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Uyeno C, Zhang R, Cornwell J, Teramoto M, Boo M, Lumba-Brown A. Acute Eye-Tracking Changes Correlated With Vestibular Symptom Provocation Following Mild Traumatic Brain Injury. Clin J Sport Med 2024; 34:411-416. [PMID: 38702871 DOI: 10.1097/jsm.0000000000001223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 02/21/2024] [Indexed: 05/06/2024]
Abstract
OBJECTIVES To quantify norms and changes in eye-tracking proficiency, and determine vestibular symptom correlations in varsity college athletes following acute mild traumatic brain injury (mTBI). We hypothesized that mTBI impacts central coordination between the vestibular and oculomotor systems with resultant changes in eye-tracking proficiency that are correlated with vestibular symptom provocation. DESIGN Retrospective cohort study. SETTING Sports medicine care at a single institution. PATIENTS One hundred and nineteen college athletes diagnosed with mTBI by a physician between 2013 and 2019. INTERVENTIONS N/A. MAIN OUTCOME MEASURES Standard deviation of tangential error, standard deviation of radian error, mean phase error, and horizontal gain from virtual reality-based, circular eye-tracking goggles used at baseline and within 72 hours post-mTBI. Headache, dizziness, nausea, and fogginess provocation after the Vestibular Ocular Motor Screening (VOMS) smooth pursuits subtest compared with pretest baseline, assessed within 72 hours post-mTBI. RESULTS One hundred and nineteen college athletes (N = 56 women and 63 men) aged 18 to 24 years sustained a total of 177 mTBI. Forty-four percent of athletes displayed abnormal eye-tracking on at least 1 eye-tracking measure following acute mTBI compared with their baseline. From the VOMS, horizontal gain showed medium-sized to large-sized positive correlations with headache ( r = 0.34) and dizziness ( r = 0.54), respectively. Mean phase error showed a medium-sized negative correlation with nausea ( r = -0.32) on the VOMS. CONCLUSIONS Eye-tracking proficiency was impaired and correlated with vestibular symptom provocation following acute mTBI in college athletes. Future research should examine eye-tracking proficiency testing in other acute care settings to support mTBI diagnosis.
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Affiliation(s)
| | - Rachel Zhang
- Department of Emergency Medicine, Stanford University, Stanford, California
| | - Jordan Cornwell
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Masaru Teramoto
- Department of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, Utah; and
| | - Marie Boo
- Department of Health & Performance, San Jose Earthquakes, San Jose, California
| | - Angela Lumba-Brown
- Department of Emergency Medicine, Stanford University, Stanford, California
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Maruta J, Spielman LA, Ghajar J. Visuomotor Synchronization: Military Normative Performance. Mil Med 2023; 188:e484-e491. [PMID: 34318327 DOI: 10.1093/milmed/usab320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/08/2021] [Accepted: 07/14/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Cognitive processes such as perception and reasoning are preceded and dependent on attention. Because of the close overlap between neural circuits of attention and eye movement, attention may be objectively quantified with recording of eye movements during an attention-dependent task. Our previous work demonstrated that performance scores on a circular visual tracking task that requires dynamic synchronization of the gaze with the target motion can be impacted by concussion, sleep deprivation, and attention deficit/hyperactivity disorder. The current study examined the characteristics of performance on a standardized predictive visual tracking task in a large sample from a U.S. Military population to provide military normative data. MATERIALS AND METHODS The sample consisted of 1,594 active duty military service members of either sex aged 18-29 years old who were stationed at Fort Hood Army Base. The protocol was reviewed and approved by the U.S. Army Medical Research and Materiel Command Institutional Review Board. Demographic, medical, and military history data were collected using questionnaires, and performance-based data were collected using a circular visual tracking test and Trail Making Test. Differences in visual tracking performance by demographic characteristics were examined with a multivariate analysis of variance, as well as a Kolmogorov-Smirnov test and a rank-sum test. Associations with other measures were examined with a rank-sum test or Spearman correlations. RESULTS Robust sex differences in visual tracking performance were found across the various statistical models, as well as age differences in several isolated comparisons. Accordingly, norms of performance scores, described in terms of percentile standings, were developed adjusting for age and sex. The effects of other measures on visual tracking performance were small or statistically non-significant. An examination of the score distributions of various metrics suggested that strategies preferred by men and women may optimize different aspects of visual tracking performance. CONCLUSION This large-scale quantification of attention, using dynamic visuomotor synchronization performance, provides rigorously characterized age- and sex-based military population norms. This study establishes analytics for assessing normal and impaired attention and detecting changes within individuals over time. Practical applications for combat readiness and surveillance of attention impairment from sleep insufficiency, concussion, medication, or attention disorders will be enhanced with portable, easily accessible, fast, and reliable dynamic eye-tracking technologies.
