The Effect of Whole-Body Fatigue on King-Devick Test and Balance

Multimodal Assessment Battery and Heart Rate Variability Enhance Clinical Utility of Buffalo Concussion Treadmill Test

CONTEXT

The Buffalo Concussion Treadmill Test (BCTT) for exercise intolerance following concussion may highlight underlying autonomic dysfunction. Autonomic function at rest and with exertion may be predictive of neurocognitive performance for individuals with sports-related concussion. The purpose of this study is to explore the feasibility and utility of combining multimodal assessments with heart rate variability (HRV) measures during the BCTT for individuals with a remote history of concussion.

DESIGN

Prospective cohort study design, pretest/posttest.

METHODS

Participants included 5 males and 5 females (N = 10, age: 25.2 [3.3] y old, height: 173.2 [11.2] cm, mass: 73.4 [13.7] kg, body mass index: 24.5 [3.9], time since last concussion of 6.3 [4.5] y). All participants completed the multimodal assessment battery including: Concentration Reverse Digits (6 digits), Stroop Incongruent, and King-Devick Test under single- (seated) and dual-task conditions (walking on treadmill at 2.0 mph, 0% incline). Heart rate and HRV was collected at rest, during the BCTT, and during postexercise recovery. HRV data were processed and analyzed based on established protocols. Paired t tests were performed for pre- and postmeasurements separately for single- and dual-task tests of the multimodal assessment battery and HRV indices.

RESULTS

During the BCTT, HRV indices reflective of peripheral nervous system activity demonstrated a significant reduction with concomitant increase in HRV indices of sympathetic nervous system activity (P < .05). Recovery in these HRV indices toward baseline was observed during postexercise recovery. Neurocognitive performance on the Stroop task significantly improved with exercise (P < .05).

CONCLUSION

Implementation of multimodal assessments to evaluate physiological and neurocognitive responses to exercise in individuals with history of sports-related concussion is feasible. Addition of these objective measures may decrease reliance on self-reporting of exercise-induced symptom exacerbation, enabling clinicians to identify individuals whose neurocognitive performance or physiologic response to exercise on the BCTT deviates from the expected.

Cognitive Assessment in Grappling Athletes Following Choke versus Nonchoke Submissions

PURPOSE

Participation in Brazilian jiu-jitsu and mixed martial arts has increased over the last three decades. These sports feature submission attacks, including strangles. These strangles, termed "chokes" in this context, primarily limit blood flow to the brain via compression of neck vasculature. There has been discussion in literature of the possibility of measurable cognitive effects following transient choking episodes. The present study used the King-Devick test (KDT) platform, a tablet-based reaction time and accuracy task designed to measure participants' number recognition, cognition, and verbal expression. This task requires functional vision, saccadic eye movements, comprehension, and expression.

METHODS

Volunteer participants were screened for exclusion (prior brain injury) criteria and survey information before testing. Athletes were tested with the KDT immediately before a Brazilian jiu-jitsu training session, again immediately after succumbing to either a choke ("Choke" arm) or nonchoke ("Non-Choke" arm) submission while sparring, and again after a 10-min rest period following the postsubmission test. Analysis was done on test failures, total test times, and individual difference scores between baseline and subsequent testing.

RESULTS

Sixty-two (32 Choke, 30 Non-Choke) participants were analyzed. There was no significant difference between Choke and Non-Choke in test failures ( χ2 (1,62) = 1.25, P = 0.263), total times ( t (60) = 0.62, P = 0.540; 95% CI, -3.44 to 6.51), and individual difference scores ( t (60) = 0.29, P = 0.776; 95% CI, -2.41 to 3.21).

CONCLUSIONS

There were no significant differences between study arms in any of the three analyzed measures. This suggests that cognitive functioning, as measured by the KDT, is not affected by transient choking episodes.

Assessing Brain Processing Deficits Using Neuropsychological and Vision-Specific Tests for Concussion

INTRODUCTION

Since verbal memory and visual processing transpire within analogous cerebral regions, this study assessed (i) if a visual function can predict verbal memory performance. It also hypothesized whether neurocognitive (e.g., ImPACT) tests focusing on the Visual Memory and Cognitive Efficacy Index will predict Verbal Memory scores and (ii) if vision metrics and age can identify individuals with a history of concussion. Finally, it also hypothesized that King-Devick and near point of convergence scores alongside age considerations will identify candidates with a prior reported history of concussion.

