Systematic review of the balance error scoring system

Response to Tendon Vibration Questions the Underlying Rationale of Proprioceptive Training

CONTEXT

Proprioceptive training on compliant surfaces is used to rehabilitate and prevent ankle sprains. The ability to improve proprioceptive function via such training has been questioned. Achilles tendon vibration is used in motor-control research as a form of proprioceptive stimulus. Using measures of postural steadiness with nonlinear measures to elucidate control mechanisms, tendon vibration can be applied to investigate the underlying rationale of proprioceptive training.

OBJECTIVE

To test whether the effect of vibration on young adults' postural control depended on the support surface.

DESIGN

Descriptive laboratory study.

SETTING

Research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Thirty healthy adults and 10 adults with chronic ankle instability (CAI; age range = 18-40 years).

INTERVENTION(S)

With eyes open, participants stood in bilateral stance on a rigid plate (floor), memory foam, and a Both Sides Up (BOSU) ball covering a force platform. We applied bilateral Achilles tendon vibration for the middle 20 seconds in a series of 60-second trials and analyzed participants' responses from previbration to vibration (pre-vib) and from vibration to postvibration (vib-post).

MAIN OUTCOME MEASURE(S)

We calculated anterior-posterior excursion of the center of pressure and complexity index derived from the area under multiscale entropy curves.

RESULTS

The excursion response to vibration differed by surface, as indicated by a significant interaction of P < .001 for the healthy group at both time points and for the CAI group vib-post. Although both groups demonstrated increased excursion from pre-vib and from vib-post, a decrease was observed on the BOSU. The complexity response to vibration differed by surface for the healthy group (pre-vib, P < .001). The pattern for the CAI group was similar but not significant. Complexity changes vib-post were the same on all surfaces for both groups.

CONCLUSIONS

Participants reacted less to ankle vibration when standing on the BOSU as compared with the floor, suggesting that proprioceptive training may not be occurring. Different balance-training paradigms to target proprioception, including tendon vibration, should be explored.

Single-task and dual-task tandem gait test performance after concussion

OBJECTIVES

To compare single-task and dual-task tandem gait test performance between athletes after concussion with controls on observer-timed, spatio-temporal, and center-of-mass (COM) balance control measurements.

DESIGN

Ten participants (19.0±5.5years) were prospectively identified and completed a tandem gait test protocol within 72h of concussion and again 1 week, 2 weeks, 1 month, and 2 months post-injury. Seven uninjured controls (20.0±4.5years) completed the same protocol in similar time increments.

METHODS

Tandem gait test trials were performed with (dual-task) and without (single-task) concurrently performing a cognitive test as whole-body motion analysis was performed. Outcome variables included test completion time, average tandem gait velocity, cadence, and whole-body COM frontal plane displacement.

RESULTS

Concussion participants took significantly longer to complete the dual-task tandem gait test than controls throughout the first 2 weeks post-injury (mean time=16.4 [95% CI: 13.4-19.4] vs. 10.1 [95% CI: 6.4-13.7] seconds; p=0.03). Single-task tandem gait times were significantly lower 72h post-injury (p=0.04). Dual-task cadence was significantly lower for concussion participants than controls (89.5 [95% CI: 68.6-110.4] vs. 127.0 [95% CI: 97.4-156.6] steps/minute; p=0.04). Moderately-high to high correlations between tandem gait test time and whole-body COM medial-lateral displacement were detected at each time point during dual-task gait (r_s=0.70-0.93; p=0.03-0.001).

CONCLUSIONS

Adding a cognitive task during the tandem gait test resulted in longer detectable deficits post-concussion compared to the traditional single-task tandem gait test. As a clinical tool to assess dynamic motor function, tandem gait may assist with return to sport decisions after concussion.

Correlation of Head Impacts to Change in Balance Error Scoring System Scores in Division I Men's Lacrosse Players

BACKGROUND

Investigation into the effect of cumulative subconcussive head impacts has yielded various results in the literature, with many supporting a link to neurological deficits. Little research has been conducted on men's lacrosse and associated balance deficits from head impacts.

HYPOTHESES

(1) Athletes will commit more errors on the postseason Balance Error Scoring System (BESS) test. (2) There will be a positive correlation to change in BESS scores and head impact exposure data.

STUDY DESIGN

Prospective longitudinal study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Thirty-four Division I men's lacrosse players (age, 19.59 ± 1.42 years) wore helmets instrumented with a sensor to collect head impact exposure data over the course of a competitive season. Players completed a BESS test at the start and end of the competitive season.

RESULTS

The number of errors from pre- to postseason increased during the double-leg stance on foam ( P < 0.001), tandem stance on foam ( P = 0.009), total number of errors on a firm surface ( P = 0.042), and total number of errors on a foam surface ( P = 0.007). There were significant correlations only between the total errors on a foam surface and linear acceleration ( P = 0.038, r = 0.36), head injury criteria ( P = 0.024, r = 0.39), and Gadd Severity Index scores ( P = 0.031, r = 0.37).

CONCLUSION

Changes in the total number of errors on a foam surface may be considered a sensitive measure to detect balance deficits associated with cumulative subconcussive head impacts sustained over the course of 1 lacrosse season, as measured by average linear acceleration, head injury criteria, and Gadd Severity Index scores. If there is microtrauma to the vestibular system due to repetitive subconcussive impacts, only an assessment that highly stresses the vestibular system may be able to detect these changes.

CLINICAL RELEVANCE

Cumulative subconcussive impacts may result in neurocognitive dysfunction, including balance deficits, which are associated with an increased risk for injury. The development of a strategy to reduce total number of head impacts may curb the associated sequelae. Incorporation of a modified BESS test, firm surface only, may not be recommended as it may not detect changes due to repetitive impacts over the course of a competitive season.

Reliability Testing of the Balance Error Scoring System in Children Between the Ages of 5 and 14

OBJECTIVE

Pediatric concussion is an extensive public health concern with a complex clinical presentation. Balance assessment has been well-studied in the adult population, but has been limited in children. We aimed to assess the reliability and minimum detectable change (MDC) of the Balance Error Scoring System (BESS) in healthy children.

DESIGN

This prospective observational study included 373 healthy children aged 5 to 14. Interrater reliability was assessed by having 4 assessors review videos of 50 random subjects distributed evenly by age and sex across the entire cohort. Intrarater reliability was performed by having assessors review videos of other assessors' live evaluations. Test-retest reliability was obtained by comparing BESS scores as recorded live at the 2 separate time points by the same rater.

SETTING

Local elementary and junior high schools.

PARTICIPANTS

Three hundred and seventy three healthy children between the ages of 5 and 14.

INTERVENTIONS

The BESS was performed on all children.

MAIN OUTCOME MEASURES

Intraclass Correlation Coefficients (ICCs) and MDC Scores.

RESULTS

The overall interrater ICC was determined to be 0.93 [95% confidence interval (CI), 0.79-0.97] and intrarater ICC was 0.96 (95% CI, 0.95-0.97) with individual intrarater ICCs ranging between 0.69 and 0.99. The test-retest reliability was 0.90 (95% CI, 0.88-0.92). The MDCs were 9.6, 4.6, and 7.3 points at the 95% CIs for interrater, intrarater, and test-retest comparisons, respectively. No learning effect was seen.

CONCLUSIONS

The BESS demonstrates excellent reliability in the pediatric population without evidence of a learning effect.

