = 15, 71%) abnormalities. Moderate to severe sensorineural hearing loss was identified in 3 individuals. Pharmacologic intervention was required for persistent sleep dysfunction (n = 15, 71%) and headache (n = 12, 57%). Fourteen individuals (67%) were held from work at the time of multidisciplinary evaluation. Of those, 7 began graduated return to work with restrictions in place, home exercise programs, and higher-level work-focused cognitive rehabilitation.

CONCLUSIONS AND RELEVANCE

In this preliminary report of a retrospective case series, persistent cognitive, vestibular, and oculomotor dysfunction, as well as sleep impairment and headaches, were observed among US government personnel in Havana, Cuba, associated with reports of directional audible and/or sensory phenomena of unclear origin. These individuals appeared to have sustained injury to widespread brain networks without an associated history of head trauma.

Sub-concussive trauma, acute concussion, and history of multiple concussions: Effects on quiet stance postural control stability

Although balance control has been studied extensively following acute concussion, little is known regarding repetitive sub-concussive head impacts or chronic exposure to multiple concussive events. Quiet stance postural control was characterized in contact sport athletes at pre-season (n = 135) and post-season (n = 48) to evaluate the effects of subconcussive trauma to the head. To determine the impact of acute concussion on postural control, athletes diagnosed with a concussion during the season (n = 12) were tested at 72-h, 2-weeks, and 1-month post-injury. Because only 4 of the concussed athletes completed baseline testing, control athletes (n = 12) matched for sport, age, body mass index (BMI), and previous concussion history served as a comparison group. Finally, the effects of previous concussion history on quiet stance postural control were determined by comparing pre-season data in contact sport athletes with either zero (Hx⁰, n = 50) or three or more (Hx³⁺, n = 25) previous concussions. A force plate was used to compare changes in centre-of-pressure root-mean-square displacement (RMSdisp) and mean-velocity (COPvel) in the anterior/posterior (AP) and medial/lateral (ML) directions. One-minute trials were performed with feet hip-width apart, hands-on-hips, and A) eyes-open and B) eyes-closed. Biomechanical head-impact exposure (impacts over 10 g) was indexed over the season using mastoid-fixed impact sensors. In acutely injured athletes, repeated-measures ANOVA revealed a significant effect of time for RMSdisp AP with increased displacement at 2 weeks compared to 72 h (p = 0.008, 95% CI: -0.180, -0.310 cm). No other COP variables were affected by acute concussion. Moreover, there was no effect of concussion history or repeated sub-concussive impacts on any quiet stance metric. Additionally, head-impact exposure metrics were not correlated with COP metrics. Taken together, the data suggests alterations in COP sway during quiet stance persist in the acute 2-week period after injury. These findings were not present with either a history of multiple concussions or exposure to sub-concussive head impacts indicating acute concussion does not have appear to have long term effects for these measures.

Visual-vestibular processing deficits in mild traumatic brain injury

BACKGROUND

The search for reliable and valid signs and symptoms of mild traumatic brain injury (mTBI), commonly synonymous with concussion, has lead to a growing body of evidence that individuals with long-lasting, unremitting impairments often experience visual and vestibular symptoms, such as dizziness, postural and gait disturbances.

OBJECTIVE

Investigate the role of visual-vestibular processing deficits following concussion.

METHODS

A number of clinically accepted vestibular, oculomotor, and balance assessments as well as a novel virtual reality (VR)-based balance assessment device were used to assess adults with post-acute concussion (n = 14) in comparison to a healthy age-matched cohort (n = 58).

RESULTS

Significant between-group differences were found with the VR-based balance device (p = 0.001), with dynamic visual motion emerging as the most discriminating balance condition. The symptom reports collected after performing the oculomotor and vestibular tests: rapid alternating horizontal eye saccades, optokinetic stimulation, and gaze stabilization, were all sensitive to health status (p < 0.05), despite the absence of oculomotor abnormalities being observed, except for near-point convergence. The BESS, King-Devick, and Dynamic Visual Acuity tests did not detect between-group differences.

CONCLUSION

Postural and visual-vestibular tasks most closely linked to spatial and self-motion perception had the greatest discriminatory outcomes. The current findings suggest that mesencephalic and parieto-occipital centers and pathways may be involved in concussion.

The Examination of Patient-Reported Outcomes and Postural Control Measures in Patients With and Without a History of ACL Reconstruction: A Case Control Study

Context: There is a lack of literature to support the diagnostic accuracy and cut-off scores of commonly used patient-reported outcome measures (PROMs) and clinician-oriented outcomes such as postural-control assessments (PCAs) when treating post-ACL reconstruction (ACLR) patients. These scores could help tailor treatments, enhance patient-centered care and may identify individuals in need of additional rehabilitation. Objective: To determine if differences in 4-PROMs and 3-PCAs exist between post-ACLR and healthy participants, and to determine the diagnostic accuracy and cut-off scores of these outcomes. Design: Case control. Setting: Laboratory. Participants: A total of 20 post-ACLR and 40 healthy control participants. Main Outcome Measures: The participants completed 4-PROMs (the Disablement in the Physically Active Scale [DPA], The Fear-Avoidance Belief Questionnaire [FABQ], the Knee Osteoarthritis Outcomes Score [KOOS] subscales, and the Tampa Scale of Kinesiophobia [TSK-11]) and 3-PCAs (the Balance Error Scoring System [BESS], the modified Star Excursion Balance Test [SEBT], and static balance on an instrumented force plate). Mann-Whitney U tests examined differences between groups. Receiver operating characteristic (ROC) curves were employed to determine sensitivity and specificity. The Area Under the Curve (AUC) was calculated to determine the diagnostic accuracy of each instrument. The Youdin Index was used to determine cut-off scores. Alpha was set a priori at P < 0.05. Results: There were significant differences between groups for all PROMs (P < 0.05). There were no differences in PCAs between groups. The cut-off scores should be interpreted with caution for some instruments, as the scores may not be clinically applicable. Conclusions: Post-ACLR participants have decreased self-reported function and health-related quality of life. The PROMs are capable of discriminating between groups. Clinicians should consider using the cut-off scores in clinical practice. Further use of the instruments to examine detriments after completion of standard rehabilitation may be warranted.

