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Bruce Leicht AS, Patrie JT, Sutherlin MA, Smart M, Hart JM. Automated Versus Traditional Scoring Agreeability During the Balance Error Scoring System. J Sport Rehabil 2024; 33:220-224. [PMID: 38295786 DOI: 10.1123/jsr.2023-0201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 09/22/2023] [Accepted: 12/13/2023] [Indexed: 03/02/2024]
Abstract
CONTEXT The Balance Error Scoring System (BESS) is a commonly used clinical tool to evaluate postural control that is traditionally performed through visual assessment and subjective evaluation of balance errors. The purpose of this study was to evaluate an automated computer-based scoring system using an instrumented pressure mat compared to the traditional human-based manual assessment. DESIGN A descriptive cross-sectional study design was used to evaluate the performance of the automated versus human BESS scoring methodology in healthy individuals. METHODS Fifty-one healthy active participants performed BESS trials following standard BESS procedures on an instrumented pressure mat (MobileMat, Tekscan Inc). Trained evaluators manually scored balance errors from frontal and sagittal plane video recordings for comparison to errors scored using center of force measurements and an automated scoring software (SportsAT, version 2.0.2, Tekscan Inc). A linear mixed model was used to determine measurement discrepancies across the 2 methods. Bland-Altman analyses were conducted to determine limit of agreement for the automated and manual scoring methods. RESULTS Significant differences between the automated and manual errors scored were observed across all conditions (P < .05), excluding bilateral firm stance. The greatest discrepancy between scoring methods was during the tandem foam stance, while the smallest discrepancy was during the tandem firm stance. CONCLUSION The 2 methods of BESS scoring are different with wide limits of agreement. The benefits and risks of each approach to error scoring should be considered when selecting the most appropriate metric for clinical use or research studies.
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Affiliation(s)
- Amelia S Bruce Leicht
- Department of Athletic Training and Clinical Nutrition, University of Kentucky, Lexington, KY, USA
| | - James T Patrie
- Department of Public Health Science, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | | | - Madeline Smart
- Department of Kinesiology, University of Virginia, Charlottesville,VA, USA
| | - Joe M Hart
- The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Sugimoto D, Stracciolini A, Berbert L, Nohelty E, Kobelski GP, Parmeter B, Weller E, Faigenbaum AD, Myer GD. Assessment of Physical Tests in 6-11 Years Old Children: Findings from the Play Lifestyle and Activity in Youth (PLAY) Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2552. [PMID: 36767925 PMCID: PMC9915144 DOI: 10.3390/ijerph20032552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/28/2023] [Accepted: 01/28/2023] [Indexed: 06/18/2023]
Abstract
The purpose was to evaluate selected physical tests in children and to compare the outcomes by sex. A cross-sectional study design was used to evaluate children 6-11 years who completed five physical tests: hand grip, vertical jump, sit and reach, Y-balance, and obstacle course (time and score). The outcome measures including test results were descriptively examined and compared by sex. The study participants consisted of 133 children (62 males and 71 females, with a median age of 7.8 years). Girls showed superior sit and reach performance (p = 0.002) compared with boys. Boys demonstrated better Y-balance scores (p = 0.007) and faster obstacle time (p = 0.042) than girls. Sex comparison within three age groups (6-<8 years, 8-<10 years, and 10-<12 years) showed that girls performed better on the sit and reach compared with boys in the in 6-<8 years (p = 0.009). Boys demonstrated higher Y-balance scores (p = 0.017) and faster obstacle time (p = 0.007) compared with girls in the 8-<10-year age group. These data will serve to guide future efforts to evaluate normative measures of physical literacy and guide targeted training interventions to promote sustained physical activity in children with deficits relative to their age and sex norms.
