Normative Tandem Gait in Collegiate Student-Athletes: Implications for Clinical Concussion Assessment

Instrumented Static and Reactive Balance in Collegiate Athletes: Normative Values and Minimal Detectable Change

CONTEXT

Wearable sensors are increasingly popular in concussion research because of their objective quantification of subtle balance deficits. However, normative data and minimal detectable change (MDC) values are necessary to serve as references for diagnostic use and tracking longitudinal recovery.

OBJECTIVE

To identify normative and MDC values for instrumented static- and reactive-balance tests, an instrumented static mediolateral (ML) root mean square (RMS) sway standing balance assessment and the instrumented, modified push and release (I-mP&R), respectively.

DESIGN

Cross-sectional study.

SETTING

Clinical setting.

PATIENTS OR OTHER PARTICIPANTS

Normative static ML RMS sway and I-mP&R data were collected on 377 (n = 184 female) healthy National Collegiate Athletic Association Division I athletes at the beginning of their competitive seasons. Test-retest data were collected in 36 healthy control athletes based on standard recovery timelines after concussion.

MAIN OUTCOME MEASURE(S)

Descriptive statistics, intraclass correlation coefficients (ICCs), and MDC values were calculated for primary outcomes of ML RMS sway in a static double-limb stance on firm ground and a foam block, and time to stability and latency from the I-mP&R in single- and dual-task conditions.

RESULTS

Normative outcomes across static ML RMS sway and I-mP&R were sensitive to sex and type of footwear. Mediolateral RMS sway demonstrated moderate reliability in the firm condition (ICC = 0.73; MDC = 2.7 cm/s2) but poor reliability in the foam condition (ICC = 0.43; MDC = 11.1 cm/s2). Single- and dual-task times to stability from the I-mP&R exhibited good reliability (ICC = 0.84 and 0.80, respectively; MDC = 0.25 and 0.29 seconds, respectively). Latency from the I-mP&R had poor to moderate reliability (ICC = 0.38 and 0.55; MDC = 107 and 105 milliseconds).

CONCLUSIONS

Sex-matched references should be used for instrumented static- and reactive-balance assessments. Footwear may explain variability in static ML RMS sway and time to stability of the I-mP&R. Moderate-to-good reliability suggests time to stability from the I-mP&R and ML RMS static sway on firm ground can be used for longitudinal assessments.

Initial investigation of kinesiophobia as a predictor of functional reaction time one year after concussion

Aim

The relationship between post-concussion kinesiophobia and clinical and functional reaction time (RT) beyond clinical recovery remains to be elucidated.

Methods

College-aged participants with (n = 20) and without (n = 20) a concussion history completed patient-reported outcomes, and RT tasks. Kinesiophobia, symptoms and RTs were compared using t-tests. Linear regressions were performed to determine if kinesiophobia predicted RT measures and dual-task cost.

Results

The concussion history group reported higher scores (p < 0.01) for all patient-reported outcomes. We observed significant single-task RT differences between groups (p = 0.013) such that those without a concussion history (m = 0.51s ± 0.08) were faster (m = 0.59s ± 0.12). There were no clinical or dual-task RT differences between groups (p > 0.05). Kinesiophobia significantly predicted single-task RT (R2 = 0.22).

Discussion

Kinesiophobia should be considered when measuring RT.

Integrative data analysis to identify persistent post-concussion deficits and subsequent musculoskeletal injury risk: project structure and methods

Concussions are a serious public health problem, with significant healthcare costs and risks. One of the most serious complications of concussions is an increased risk of subsequent musculoskeletal injuries (MSKI). However, there is currently no reliable way to identify which individuals are at highest risk for post-concussion MSKIs. This study proposes a novel data analysis strategy for developing a clinically feasible risk score for post-concussion MSKIs in student-athletes. The data set consists of one-time tests (eg, mental health questionnaires), relevant information on demographics, health history (including details regarding the concussion such as day of the year and time lost) and athletic participation (current sport and contact level) that were collected at a single time point as well as multiple time points (baseline and follow-up time points after the concussion) of the clinical assessments (ie, cognitive, postural stability, reaction time and vestibular and ocular motor testing). The follow-up time point measurements were treated as individual variables and as differences from the baseline. Our approach used a weight-of-evidence (WoE) transformation to handle missing data and variable heterogeneity and machine learning methods for variable selection and model fitting. We applied a training-testing sample splitting scheme and performed variable preprocessing with the WoE transformation. Then, machine learning methods were applied to predict the MSKI indicator prediction, thereby constructing a composite risk score for the training-testing sample. This methodology demonstrates the potential of using machine learning methods to improve the accuracy and interpretability of risk scores for MSKI.

Tandem gait test-retest reliability among healthy physically active young adults

BACKGROUND

A tandem gait assessment is recommended after concussion. There is limited research examining psychometric properties of tandem gait assessments.