Using concurrent gait and cognitive assessments to identify impairments after concussion: a narrative review

Understanding how a concussion affects an individual is oftentimes difficult for clinicians due to the varying symptom profiles reported by the patient and the multifaceted and heterogeneous nature of the injury. Accordingly, the interpretation of postconcussion performance can be challenging, because many different testing paradigms have been reported as potentially useful in the literature. Among the types of tests clinicians use to understand how concussion affects an individual, both gait and neurocognitive evaluations have demonstrated utility. Our purpose is to describe how combined gait and cognitive (i.e., dual task), as well as single-task gait and computerized neurocognitive examinations can assist clinical decision-making.

A Longitudinal Examination of Postural Impairments in Children With Mild Traumatic Brain Injury: Implications for Acute Testing

OBJECTIVE

To examine how postural control changes following pediatric mild traumatic brain injury.

SETTING

Urban pediatric emergency department.

PARTICIPANTS

Children 11 to 16 years old who presented within 6 hours of sustaining mild traumatic brain injury.

DESIGN

Prospective observational cohort followed for 1 month.

MAIN MEASURES

Total center of pressure path velocity and path velocity within distinct frequency bands, ranging from moderate to ultralow, were recorded by the Nintendo Wii Balance Board during a 2-legged stance. Measurements were recorded in 2 separate tests with eyes open and closed. The scores of the 2 tests were compared, and a Romberg quotient was computed.

RESULTS

Eleven children were followed for 1 month postinjury. The ultralow frequency, which reflects slow postural movements associated with exploring stability boundaries, was lower (p = .02) during the eyes closed stance acutely following injury. The Romberg quotient for this frequency was also significantly lower acutely following injury (p = .007) than at 1 month.

CONCLUSION

Following mild traumatic brain injury, children acutely demonstrate significantly more rigid sway patterns with eyes closed than with eyes open, which were highlighted by the Romberg quotient. The Romberg quotient could allow for accurate identification and tracking of postural instability without requiring knowledge of preinjury balance ability.

Posttraumatic Headache

After sustaining a concussion or mild traumatic brain injury, headaches are one of the most common complaints. The pathophysiologic changes that occur in the setting of injury likely contribute to or cause posttraumatic headaches. Posttraumatic headaches often present as migraine or tension-type headaches. Unlike pain from other types of injuries, headaches following mild traumatic brain injury are more likely to persist. Preexisting conditions such as migraine and mood disorders may influence posttraumatic headache and complicate management. Patients are at high risk to overuse abortive medications and develop medication overuse headache. Headache hygiene and early education are essential for effective management. Abortive medications include nonsteroidal anti-inflammatory drugs and triptans. Preventive medications include tricyclic antidepressants and antiepileptics. Patients who fail outpatient therapies may benefit from referral for intravenous medications in the emergency department. Patients with persistent posttraumatic headache may benefit from multimodal treatments including physical rehabilitation and pain-focused cognitive-behavioral therapies. [Pediatr Ann. 2018;47(2):e61-e68.].

Sport Concussion and the Female Athlete

Sport concussion (SC) has emerged as a major health concern in the medical community and general public owing to increased research and media attention, which has primarily focused on male athletes. Female athletes have an equal, if not increased, susceptibility to SC. An ever-growing body of research continues to compare male and female athletes in terms of SC before and after an injury. Clinicians must be cognizant of this literature to make evidence-based clinical decision when providing care to female athletes and discern between dated and/or unsupported claims in terms of SC.

Acute diesel exhaust exposure and postural stability: a controlled crossover experiment

Recent epidemiological evidence connects ambient air pollutants to adverse neurobehavioural effects in adults. In animal models, subchronic controlled exposures to diesel exhaust (DE) have also showed evidence of neuroinflammation. Evidence suggests that DE not only affects outcomes commonly associated with cognitive dysfunction, but also balance impairment. We conducted a controlled human exposure experiment with 28 healthy subjects (average age = 28 years (SD = 7.1; range = 21-49); and 40% female) who were exposed to two conditions, filtered air (FA) and DE (300 μg PM2.5/m3) for 120 min, in a double-blinded crossover study with randomized exposures separated by four weeks. Postural stability was assessed by the Balance Error Scoring System (BESS), a brief, easily-administered test of static balance. The BESS consists of a sequence of three stances performed on two surfaces. With hands on hips and eyes closed, each stance is held for 20 s. "Error" points are awarded for deviations from those stances. Pre- and immediately post-exposure BESS "error" point totals were calculated and the difference between the two timepoints were compared for each of the two exposure conditions. A mixed effect model assessed the significance of the association. While our data demonstrates a trend of reduced postural stability in response to exposure to DE, exposure was not significantly associated with BESS value. This is the first study to investigate changes in postural stability as a result of exposure to DE in human subjects.

A Novel EEG Based Spectral Analysis of Persistent Brain Function Alteration in Athletes with Concussion History

The neurocognitive sequelae of a sport-related concussion and its management are poorly defined. Detecting deficits are vital in making a decision about the treatment plan as it can persist one year or more following a brain injury. The reliability of traditional cognitive assessment tools is debatable, and thus attention has turned to assessments based on electroencephalogram (EEG) to evaluate subtle post-concussive alterations. In this study, we calculated neurocognitive deficits combining EEG analysis with three standard post-concussive assessment tools. Data were collected for all testing modalities from 21 adolescent athletes (seven concussive and fourteen healthy) in three different trials. For EEG assessment, along with linear frequency-based features, we introduced a set of time-frequency (Hjorth Parameters) and nonlinear features (approximate entropy and Hurst exponent) for the first time to explore post-concussive deficits. Besides traditional frequency-band analysis, we also presented a new individual frequency-based approach for EEG assessment. While EEG analysis exhibited significant discrepancies between the groups, none of the cognitive assessment resulted in significant deficits. Therefore, the evidence from the study highlights that our proposed EEG analysis and markers are more efficient at deciphering post-concussion residual neurocognitive deficits and thus has a potential clinical utility of proper concussion assessment and management.