MATERIALS AND METHODS

This observational cohort assessed 25 collegiate ice hockey players prior to the competitive season considering age (19.76 ± 1.42 years) and BMI (25.9 ± 3.0 kg/cm2). Hypothesis 1 was assessed using a hierarchical (sequential) multiple regression analysis, assessing the predictive capacity of Visual Memory and Cognitive Efficacy Index scores in relation to Verbal Memory scores. Hypothesis 2 utilized a binomial logistic regression to determine if King-Devick and near point of convergence scores predict those with a prior history of concussion.

RESULTS

Hypothesis 1 developed two models, where Model 1 included Visual Memory as the predictor, while Model 2 added the Cognitive Efficacy Index as a predictor for verbal memory scores. Model 1 significantly explained 41% of the variance. Results from Model 2 suggest that the Cognitive Efficacy Index explained an additional 24.4%. Thus, Model 2 was interpreted where only the Cognitive Efficacy Index was a significant predictor (p = 0.001). For every 1 unit increase in the Cognitive Efficacy Index, Verbal Memory increased by 41.16. Hypothesis 2's model was significant, accounting for 37.9% of the variance in those with a history of concussion. However, there were no significant unique predictors within the model as age (Wald = 1.26, p = 0.261), King-Devick (Wald = 2.31, p = 0.128), and near point of convergence (Wald = 2.43, p = 0.119) were not significant predictors individually.

CONCLUSIONS

The conflicting findings of this study indicate that baseline data for those with a history of concussion greater than one year may not be comparable to the same metrics during acute concussion episodes. Young athletes who sustain a concussion may be able to overcompensate via the visual system. Future prospective studies with larger sample sizes are required using the proposed model's objective metrics.

Combining Static and Dynamic Myofascial Dry Cupping Therapy to Improve Local and Regional Symptoms in Individuals with Low Back Pain: A Case Series

Introduction

Chronic low back pain is a common musculoskeletal healthcare presentation with an expense of over $100 billion annually. The clinical effect of myofascial cupping on pain and function is not clear, especially when different cupping techniques are combined. The purpose of this case series was to explore changes in pain and function following local static and distal dynamic myofascial dry cupping treatments in patients with chronic low back pain.

Case Descriptions

Three adults from the general population received three ten-minute treatment sessions, 48 hours between each session, of static dry cupping to the low back followed by dynamic myofascial cupping of the quadriceps and hamstring musculature. Outcome measures were taken at two different time points within one-week per participant. Subjective measures included the numeric pain rating scale and the Oswestry Disability Index, objective measures included passive straight leg raise measurements, and pressure pain threshold.

Results and Discussion

Local static combined with distal dynamic myofascial cupping reduced pain, pain sensitivity and perceived disability, and improved hamstring muscle extensibility in all three participants. These encouraging results support the initiation of a larger controlled trial aimed at investigating the efficacy of combined dry cupping interventions to treat musculoskeletal dysfunction and pain.

Level of Evidence

4 (case series).

Reliability and Validity of Inertial Sensor Assisted Reaction Time Measurement Tools among Healthy Young Adults

The assessment of movement reaction time (RT) as a sideline assessment is a valuable biomarker for mild TBI or concussion. However, such assessments require controlled laboratory environments, which may not be feasible for sideline testing during a game. Body-worn wearable devices are advantageous as being cost-effective, easy to don and use, wirelessly transmit data, and ensure unhindered movement performance. This study aimed to develop a Drop-stick Test System (DTS) with a wireless inertial sensor and confirm its reliability for different standing conditions (Foam versus No Foam) and task types (Single versus Dual), and postures (Standing versus sitting). Fourteen healthy young participants (seven females, seven males; age 24.7 ± 2.6 years) participated in this study. The participants were asked to catch a falling stick attached to the sensor during a drop test. Reaction Times (RTs) were calculated from data for each trial from DTS and laboratory camera system (gold standard). Intraclass correlation coefficients (ICC 3,k) were computed to determine inter-instrument reliability. The RT measurements from participants using the camera system and sensor-based DTS showed moderate to good inter-instrument reliability with an overall ICC of 0.82 (95% CI 0.78-0.85). Bland-Altman plots and 95% levels of agreement revealed a bias where the DTS underestimated RT by approximately 50 ms.