OBJECTIVE

To determine tandem gait test intertrial and 1-week test-retest reliability. It was hypothesized that the tandem gait test would yield moderate to good reliability, times would improve across trials/sessions, and average scores would have higher reliability.

DESIGN

Reliability study.

SETTING

Research laboratory.

INTERVENTIONS

Sixty participants (36 females, age: 20.4 ± 1.8 years) completed 10 tandem gait test trials on two occasions.

MAIN OUTCOME MEASURES

Dependent variables included number of normal trials (participants stayed on the line, heel and toe touched on every step, and they avoided touching an examiner/object) and times for each trial. We analyzed intertrial reliability using a one-way analysis of covariance and intraclass correlation coefficients (ICC), and test-retest reliability using dependent samples t-tests and ICCs.

RESULTS

At the first testing session, there were significant differences in times across seven trials (F2.44,80.42  = 21.55, p < .001). All trials were faster than the first trial. The second, third, and fifth trial were faster than the previous trial. There was moderately high overall reliability across the first seven trials (ICC2,1  = 0.77, 95% confidence interval = 0.63, 0.87). All times were faster at the second testing session (compared to the first). Most outcomes for the 1-week test-retest reliability demonstrated at least moderate reliability, including the best times for the first three, four, and five trials; average times for the first four and five trials; and best and average times for all of the participants' normal trials during five and 10 attempted trials.

CONCLUSIONS

There are practice effects when administering multiple tandem gait test trials, but scores stabilize after the fifth trial. There are practice effects associated with multiple administrations of the tandem gait test, but outcomes using times for four or five trials have adequate 1-week test-retest reliability in healthy physically active young adults.

Spatiotemporal Parameters of Gait Among Adolescent Athletes with Concussion When Performing a Visuospatial Cognitive Task

Background

Adolescent athletes aged 10 to 19 years are at the highest risk of experiencing sport-related concussions (SRCs). Despite the known deficits and battery of assessments following concussion, postural stability during dual-task gait remains understudied in this population.

Purpose

The purpose of this study was to evaluate the dual-task cost (DTC) in adolescents with an acute or chronic SRC compared to reference values from healthy athlete peers for spatiotemporal parameters of gait during walking with and without a concurrent visuospatial memory task presented on a hand-held tablet. Researchers hypothesized that adolescents during the acute phase of concussion would be likely to experience a greater DTC compared to healthy peers in at least one spatiotemporal parameter of gait when walking within the dual-task paradigm.

Study Design

Cross-sectional, observational cohort design.

Methods

Adolescents with concussion were recruited to participate. Subjects were divided into acute and chronic categories based on significant differences in the neuropsychological function after a period of 28 days. They walked at a self-selected speed along the 5.186-meter GAITRite® Walkway System with and without a concurrent visuospatial cognitive task presented on a hand-held tablet. Outcomes included normalized velocity (m/s), step length (m), and double limb (DLS) and single limb support (SLS) (defined as the percent of a gait cycle [%GC]). The data were then compared to the previously published reference values established using the same methods in the healthy athlete participants for all spatiotemporal parameters of gait.

Results

Data was collected on 29 adolescent athletes with SRC. Among males (15.53+/-1.12 years) with SRC, 20% of acute and 10% of chronic cases experienced a greater DTC compared to healthy athlete reference values. A similarly increased DTC was experienced by 83% of acute and 29% of chronic SRC cases for females (15.58+/-1.16 years).

Conclusions

Adolescent athletes with concussion may continue demonstrating deficits in gait capabilities even in the chronic phase, and compensatory gait strategies were not the same between males and females. Dual-task cost assessment using the GAITRite® may be a valuable adjunct to comprehensive analysis of gait following SRC.

Level of Evidence

2.

Single-Task and Dual-Task Tandem Gait Performance Across Clinical Concussion Milestones in Collegiate Student-Athletes

OBJECTIVE

To determine the length of time after concussion that impaired tandem gait performance is observed.

DESIGN

Clinical measurement, prospective longitudinal.

SETTING

NCAA collegiate athletic facility.

PARTICIPANTS

Eighty-eight concussed NCAA Division I student-athletes and 30 healthy controls.

INDEPENDENT VARIABLES

Group (concussion/control) and time (Baseline, Acute, Asymptomatic, and RTP).

MAIN OUTCOME MEASURES

Participants completed 4 single-task and dual-task tandem gait trials. The concussion group completed tests at the following time points: preseason (Baseline), within 48 hours after concussion (Acute), on the day symptoms were no longer reported (Asymptomatic), and when cleared to return to sports (RTP). Controls completed the same protocol at similar intervals. The dual-task trials involved minimental style cognitive questions answered simultaneously during tandem gait. We analyzed the best time of the 4 trials, comparing groups with a linear mixed model.