Challenging concussed athletes: the future of balance assessment in concussion

The assessment and management of sports-related concussion has become a contentious issue in the field of sports medicine. The current consensus in concussion evaluation involves the use of a subjective examination, supported by multifactorial assessment batteries designed to target the various components of cerebral function. Balance assessment forms an important component of this multifactorial assessment, as it can provide an insight into the function of the sensorimotor subsystems post-concussion. In recent times, there has been a call to develop objective clinical assessments that can aid in the assessment and monitoring of concussion. However, traditional static balance assessments are derived from neurologically impaired populations, are subjective in nature, do not adequately challenge high functioning athletes and may not be capable of detecting subtle balance disturbances following a concussive event. In this review, we provide an overview of the importance of assessing motor function following a concussion, and the challenges facing clinicians in its assessment and monitoring. Additionally, we discuss the limitations of the current clinical methods employed in balance assessment, the role of technology in improving the objectivity of traditional assessments, and the potential role inexpensive portable technology may play in providing objective measures of more challenging dynamic tasks.

Quantitative measurement of post-concussion syndrome Using Electrovestibulography

In this study, a noninvasive quantitative measure was used to identify short and long term post-concussion syndrome (PCS) both from each other and from healthy control populations. We used Electrovestibulography (EVestG) for detecting neurophysiological PCS consequent to a mild traumatic brain injury (mTBI) in both short-term (N = 8) and long-term (N = 30) (beyond the normal recovery period) symptomatic individuals. Peripheral, spontaneously evoked vestibuloacoustic signals incorporating - and modulated by - brainstem responses were recorded using EVestG, while individuals were stationary (no movement stimulus). Tested were 38 individuals with PCS in comparison to those of 33 age-and-gender-matched healthy controls. The extracted features were based on the shape of the averaged extracted field potentials (FPs) and their detected firing pattern. Linear discriminant analysis classification, incorporating a leave-one-out routine, resulted in (A) an unbiased 84% classification accuracy for separating healthy controls from a mix of long and short-term symptomatology PCS sufferers and (B) a 79% classification accuracy for separating between long and short-term symptomatology PCS sufferers. Comparatively, short-term symptomatology PCS was generally detected as more distal from controls. Based on the results, the EVestG recording shows promise as an assistive objective tool for detecting and monitoring individuals with PCS after normal recovery periods.

Descriptive Values for Dancers on Baseline Concussion Tools

CONTEXT

  Capturing baseline data before a concussion can be a valuable tool in individualized care. However, not all athletes, including dancers, have access to baseline testing. When baseline examinations were not performed, clinicians consult normative values. Dancers are unique athletes; therefore, describing values specific to dancers may assist those working with these athletes in making more informed decisions.

OBJECTIVE

  To describe values for key concussion measures of dancers. Our secondary aim was to examine whether differences existed between sexes and professional status. Finally, we explored factors that may affect dancers' scores.

DESIGN

  Cross-sectional study.

SETTING

  Professional dance companies and a collegiate dance conservatory.

PATIENTS OR OTHER PARTICIPANTS

  A total of 238 dancers (university = 153, professional = 85; women = 171; men = 67; age = 21.1 ± 4.8 years).

MAIN OUTCOME MEASURE(S)

  We calculated the total symptom severity from the Sport Concussion Assessment Tool-3rd edition; the Standardized Assessment of Concussion score; the modified Balance Error Scoring System score; and the King-Devick score for each participant. Group differences were analyzed with Mann-Whitney or t tests, depending on the data distribution. We used bivariate correlations to explore the effects of other potential influencing factors.

RESULTS

  Participants demonstrated the following baseline outcomes: symptom severity = 16.6 ± 12.8; Standardized Assessment of Concussion = 27.5 ± 1.8; modified Balance Error Scoring System = 3.2 ± 3.1 errors; and King-Devick = 41.5 ± 8.2 seconds. A Mann-Whitney test revealed differences in King-Devick scores between female (40.8 ± 8.0 seconds) and male (43.4 ± 8.4 seconds) dancers ( P = .04). An independent-samples t test also demonstrated a difference in modified Balance Error Scoring System scores between female (2.95 ± 3.1 errors) and male (3.8 ± 3.1 errors) dancers ( P = .02). Age, hours of sleep, height, and history of concussion, depression, or injury did not display moderate or strong associations with any of the outcome measures.

CONCLUSIONS

  Dancers' symptom severity scores appeared to be higher than the values reported for other athletes. Additional studies are needed to establish normative values and develop a model for predicting baseline scores.

Balance Performance as Observed by Center-of-Pressure Parameter Characteristics in Male Soccer Athletes and Non-Athletes

Static balance has a relevant influence on athletic performance as well as on reducing the risk of injury. The main goal of this study was to assess soccer athlete versus non-athlete balance performance via displacement and velocity parameters extracted from the center-of-pressure (COP) position time series. In order to accomplish our goal, we investigated standing balance in two male groups with unimpaired balance: non-athletes (n = 12) and collegiate varsity soccer athletes (n = 12). In order to make the standing balancing task more or less difficult, we altered participant base-of-support, as well as vision, yielding static (quiet stance) test conditions increasing in difficulty. From the COP position time series, displacement and velocity parameters were computed and plotted as a function of increasing test condition difficulty level. COP parameters showed steeper increases with increased test difficulty in non-athletes compared to athletes; this demonstrated athletes’ better ability to control their balance. We concluded that balance performance could be characterized via COP displacement and velocity response curves. This study lends new insights into how COP parameters can be utilized to determine and characterize improvements in balance between un-impaired subject populations (athletes versus non-athletes).

Reliability and Concurrent Validity of Select C3 Logix Test Components

We sought to investigate the one-week and within-session reliability of the instrumented balance error scoring system test and the concurrent validity/one-week reliability of two neurocognitive assessments available through C3 Logix. (n = 37) Participants completed two balance error scoring system tests separated by the Trails A, Trails B, and Symbol Digit Modality test available through C3 Logix, and with paper and pencil. We found that the instrumented balance error scoring system test demonstrated strong one-week reliability and that neuropsychological tests available through C3 Logix show acceptable concurrent validity with standard (comparable) paper and pencil measures.