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Affiliation(s)
- Jun Maruta
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Brain Trauma Foundation, Palo Alto, CA 94301, USA
| | - Lisa A Spielman
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Brain Trauma Foundation, Palo Alto, CA 94301, USA
| | - Jamshid Ghajar
- Brain Trauma Foundation, Palo Alto, CA 94301, USA
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
- Brain Performance Center, Stanford University School of Medicine, Palo Alto, CA 94304, USA
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Powell D, Stuart S, Godfrey A. Sports related concussion: an emerging era in digital sports technology. NPJ Digit Med 2021; 4:164. [PMID: 34857868 PMCID: PMC8639973 DOI: 10.1038/s41746-021-00538-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 10/19/2021] [Indexed: 11/24/2022] Open
Abstract
Sports-related concussion (SRC) is defined as a mild traumatic brain injury (mTBI) leading to complex impairment(s) in neurological function with many seemingly hidden or difficult to measure impairments that can deteriorate rapidly without any prior indication. Growing numbers of SRCs in professional and amateur contact sports have prompted closer dialog regarding player safety and welfare. Greater emphasis on awareness and education has improved SRC management, but also highlighted the difficulties of diagnosing SRC in a timely manner, particularly during matches or immediately after competition. Therefore, challenges exist in off-field assessment and return to play (RTP) protocols, with current traditional (subjective) approaches largely based on infrequent snapshot assessments. Low-cost digital technologies may provide more objective, integrated and personalized SRC assessment to better inform RTP protocols whilst also enhancing the efficiency and precision of healthcare assessment. To fully realize the potential of digital technologies in the diagnosis and management of SRC will require a significant paradigm shift in clinical practice and mindset. Here, we provide insights into SRC clinical assessment methods and the translational utility of digital approaches, with a focus on off-field digital techniques to detect key SRC metrics/biomarkers. We also provide insights and recommendations to the common benefits and challenges facing digital approaches as they aim to transition from novel technologies to an efficient, valid, reliable, and integrated clinical assessment tool for SRC. Finally, we highlight future opportunities that digital approaches have in SRC assessment and management including digital twinning and the "digital athlete".
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Affiliation(s)
- Dylan Powell
- Department of Computer and Information Sciences, Faculty of Engineering and Environment, Northumbria University, Newcastle upon Tyne, NE1 8ST, UK
| | - Sam Stuart
- Department of Sports, Exercise and Rehabilitation, Northumbria University, Newcastle upon Tyne, UK
| | - Alan Godfrey
- Department of Computer and Information Sciences, Faculty of Engineering and Environment, Northumbria University, Newcastle upon Tyne, NE1 8ST, UK.