Validity and Reliability of the Vestibular/Ocular Motor Screening and Associations With Common Concussion Screening Tools

BACKGROUND

Sustaining a concussion commonly results in vestibular impairments that may be associated with balance deficits. To screen for vestibular impairments after a concussion, the Vestibular/Ocular Motor Screening (VOMS) tool was developed. The relationship between the VOMS and other concussion screening tools, such as the Balance Error Scoring System (BESS) and King-Devick (K-D), have not been explored.

HYPOTHESES

(1) VOMS would provide reliable results and not provoke symptoms in healthy adolescents and (2) VOMS test items would measure related aspects of vestibular function that are not measured through the BESS or K-D.

STUDY DESIGN

Cross-sectional, descriptive.

LEVEL OF EVIDENCE

Level 4.

METHODS

A total of 105 healthy adolescents (53 male, 52 female; mean age, 15.4 years) completed the VOMS, BESS, and K-D tests. A subsample of 21 adolescents (16 male, 5 female; mean age, 15.5 years) completed the VOMS twice.

RESULTS

The median total symptom score for all 7 VOMS items was 0 (0-5). The majority of the individual VOMS test items total symptom scores demonstrated a significant correlation with each other ( rs = 0.25-0.66, P < 0.02). The individual VOMS items did not demonstrate a significant relationship to the BESS or K-D. VOMS items demonstrated high agreement in total symptom scores between testing trials, with near point convergence (NPC) distance demonstrating an intraclass correlation coefficient (ICC) of 0.95 (95% CI, 0.89-0.98; P < 0.001). The MDC95 (minimal detectable change with 95 confidence) for NPC distance was 4 cm.

CONCLUSION

The VOMS did not provoke vestibular symptoms in healthy adolescents. The VOMS items measured unique aspects of vestibular function other than those measured by the BESS or K-D with good reliability.

CLINICAL RELEVANCE

Clinicians should consider implementing the VOMS as part of a comprehensive concussion assessment if vestibular impairment is suspected. If NPC distance is measured twice, a difference of >4 cm would be considered real change outside of measurement error.

Influence of Age on Postconcussive Postural Control Measures and Future Implications for Assessment

OBJECTIVE

To examine the influence of age, sex, attention-deficit hyperactivity disorder (ADHD) status, previous history of concussion, and days since injury on postconcussion postural control assessment in adolescents who have suffered a concussion.

DESIGN

Prospective cohort study.

SETTING

Hospital-based outpatient clinic.

PARTICIPANTS

Seventy-one participants (42 males; 29 females) with mean age 14.14 ± 2.44.

INDEPENDENT VARIABLES

Age, sex, previous concussion history, ADHD status, total and severity of postconcussion symptoms, and days since injury.

MAIN OUTCOME MEASURES

Total Balance Error Scoring System score, path length, center-of-pressure (COP) area, sample entropy, and Romberg quotient.

RESULTS

Pearson product-moment correlation coefficients were calculated to test for potential associations between the continuous participant characteristics and the postural control variables. Spearman correlation was used to test the association between symptom severity and the postural control variables. Standard multiple regression was used to model the extent to which participant characteristics accounted for the variance in the postural sway variables. Age was significantly associated with all of the postural sway variables except COP area for the eyes open condition and sample entropy in the anterior-posterior direction for the eyes closed condition. Sex, ADHD status, and previous concussion history did not significantly predict postural control scores.

CONCLUSIONS

Age significantly influences scores on common postconcussion postural control assessments.

CLINICAL RELEVANCE

This study demonstrates that age is a critical factor that needs to be accounted for to improve the clinical appropriateness and utility of current postconcussion postural control assessments.

MUSCULOSKELETAL SCREENING AND FUNCTIONAL TESTING: CONSIDERATIONS FOR BASKETBALL ATHLETES

BACKGROUND AND PURPOSE

Youth participation in basketball is on the rise, with basketball one of the top five participation sports in Australia. With increased participation there is a need for greater awareness of the importance of the pre-participation examination, including musculoskeletal screening and functional performance testing as part of a multidisciplinary approach to reducing the risk for future injuries. As majority of all basketball injuries affect the lower extremities, pre-participation musculoskeletal screening and functional performance testing should assess fundamental movement qualities throughout the kinetic chain with an emphasis on lower extremity force characteristics, specifically eccentric loading tasks. Thus, the purpose of this clinical commentary is to review the existing literature elucidating pre-participation musculoskeletal screening and functional performance tests that can be used as a framework for rehabilitation professionals in assessing basketball athletes' readiness to safely perform the movement demands of their sport.

METHODS

Relevant articles published between 2000 and 2016 using the search terms 'musculoskeletal screening', 'functional testing', 'youth athletes', and 'basketball' were identified using MEDLINE. From a basketball-specific perspective, several relevant musculoskeletal assessments were identified, including: the Functional Hop Test Combination, the Landing Error Scoring System, the Tuck Jump Assessment, the Weight-Bearing Lunge Test, and the Star Excursion Balance Test. Each of these assessments creates movement demands that allow for easy identification of inefficient and/or compensatory movement tendencies. A basic understanding of musculoskeletal deficits including bilateral strength and flexibility imbalances, lower crossed syndrome, and dominance-related factors are key components in determination of injury risk.

DISCUSSION

Assessment of sport-specific movement demands through musculoskeletal screening and functional performance testing is essential for rehabilitation professionals to determine movement competency during performance of fundamental movements related to basketball performance. Youth athletes represent a unique population due to their developing musculoskeletal and neuromuscular systems and should undergo pre-participation musculoskeletal screening for identification of movement limitations. Such an approach to musculoskeletal screening and functional performance may assist in identifying injury risk and also be useful at the end of rehabilitation in determining readiness to return to sport models.

LEVEL OF EVIDENCE

Level 5.

Effects of Achilles tendon vibration, surface and visual conditions on lower leg electromyography in young adults with and without recurrent ankle sprains

Functional ankle instability is associated with decreased ankle muscle function. Compliant surfaces and eyes-closed training are commonly used for rehabilitation and prevention of ankle sprains. Brief Achilles tendon vibration is commonly used in the study of postural control. To test the level of activation of tibialis anterior (TIB) and fibularis longus (FIB), bilateral Achilles tendon vibration was applied for the middle 20 s in a series of 60-s trials, when 10 healthy young adults and 10 adults with history of repeated ankle sprains were standing bipedal: on floor, on memory foam, or on a Both Sides Up (BOSU) ball, with eyes open, and on floor and foam with eyes closed. Differences in Integrated surface electromyography (IEMG) of TIB and FIB were significant for both groups pre, during, and post vibration (Friedman Tests, p < 0.001 for all). In both groups, the highest IEMG for TIB was obtained during vibration when standing on foam with eyes closed, whereas the highest IEMG for FIB was obtained during vibration when standing on the BOSU. Bipedal stance on BOSU and brief Achilles tendon vibration may be a useful intervention when a session's goal is to facilitate lower leg muscles activation. Future research should explore training effects as well as the effect of FIB tendon vibration.

Changes in baseline concussion assessment scores following a school bus crash

OBJECTIVE

The objective of this article is to present concussion assessment data for 30 male athletes prior to and after being involved in a large school bus crash. The athletes on the bus, all male and aged 14-18 years, were participants in their school's concussion management program that included baseline and postinjury testing using Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT).

METHODS

This case study described changes in concussion assessment scores for 30 male athletes following a primarily frontal school bus crash. Data from the school's concussion management program, including baseline test data and postinjury assessment data, were reviewed. Athletes who required multiple postinjury assessments by the program were identified as having had significant cognitive changes as a result of the bus crash.