An Objective Balance Error Scoring System for Sideline Concussion Evaluation Using Duplex Kinect Sensors

Sports-related concussion is a common sports injury that might induce potential long-term consequences without early diagnosis and intervention in the field. However, there are few options of such sensor systems available. The aim of the study is to propose and validate an automated concussion administration and scoring approach, which is objective, affordable and capable of detecting all balance errors required by the balance error scoring system (BESS) protocol in the field condition. Our approach is first to capture human body skeleton positions using two Microsoft Kinect sensors in the proposed configuration and merge the data by a custom-made algorithm to remove the self-occlusion of limbs. The standing balance errors according to BESS protocol were further measured and accessed automatically by the proposed algorithm. Simultaneously, the BESS test was filmed for scoring by an experienced rater. Two results were compared using Pearson coefficient r, obtaining an excellent consistency (r = 0.93, p < 0.05). In addition, BESS test–retest was performed after seven days and compared using intraclass correlation coefficients (ICC), showing a good test–retest reliability (ICC = 0.81, p < 0.01). The proposed approach could be an alternative of objective tools to assess postural stability for sideline sports concussion diagnosis.

Cortical thinning in former professional soccer players

Soccer is the most popular sport in the world. Soccer players are at high risk for repetitive subconcussive head impact when heading the ball. Whether this leads to long-term alterations of the brain's structure associated with cognitive decline remains unknown. The aim of this study was to evaluate cortical thickness in former professional soccer players using high-resolution structural MR imaging. Fifteen former male professional soccer players (mean age 49.3 [SD 5.1] years) underwent high-resolution structural 3 T MR imaging, as well as cognitive testing. Fifteen male, age-matched former professional non-contact sport athletes (mean age 49.6 [SD 6.4] years) served as controls. Group analyses of cortical thickness were performed using voxel-based statistics. Soccer players demonstrated greater cortical thinning with increasing age compared to controls in the right inferolateral-parietal, temporal, and occipital cortex. Cortical thinning was associated with lower cognitive performance as well as with estimated exposure to repetitive subconcussive head impact. Neurocognitive evaluation revealed decreased memory performance in the soccer players compared to controls. The association of cortical thinning and decreased cognitive performance, as well as exposure to repetitive subconcussive head impact, further supports the hypothesis that repetitive subconcussive head impact may play a role in early cognitive decline in soccer players. Future studies are needed to elucidate the time course of changes in cortical thickness as well as their association with impaired cognitive function and possible underlying neurodegenerative process.

Dizziness-related disability following mild-moderate traumatic brain injury

OBJECTIVE

To investigate the associations between dizziness-related disability after mild- moderate Traumatic Brain Injury (TBI) and personal factors, injury-related factors and post-injury functioning using the International Classification of Functioning, Disability and Health (ICF) as a framework.

METHODS

Baseline assessments for a Randomised Controlled Trial (RCT) were obtained for 65 patients (mean age 39.2 years; SD 12.9 years; 70.8% women) who had dizziness and reduced balance 2-6 months after injury. The severity of the brain injury, physical and psychological self-reported symptoms and results from the performance based tests were used as independent variables. The main outcome measure (dependent variable) was the Dizziness Handicap Inventory (DHI).

RESULTS

Multivariate analyses showed that, the dizziness-related disability was predicted by pre-injury comorbidities (p ≤ 0.05) and was associated with self-reported vertigo symptoms (p < 0.001), reduced performance-based balance (p ≤ 0.05) and psychological distress (p ≤ 0.05). These factors accounted for 62% of the variance in DHI.

CONCLUSION

Dizziness and balance problems after mild-moderate TBI appear to be complex biopsychosocial phenomena. Assessments linked to the ICF domains of functioning might contribute to a broader understanding of the needs of these patients. Further, prospective clinical studies with non-dizzy control groups are needed to investigate dizziness-related disability after TBI.

Assessment of the Postural Stability of Female and Male Athletes

OBJECTIVE

Postural stability is often affected by sport-related injuries and subsequently evaluated during postinjury examinations. Intrinsic factors, however, may also affect postural control. We sought to compare the postural control of female and male athletes as measured simultaneously by (1) the modified balance error scoring system (mBESS) and (2) a video-force plate system.

DESIGN

Cross-sectional study.

SETTING

Sports injury prevention center.

PARTICIPANTS

Pediatric, adolescent, and young adult athletes who performed mBESS during an injury prevention evaluation.

INDEPENDENT VARIABLES

We compared the postural control of female and male athletes. We also accounted for independent variables associated with postural stability, including age, body mass index, and history of ankle injury, concussion, and migraine headache.

MAIN OUTCOME MEASURES

Total errors committed during the mBESS and measurements derived from integrated kinematic and kinetic data obtained by a video-force plate system. Differences between males and females were tested using analysis of covariance.

RESULTS

Participants (n = 409) ranged in age from 10 to 29 years (mean = 14.6 ± 2.8); 60% were female. No significant differences on mBESS were detected between females and males; however, female athletes demonstrated significantly better postural stability on the video-force plate analysis during double-leg (P = 0.03, d = 0.28), single-leg (P < 0.001, d = 0.62), and tandem stances (P < 0.001, d = 0.53) when compared with males.

CONCLUSIONS

Uninjured female athletes demonstrate better postural stability on video-force plate analysis than their uninjured male counterparts. These findings provide an important information assistive to clinicians during interpretation of postinjury balance tests.