RESULTS

Acutely after concussion, the concussion group performed single-task tandem gait slower (worse) than controls (concussion: 11.36 ± 2.43 seconds, controls: 9.07 ± 1.78 seconds, P < 0.001). The concussion group remained significantly slower than controls (9.95 ± 2.21 vs 8.89 ± 1.65 seconds, P = 0.03) at Asymptomatic day but not RTP. There were significant group (P < 0.001) and time (P < 0.001) effects for dual-task tandem gait. The groups were not significantly different at baseline for single-task (P = 0.95) or dual-task (P = 0.22) tandem gait.

CONCLUSIONS

Our results indicate that tandem gait performance is significantly impaired acutely after concussion, compared with both preseason measures and controls. Postural control impairments were not present when the student-athletes were cleared for RTP. This information can assist clinicians when assessing postural control and determining recovery after a concussive injury.

The tandem gait test: kinematics and temporal parameters for normal children and for posterior fossa tumor survivors

Background: Tandem Gait (TG) testing is known as a clinical method for studying the walking function with complicated coordination. The precise biomechanical walking parameters in this test remain poorly investigated. Moreover, TG is a modified locomotion of walking. In general, walking is a highly automated movement. TG introduces a component of voluntary control into it. Aims: A study of functional and biomechanical symptoms in children after the treatment for the posterior fossa tumor in the long term. Methods: The study involved 15 healthy subjects aged 12 to 35 years (20.47.2), among them 4 men and 11 women control group. The group of patients comprised 33 children who had a tumor of the posterior cranial fossa (HF) at the age of 7 to 17 years (12.33.1), of these 15 boys and 18 girls, who were admitted for rehabilitation treatment to the "Russkoe pole" Rehabilitation Center. A study on the TG kinematics was performed with the Optitrack system. Results: The results showed asymmetry in the duration of the step cycle and an increase in its duration proportional to the severity of the functional state. The pelvic movements showed different abnormalities. The flexion-extension movements in the hip joints were characterized by an extension lag at the end of the transfer period and a slight decrease in the amplitude, which probably became more pronounced with an increase in the degree of the motor impairment. The movements in the knee joints demonstrated two main phenomena: an increase in the flexion setting of the joint and a decrease in the amplitude of the main swing flexion. In addition, there was a delay in the maximum of the swing flexion. The kinematic parameters of the TG of the examined patients, in contrast to the control group, are not stable. This is, presumably, due to the fact, that normally such a modification of walking is easily automated and does not require voluntary control. In patients with SCF, each step in the TG mode requires additional voluntary control, and under these conditions, the stability and repeatability of a movement are dramatically reduced. Conclusions: In contrast to the routine clinical version of the test, the analysis of the movement biomechanics allows one to present an accurate qualitative and quantitative characterization of functional disorders. According to our research, motor function disorders develop at various levels of the musculoskeletal system. The degree of their severity is in a good agreement with the expert assessment of the patient's functional state.

Sport-related concussion adopt a more conservative approach to straight path walking and turning during tandem gait

BACKGROUND

It is currently unknown what specific neuronal deficits influence postural instability following SRC; however, the modulation of postural control relies heavily on the appropriate integration of sensory information from the visual, vestibular, and somatosensory system. It is possible symptom provocation of vestibular or ocular function is related to unsteady gait patterns during tandem gait.

AIM

The purpose of this study was to evaluate the differences in temporal and center of pressure (CoP) metrics during discrete events of instrumented tandem gait (iTG) among those with sport-related concussion (SRC) compared to healthy controls. Secondarily, this study attempted to evaluate the relationship between iTG CoP metrics and the Vestibular/Ocular Motor Screening (VOMS) Exam.

MATERIALS AND METHODS

30 collegiate athletes with SRC and 30 healthy controls completed three single task (ST) iTG trials on an instrumented walkway and the VOMS. All individuals with SRC were assessed within 24-48 h post-injury while all controls were measured during pre-participation physicals. CoP metrics in the anteroposterior (AP) and mediolateral (ML) directions and time to completion were evaluated during the first, turn and second pass of iTG between groups. VOMS score was correlated to the CoP metrics across the discrete events.

RESULTS

Athletes with SRC took longer to complete tandem gait (P<0.001) along with the first pass, second pass but not the turn when compared to the control group. SRC had slower velocity in the AP direction during both the first (P<0.001) and second pass (P<0.001) with increased postural sway in the ML direction during the first pass (P=0.014). During the turn, athletes with SRC had postural sway in the ML direction (P=0.008). Finally, VOMS score was weakly negatively related to CoP velocity in the AP direction during first (r=-0.39) and second (r=-0.36) pass while being weakly positively related to postural sway during the turn (r=-0.30).

CONCLUSIONS

Athletes with SRC adopted a more conservative walking pattern and the presence of vestibular and/or ocular symptoms influence the ability to perform heel-to-toe walking.