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Affiliation(s)
- Dai Sugimoto
- The Micheli Center for Sports Injury Prevention, Waltham, MA 02453, USA
- Faculty of Sport Sciences, Waseda University, Tokyo 202-0021, Japan
| | - Andrea Stracciolini
- The Micheli Center for Sports Injury Prevention, Waltham, MA 02453, USA
- Division of Sports Medicine, Department of Orthopaedics, Boston Children’s Hospital, Boston, MA 02115, USA
- Harvard Medical School, Boston, MA 02115, USA
- Division of Emergency Medicine, Department of Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Laura Berbert
- Biostatistics and Research Design Center, Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Eric Nohelty
- Division of Sports Medicine, Department of Orthopaedics, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Greggory P. Kobelski
- Division of Sports Medicine, Department of Orthopaedics, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Becky Parmeter
- Division of Sports Medicine, Department of Orthopaedics, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Edie Weller
- Harvard Medical School, Boston, MA 02115, USA
- Biostatistics and Research Design Center, Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA 02115, USA
- Division of Hematology and Oncology, Boston Children’s Hospital, Boston, MA 02115, USA
| | | | - Gregory D. Myer
- The Micheli Center for Sports Injury Prevention, Waltham, MA 02453, USA
- Emory Sports Performance and Research Center (SPARC), Flowery Branch, GA 30542, USA
- Emory Sports Medicine Center, Atlanta, GA 30329, USA
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA 30307, USA
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Ross JD, Hoch MC, Malvasi SR, Cameron KL, Roach MH. The Relationship Between Human-rated Errors and Tablet-based Postural Sway During the Balance Error Scoring System in Military Cadets. Sports Health 2022; 15:427-432. [PMID: 35658667 PMCID: PMC10170225 DOI: 10.1177/19417381221093566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The Balance Error Scoring System (BESS) is commonly accepted as a valid measure of postural stability. However, reliability values have varied, and subtle changes undetectable with the human eye may exist postinjury. The inertial measurement unit in commercially available tablets has been used to quantify postural sway (instrumented Balance Error Scoring System [iBESS] volume). However, iBESS has not been validated in a military population, and the stability of the tests beyond 1 week is unknown. HYPOTHESIS iBESS volume is capable of objectively measuring postural sway during the traditional BESS. STUDY DESIGN Prospective repeated-measures study. LEVEL OF EVIDENCE Level 3. METHODS Eighty-three cadets (40.96% women; age 20.0 ± 1.44 years; height 68.7 ± 4.1 inches; weight 166.7 ± 30.2 lb) with no history of concussion or lower extremity injury agreed to participate. All participants completed the BESS at baseline and 6 months post baseline. During testing, a tablet equipped with an inertial measurement unit was positioned on the participant's sacrum to capture postural sway. RESULTS Moderate to strong correlations were exhibited between baseline measurements for single-limb (SL)-firm (r = 0.84; P < 0.01), tandem (TAN)-firm (r = 0.85; P < 0.01), double-limb (DL)-foam (r = 0.50; P < 0.01), SL-foam (r = 0.59; P < 0.01), and TAN-foam (r = 0.79; P < 0.01). Balance improved significantly at 6 months for SL-firm human-rated errors (Effect Size [ES] = 0.32) and for SL-firm (ES = 0.38), DL-foam (ES = 0.21), and SL-foam iBESS volume (ES = 0.35). Moderate to strong correlations were exhibited between human-rated and iBESS change scores for SL-firm (r = 0.71; P < 0.01), TAN-firm (r = 0.75; P < 0.01), and TAN-foam (r = 0.71; P < 0.01), and a weak correlation was exhibited for DL-foam (r = 0.29; P < 0.01) and SL-foam (r = 0.40; P < 0.01). CONCLUSION Moderate to strong correlations existed between human-rated BESS errors and iBESS volume at baseline and between change scores. In addition, iBESS volume may be more sensitive to balance changes than the human-rated BESS. CLINICAL RELEVANCE This evidence supports the use of iBESS volume as a valid measure of postural stability in military cadets. iBESS volume may provide clinicians with an objective and more sensitive measure of postural stability than the traditional human-rated BESS.