The Automated Assessment of Postural Stability: Balance Detection Algorithm

Impaired balance is a common indicator of mild traumatic brain injury, concussion and musculoskeletal injury. Given the clinical relevance of such injuries, especially in military settings, it is paramount to develop more accurate and reliable on-field evaluation tools. This work presents the design and implementation of the automated assessment of postural stability (AAPS) system, for on-field evaluations following concussion. The AAPS is a computer system, based on inexpensive off-the-shelf components and custom software, that aims to automatically and reliably evaluate balance deficits, by replicating a known on-field clinical test, namely, the Balance Error Scoring System (BESS). The AAPS main innovation is its balance error detection algorithm that has been designed to acquire data from a Microsoft Kinect^® sensor and convert them into clinically-relevant BESS scores, using the same detection criteria defined by the original BESS test. In order to assess the AAPS balance evaluation capability, a total of 15 healthy subjects (7 male, 8 female) were required to perform the BESS test, while simultaneously being tracked by a Kinect 2.0 sensor and a professional-grade motion capture system (Qualisys AB, Gothenburg, Sweden). High definition videos with BESS trials were scored off-line by three experienced observers for reference scores. AAPS performance was assessed by comparing the AAPS automated scores to those derived by three experienced observers. Our results show that the AAPS error detection algorithm presented here can accurately and precisely detect balance deficits with performance levels that are comparable to those of experienced medical personnel. Specifically, agreement levels between the AAPS algorithm and the human average BESS scores ranging between 87.9% (single-leg on foam) and 99.8% (double-leg on firm ground) were detected. Moreover, statistically significant differences in balance scores were not detected by an ANOVA test with alpha equal to 0.05. Despite some level of disagreement between human and AAPS-generated scores, the use of an automated system yields important advantages over currently available human-based alternatives. These results underscore the value of using the AAPS, that can be quickly deployed in the field and/or in outdoor settings with minimal set-up time. Finally, the AAPS can record multiple error types and their time course with extremely high temporal resolution. These features are not achievable by humans, who cannot keep track of multiple balance errors with such a high resolution. Together, these results suggest that computerized BESS calculation may provide more accurate and consistent measures of balance than those derived from human experts.

Assessing balance through the use of a low-cost head-mounted display in older adults: a pilot study

Introduction

As the population ages, the prevention of falls is an increasingly important public health problem. Balance assessment forms an important component of fall-prevention programs for older adults. The recent development of cost-effective and highly responsive virtual reality (VR) systems means new methods of balance assessment are feasible in a clinical setting. This proof-of-concept study made use of the submillimeter tracking built into modern VR head-mounted displays (VRHMDs) to assess balance through the use of visual–vestibular conflict. The objective of this study was to evaluate the validity, acceptability, and reliability of using a VRHMD to assess balance in older adults.

Materials and methods

Validity was assessed by comparing measurements from the VRHMD to measurements of postural sway from a force plate. Acceptability was assessed through the use of the Simulator Sickness Questionnaire pre- and postexposure to assess possible side effects of the visual–vestibular conflict. Reliability was assessed by measuring correlations between repeated measurements 1 week apart. Variables of possible importance that were found to be reliable (r≥0.9) between tests separated by a week were then tested for differences compared to a control group. Assessment was performed as a cross-sectional single-site community center-based study in 13 older adults (≥65 years old, 80.2±7.3 years old, 77% female, five at risk of falls, eight controls). The VR balance assessment consisted of four modules: a baseline module, a reaction module, a balance module, and a seated assessment.

Results

There was a significant difference in the rate at which participants with a risk of falls changed their tilt in the anteroposterior direction compared to the control group. Participants with a risk of falls changed their tilt in the anteroposterior direction at 0.7°/second vs 0.4°/second for those without a history of falls. No significant differences were found between pre/postassessment for oculomotor score or total Simulator Sickness Questionnaire score. Both the force plate and the head-mounted display balance-assessment system were able to detect differences between conditions meant to mask visual and proprioceptive information.

Conclusion

This VRHMD is both affordable and portable, causes minimal simulator sickness, and produces repeatable results that can be used to assess balance in older adults.

Symptom correlates of cerebral blood flow following acute concussion

Concussion is associated with significant symptoms within hours to days post-injury, including disturbances in physical function, cognition, sleep and emotion. However, little is known about how subjective impairments correlate with objective measures of cerebrovascular function following brain injury. This study examined the relationship between symptoms and cerebral blood flow (CBF) in individuals following sport-related concussion. Seventy university level athletes had CBF measured using Arterial Spin Labelling (ASL), including 35 with acute concussion and 35 matched controls and their symptoms were assessed using the Sport Concussion Assessment Tool 3 (SCAT3). For concussed athletes, greater total symptom severity was associated with elevated posterior cortical CBF, although mean CBF was not significantly different from matched controls (p = 0.46). Examining symptom clusters, athletes reporting greater cognitive symptoms also had lower frontal and subcortical CBF, relative to athletes with greater somatic symptoms. The "cognitive" and "somatic" subgroups also exhibited significant differences in CBF relative to controls (p ≤ 0.026). This study demonstrates objective CBF correlates of symptoms in recently concussed athletes and shows that specific symptom clusters may have distinct patterns of altered CBF, significantly extending our understanding of the neurobiology of concussion and traumatic brain injury.

Balance training improves memory and spatial cognition in healthy adults

Physical exercise has been shown to improve cognitive functions. However, it is still unknown which type of exercise affects cognition. In the present study, we tested the hypothesis that a demanding balance training program improves memory and spatial cognition. Forty healthy participants aged 19–65 years were randomly assigned to either a balance or relaxation training intervention. Each group exercised twice a week for a total of 12 weeks. Pre- and posttests assessed balance performance, cardiorespiratory fitness, memory, spatial cognition, and executive functions. Only the balance group significantly increased in balance performance from pre- to posttest, while cardiorespiratory fitness remained unchanged in both groups. Moreover, the balance group significantly improved in memory and spatial cognition. Effects on executive functions were not observed. These results suggest that balance training is capable of improving particularly memory and spatial cognition. Therefore, an increase in cardiorespiratory fitness does not seem to be necessary to induce beneficial effects of physical exercise on cognition. It might be speculated that stimulating the vestibular system during balance training induces changes of the hippocampus and parietal cortex possibly via direct pathways between the vestibular system and these brain regions.

Performance of high school male athletes on the Functional Movement Screen™

OBJECTIVES

(1) Describe the performance of the Functional Movement Screen™ (FMS™) by reporting the proportion of adolescents with a score of ≤14 and the frequency of asymmetries in a cross-sectional sample; (2) explore associations between FMS™ to age and body mass, and explore the construct validity of the FMS™ against common postural stability measures; (3) examine the inter-rater and test-retest reliability of the FMS™ in adolescents.