RELEVANCE FOR PATIENTS

Individuals with SRC will walk slower during heel-to-toe walking and move more in the ML direction with great movement in the ML direction while en pointe turning. This may increase given the total amount of vestibular or vision symptoms following the SRC.

Gait Assessment in College Athletes: Do Concussion History, Symptoms, Gender, and Type of Sport Matter?

CONTEXT

Though previous research has focused on examining the effects of concussion history using a dual-task paradigm, the influence of factors like symptoms (unrelated to concussion), gender, and type of sport on gait in college athletes is unknown.

OBJECTIVE

To examine the effect of concussion history, symptoms, gender, and type of sport (noncontact/limited contact/contact) individually on gait among college athletes.

DESIGN

Exploratory cross-sectional study.

SETTING

Laboratory.

PARTICIPANTS

In total, 98 varsity athletes (age, 18.3 [1.0] y; height, 1.79 [0.11] m; mass, 77.5 [19.2] kg; 27 with concussion history, 58 reported at least one symptom, 44 females; 8 played noncontact sports and 71 played contact sports) walked under single- and dual-task (walking while counting backward by 7) conditions.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Dual-task cost (DTC; % difference between single task and dual task) of gait speed, cadence, step length and width, percentage of swing and double-support phases, symptom score, and total symptom severity score. Independent samples t tests and 1-way analysis of variance were conducted (α value = .05).

RESULTS

Self-reported concussion history resulted in no significant differences (P > .05). Those who reported symptoms at testing time showed significantly greater DTC of step length (mean difference [MD], 2.7%; 95% confidence interval [CI], 0.3% to 5.1%; P = .012), % of swing phase (MD, 1.0%; 95% CI, -0.2 to 2.1%; P = .042), and % of double-support phase (MD, 3.9%; 95% CI, 0.2% to 7.8%; P = .019). Females demonstrated significantly higher DTC of gait speed (MD, 5.3%; 95% CI, 1.3% to 9.3%; P = .005), cadence (MD, 4.0%; 95% CI, 1.4% to 6.5%; P = .002), % of swing phase (MD, 1.2%; 95% CI, 0.1% to 2.3%; P = .019), and % of double-support phase (MD, 4.1%; 95% CI, 0.4% to 7.9%; P = .018). Noncontact sports athletes had significantly greater step width DTC than contact sports athletes (MD, 14.2%; 95% CI, 0.9% to 27.6%; P = .032).

CONCLUSIONS

Reporting symptoms at testing time may influence gait under dual-task conditions. Additionally, female athletes showed more gait changes during a dual task. Sports medicine professionals should be aware that these variables, while unrelated to injury, may affect an athlete's gait upon analysis.

Age is associated with postural control performance following youth concussion

PURPOSE

To examine the effect of age on postural control outcomes among patients being seen during their initial post-concussion clinical visit.

METHODS

Youth patients were seen≤14 days post-concussion, and completed a series of postural control evaluations: tandem gait, Romberg, and Balance Error Scoring System (BESS) tests.

RESULTS

We included 109 children 8-12 years of age (24% female, evaluated median = 7 [interquartile range = 4-10] days post-injury) and 353 adolescents aged 13-18 years (36% female, evaluated median = 7 [4-10] days post-injury). There was a higher proportion of children who demonstrated abnormal tandem gait relative to adolescents (26% vs. 11%; p < 0.001). They also made more BESS errors in single (median = 5 [2-10] vs. 4 [2-6] errors) and tandem (median = 3 [1-6] vs. 2 [0-4]) firm stances. After covariate adjustment, children demonstrated worse tandem gait (adjusted odds ratio = 3.05, 95% CI = 1.68-5.53) and more firm surface BESS errors (double stance β=0.51, 95% CI = 0.22-0.80; single stance β= 1.18, 95% CI = 0.42-1.95; tandem stance β= 0.98, 95% CI = 0.28-1.68) than adolescents.

CONCLUSIONS

Tandem gait and BESS performance following concussion differ in children compared to adolescents who present within 2 weeks of injury. Clinicians assessing and managing concussion should recognize age differences in postural control performance when assessing those with concussion.

No differences in tandem gait performance between male and female athletes acutely post-concussion

OBJECTIVES

To test whether 1) concussed athletes demonstrate slower tandem gait times compared to controls and 2) concussed female athletes display greater post-injury deficits than males.

DESIGN

Prospective longitudinal METHOD: Fifty concussed collegiate student-athletes (32% female, age=20.18±1.27 years) completed tandem gait tests during pre-season (Time 1) and acutely (<72hours) post-concussion (Time 2), and twenty-five controls (52% female, age=21.08±2.22 years) completed tandem gait at two time points, 1.96±0.46 days apart. Participants completed four single-task (ST) and dual-task (DT) trials. During DT trials, they simultaneously completed a cognitive assessment. The best ST and DT times were recorded, along with cognitive accuracy, and the change score between the two assessments was calculated. A positive change in tandem gait time was indicative of worsening performance. A 2×2 (group*sex) ANOVA was used to examine change between pre-injury and post-injury tests for ST/DT tandem gait time and DT cognitive accuracy.