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Rowson B, Duma SM. Special Issue on Concussions in Sports. Ann Biomed Eng 2021; 49:2673-2676. [PMID: 34435277 DOI: 10.1007/s10439-021-02847-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 08/02/2021] [Indexed: 01/04/2023]
Affiliation(s)
- Bethany Rowson
- Institute for Critical Technology and Applied Science (ICTAS), Virginia Tech, Blacksburg, VA, USA.
| | - Stefan M Duma
- Institute for Critical Technology and Applied Science (ICTAS), Virginia Tech, Blacksburg, VA, USA
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Potential Mechanisms of Acute Standing Balance Deficits After Concussions and Subconcussive Head Impacts: A Review. Ann Biomed Eng 2021; 49:2693-2715. [PMID: 34258718 DOI: 10.1007/s10439-021-02831-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 06/29/2021] [Indexed: 01/04/2023]
Abstract
Standing balance deficits are prevalent after concussions and have also been reported after subconcussive head impacts. However, the mechanisms underlying such deficits are not fully understood. The objective of this review is to consolidate evidence linking head impact biomechanics to standing balance deficits. Mechanical energy transferred to the head during impacts may deform neural and sensory components involved in the control of standing balance. From our review of acute balance-related changes, concussions frequently resulted in increased magnitude but reduced complexity of postural sway, while subconcussive studies showed inconsistent outcomes. Although vestibular and visual symptoms are common, potential injury to these sensors and their neural pathways are often neglected in biomechanics analyses. While current evidence implies a link between tissue deformations in deep brain regions including the brainstem and common post-concussion balance-related deficits, this link has not been adequately investigated. Key limitations in current studies include inadequate balance sampling duration, varying test time points, and lack of head impact biomechanics measurements. Future investigations should also employ targeted quantitative methods to probe the sensorimotor and neural components underlying balance control. A deeper understanding of the specific injury mechanisms will inform diagnosis and management of balance deficits after concussions and subconcussive head impact exposure.
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Kuo KT, Hunter BC, Obayashi M, Lider J, Teramoto M, Cortez M, Hansen C. Novice vs expert inter-rater reliability of the balance error scoring system in children between the ages of 5 and 14. Gait Posture 2021; 86:13-16. [PMID: 33668005 DOI: 10.1016/j.gaitpost.2021.02.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 01/22/2021] [Accepted: 02/23/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The Balance Error Scoring System (BESS) is a tool to measure balance, however, no studies have shown its reliability between novice and expert raters. RESEARCH QUESTION What is the inter-rater reliability of BESS measurements when performed by novice raters compared to experts, and does completion of a focused, online training module increase the inter-rater reliability among novice raters? METHODS In this reliability study, 5 novice volunteers were asked to independently rate BESS tests from 50 random prerecorded BESS videos of normal healthy subjects aged 5-14. Novice raters regraded the same 50 videos after receiving a formal training. The novices' scores before and after the formal training were compared to one another and then the scores were compared to 4 expert scores. Intraclass correlation (ICC) with 95 % confidence intervals or percent agreements were calculated and compared across groups. RESULTS For the total BESS score, novice raters showed good reliability (ICC 0.845) which did not change with a formal training (ICC 0.846). Expert raters showed excellent reliability (ICC 0.929). Poor to moderate reliability was noted in the foam stance-single leg in the untrained novice and trained novice group (ICCs 0.452 and 0.64 L respectively). SIGNIFICANCE BESS testing by novice raters with only written instruction and no formal training yields good inter-rater reliability. In contrast, BESS testing by expert raters yields excellent reliability. A focused training for novice raters conferred a small improvement in the reliability of the scoring of the single leg stance on foam condition but not a significant difference to the overall BESS score. While novices demonstrated promising reliability for overall BESS scores, optimizing clinical research using the BESS with expert raters show the highest reliability.
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Affiliation(s)
- Keith T Kuo
- Division of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, UT, USA.