DESIGN

Cross-sectional.

SETTING

Field-setting.

PARTICIPANTS

94 male high-school athletes.

MAIN OUTCOME MEASURE

The FMS™, Y-Balance Test (YBT) and Balance Error Scoring System (BESS).

RESULTS

The median FMS™ composite score was 16 (9-21), 33% of participants scored below the suggested injury risk cutoff composite score of ≤14, and 62.8% had at least one asymmetry. No relationship was observed between the FMS™ to common static/dynamic balance tests. The inter-rater reliability of the FMS™ composite score suggested good reliability (ICC = 0.88, CI 95%:0.77, 0.94) and test-retest reliability for FMS™ composite scores was good with ICC = 0.83 (CI 95%:0.56, 0.95).

CONCLUSIONS

FMS™ results should be interpreted cautiously with attention to the asymmetries identified during the screen, regardless of composite score. The lack of relationship between the FMS™ and other balance measures supports the notion that multiple screening tests should be used in order to provide a comprehensive picture of the adolescent athlete.

A COMPREHENSIVE INSTRUMENT FOR EVALUATING MILD TRAUMATIC BRAIN INJURY (MTBI)/CONCUSSION IN INDEPENDENT ADULTS: A PILOT STUDY

BACKGROUND

One common component of concussion rehabilitation is a computerized cognitive test free of concomitant physical demands. Healthcare professionals may be able to provide more patient-centered care after a diagnosed concussion if specific areas of impairment are identified and treated, such as the physical aspect of neurocognitive function. Hypothesis/Purpose: To evaluate the test-retest reliability of a unique combination of neurocognitive assessment tools currently utilized in concussion assessments into one single, inclusive instrument that measures both neurocognitive function and physical capability.

STUDY DESIGN

Original research - diagnostic tests.

METHODS

Fourteen individuals (nine males, age: 29 + 17.9, five females, age: 46.0 ± 21.5 years) either with normal cognitive function (NBI) without history of a health event (e.g. cerebral vascular accident/stroke, mTBI) that resulted in brain injury within one year of the study, or who had suffered a health event that has resulted in a medically documented brain injury (BI) participated in the study. Participants completed the full hybrid assessment instrument for a baseline test, then completed a follow-up test using the same instrument within 72-96 hours of baseline. Test-retest reliability was measured using Pearson product-moment correlations of the first and second testing sessions, and a two-way ANOVA (group between factor: NBI and BI and time within factor: session 1 and session 2) was performed on the summative scores to determine differences between each group.

RESULTS

Test-retest reliability was strong and statistical significant for both the NBI (r = .858, p = .014) and the BI (r = .967, p = .033) groups. There was a significant difference between summative scores for the NBI and BI groups (F_1,20 = 42.325, p < .0001).

CONCLUSION

The newly created Comprehensive Instrument for Evaluating Mild Traumatic Brain Injury (CIEMTBI) demonstrates good test-retest reliability and was able to discriminate the results between individuals in the NBI and BI groups. Further research, specifically with different samples, is needed to better determine the reliability and diagnostic accuracy of the instrument.

LEVEL OF EVIDENCE

2c.

Outcome Measures for Persons With Moderate to Severe Traumatic Brain Injury: Recommendations From the American Physical Therapy Association Academy of Neurologic Physical Therapy TBI EDGE Task Force

BACKGROUND AND PURPOSE

The use of standardized outcome measures (OMs) is essential in assessing the effectiveness of physical therapy (PT) interventions. The purposes of this article are (1) to describe the process used by the TBI EDGE task force to assess the psychometrics and clinical utility of OMs used with individuals with moderate to severe traumatic brain injury (TBI); (2) to describe the consensus recommendations for OM use in clinical practice, research, and professional (entry-level) PT education; and (3) to make recommendations for future work.

METHODS

An 8-member task force used a modified Delphi process to develop recommendations on the selection of OMs for individuals with TBI. A 4-point rating scale was used to make recommendations based on practice setting and level of ambulation. Recommendations for appropriateness for research use and inclusion in entry-level education were also provided.

RESULTS

The TBI EDGE task force reviewed 88 OMs across the International Classification of Functioning, Disability, and Health (ICF) domains: 15 measured body functions/structure only, 21 measured activity only, 23 measured participation only, and 29 OMs covered more than 1 ICF domain.

DISCUSSION AND CONCLUSIONS

Recommendations made by the TBI EDGE task force provide clinicians, researchers, and educators with guidance for the selection of OMs. The use of these recommendations may facilitate identification of appropriate OMs in the population with moderate to severe TBI. TBI EDGE task force recommendations can be used by clinicians, researchers, and educators when selecting OMs for their respective needs. Future efforts to update the recommendations are warranted in order to ensure that recommendations remain current and applicable.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A140).

Sensor-Based Balance Measures Outperform Modified Balance Error Scoring System in Identifying Acute Concussion

Balance assessment is an integral component of concussion evaluation and management. Although the modified balance error scoring system (mBESS) is the conventional clinical tool, objective metrics derived from wearable inertial sensors during the mBESS may increase sensitivity in detecting subtle balance deficits post-concussion. The aim of this study was to identify which stance condition and postural sway metrics obtained from an inertial sensor placed on the lumbar spine during the mBESS best discriminate athletes with acute concussion. Fifty-two college athletes in the acute phase of concussion and seventy-six controls participated in this study. Inertial sensor-based measures objectively detected group differences in the acutely concussed group of athletes while the clinical mBESS did not (p < 0.001 and p = 0.06, respectively). Mediolateral postural sway during the simplest condition of the mBESS (double stance) best classified those with acute concussion. Inertial sensors provided a sensitive and objective measure of balance in acute concussion. These results may be developed into practical guidelines to improve and simplify postural sway analysis post-concussion.