RESULTS

The change in tandem gait time from Time 1 to Time 2 was significantly higher for the concussion group relative to controls during both ST (Concussion: 1.36±2.6 seconds, Controls: -1.16±0.8 seconds, p<0.001) and DT (Concussion: 1.70±3.8 seconds, Controls: -0.94±1.7 seconds, p=0.002) tandem gait. There were no interactions or main effects of sex for tandem gait time or cognitive accuracy.

CONCLUSIONS

There were no sex-specific differences in the change in tandem gait performance among concussed collegiate athletes or controls. However, all concussed participants, regardless of sex, performed significantly worse on tandem gait than male and female controls, who both improved between testing time points.

Effects of Repetitive Head Impacts on a Concussion Assessment Battery

PURPOSE

The purpose of this study was to determine the relationship between repetitive head impacts (RHI) and clinical concussion assessments across a season among collegiate football (FB) and women's soccer (WSOC) players.

METHODS

Fifteen male FB and 23 WSOC players participated in this study. Participants were included if they were medically cleared for unrestricted athletic participation. Participants were tested in a university athletic training room on two occasions: preseason (PRE) and postseason (POST). The outcome measures consisted of tandem gait (TG), Standardized Assessment of Concussion, Balance Error Scoring System, King-Devick (KD), clinical reaction time, and Immediate Post-Concussion Assessment and Cognitive Testing. Repetitive head impact during the season was quantified using the Head Impact Telemetry System (Simbex, NH) for FB and the Smart Impact Monitor (SIM; Triax Technologies, Norwalk, CT) for WSOC. Independent variables included total number of impacts, average magnitude of peak linear acceleration, cumulative linear exposure, and number of impacts ≥98g.

RESULTS

Results from direct-entry multiple regression analyses suggest significant associations between RHI and both visual memory (R = 0.670, F = 6.487, P = 0.002) and TG (R = 0.636, F = 3.841, P = 0.029) for WSOC and between RHI and KD (R = 0.756, F = 5.579, P = 0.013) for FB, whereby those with greater exposure performed worse. No other regression analyses within or across groups were significant.

CONCLUSIONS

These data suggest that RHI do not represent clinically meaningful changes on a multifaceted and multimodal concussion assessment battery. However, there may be subtle visual/vestibular impairments as observed by the associations between RHI and visual memory/TG among WSOC, RHI, and KD among FB.

Tandem Gait Test-Retest Reliability Among Healthy Child and Adolescent Athletes

CONTEXT

The tandem gait test is a method for assessing dynamic postural control and part of the Sport Concussion Assessment Tool, versions 3 and 5. However, its reliability among child and adolescent athletes has yet to be established.

OBJECTIVE

To examine the test-retest reliability of the single-task and dual-task tandem gait test among healthy child and adolescent athletes.

DESIGN

Descriptive laboratory study.

SETTING

Sports injury-prevention center.

PATIENTS OR OTHER PARTICIPANTS

Uninjured and healthy athletes between the ages of 9 and 18 years.

INTERVENTION(S)

Tandem gait measures repeated 3 times across the period of approximately 1 month.

MAIN OUTCOME MEASURE(S)

Participants completed the tandem gait test under single-task and dual-task (ie, while simultaneously executing a cognitive task) conditions. Our primary outcome measure was completion time during the single-task and dual-task conditions. We also assessed cognitive accuracy and response rate while participants completed the dual-task tandem gait test.

RESULTS

Thirty-two child and adolescent athletes completed the study (mean age = 14.3 ± 2.4 years; females = 16). Single-task tandem gait times were similar across the 3 testing sessions (14.4 ± 4.8, 13.5 ± 4.2, and 13.8 ± 4.8 seconds; P = .45). Dual-task tandem gait times steadily improved across the test timeline (18.6 ± 6.9, 16.6 ± 4.5, and 15.8 ± 4.7 seconds; P = .02). Bivariate correlations indicated moderately high to high agreement from test 1 to test 2 (single-task r = .627; dual-task r = 0.655) and from test 2 to test 3 (single-task r = 0.852; dual-task r = 0.775). Both the single-task (intraclass correlation coefficient; ICC [3,1] = 0.86; 95% confidence interval [CI] = 0.73, 0.93) and dual-task (ICC [3,1] = 0.84; 95% CI = 0.69, 0.92) conditions demonstrated high reliability across testing sessions.