RESULTS

Twenty-nine of 30 athletes were injured. One had lumbar compression fractures; others had various lacerations, abrasions, contusions, sprains, and nasal fractures. ImPACT data (postcrash) were available for all 30 athletes and 28 had available precrash baseline data. A total of 16 athletes (53.3%) had significant cognitive changes indicated by changes in their concussion assessment scores, some of which took months to improve.

CONCLUSION

This case study highlights a unique opportunity to evaluate concussion assessment data from 30 male athletes involved in a high-speed school bus crash. Further, these data provide additional insight into assessing the effectiveness of current school bus occupant protection systems.

Evaluation of postural stability in youth athletes: the relationship between two rating systems

OBJECTIVES

The Balance Error Scoring System (BESS) has been documented as a useful way to evaluate postural control following sport-related concussions sustained by youth athletes. However, limitations have been reported with its use due to the reliance on visual observation as the primary measurement outcome. The primary purpose of this study was to examine the correlation between the modified BESS (mBESS) as rated by a clinician and a simultaneous analysis performed by an integrated video-force plate system. The secondary purpose was to assess if a history of prior concussion affected postural control.

METHODS

A group of healthy youth athletes (n = 398; mean age 13.7 ± 2.4 years) completed the mBESS while simultaneously undergoing an integrated video-force plate evaluation to measure postural stability. Spearman rank-order correlations were used to determine the strength of correlation between the 2 rating systems. In addition, performance on the mBESS between those with and without a history of concussion was compared using univariate ANCOVAs.

RESULTS

A moderately high correlation was found during single-leg stance (ρ = -0.64, p < .001), while a weak correlation was found during tandem stance (ρ = -0.30, p < .001). No postural control differences were found between groups with and without a concussion history.

CONCLUSION

The video-force plate rating system correlates well with the clinician rating during the single-leg stance of the mBESS, but not during double-leg or tandem stances. A history of concussion did not affect mBESS scores.

Normative values for a video-force plate assessment of postural control in athletic children

The objective of this study was to provide normative data for young athletes during the three stances of the modified Balance Error Scoring System (mBESS) using an objective video-force plate system. Postural control was measured in 398 athletes between 8 and 18 years of age during the three stances of the mBESS using a video-force plate rating system. Girls exhibited better postural control than boys during each stance of the mBESS. Age was not significantly associated with postural control. We provide normative data for a video-force plate assessment of postural stability in pediatric athletes during the three stances of the mBESS.

Vestibular Rehabilitation After Traumatic Brain Injury: Case Series

BACKGROUND AND PURPOSE

There has been an increasing focus on vestibular rehabilitation (VR) after traumatic brain injury (TBI) in recent years. However, detailed descriptions of the content of and patient responses to VR after TBI are limited. The purposes of this case series are (1) to describe a modified, group-based VR intervention and (2) to examine changes in self-reported and performance-based outcome measures.

CASE DESCRIPTION

Two women and 2 men (aged 24-45 years) with mild TBI, dizziness, and balance problems participated in an 8-week intervention consisting of group sessions with guidance, individually modified VR exercises, a home exercise program, and an exercise diary. Self-reported and performance-based outcome measures were applied to assess the impact of dizziness and balance problems on functions related to activity and participation.

OUTCOMES

The intervention caused no adverse effects. Three of the 4 patients reported reduced self-perceived disability because of dizziness, diminished frequency and severity of dizziness, improved health-related quality of life, reduced psychological distress, and improved performance-based balance. The change scores exceeded the minimal detectable change, indicating a clinically significant change or improvement in the direction of age-related norms. The fourth patient did not change or improve in most outcome measures.

DISCUSSION

A modified, group-based VR intervention was safe and appeared to be viable and beneficial when addressing dizziness and balance problems after TBI. However, concurrent physical and psychological symptoms, other neurological deficits, and musculoskeletal problems might influence the course of central nervous system compensation and recovery. The present case series may be useful for tailoring VR interventions to patients with TBI. Future randomized controlled trials are warranted to evaluate the short- and long-term effects of VR after TBI.

Modified Balance Error Scoring System (M-BESS) test scores in athletes wearing protective equipment and cleats

Background

Balance testing is an important part of the initial concussion assessment. There is no research on the differences in Modified Balance Error Scoring System (M-BESS) scores when tested in real world as compared to control conditions.

Objective

To assess the difference in M-BESS scores in athletes wearing their protective equipment and cleats on different surfaces as compared to control conditions.

Methods

This cross-sectional study examined university North American football and soccer athletes. Three observers independently rated athletes performing the M-BESS test in three different conditions: (1) wearing shorts and T-shirt in bare feet on firm surface (control); (2) wearing athletic equipment with cleats on FieldTurf; and (3) wearing athletic equipment with cleats on firm surface. Mean M-BESS scores were compared between conditions.

Results

60 participants were recruited: 39 from football (all males) and 21 from soccer (11 males and 10 females). Average age was 21.1 years (SD=1.8). Mean M-BESS scores were significantly lower (p<0.001) for cleats on FieldTurf (mean=26.3; SD=2.0) and for cleats on firm surface (mean=26.6; SD=2.1) as compared to the control condition (mean=28.4; SD=1.5). Females had lower scores than males for cleats on FieldTurf condition (24.9 (SD=1.9) vs 27.3 (SD=1.6), p=0.005). Players who had taping or bracing on their ankles/feet had lower scores when tested with cleats on firm surface condition (24.6 (SD=1.7) vs 26.9 (SD=2.0), p=0.002).

Conclusions

Total M-BESS scores for athletes wearing protective equipment and cleats standing on FieldTurf or a firm surface are around two points lower than M-BESS scores performed on the same athletes under control conditions.

Sideline Management of Concussion

Concussion associated with sport is a common occurrence with an estimated 1.6 to 3.8 million sports-related concussions yearly in the United States. The sideline assessment of concussion focuses on four areas: cognitive ability, balance, associated symptoms, and visual tracking. Tools available on the sideline to assist in the diagnosis of concussion are discussed in this article. Some of these tools are validated and reliable and some are developing and have yet to be proven to be sensitive enough for routine use. These tools along with a thorough history and physical examination enable a sideline physician to accurately diagnose concussion.

Investigating the Feasibility and Utility of Bedside Balance Technology Acutely After Pediatric Concussion: A Pilot Study

OBJECTIVE

To examine postural instability in children acutely after concussion, using the Wii Balance Board (WBB). We hypothesized that children with traumatic brain injury would have significantly worse balance relative to children without brain injury.

DESIGN

Prospective case-control pilot study.

SETTING

Emergency department of a tertiary urban pediatric hospital.

PARTICIPANTS

Cases were a convenience sample 11-16 years old who presented within 6 hours of sustaining concussion. Two controls, matched on gender, height, and age, were enrolled for each case that completed study procedures. Controls were children who presented for a minor complaint that was unlikely to affect balance.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The participant's postural sway expressed as the displacement in centimeters of the center of pressure during a timed balance task. Balance testing was performed using 4 stances (single or double limb, eyes open or closed).

RESULTS

Three of the 17 (17.6%) cases were too dizzy to complete testing. One stance, double limbs eyes open, was significantly higher in cases versus controls (85.6 vs 64.3 cm, P = 0.04).

CONCLUSIONS

A simple test on the WBB consisting of a 2-legged standing balance task with eyes open discriminated children with concussion from non-head-injured controls. The low cost and feasibility of this device make it a potentially viable tool for assessing postural stability in children with concussion for both longitudinal research studies and clinical care.

CLINICAL RELEVANCE

These pilot data suggest that the WBB is an inexpensive tool that can be used on the sideline or in the outpatient setting to objectively identify and quantify postural instability.