Evaluation of Nintendo Wii Balance Board as a Tool for Measuring Postural Stability After Sport-Related Concussion

CONTEXT

Recent changes to postconcussion guidelines indicate that postural-stability assessment may augment traditional neurocognitive testing when making return-to-participation decisions. The Balance Error Scoring System (BESS) has been proposed as 1 measure of balance assessment. A new, freely available software program to accompany the Nintendo Wii Balance Board (WBB) system has recently been developed but has not been tested in concussed patients.

OBJECTIVE

To evaluate the feasibility of using the WBB to assess postural stability across 3 time points (baseline and postconcussion days 3 and 7) and to assess concurrent and convergent validity of the WBB with other traditional measures (BESS and Immediate Post-Concussion Assessment and Cognitive Test [ImPACT] battery) of assessing concussion recovery.

DESIGN

Cohort study.

SETTING

Athletic training room and collegiate sports arena.

PATIENTS OR OTHER PARTICIPANTS

We collected preseason baseline data from 403 National Collegiate Athletic Association Division I and III student-athletes participating in contact sports and studied 19 participants (age = 19.2 ± 1.2 years, height = 177.7 ± 8.0 cm, mass = 75.3 ± 16.6 kg, time from baseline to day 3 postconcussion = 27.1 ± 36.6 weeks) who sustained concussions.

MAIN OUTCOME MEASURE(S)

We assessed balance using single-legged and double-legged stances for both the BESS and WBB, focusing on the double-legged, eyes-closed stance for the WBB, and used ImPACT to assess neurocognition at 3 time points. Descriptive statistics were used to characterize the sample. Mean differences and Spearman rank correlation coefficients were used to determine differences within and between metrics over the 3 time points. Individual-level changes over time were also assessed graphically.

RESULTS

The WBB demonstrated mean changes between baseline and day 3 postconcussion and between days 3 and 7 postconcussion. It was correlated with the BESS and ImPACT for several measures and identified 2 cases of abnormal balance postconcussion that would not have been identified via the BESS.

CONCLUSIONS

When accompanied by the appropriate analytic software, the WBB may be an alternative for assessing postural stability in concussed student-athletes and may provide additional information to that obtained via the BESS and ImPACT. However, verification among independent samples is required.

Test-Retest Reliability of the King-Devick Test in an Adolescent Population

CONTEXT

  The King-Devick (KD) test is a screening tool designed to assess cognitive visual impairments, namely saccadic rhythm, postconcussion. Test-retest reliability of the KD in a healthy adolescent population has not yet been established.

OBJECTIVE

  To investigate the overall test-retest reliability of the KD among a sample of healthy adolescents. Additionally, we sought to determine if sex and age influenced reliability.

DESIGN

  Cross-sectional study.

SETTING

  Secondary school.

PATIENTS OR OTHER PARTICIPANTS

  Sixty-eight healthy adolescents, 41 boys (age = 15.4 ± 1.9 years) and 27 girls (age = 15.4 ± 1.9 years).

MAIN OUTCOME MEASURE(S)

  Participants completed the KD (version 1) at 3 testing sessions (days 1, 30, and 45) following standard instructions. We recorded total time to complete the reading of 3 cards for each participant during each testing session. Two-way random-effects intraclass correlation coefficients (ICCs) using single measurements repeated over time and repeatability coefficients were calculated. Linear mixed models were used to determine whether differences existed at each testing time and to examine whether changes that took place among visits were different by sex or age.

RESULTS

  Adolescents who completed the KD demonstrated acceptable reliability (ICC = 0.81; 95% confidence interval = 0.73, 0.87); however, the repeatability coefficient was large (±8.76 seconds). The sample demonstrated improvements between visits 1 and 2 (mean ± standard error = 4.3 ± 0.5 seconds, P < .001) and between visits 2 and 3 (2.4 ± 0.5 seconds, P < .001) for a total improvement of 6.9 seconds over 3 tests. No significant visit-by-sex or visit-by-age interactions were observed.

CONCLUSIONS

  Despite the ICC being clinically acceptable, providers using the KD test for serial assessment of concussion in adolescents should be cautious in interpreting the results due to a large learning effect. Incorporating multiple measures can ensure accurate detection of sport concussion.

Balance Markers in Adolescents at 1 Month Postconcussion

Background:

The Balance Error Scoring System (BESS) shows that balance tends to recover within days after a concussion, whereas measures of the movement of the center of pressure (COP) show that balance deficits can persist up to 1 month after concussion. While approximately 30% of adolescents suffering concussion have functional consequences including balance deficits, evidence of the use of different balance assessments for concussion is limited within this population.

Purpose:

To compare performance on a series of balance assessments between adolescents with a diagnosed concussion at 1 month postinjury and noninjured control participants within the same age distribution.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

Thirty-three adolescents 1 month postconcussion and 33 control participants completed the BESS followed by two, 2-minute trials standing on a Nintendo Wii Balance Board (WBB), during which the COP under their feet was recorded using 2 testing protocols: (1) double-leg stance, eyes open (EO) and (2) double-leg stance, eyes closed (EC). Participants then completed a dual-task condition (DT) with eyes open combining a double-leg stance and a Stroop color and word test while standing on the WBB. Three commonly used COP variables, anterior-posterior (A/P) and mediolateral (M/L) velocity and 95% ellipse, were computed for each condition performed on the WBB.

Results:

Participants postconcussion swayed over a significantly larger ellipse area compared with the control group in the EO (P = .008), EC (P = .002), and DT (P = .003) conditions and also performed the DT condition with faster COP velocity in the M/L direction (P = .007). No significant group difference was identified for BESS total score.

Conclusion:

At 1 month postconcussion, participants continued to demonstrate balance deficits in COP control despite scoring similar to controls on the BESS. Simple COP measures of balance may identify subtle impairments not captured by the BESS.

Automated assessment of postural stability system

The Balance Error Scoring System (BESS) is one of the most commonly used clinical tests to evaluate static postural stability deficits resulting from traumatic brain events and musculoskeletal injury. This test requires a trained operator to visually assess balance and give the subject a performance score based on the number of balance "errors" they committed. Despite being regularly used in several real-world situations, the BESS test is scored by clinician observation and is therefore (a) potentially susceptible to biased and inaccurate test scores and (b) cannot be administered in the absence of a trained provider. The purpose of this research is to develop, calibrate and field test a computerized version of the BESS test using low-cost commodity motion tracking technology. This `Automated Assessment of Postural Stability' (AAPS) system will quantify balance control in field conditions. This research goal is to overcome the main limitations of both the commercially available motion capture systems and the standard BESS test. The AAPS system has been designed to be operated by a minimally trained user and it requires little set-up time with no sensor calibration necessary. These features make the proposed automated system a valuable balance assessment tool to be utilized in the field.