CONCLUSIONS

Tandem gait outcome measures demonstrated high test-retest reliability in both the single- and dual-task conditions. The overall reliability was within the acceptable range for clinical practice, but improvements across tests suggested a moderate practice effect. Tandem gait represents a reliable, dynamic, postural-control test that requires minimal space, cost, and time.

Single and dual tandem gait assessment post concussion: What performance time is clinically relevant across adult ages and what can influence results?

AIM

The three-metre tandem gait test (TG) is used to assess postural control during locomotion following sports concussion. However, values used to determine a pass/fail result are currently based on young athletic populations. Times for test completion may be influenced by several intrinsic or extrinsic factors. The aim of this study was to collate healthy individual single, dual task as well as dual task cost - motor TG times for a non-elite athlete population, across several age groups, and to investigate several potential influencing factors.

METHODS

Healthy individuals aged 18-55+, who had never experienced a concussion completed single and dual task TG following the SCAT5 protocol. A separate group (n = 20, age, foot length and body mass index matched) performed the tests with alternate instructions.

RESULTS

Mean best TG time for all participants were: single task 21.03 (±5.26s), dual task 29.59 (±9.84s) and DTC-motor 8.57 (±7.5s:41.7%). Age and foot length but not specificity of verbal instructions were related to TG times. Significantly slower single and dual task times were identified for the 55 + age group when compared to the three youngest groups (p < 0.01). No difference was seen for DTC-motor time or % between age groups (p > 0.05).

CONCLUSION

Healthy individual data collected exceeded previously reported average times. Faster times were evident in younger participants and those with longer foot length. Results from this study can be used as a reliable guideline to inform clinical decisions around the pass/fail result of TGT across age ranges in non-elite athlete populations post-concussion.

Self-reported head injury symptoms exacerbated in those with previous concussions following an acute bout of purposeful soccer heading

Rates of concussion in soccer are high, especially in female players. The primary aim of this study was to examine differences in self-reported concussion-related symptoms (CRS), balance (BESS), and neurocognitive performance (ImPACT) following an acute bout of soccer heading in a group of female collegiate players with and without a history of concussion. Eighty-seven players with 0 to 3+ previous concussions participated. The measurement variables were assessed before and after heading sessions; including one linear and one rotational bout. Players with concussion histories reported more CRS than their non-concussed teammates both before and after the heading sessions. Balance and neurocognitive scores were generally unaffected. This finding should heighten our awareness to carefully monitor soccer players who have experienced concussions and be aware that they may develop concussion-like symptoms, especially after acute bouts of heading either during practice or in matches. The long-term implications of this finding remain unknown.

Dual-Task Tandem Gait and Average Walking Speed in Healthy Collegiate Athletes

OBJECTIVES

To (1) examine the association between a commonly used concussion test, tandem gait, in single/dual-task conditions with single-task and dual-task average walking speed, (2) characterize the prevalence of tandem gait false positives, and (3) develop a normative reference range of dual-task tandem gait times.

DESIGN

Cross-sectional study.

SETTING

Two NCAA collegiate athletic facilities.

INDEPENDENT VARIABLES

Athletes completed the tandem gait test and a gait evaluation in single/dual-task conditions during a preseason examination.

MAIN OUTCOME MEASURES

Associations between tandem gait times and average walking speeds were evaluated using multiple linear regression models. Various tandem gait test time pass/fail cutoffs were calculated to examine false-positive rates.

RESULTS

Among the 171 participants (103 men, 19.8 ± 1.2 years of age), dual-task tandem gait completion times were independently associated with dual-task average walking speed [β = -4.018; 95% confidence interval (CI), -7.153 to -0.883], but single-task associations were not found. Male gender was associated with faster tandem gait times in both single-task (β = -0.880, 95% CI, -1.731 to -0.029) and dual-task conditions (β = -2.225, 95% CI, -3.691 to -0.759). A pass/fail cutoff threshold of 14 seconds resulted in a 2% false-positive rate for single-task tandem gait, while it resulted in a 29% false-positive rate during dual-task tandem gait.

CONCLUSIONS

Average walking speed and dual-task tandem gait represent objective measures that are useful in concussion management. While a single-task tandem gait cutoff of 14 seconds seems appropriate for males, adjustments may be necessary based on sex and alternate pass/fail criteria may be appropriate for dual-task tandem gait.

Efficacy of Tandem Gait to Identify Impaired Postural Control after Concussion

PURPOSE

The purpose was to evaluate tandem gait (TG), Balance Error Scoring System (BESS), and modified Balance Error Scoring System (mBESS) performance acutely after concussion in collegiate student-athletes. In addition, we sought to evaluate the psychometric properties of TG, including minimal detectable change (MDC), sensitivity, and specificity.