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Eye tracking to assess concussions: an intra-rater reliability study with healthy youth and adult athletes of selected contact and collision team sports. Exp Brain Res 2021; 239:3289-3302. [PMID: 34467416 DOI: 10.1007/s00221-021-06205-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 08/21/2021] [Indexed: 10/20/2022]
Abstract
Eye movements that are dependent on cognition hold promise in assessing sports-related concussions but research on reliability of eye tracking measurements in athletic cohorts is very limited. This observational test-retest study aimed to establish whether eye tracking technology is a reliable tool for assessing sports-related concussions in youth and adult athletes partaking in contact and collision team sports. Forty-three youth (15.4 ± 2.2 years) and 27 adult (22.2 ± 2.9 years) Rugby Union and soccer players completed the study. Eye movements were recorded using SMIRED250mobile while participants completed a test battery twice, with a 1-week interval that included self-paced saccade (SPS), fixation stability, memory-guided sequence (MGS), smooth pursuit (SP), and antisaccades (AS) tasks. Intra-class correlation coefficient (ICC), measurement error (SEM) and smallest real difference (SRD) were calculated for 47 variables. Seventeen variables achieved an ICC > 0.50. In the adults, saccade count in SPS had good reliability (ICC = 0.86, SRD = 146.6 saccades). In the youth, the average blink duration in MGS had excellent reliability (ICC = 0.99, SRD = 59.4 ms); directional errors in AS tasks and gain of diagonal SP had good reliability (ICC = 0.78 and 0.77, SRD = 25.3 and 395.1%, respectively). Four metrics were found in this study to be reliable candidates for further biomarker validity research in contact and collision sport cohorts. Many variables failed to present a sufficient level of robustness for a practical diagnostic tool; possibly, because athletic cohorts have higher homogeneity, along with latent adverse effects of undetected concussions and repetitive head impacts. Since reliability of a measure can influence type II error, effect sizes, and confidence intervals, it is strongly advocated to conduct dedicated reliability evaluations prior to any validity studies.
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Bohr AD, Aukerman DF, Harmon KG, Romano R, Hernández TD, Konstantinides N, Petron DJ, Ghajar J, Giza C, Poddar SK, McQueen MB. Pac-12 CARE-Affiliated Program: structure, methods and initial results. BMJ Open Sport Exerc Med 2021; 7:e001055. [PMID: 34079621 PMCID: PMC8137172 DOI: 10.1136/bmjsem-2021-001055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2021] [Indexed: 11/28/2022] Open
Abstract
Sport-related concussion has garnered increasing scientific attention and research over the last decade. Collegiate student-athletes represent an important cohort in this field. As such, the Pac-12 CARE-Affiliated Program (CAP) was formed in 2017 as a regional hub of the Concussion Assessment, Research and Education (CARE) consortium. CAP is multisite, prospective, longitudinal study that aims to improve student-athlete health by identifying factors associated with concussion incidence and recovery and using this knowledge to inform best clinical practices and policy decisions. CAP employed a staggered rollout across the Pac-12, with the first four institutions enrolling in fall 2018. After receiving institutional review board (IRB) approval, these institutions began consenting student-athletes to share clinical concussion and baseline data for research purposes. Athletes completed baseline testing that included a medical questionnaire, concussion history and a battery for clinical concussion assessments. Concussed student-athletes were given the same battery of assessments in addition to full injury and return to play reports. Clinicians at each university worked with a data coordinator to ensure appropriate reporting, and the Pac-12 Concussion Coordinating Unit at the University of Colorado Boulder provided oversight for quality control of the data study wide. During year 1, CAP consented 2181 student-athletes and tracked 140 concussions. All research was conducted with the appropriate IRB approval across the participating Pac-12 institutions. Data security and dissemination are managed by the Presagia Sports Athlete Electronic Health Record software (Montreal, Quebec, Canada) and QuesGen Systems (San Francisco, California, USA).