Reference values for the balance error scoring system in adolescents

OBJECTIVES

Adolescents with mild traumatic brain injury (i.e. concussion) may experience postural stability impairments. The Balance Error Scoring System (BESS) is widely used in assessment of postural stability after concussion. Despite its common use in adolescents, the BESS lacks reference values in adolescents, limiting its clinical utility. The objective of this study is to report the reference values for the BESS in adolescents and to examine the effect of gender on the BESS scores.

METHODS

One hundred and ninety-one high school adolescents between the ages of 14-18 (M = 16.1, SD = 1.1) years of age completed the BESS. The effects of gender, age, body mass and height on the performance of BESS were examined. Additionally, the reported reference values for the BESS were stratified by gender.

RESULTS

Female participants demonstrated better performance on five of the six BESS conditions as well as the total error score (p < 0.001). No relationships were observed between age and body mass to the BESS scores.

CONCLUSIONS

The effects of gender on the BESS performance support the gender-specific reference values reported in this study. These reference values provide benchmarks for clinicians when interpreting the BESS in the absence of individual baseline scores.

Sleep Disorders Associated With Mild Traumatic Brain Injury Using Sport Concussion Assessment Tool 3

BACKGROUND

Sleep problems affect 30% to 80% of patients with mild traumatic brain injury. We assessed the prevalence of sleep disorders after mild traumatic brain injury and its correlation with other symptoms.

METHODS AND MATERIALS

Individuals with mild traumatic brain injury were assessed at the New York University Concussion Center during 2013-2014 with the Sports Concussion Assessment Tool, third edition, data following mild traumatic brain injury. The relationship between sleep problems (drowsiness, difficulty falling asleep, fatigue or low energy), psychiatric symptoms (sadness, nervousness or anxiousness), headache, and dizziness were analyzed by Spearman correlation and logistic regression using moderate to severe versus none to mild categorization.

RESULTS

Ninety-three patients were retrospectively considered. The most common injury causes were falls (34.4%) and motor vehicle accidents (21.5%). There was a positive correlation between dizziness, headache, psychiatric problems (sadness, anxiety, irritability), and sleep problems (fatigue, drowsiness, and difficulty falling asleep) (P < 0.001). Logistic regression showed a significant association between moderate to severe psychiatric symptoms and moderate to severe sleep symptoms (P < 0.05). Sleep symptoms became more severe with increased time interval from mild traumatic brain injury to Sport Concussion Assessment Tool 3 administration (odds ratio = 1.005, 1.006, and 1.008, P < 0.05). There was significant correlation between motor vehicle accident and drowsiness and difficulty falling asleep (P < 0.05). Medications given in the emergency department had a positive correlation with drowsiness (P < 0.05).

CONCLUSIONS

Individuals who report moderate to severe headache, dizziness, and psychiatric symptoms have a higher likelihood of reporting moderate to severe sleep disorders following mild traumatic brain injury and should be counseled and initiated with early interventions.

Novel Use of a Smartphone to Measure Standing Balance

Background

Balance assessment and training is utilized by clinicians and their patients to measure and improve balance. There is, however, little consistency in terms of how clinicians, researchers, and patients measure standing balance. Utilizing the inherent sensors in every smartphone, a mobile application was developed to provide a method of objectively measuring standing balance.

Objective

We aimed to determine if a mobile phone application, which utilizes the phone’s accelerometer, can quantify standing balance.

Methods

Three smartphones were positioned simultaneously above the participants’ malleolus and patella and at the level of the umbilicus. Once secured, the myAnkle application was initiated to measure acceleration. Forty-eight participants completed 8 different balance exercises separately for the right and left legs. Accelerometer readings were obtained from each mobile phone and mean acceleration was calculated for each exercise at each ankle and knee and the torso.

Results

Mean acceleration vector magnitude was reciprocally transformed to address skewness in the data distribution. Repeated measures ANOVAs were completed using the transformed data. A significant 2-way interaction was revealed between exercise condition and the body position of the phone (P<.001). Post-hoc tests indicated higher acceleration vector magnitude for exercises of greater difficulty. ANOVAs at each body position were conducted to examine the effect of exercise. The results revealed the knee as the location most sensitive for the detection of differences in acceleration between exercises. The accelerometer ranking of exercise difficulty showed high agreement with expert clinical rater rankings (kappa statistic>0.9).

Conclusions

The myAnkle application revealed significantly greater acceleration magnitude for exercises of greater difficulty. Positioning of the mobile phone at the knee proved to be the most sensitive to changes in accelerometer values due to exercise difficulty. Application validity was shown through comparison with clinical raters. As such, the myAnkle app has utility as a measurement tool for standing balance.

Age Differences in Recovery After Sport-Related Concussion: A Comparison of High School and Collegiate Athletes

CONTEXT

Younger age has been hypothesized to be a risk factor for prolonged recovery after sport-related concussion, yet few studies have directly evaluated age differences in acute recovery.

OBJECTIVE

To compare clinical recovery patterns for high school and collegiate athletes.

DESIGN

Prospective cohort study.

SETTING

Large, multicenter prospective sample collected from 1999-2003 in a sports medicine setting.

SUBJECTS

Concussed athletes (n = 621; 545 males and 76 females) and uninjured controls (n = 150) participating in high school and collegiate contact and collision sports (79% in football, 15.7% in soccer, and the remainder in lacrosse or ice hockey).

MAIN OUTCOME MEASURE(S)

Participants underwent evaluation of symptoms (Graded Symptom Checklist), cognition (Standardized Assessment of Concussion, paper-and-pencil neuropsychological tests), and postural stability (Balance Error Scoring System). Athletes were evaluated preinjury and followed serially at several time points after concussive injury: immediately, 3 hours postinjury, and at days 1, 2, 3, 5, 7, and 45 or 90 (with neuropsychological measures administered at baseline and 3 postinjury time points).

RESULTS

Comparisons of concussed high school and collegiate athletes with uninjured controls suggested that high school athletes took 1 to 2 days longer to recover on a cognitive (Standardized Assessment of Concussion) measure. Comparisons with the control group on other measures (symptoms, balance) as well as direct comparisons between concussed high school and collegiate samples revealed no differences in the recovery courses between the high school and collegiate groups on any measure. Group-level recovery occurred at or before 7 days postinjury on all assessment metrics.

CONCLUSIONS

The findings suggest no clinically significant age differences exist in recovery after sport-related concussion, and therefore, separate injury-management protocols are not needed for high school and collegiate athletes.

Assessing performance, stability, and cleat comfort/support in collegiate club soccer players using prophylactic ankle taping and bracing

Soccer athletes at all levels of play are keenly aware of their equipment needs including cleat wear, and want to be protected from injury but without impeding on-field performance. Ankle injury is a common disorder that is prevalent in the sport of soccer and recent improvements in ankle prophylaxis interventions have proven effective. The aim of this study was to determine if the use of elastic taping or a neoprene sleeve alters performance, stability, and cleat comfort/support in soccer players compared to wearing a soccer cleat without any external support. Twenty male collegiate club soccer players were recruited and randomly assigned to the three conditions (untaped control, taped, neoprene sleeve). Performance testing and comfort/support assessment for each condition took place in one on-field test session, while stability testing was completed during a separate laboratory session. The only significant finding was improved inversion/eversion stability in both the tape and sleeve conditions as compared to the cleated condition. The addition of tape or a sleeve did not have an adverse effect on performance or comfort during functional and stability testing, and should therefore be considered as a method to decrease ankle injuries in soccer athletes as external supports provide increased stability in inversion/eversion range of motion.