METHODS

Seventy-six National Collegiate Athletic Association student-athletes performed TG and BESS tests: 38 acutely after concussion and 38 controls. Participants were tested at baseline (time 1) and again acutely after concussion, or the following year for controls (time 2). Ten controls, tested simultaneously by two researchers, established a TG interrater minimal detectable change. A 2 × 2 mixed-design ANOVA compared each outcome variable. An receiver operating characteristic curve analysis was used to evaluate sensitivity, specificity, and area under the curve (AUC).

RESULT

There was a significant interaction (F = 8.757, P = 0.004) for TG whereby the concussion group was slower after concussion (10.59 ± 1.53 vs 11.80 ± 2.67 s), whereas there was no difference for controls (10.13 ± 1.72 vs 9.93 ± 1.85 s). There was no significant interaction for BESS (F = 0.235, P = 0.630) or mBESS (F = 0.007, P = 0.935). TG had a sensitivity of 0.632, a specificity of 0.605, and an AUC of 0.704. BESS had a sensitivity of 0.447, a specificity of 0.500, and an AUC of 0.508. mBESS had a sensitivity of 0.474, a specificity of 0.632, and an AUC of 0.535.

CONCLUSIONS

Participants completed TG significantly slower after concussion, whereas no change across time was detected for controls. In contrast, BESS and mBESS performances were similar at both testing times in both groups. Our AUC analysis was acceptable for TG, but a failure for both BESS and mBESS; thus, TG may be a useful alternative for clinicians conducting postconcussion postural control assessments.

Detecting gait abnormalities after concussion or mild traumatic brain injury: A systematic review of single-task, dual-task, and complex gait

BACKGROUND

While a growing number of studies have investigated the effects of concussion or mild traumatic brain injury (mTBI) on gait, many studies use different experimental paradigms and outcome measures. The path for translating experimental studies for objective clinical assessments of gait is unclear.

RESEARCH QUESTION

This review asked 2 questions: 1) is gait abnormal after concussion/mTBI, and 2) what gait paradigms (single-task, dual-task, complex gait) detect abnormalities after concussion.

METHODS

Data sources included MEDLINE/PubMed, Scopus, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) accessed on March 14, 2017. Original research articles reporting gait outcomes in people with concussion or mTBI were included. Studies of moderate, severe, or unspecified TBI, and studies without a comparator were excluded.

RESULTS

After screening 233 articles, 38 studies were included and assigned to one or more sections based on the protocol and reported outcomes. Twenty-six articles reported single-task simple gait outcomes, 24 reported dual-task simple gait outcomes, 21 reported single-task complex gait outcomes, and 10 reported dual-task complex gait outcomes.

SIGNIFICANCE

Overall, this review provides evidence for two conclusions: 1) gait is abnormal acutely after concussion/mTBI but generally resolves over time; and 2) the inconsistency of findings, small sample sizes, and small number of studies examining homogenous measures at the same time-period post-concussion highlight the need for replication across independent populations and investigators. Future research should concentrate on dual-task and complex gait tasks, as they showed promise for detecting abnormal locomotor function outside of the acute timeframe. Additionally, studies should provide detailed demographic and clinical characteristics to enable more refined comparisons across studies.

Self-reported sleep duration affects tandem gait, but not steady-state gait outcomes among healthy collegiate athletes

BACKGROUND

Sleep deficits are associated with motor and cognitive function deficits, even in the absence of a recent concussion.

RESEARCH QUESTION

Does the amount of self-reported sleep prior to pre-season concussion testing affect single-task and dual-task instrumented steady-state gait and timed tandem gait test performance?

METHODS

One hundred and fourteen healthy collegiate athletes (mean age 18.8 ± 0.7 years; 60% female) reported the amount of sleep they received during the prior night and completed a timed tandem gait test and an instrumented assessment of steady-state gait in both single-task and dual-task conditions. Outcome variables included spatio-temporal gait parameters during steady-state gait, best and mean tandem gait times, and cognitive test accuracy.

RESULTS

Participants who reported sleeping <7 h of sleep during the night prior to testing (n = 62) had significantly longer tandem gait times in single-task and dual-task conditions (11.1 ± 2.2 vs. 10.1 ± 2.0 s and 14.5 ± 4.3 vs. 12.3 ± 2.6 s, respectively; p = .009) compared to those who reported sleeping ≥7 h (n = 52). No significant differences between groups were observed for spatio-temporal steady-state gait variables or for cognitive test accuracy.

SIGNIFICANCE

Self-reported sleep duration may be associated with baseline testing tandem gait performance. Thus, as sleep can play a role in motor abilities, clinicians may consider interpreting tandem gait performance in light of sleep duration during the night prior to testing.

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

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

Lower Extremity Musculoskeletal Injury Risk After Concussion Recovery in High School Athletes

CONTEXT

  Although an association between concussion and musculoskeletal injury has been described in collegiate and professional athletes, no researchers have investigated an association in younger athletes.

OBJECTIVE

  To determine if concussion in high school athletes increased the risk for lower extremity musculoskeletal injury after return to activity.