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Affiliation(s)
- Adam D Bohr
- Integrative Physiology, University of Colorado Boulder, Boulder, Colorado, USA
| | - Doug F Aukerman
- Sports Medicine, Samaritan Health Services & Oregon State University, Corvallis, Oregon, USA
| | - Kimberly G Harmon
- Family Medicine and Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, USA
| | - Russell Romano
- Athletic Medicine, University of Southern California, Los Angeles, California, USA
| | - Theresa D Hernández
- Psychology and Neuroscience, University of Colorado Boulder, Boulder, Colorado, USA
| | - Niki Konstantinides
- Integrative Physiology, University of Colorado Boulder, Boulder, Colorado, USA
| | - David J Petron
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
| | - Jamshid Ghajar
- Neurosurgery, Brain Performance Center, Stanford University, Stanford, California, USA
| | - Christopher Giza
- Pediatrics and Neurosurgery, University of California, Los Angeles, California, USA
| | - Sourav K Poddar
- Family Medicine and Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Matthew B McQueen
- Integrative Physiology, University of Colorado Boulder, Boulder, Colorado, USA
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Harmon KG, Whelan BM, Aukerman DF, Bohr AD, Nerrie JM, Elkinton HA, Holliday M, Poddar SK, Chrisman SPD, McQueen MB. Diagnostic accuracy and reliability of sideline concussion evaluation: a prospective, case-controlled study in college athletes comparing newer tools and established tests. Br J Sports Med 2021; 56:144-150. [PMID: 33883170 DOI: 10.1136/bjsports-2020-103840] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess diagnostic accuracy and reliability of sideline concussion tests in college athletes. METHODS Athletes completed baseline concussion tests including Post-Concussion Symptom Scale, Standardised Assessment of Concussion (SAC), modified Balance Error Scoring System (m-BESS), King-Devick test and EYE-SYNC Smooth Pursuits. Testing was repeated in athletes diagnosed acutely with concussion and compared to a matched teammate without concussion. RESULTS Data were collected on 41 concussed athletes and 41 matched controls. Test-retest reliability for symptom score and symptom severity assessed using control athletes was 0.09 (-0.70 to 0.88) and 0.08 (-1.00 to 1.00) (unweighted kappa). Intraclass correlations were SAC 0.33 (-0.02 to 0.61), m-BESS 0.33 (-0.2 to 0.60), EYE-SYNC Smooth Pursuit tangential variability 0.70 (0.50 to 0.83), radial variability 0.47 (0.19 to 0.69) and King-Devick test 0.71 (0.49 to 0.84). The maximum identified sensitivity/specificity of each test for predicting clinical concussion diagnosis was: symptom score 81%/94% (3-point increase), symptom severity score 91%/81% (3-point increase), SAC 44%/72% (2-point decline), m-BESS 40%/92% (5-point increase), King-Devick 85%/76% (any increase in time) and EYE-SYNC Smooth Pursuit tangential variability 48%/58% and radial variability 52%/61% (any increase). Adjusted area under the curve was: symptom score 0.95 (0.89, 0.99), symptom severity 0.95 (95% CI 0.88 to 0.99), SAC 0.66 (95% CI 0.54 to 0.79), m-BESS 0.71 (0.60, 0.83), King-Devick 0.78 (0.69, 0.87), radial variability 0.47 (0.34, 0.59), tangential variability 0.41 (0.30, 0.54) CONCLUSION: Test-retest reliability of most sideline concussion tests was poor in uninjured athletes, raising concern about the accuracy of these tests to detect new concussion. Symptom score/severity had the greatest sensitivity and specificity, and of the objective tests, the King-Devick test performed best.
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Affiliation(s)
| | - Bridget M Whelan
- Family Medicine, University of Washington, Seattle, Washington, USA
| | - Douglas F Aukerman
- Department of Family Medicine, Oregon State University, Corvallis, Oregon, USA
| | - Adam D Bohr
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, Colorado, USA
| | - J Matthew Nerrie
- Intercollegiate Athletics, University of Washington, Seattle, Washington, USA
| | - Heather A Elkinton
- Intercollegiate Athletics, Oregon State University, Corvallis, Oregon, USA
| | - Marissa Holliday
- Intercollegiate Athletics, University of Colorado Boulder, Boulder, Colorado, USA
| | - Sourav K Poddar
- Department of Family Medicine, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sara P D Chrisman
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington, USA.,Harborview Injury Prevention and Research Center, Seattle, Washington, USA
| | - Matthew B McQueen
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, Colorado, USA
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