What are the critical elements of sideline screening that can be used to establish the diagnosis of concussion? A systematic review

BACKGROUND

Sideline detection is the first and most significant step in recognising a potential concussion and removing an athlete from harm. This systematic review aims to evaluate the critical elements aiding sideline recognition of potential concussions including screening tools, technologies and integrated assessment protocols.

DATA SOURCES

Bibliographic databases, grey literature repositories and relevant websites were searched from 1 January 2000 to 30 September 2016. A total of 3562 articles were identified.

STUDY SELECTION

Original research studies evaluating a sideline tool, technology or protocol for sports-related concussion were eligible, of which 27 studies were included.

DATA EXTRACTION

A standardised form was used to record information. The QUADAS-2 and Newcastle-Ottawa tools were used to rate risk of bias. Strength of evidence was assessed using the Grades of Recommendation, Assessment, Development and Evaluation Working Group system.

DATA SYNTHESIS

Studies assessing symptoms, the King-Devick test and multimodal assessments reported high sensitivity and specificity. Evaluations of balance and cognitive tests described lower sensitivity but higher specificity. However, these studies were at high risk of bias and the overall strength of evidence examining sideline screening tools was very low. A strong body of evidence demonstrated that head impact sensors did not provide useful sideline concussion information. Low-strength evidence suggested a multimodal, multitime-based concussion evaluation process incorporating video review was important in the recognition of significant head impact events and delayed onset concussion.

CONCLUSION

In the absence of definitive evidence confirming the diagnostic accuracy of sideline screening tests, consensus-derived multimodal assessment tools, such as the Sports Concussion Assessment Tool, are recommended. Sideline video review may improve recognition and removal from play of athletes who have sustained significant head impact events. Current evidence does not support the use of impact sensor systems for real-time concussion identification.

Survey of Primary Contact Medical and Chiropractic Clinicians on Self-Reported Knowledge and Recognition of Mild Traumatic Brain Injuries: A Pilot Study

OBJECTIVE

The purpose of this study was to assess the self-reported knowledge of concussion recognition and treatment with first-contact family medical and chiropractic practitioners by means of a pilot study of the need, construct validity, and feasibility for further investigation of mild traumatic brain injury (MTBI) knowledge base.

METHODS

Two hundred forty-eight practicing chiropractic and 120 medical physicians in the south and northeastern sections of the United States were contacted by e-mail, telephone, and postal mail to answer an 18-item survey on knowledge, diagnosis, and common practice with respect to traumatic brain injury patients. Descriptive analysis was used to assess common trends.

RESULTS

Twenty-three chiropractic and 11 medical primary care practitioners returned completed surveys, making this a low-power pilot study. The majority claimed confidence in diagnosis of MTBI, but a lack of knowledge of many of the assessment tools and the international guidelines. Chiropractic and medical clinicians revealed similar competencies and differing deficiencies. Both groups admitted infrequent diagnosis of MTBI in practice. There was recognition of major TBI signs, but lack of recognition or inquiry for subtle MTBI signs.

CONCLUSIONS

There is a need and feasibility for further study of the knowledge transfer to the chiropractic physician with a larger population. These findings correlate with similar medical practitioner studies, and may also support previous findings of underreporting of the prevalence of MTBI. The survey instrument appears to provide valid data on knowledge of MTBIs, with some modifications.

Clinical evaluation of concussion: the evolving role of oculomotor assessments

Sports-related concussion is a change in brain function following a direct or an indirect force to the head, identified in awake individuals and accounting for a considerable proportion of mild traumatic brain injury. Although the neurological signs and symptoms of concussion can be subtle and transient, there can be persistent sequelae, such as impaired attention and balance, that make affected patients particularly vulnerable to further injury. Currently, there is no accepted definition or diagnostic criteria for concussion, and there is no single assessment that is accepted as capable of identifying all patients with concussion. In this paper, the authors review the available screening tools for concussion, with particular emphasis on the role of visual function testing. In particular, they discuss the oculomotor assessment tools that are being investigated in the setting of concussion screening.

A Practical Concussion Physical Examination Toolbox

CONTEXT

With heightened awareness of concussion, there is a need to assess and manage the concussed patient in a consistent manner. Unfortunately, concussion physical examination has not been standardized or supported by evidence. Important questions remain about the physical examination.

EVIDENCE ACQUISITION

Review of ClinicalKey, Cochrane, MEDLINE, and PubMed prior to July 2015 was performed using search terms, including concussion, mTBI, physical examination, mental status, cranial nerves, reflexes, cervical, vestibular, and oculomotor. The references of the pertinent articles were reviewed for other relevant sources.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 3.

RESULTS

The pertinent physical examination elements for concussion include evaluation of cranial nerves, manual muscle testing, and deep tendon reflexes; inspecting the head and neck for trauma or tenderness and cervical range of motion; Spurling maneuver; a static or dynamic balance assessment; screening ocular examination; and a mental status examination that includes orientation, immediate and delayed recall, concentration, mood, affect, insight, and judgment. Other examination elements to consider, based on signs, symptoms, or clinical suspicion, include testing of upper motor neurons, cervical strength and proprioception, coordination, pupillary reactivity, and visual acuity; examination of the jaw, temporomandibular joint, and thoracic spine; fundoscopic evaluation; orthostatic vital signs; assessment of dynamic visual acuity; and screening for depression, anxiety, substance abuse disorders, and preinjury psychiatric difficulties.

CONCLUSION

Various elements of the physical examination, such as screening ocular examination, cervical musculoskeletal examination, static and/or dynamic balance assessment, and mental status examination, appear to have utility for evaluating concussion; however, data on validity are lacking.