DESIGN

  Observational cohort study.

SETTING

  One hundred ninety-six high schools across 26 states.

PATIENTS OR OTHER PARTICIPANTS

  We used data from the National Athletic Treatment, Injury and Outcomes Network surveillance system. Athletic trainers provided information about sport-related concussions and musculoskeletal injuries in athletes in 27 sports, along with missed activity time due to these injuries.

MAIN OUTCOME MEASURE(S)

  Three general estimating equations were modeled to predict the odds of sustaining (1) any lower extremity injury, (2) a time-loss lower extremity injury, or (3) a non-time-loss lower extremity injury after concussion. Predictors were the total number of previous injuries, number of previous concussions, number of previous lower extremity injuries, number of previous upper extremity injuries, and sport contact classification.

RESULTS

  The initial dataset contained data from 18 216 athletes (females = 39%, n = 6887) and 46 217 injuries. Lower extremity injuries accounted for most injuries (56.3%), and concussions for 4.3% of total injuries. For every previous concussion, the odds of sustaining a subsequent time-loss lower extremity injury increased 34% (odds ratio [OR] = 1.34; 95% confidence interval [CI] = 1.13, 1.60). The number of previous concussions had no effect on the odds of sustaining any subsequent lower extremity injury (OR = 0.97; 95% CI = 0.89, 1.05) or a non-time-loss injury (OR = 1.01; 95% CI = 0.92, 1.10).

CONCLUSIONS

  Among high school athletes, concussion increased the odds of sustaining subsequent time-loss lower extremity injuries but not non-time-loss injuries. By definition, time-loss injuries may be considered more severe than non-time-loss injuries. The exact mechanism underlying the increased risk of lower extremity injury after concussion remains elusive and should be further explored in future research.

How tandem gait stumbled into the neurological exam: a review

Tandem gait testing is an integral part of the neurological exam. It is informative in a wide variety of disorders ranging from cerebellar disease to vestibular and peripheral neuropathies, parkinsonism, and other neurodegenerative conditions. We discuss the history and development of tandem gait testing as well as its technique, utility, and limitations in the assessment of neurological conditions. Tandem gait has emerged as a tool in the assessment of cerebellar disease, Huntington disease, idiopathic Parkinson's disease, atypical parkinsonism, peripheral neuropathies, and vestibulopathies. Its origin can be deduced from experimental observation and clinical experience as far back as the early nineteenth century. Despite the long history and ubiquitous performance of tandem gait testing, there is no standardized, guideline-based protocol to model for more homogenous research and clinical practices. Such a protocol should be developed using historical texts and manuscripts as well as the consensus of the medical research community. With standard protocols, further studies could define the sensitivity of abnormal tandem gait testing in cerebellar disorders, more diffuse neurodegeneration, and peripheral pathologies. Tandem gait can be a useful marker of dysfunction in neurologic conditions whose pathologies extend beyond the vermis or vestibulocerebellar module to include interconnected networks throughout the nervous system.

Decreased Anticipatory Postural Adjustments During Gait Initiation Acutely Postconcussion

OBJECTIVE

To investigate anticipatory postural adjustments (APAs) during the transitional movement task of gait initiation (GI) in individuals acutely after a concussion.

DESIGN

Cohort study.

SETTING

University research center.

PARTICIPANTS

A population-based sample of participants (N=84) divided into 2 equal groups of acutely postconcussion and healthy student athletes.

INTERVENTION

Participants were tested on 2 occasions: a preinjury baseline test and then the concussion group was retested acutely postconcussion and the healthy student athlete group again at a similar time. All participants completed 5 trials of GI on 4 forceplates.

MAIN OUTCOME MEASURES

The dependent variables were the displacement and velocity of the center of pressure (COP) during the APA phase and initial step kinematics. Comparisons were made with a 2 (group) × 2 (time) repeated-measures analysis of variance.

RESULTS

There was a significant interaction for COP posterior displacement (P<.001) and lateral displacement (P<.001). Posteriorly, post hoc testing identified a significant reduction in the concussion group (pretest: 5.7±1.6cm; posttest: 2.6±2.1cm; P<.001), but no difference in the healthy student athlete group (pretest: 4.0±1.6cm; posttest: 4.0±2.5cm; P=.921). Laterally, post hoc testing identified a significant reduction in the concussion group (pretest: 5.8±2.1cm; posttest: 3.8±1.8cm; P<.001), but no difference in the healthy student athlete group (pretest: 5.0±2.5cm; posttest: 5.2±2.4cm; P=.485).

CONCLUSIONS

The results of this study suggest difficulty in the planning and execution of GI acutely postconcussion, and posterior APA displacement and velocity are highly effective measures of impaired postural control. Finally, the APA phase is linked to the supplementary motor area, which suggests a supraspinal contribution to postconcussion impaired postural control.