Examination of Age-Related Differences on Clinical Tests of Postural Stability

BACKGROUND

The modified Balance Error Scoring System (mBESS) and Y-Balance Test are common clinical measurements of postural control, but little is known about the effect of age on performance of these tasks. The purpose of this study was to examine how healthy child and adolescent athletes perform on 2 common clinical measurements of postural control.

HYPOTHESIS

Younger athletes would demonstrate poorer postural control compared with older athletes.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Three hundred eighty-nine athletes between the ages of 10 and 18 years underwent an evaluation of postural control. Each participant completed the mBESS in the double-leg, single-leg, and tandem stances as well as the Y-Balance Test. Postural stability data were analyzed between age groups (10-12, 13-15, and 16-18 years) using univariate analyses of covariance.

RESULTS

The youngest athletes (10-12 years) had a greater mean number of errors in the single-leg stance of the mBESS than the 13- to 15-year-old and 16- to 18-year-old athletes (3.8, 3, and 2.5 errors, respectively; P < 0.01). They also had greater right to left asymmetry compared with the 16- to 18-year-old athletes on the Y-Balance Test in the posterolateral (6.8 and 3.8 cm, respectively; P = 0.006) and posteromedial (5.3 and 3.6 cm, respectively; P = 0.014) directions of movement.

CONCLUSION

Athletes between the ages of 10 and 12 years performed worse on the single-leg stance of the mBESS and demonstrated more asymmetry on the Y-Balance Test in the posterolateral and posteromedial directions compared with older athletes.

CLINICAL RELEVANCE

In the absence of a baseline balance test for athletes younger than the age of 13 years, caution should be used in interpreting postural stability assessments, as age may be a modifying factor in performance.

Effects of training on postural stability in young basketball players

BACKGROUND

in basketball, balance ability is important to reduce non-contact injuries. The purpose of the present study was to investigate the effect of training on balance.

METHODS

thirty-two healthy male volunteers were recruited from amateur basketball teams. They were asked to perform the Balance Error Scoring System BESS test in order to measure the number of stability errors in six conditions. The test was performed at the beginning of the season (T0) and after 12 weeks (T1). In both cases the test was carried out before (pre-session) and after a training session (post-session).

RESULTS

the comparison of the total BESS scores both pre- and post-session showed a statistically significant increase of stability errors at both T0 and T1 (T0: pre-session 8.6±6.1 errors, post-session 10.7±6.3 errors; t=-4.03; p=0.002) (T1: pre-session 7.2±3.8 errors, post-session 9.1±5.4 errors; t=-1.93; p=0.03). Between T0 and T1 we noticed a reduction of errors which reached a statistical significance during the pre-session time (t=2.75; p=0.0049).

CONCLUSION

stability improved after 12 weeks of training, even for those conditions for which no specific training was done to improve, such as on the soft surface and feet aligned in a tandem stance.

Neurologic Care in Concussion and Post-Concussive Encephalopathy

Concussion has become a more recent "medical fad" with a lot of media coverage and hence an increasing incidence. According to the Center for Disease Control (CDC) and Prevention there are estimates of as many as 3.8 million sport-related traumatic brain injuries occurring annually (Centers for Disease Control and Prevention, 2007). Given these numbers, concussion care will require that both primary and specialist physicians feel comfortable in its management. This article will discuss the pathophysiology, epidemiology, clinical evaluation, therapies and prognosis in patients with concussion. The complex and chronic symptoms after a concussion and their management will be highlighted. Appropriate concussion care is essential for improving both the long and short term outcomes in adolescent athletes. There is an important role for the neurologist in improving the outcome in these athletes.

Extended use of Kinesiology Tape and Balance in Participants with Chronic Ankle Instability

CONTEXT

Participants with chronic ankle instability (CAI) have been shown to have balance deficits related to decreased proprioception and neuromuscular control. Kinesiology tape (KT) has been proposed to have many benefits, including increased proprioception.

OBJECTIVE

To determine if KT can help with balance deficits associated with CAI.

DESIGN

Cohort study.

SETTING

Research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Thirty participants with CAI were recruited for this study.

INTERVENTION(S)

Balance was assessed using the Balance Error Scoring System (BESS). Participants were pretested and then randomly assigned to either the control or KT group. The participants in the KT group had 4 strips applied to the foot and lower leg and were instructed to leave the tape on until they returned for testing. All participants returned 48 hours later for another BESS assessment. The tape was then removed, and all participants returned 72 hours later to complete the final BESS assessment.

MAIN OUTCOME MEASURE(S)

Total BESS errors.

RESULTS

Differences between the groups occurred at 48 hours post-application of the tape (mean difference = 4.7 ± 1.4 errors, P < .01; 95% confidence interval = 2.0, 7.5) and at 72 hours post-removal of the tape (mean difference = 2.3 ± 1.1 errors, P = .04; 95% confidence interval = 0.1, 4.6).

CONCLUSIONS

The KT improved balance after it had been applied for 48 hours when compared with the pretest and with the control group. One of the most clinically important findings is that balance improvements were retained even after the tape had been removed for 72 hours.

Sensitivity of the Balance Error Scoring System and the Sensory Organization Test in the Combat Environment

This study evaluated the utility of the Balance Error Scoring System (BESS) and the Sensory Organization Test (SOT) as tools for the screening and monitoring of Service members (SMs) with mild traumatic brain injury (mTBI) in a deployed setting during the acute and subacute phases of recovery. Patient records (N = 699) were reviewed for a cohort of SMs who sustained a blast-related mTBI while deployed to Afghanistan and were treated at the Concussion Restoration Care Center (CRCC) at Camp Leatherneck. On initial intake into the CRCC, participants completed two assessments of postural control, the BESS, and SOT. SMs with mTBI performed significantly worse on the BESS and SOT when compared with comparative samples. When the SOT data were further examined using sensory ratios, the results indicated that postural instability was primarily a result of vestibular and visual integration dysfunction (r > 0.62). The main finding of this study was that the sensitivity of the SOT composite score (50-58%) during the acute phase was higher than previous sensitivities found in the sports medicine literature for impact-related trauma.

Effect of different types of shoes on balance among soccer players

BACKGROUND

in soccer, balance ability is important to reduce non-contact injuries. The effect of footwear on balance is poorly understood in this sport. Soccer boots and futsal trainers need to guarantee a good grip on compliant surfaces. Running shoes are designed to reduce friction on rigid su rfaces. The purpose of the present study was to investigate these types of shoes on balance ability.

METHODS

twenty-four healthy male volunteers were recruited from amateur soccer teams. They were ask to perform the BESS (Balance Error Scoring System) test to measure the number of instability episodes in 6 conditions: double-leg, single-leg, and tandem stances on firm and foam surfaces. Anova with factor (several shoes) and Bonferroni were used to compare the means of two subtotal scores (firm and foam surface) and the final total score (BESS).

RESULTS

the three shoe models led to greater stability than when the subject was barefoot (p=0.001). Only on the firm surface the soccer boots were statistically better than futsal trainers (p=0.009).

CONCLUSIONS

the lack of stability while barefoot could be explained by the fact that with shoes there is a greater surface area, which produces a sensory filter that leads to posture modifications to improve stability. The greater stability, that was found in the three types of footwear, could be guaranteed by the design to reduce friction (for running shoes) and by the presence of studs (for soccer boots and futsal trainers).

Measuring postural stability with an inertial sensor: validity and sensitivity

Introduction/purpose

To examine the concurrent validity, and sensitivity, of an inertial sensor for use in the assessment of postural sway.