| | | | - Mizuho Obayashi
- Johns Hopkins University Krieger School of Arts & Science, Baltimore, MD, USA
| | - Joshua Lider
- Division of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, UT, USA
| | - Masaru Teramoto
- Division of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, UT, USA
| | - Melissa Cortez
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Colby Hansen
- Division of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, UT, USA
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Rowson B, Duma SM. A Review of On-Field Investigations into the Biomechanics of Concussion in Football and Translation to Head Injury Mitigation Strategies. Ann Biomed Eng 2020; 48:2734-2750. [PMID: 33200263 DOI: 10.1007/s10439-020-02684-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 10/27/2020] [Indexed: 11/28/2022]
Abstract
This review paper summarizes the scientific advancements in the field of concussion biomechanics in American football throughout the past five decades. The focus is on-field biomechanical data collection, and the translation of that data to injury metrics and helmet evaluation. On-field data has been collected with video analysis for laboratory reconstructions or wearable head impact sensors. Concussion biomechanics have been studied across all levels of play, from youth to professional, which has allowed for comparison of head impact exposure and injury tolerance between different age groups. In general, head impact exposure and injury tolerance increase with increasing age. Average values for concussive head impact kinematics are lower for youth players in both linear and rotational acceleration. Head impact data from concussive and non-concussive events have been used to develop injury metrics and risk functions for use in protective equipment evaluation. These risk functions have been used to evaluate helmet performance for each level of play, showing substantial differences in the ability of different helmet models to reduce concussion risk. New advances in head impact sensor technology allow for biomechanical measurements in helmeted and non-helmeted sports for a more complete understanding of concussion tolerance in different demographics. These sensors along with advances in finite element modeling will lead to a better understanding of the mechanisms of injury and human tolerance to head impact.
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Affiliation(s)
- Bethany Rowson
- Department of Biomedical Engineering and Mechanics, Virginia Tech, Blacksburg, VA, USA.
| | - Stefan M Duma
- Department of Biomedical Engineering and Mechanics, Virginia Tech, Blacksburg, VA, USA
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Houston MN, O'Donovan KJ, Trump JR, Brodeur RM, McGinty GT, Wickiser JK, D'Lauro CJ, Jackson JC, Svoboda SJ, Susmarski AJ, Broglio SP, McAllister TW, McCrea MA, Pasquina P, Cameron KL. Progress and Future Directions of the NCAA-DoD Concussion Assessment, Research, and Education (CARE) Consortium and Mind Matters Challenge at the US Service Academies. Front Neurol 2020; 11:542733. [PMID: 33101171 PMCID: PMC7546354 DOI: 10.3389/fneur.2020.542733] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 08/13/2020] [Indexed: 02/02/2023] Open
Abstract
Despite the significant impact that concussion has on military service members, significant gaps remain in our understanding of the optimal diagnostic, management, and return to activity/duty criteria to mitigate the consequences of concussion. In response to these significant knowledge gaps, the US Department of Defense (DoD) and the National Collegiate Athletic Association (NCAA) partnered to form the NCAA-DoD Grand Alliance in 2014. The NCAA-DoD CARE Consortium was established with the aim of creating a national multisite research network to study the clinical and neurobiological natural history of concussion in NCAA athletes and military Service Academy cadets and midshipmen. In addition to the data collected for the larger CARE Consortium effort, the service academies have pursued military-specific lines of research relevant to operational and medical readiness associated with concussion. The purpose of this article is to describe the structure of the NCAA-DoD Grand Alliance efforts at the service academies, as well as discuss military-specific research objectives and provide an overview of progress to date. A secondary objective is to discuss the challenges associated with conducting large-scale studies in the Service Academy environment and highlight future directions for concussion research endeavors across the CARE Service Academy sites.
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Affiliation(s)
- Megan N Houston
- Department of Orthopaedic Research, John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Community Hospital, West Point, NY, United States
| | - Kevin J O'Donovan
- Department of Chemistry and Life Sciences, United States Military Academy, West Point, NY, United States
| | - Jesse R Trump
- Department of Orthopaedic Research, John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Community Hospital, West Point, NY, United States
| | - Rachel M Brodeur
- United States Coast Guard Academy, New London, CT, United States
| | - Gerald T McGinty
- United States Air Force Academy, Colorado Springs, CO, United States
| | - J Kenneth Wickiser
- Department of Chemistry and Life Sciences, United States Military Academy, West Point, NY, United States
| | | | | | | | | | - Steven P Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI, United States
| | - Thomas W McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Paul Pasquina
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Kenneth L Cameron
- Department of Orthopaedic Research, John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Community Hospital, West Point, NY, United States.,Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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