Methods

This was a laboratory-based, repeated-measures design with ten healthy participants. Concurrent validity was tested between an inertial sensor, forceplate, and rigid-body kinematics across three commonly used balance tests. Further, the inertial sensor measures were compared across eight commonly used tests of balance. Variables manipulated include stance position, surface condition, and eyes-open versus eyes-closed.

Results

The inertial sensor was correlated to both the forceplate-derived measures (r=0.793) and rigid-body kinematics (r=0.887). Significant differences between the balance tests were observed when tested with the inertial sensor. In general, there was a three-way interactions between the three balance factors (surface, stance, and vision) leading to pairwise comparisons between each balance test. The root-mean-square showed an increase across tasks of greater difficulty ranging from an average of 0.0368 with two legs, eyes-open to 0.911 when tested during tandem stance, eyes-closed tested on a foam pad.

Conclusion

The new inertial sensor shows promise for use in the assessment of postural sway. Additionally, the inertial sensor appears sensitive to differences in balance tasks of varying degrees of difficulty when tested in a healthy sample of young adults. This inertial sensor may provide new opportunities for further research in the assessment of balance changes in the mild traumatic brain injury population.

Characteristics of Pediatric and Adolescent Concussion Clinic Patients With Postconcussion Amnesia

OBJECTIVE

The current study examines the demographics, injury characteristics, and outcomes associated with the presence of postconcussion amnesia in young concussion clinic patients.

DESIGN

Cross-sectional, retrospective clinical cohort.

SETTING

Concussion services clinic.

PATIENTS

Pediatric and adolescent concussion services program patients, presenting within 10 days postinjury, aged 10-18 years, with the goal of returning to sport (n = 245).

ASSESSMENT OF RISK FACTORS

Age, gender, race, head trauma history, injury mechanism, loss of consciousness (LOC), injury-related visit to an emergency department, cognitive and balance scores, symptoms, and management recommendations.

MAIN OUTCOME MEASURES

Univariate and multivariate analyses determined adjusted odds ratios for reported presence of any postconcussion amnesia (anterograde or retrograde).

RESULTS

Factors associated with amnesia (univariate, P < 0.10) and included in the multivariate model were race, head trauma history, mechanism of injury, LOC, injury-related visit to an emergency department, management recommendations and time of injury and initial visit symptom severity. Age and gender were also included in the model due to biological significance. Of the 245 patients, 181 had data for all model variables. Of the 181 patients, 58 reported amnesia. History of head trauma [odds ratio (OR), 2.7; 95% confidence interval (CI), 1.3-5.7]; time of injury (TOI) symptom severity >75th percentile (OR, 2.6; 95% CI, 1.2-5.3) and LOC (OR, 2.2; 95% CI, 1.1-4.6) were found to have significant and independent relationships with amnesia in the multivariate model.

CONCLUSIONS

This study illustrates that patients presenting with postconcussion amnesia are more likely to have a history of head trauma, LOC, and greater symptom severity. Future research is needed to better understand amnesia following concussion.

CLINICAL RELEVANCE

Amnesia presence, previous head trauma, LOC, and increased symptom severity may aid in identifying patients with a greater initial injury burden who warrant closer observation and more conservative management.

Differences in Adolescent Physical Fitness: A Multivariate Approach and Meta-analysis

Physical fitness can be defined as a set of components that determine exercise ability and influence performance in sports. This study investigates the genetic and environmental influences on individual differences in explosive leg strength (vertical jump), handgrip strength, balance, and flexibility (sit-and-reach) in 227 healthy monozygotic and dizygotic twin pairs and 38 of their singleton siblings (mean age 17.2 ± 1.2). Heritability estimates were 49 % (95 % CI 35–60 %) for vertical jump, 59 % (95 % CI 46–69 %) for handgrip strength, 38 % (95 % CI 22–52 %) for balance, and 77 % (95 % CI 69–83 %) for flexibility. In addition, a meta-analysis was performed on all twin studies in children, adolescents and young adults reporting heritability estimates for these phenotypes. Fifteen studies, including results from our own study, were meta-analyzed by computing the weighted average heritability. This showed that genetic factors explained most of the variance in vertical jump (62 %; 95 % CI 47–77 %, N = 874), handgrip strength (63 %; 95 % CI 47–73 %, N = 4516) and flexibility (50 %; 95 % CI 38–61 %, N = 1130) in children and young adults. For balance this was 35 % (95 % CI 19–51 %, N = 978). Finally, multivariate modeling showed that the phenotypic correlations between the phenotypes in current study (0.07 < r < 0.27) were mostly driven by genetic factors. It is concluded that genetic factors contribute significantly to the variance in muscle strength, flexibility and balance; factors that may play a key role in the individual differences in adolescent exercise ability and sports performance.

PHYSICAL THERAPY INTERVENTION STRATEGIES FOR PATIENTS WITH PROLONGED MILD TRAUMATIC BRAIN INJURY SYMPTOMS: A CASE SERIES

BACKGROUND AND PURPOSE

Although most patients recover from a mild traumatic brain injury (mTBI) within 7-14 days, 10-30% of people will experience prolonged mTBI symptoms. Currently, there are no standardized treatment protocols to guide physical therapy interventions for this population. The purpose of this case series was to describe the unique, multimodal evaluation and treatment approaches for each of the patients with post-concussion syndrome (PCS).

CASE DESCRIPTION

Six pediatric athletes with PCS who had participated in physical therapy and fit the inclusion criteria for review were retrospectively chosen for analysis. Patients received a cervical evaluation, an aerobic activity assessment, an oculomotor screen, and postural control assessment. Each patient participated in an individualized physical therapy treatment plan-of-care based on their presentation during the evaluation.

OUTCOMES

Patients were treated for a mean of 6.8 treatment sessions over 9.8 weeks. Four of six patients returned to their pre-injury level of activity while two returned to modified activity upon completion of physical therapy. Improvements were observed in symptom scores, gaze stability, balance and postural control measures, and patient self-management of symptoms. All patients demonstrated adequate self-management of symptoms upon discharge from physical therapy.

DISCUSSION/CONCLUSIONS

Physical therapy interventions for pediatric athletes with PCS may facilitate recovery and improve function. Further research is needed to validate effective tools for assessment of patients who experience prolonged concussion symptoms as well as to establish support for specific post-mTBI physical therapy interventions.

LEVEL OF EVIDENCE

Level 4.

The Acute Management of Sport Concussion in Pediatric Athletes

During the past two decades the focus on sport concussion has increased significantly. Young athletes represent the most vulnerable population to sustain a sport concussion yet receive the least amount of attention. Specifically, young athletes who sustain a sport concussion can go unrecognized and continue to participate in sport putting them at an increased risk for a more significant injury. The purpose of this review is to provide a clinical framework for the evaluation and management of sport concussion. In addition, this review provides considerations for health care professionals in regard to clinical measures and follow-up strategies during the acute phase following concussion in young concussed athletes following injury.

EFFECTS OF A SEASON OF SUBCONCUSSIVE CONTACT ON CHILD- SCAT3 SCORES IN 8-12 YEAR-OLD MALE ATHLETES

BACKGROUND

Each year, over 173,000 children and adolescents visit emergency departments due to sports and recreation related concussions, an increase of 60% over the last decade due to the rise in the number of children participating in sport. While numerous authors have sought to address the epidemiology of concussions across multiple age groups who participate in contact sports, a recent review of literature did not reveal a substantial amount of published articles that addressed the issue of subconcussive contact. Multiple tools have been developed to assess acute episodes of concussion. Among the assessment protocols many include an assessment of balance, short and long term memory recall, and balance. The Child-SCAT3 was designed specifically to evaluate concussions in children 5-12 years of age.

OBJECTIVE

The purpose of this study was to determine the effect of a season of subconcussive contact on Child-SCAT3 scores in 8-12 year old males compared to their age matched peers who participated in non-contact sports. A secondary purpose was to evaluate how scores of the sub- components of the Child-SCAT3 compare between contact and non-contact athletes.

DESIGN

A prospective cohort study was performed of 71 male athletes (58 football, 13 baseball) ages 8-12 (contact mean age 10.30 years, SD 1.20; non-contact mean age 10.03 years, SD 1.26) over the course of a season.

METHODS

Portions of The Child-SCAT3 were administered and scored in pre-adolescent athletes prior to and following a season of participation in football (contact sport group) and baseball (non-contact sport group). The outcome measures of interest included the portions related to Cognitive ability, Balance, and Coordination.

RESULTS

No statistically significant differences were found in group, time or time and group interaction for any of the utilized portions of the Child-SCAT3. Statistically significant differences were found between groups for preseason cognitive orientation and postseason immediate memory. Cognitive orientation and coordination were also found to be statistically significantly improved across both groups over the course of the season.

LIMITATIONS

This study was potentially limited by the number of control subjects tested.

CONCLUSIONS

A season of subconcussive contact in football was not detrimental to cognitive and balance scores on the Child-SCAT3.

LEVEL OF EVIDENCE

3.

Variability of the modified Balance Error Scoring System at baseline using objective and subjective balance measures

Aim:

To investigate preseason modified Balance Error Scoring System (mBESS) performance in a collegiate football cohort; to compare scores to an objective mobile balance measurement tool.

Materials & methods:

Eighty-two athletes completed simultaneous balance testing using mBESS and the King–Devick Balance Test, an objective balance measurement tool. Errors on mBESS and objective measurements in the double-leg, single-leg (SS) and tandem stances were compared.

Results:

Mean mBESS error score was 7.23 ± 4.65. The SS accounted for 74% of errors and 21% of athletes demonstrated the maximum error score. There was no significant correlation between mBESS score and objective balance score.

Conclusion:

The high variability and large number of errors in the SS raises concerns over the utility of the SS in identifying suspected concussion.

Effects of ankle balance taping with kinesiology tape for a patient with chronic ankle instability

[Purpose] To report the effects of ankle balance taping for a patient with chronic ankle instability (CAI). [Subject] A 33-year-old man with a 10 year history of chronic ankle stability. [Methods] ABT with kinesiology tape was performed for 2 months (average, 16 h/day) around the right ankle. [Results] At the end of two months, no ankle instability was noted when ascending and descending the stairs, jumping, turning, operating the pedals while driving, and lifting heavy objects. [Conclusion] The repeated use of kinesiology tape in ankle balance taping may be an effective treatment for recovering the ankle stability of patients with chronic ankle instability.

Balance Error Scoring System Performance in Children and Adolescents With No History of Concussion

BACKGROUND

The Balance Error Scoring System (BESS) is a useful means of measuring postural stability, which frequently exhibits deficits after a concussion. However, it has limited applicability for children since there is insufficient normative data available for the BESS in the pediatric population. The purposes of this study were to report scores for the BESS in children 10 to 17 years old with no history of concussion and to identify whether BESS score is correlated with age, sex, sports participation, height, weight, or body mass index.

HYPOTHESIS

Baseline BESS scores will be related to age and sports participation.

STUDY DESIGN

Descriptive laboratory study.

LEVEL OF EVIDENCE

Level 3.

METHODS

One examiner recruited 100 participants 10 to 17 years old over a period of 4 months; performed all of the BESS tests; surveyed participants regarding age, sex, and sports participation; recorded participants' heights and weights; and calculated body mass indices. Intrarater reliability was measured. The main outcome measures were total, firm, and foam surface BESS scores. We assessed data for normality using the Shapiro-Wilk test and used the Spearman rank test to determine whether BESS scores correlated with sex, age, sports participation, height, weight, or body mass index.

RESULTS

There was no correlation between the BESS firm surface (5.37 ± 4.4), BESS foam surface (12.28 ± 4.43), or total surface scores (17.64 ± 7.52) and age, anthropometrics, or sports participation. Male and female subjects had similar scores except in the 10- to 13-year-old age group on the foam surface, where girls performed better than boys (10.42 ± 4.53 vs 13.07 ± 4.23; P = 0.02).

CONCLUSION

Baseline BESS scores in children aged 10 to 17 years were normally distributed and were not related to age, sex, height, weight, body mass index, or sports participation.

CLINICAL RELEVANCE

These results provide a reference for clinicians using BESS to evaluate and manage children and teens with concussions.

Reliability and concurrent validity of instrumented balance error scoring system using a portable force plate system

OBJECTIVES

The Balance Error Scoring System (BESS) is a commonly used test in adolescents and young adults. Affordability and portability of newer force plates has led to instrumentation of many clinical balance tests including the BESS. Despite the higher precision of force plate measures compared with clinical scoring, it is unclear if the instrumented BESS demonstrate concurrent validity and reliability when compared with the original BESS. The purpose of this study was to examine the reliability and concurrent validity of instrumented BESS testing using a commercially available force plate system.

METHODS

Thirty-six participants participated in the initial testing day (17 male/19 female, M = 15.9 years, SD = 1.5 years). The test-retest sample consisted of 26 participants who completed the same testing procedure after 1 week. For all testing sessions, participants performed the BESS while standing on a portable force plate system. Number of errors and sway velocity were obtained. Concurrent validity was established through correlation analysis examining the relationship between the original and the instrumented BESS scores. Reliability was established using Intraclass Correlation Coefficient (ICC3,1) computed for the instrumented and the original BESS.

RESULTS

A significant moderate relationship exists between the total scores of the original and the instrumented BESS (rs = 0.54, p = 0.001). Despite a range of reliability scores for the different conditions in the instrumented BESS (ICC3,1 = 0.19-0.61) and the clinically scored BESS (ICC3,1 = 0.13-0.71), the reliability score for the total test score was the same for the instrumented and the clinical test (ICC3,1 = 0.74).

CONCLUSION

Although the instrumented BESS may appear to demonstrate concurrent validity against the original BESS, instrumentation did not improve its reliability. Future research should examine if the instrumented BESS demonstrates validity against laboratory level force plates and if it is able to overcome the ceiling effect reported for the clinical BESS test.

Concussion Treatment Using Massage Techniques: a Case Study

BACKGROUND

Concussion, its recognition, diagnosis, and treatment is a growing public health issue. Massage practitioners who specialize in rehabilitation deal with a variety of injury cases that involve concussion, including those incurred by falls, motor vehicle incidents, and sports injuries.

PURPOSE

This case study presents a unique massage therapy approach to concussion trauma treatment.

PARTICIPANT

Male 23-year-old intramural soccer player diagnosed with postconcussion syndrome resulting from a fall.

INTERVENTION

Assessment and treatment were completed in two sessions of 45 minutes spaced two days apart. Massage therapy techniques were applied to injury areas by a Licensed Massage Practitioner.

RESULTS

Using the Balance Error Scoring System (BESS) and self-report, the outcome measures showed diminished concussion symptoms and regained ease in range of motion in the cervical area.

CONCLUSION

Positive results for this case highlight the potential importance of massage therapy work to reduce headache, dizziness, and nausea in concussion recovery. In the presence of such outcomes, massage therapy may also have a supportive role in a person's return to function after concussion.

Altered Neurochemistry in Former Professional Soccer Players without a History of Concussion

Soccer is played by more than 250 million people worldwide. Repeatedly heading the ball may place soccer players at high risk for repetitive subconcussive head impacts (RSHI). This study evaluates the long-term effects of RSHI on neurochemistry in athletes without a history of clinically diagnosed concussion, but with a high exposure to RSHI. Eleven former professional soccer players (mean age 52.0±6.8 years) and a comparison cohort of 14 age- and gender-matched, former non-contact sport athletes (mean age 46.9±7.9 years) underwent 3T magnetic resonance spectroscopy (MRS) and neurocognitive evaluation. In the soccer players a significant increase was observed in both choline (Cho), a membrane marker, and myo-inositol (ml), a marker of glial activation, compared with control athletes. Additionally, ml and glutathione (GSH) were significantly correlated with lifetime estimate of RSHI within the soccer group. There was no significant difference in neurocognitive tests between groups. Results of this study suggest an association between RSHI in soccer players and MRS markers of neuroinflammation, suggesting that even subconcussive head impacts affect the neurochemistry of the brain and may precede neurocognitive changes. Future studies will need to determine the role of neuroinflammation in RSHI and the effect on neurocognitive function.

Validation of a virtual reality balance module for use in clinical concussion assessment and management

OBJECTIVE

To determine the criterion and content validity of a virtual reality (VR) balance module for use in clinical practice.

DESIGN

Retrospective, VR balance module completed by participants during concussion baseline or assessment testing session.

SETTING

A Pennsylvania State University research laboratory.

PARTICIPANTS

A total of 60 control and 28 concussed students and athletes from the Pennsylvania State University.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

This study examined: (1) the relationship between VR composite balance scores (final, stationary, yaw, pitch, and roll) and area of the center-of-pressure (eyes open and closed) scores and (2) group differences (normal volunteers and concussed student-athletes) on VR composite balance scores.

RESULTS

With the exception of the stationary composite score, all other VR balance composite scores were significantly correlated with the center of pressure data obtained from a force platform. Significant correlations ranged from r = -0.273 to -0.704 for the eyes open conditions and from r = -0.353 to -0.876 for the eyes closed condition. When examining group differences on the VR balance composite modules, the concussed group did significantly (P < 0.01) worse on all measures compared with the control group.

CONCLUSIONS

The VR balance module met or exceeded the criterion and content validity standard set by the current balance tools and may be appropriate for use in a clinical concussion setting.

CLINICAL RELEVANCE

Virtual reality balance module is a valid tool for concussion assessment in clinical settings. This novel type of balance assessment may be more sensitive to concussion diagnoses, especially later (7-10 days) in the recovery phase than current clinical balance tools.

Benefits of strict rest after acute concussion: a randomized controlled trial

OBJECTIVES

To determine if recommending strict rest improved concussion recovery and outcome after discharge from the pediatric emergency department (ED).

METHODS

Patients aged 11 to 22 years presenting to a pediatric ED within 24 hours of concussion were recruited. Participants underwent neurocognitive, balance, and symptom assessment in the ED and were randomized to strict rest for 5 days versus usual care (1-2 days rest, followed by stepwise return to activity). Patients completed a diary used to record physical and mental activity level, calculate energy exertion, and record daily postconcussive symptoms. Neurocognitive and balance assessments were performed at 3 and 10 days postinjury. Sample size calculations were powered to detect clinically meaningful differences in postconcussive symptom, neurocognitive, and balance scores between treatment groups. Linear mixed modeling was used to detect contributions of group assignment to individual recovery trajectory.

RESULTS

Ninety-nine patients were enrolled; 88 completed all study procedures (45 intervention, 43 control). Postdischarge, both groups reported a 20% decrease in energy exertion and physical activity levels. As expected, the intervention group reported less school and after-school attendance for days 2 to 5 postconcussion (3.8 vs 6.7 hours total, P < .05). There was no clinically significant difference in neurocognitive or balance outcomes. However, the intervention group reported more daily postconcussive symptoms (total symptom score over 10 days, 187.9 vs 131.9, P < .03) and slower symptom resolution.

CONCLUSIONS

Recommending strict rest for adolescents immediately after concussion offered no added benefit over the usual care. Adolescents' symptom reporting was influenced by recommending strict rest.

Postconcussion Postural Sway Variability Changes in Youth: The Benefit of Structural Variability Analyses

PURPOSE

The purpose of this study was to evaluate the utility of postural sway variability as a potential assessment to detect altered postural sway in youth with symptoms related to a concussion.

METHODS

Forty participants (20 who were healthy and 20 who were injured) aged 10 to 16 years were assessed using the Balance Error Scoring System (BESS) and postural sway variability analyses applied to center-of-pressure data captured using a force plate.

RESULTS

Significant differences were observed between the 2 groups for postural sway variability metrics but not for the BESS. Specifically, path length was shorter and Sample and Renyi Entropies were more regular for the participants who were injured compared with the participants who were healthy (P < .05).

CONCLUSION

The results of this study indicate that postural sway variability may be a more valid measure than the BESS to detect postconcussion alterations in postural control in young athletes.

Sports Concussions (TBI), Imbalance, and Dizziness

It has been widely accepted that the assessment of balance after concussion plays a large role in determining deficit. Qualitative balance assessments have been an established piece of the post-injury assessment as a clinical behavioral marker of concussion for many years. Recently more specific guidelines outlining the role of balance evaluation in concussion identification and management have been developed as part of concussion management tools. As part of the ongoing development of concussions protocols, quantitative assessment of balance function following concussion has also been identified to have an important role. Frequently imbalance and dizziness reported following concussion is assumed to be associated with post-concussion syndrome (PCS). While imbalance and dizziness are common complaints in PCS, they can also be a sign of additional underlying pathology. In cases of specific dizziness symptoms or limited balance recovery beyond the initial post-concussive period, a quantitative vestibular assessment may also be needed. Electronystagmography and videonystagmography (ENG/VNG), rotary chair testing (RCT), and vestibular evoked myogenic potentials (VEMPs) have all been identified as valid assessment tools for vestibular dysfunction following traumatic brain injury (TBI). The assessment of balance and dizziness following sports-related concussions is an integral piece of the puzzle for removal from play, assessment of severity, and management.

Assessing postural stability in the concussed athlete: what to do, what to expect, and when

Context:

Postural stability assessment is included as part of the diagnostic and monitoring process for sports-related concussions. Particularly, the relatively simple Balance Error Scoring System (BESS) and more sophisticated force plate measures like the Sensory Organization Test (SOT) are suggested.

Evidence Acquisition:

Relevant studies were identified via the following electronic databases: PubMed, MEDLINE, EMBASE, Web of Science, ScienceDirect, and CINAHL (1980 to July 2013). Inclusion was based on the evaluation of postural sway or balance in concussed athletes of any age or sex and investigating the reliability or validity of the included tests.

Study Design:

Clinical review.

Level of Evidence:

Level 4

Results:

Both the SOT and the BESS show moderate reliability, but a learning effect due to repetitive testing needs to be considered. Both tests indicate that postural stability returns to baseline by day 3 to 5 in most concussed athletes. While the BESS is a simple and valid method, it is sensitive to subjectivity in scoring and the learning effect. The SOT is very sensitive to even subtle changes in postural sway, and thus, more accurate than the BESS; however, it is a rather expensive method of balance testing.

Conclusion:

Both tests serve the purpose of monitoring balance performance in the concussed athlete; however, neither may serve as a stand-alone diagnostic or monitoring tool.

Strength of Recommendation Taxonomy:

B