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Jain D, Porfido T, de Souza NL, Brown AM, Caccese JB, Czykier A, Dennis EL, Tosto-Mancuso J, Wilde EA, Esopenko C. Neural Mechanisms Associated With Postural Control in Collegiate Soccer and Non-Soccer Athletes. J Neurol Phys Ther 2024; 48:151-158. [PMID: 38709008 DOI: 10.1097/npt.0000000000000476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 01/15/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND AND PURPOSE Sport-specific training may improve postural control, while repetitive head acceleration events (RHAEs) may compromise it. Understanding the neural mechanisms underlying postural control may contextualize changes due to training and RHAE. The goal of this study was to determine whether postural sway during the Balance Error Scoring System (BESS) is related to white matter organization (WMO) in collegiate athletes. METHODS Collegiate soccer ( N = 33) and non-soccer athletes ( N = 44) completed BESS and diffusion tensor imaging. Postural sway during each BESS stance, fractional anisotropy (FA), and mean diffusivity (MD) were extracted for each participant. Partial least squares analyses determined group differences in postural sway and WMO and the relationship between postural sway and WMO in soccer and non-soccer athletes separately. RESULTS Soccer athletes displayed better performance during BESS 6, with lower FA and higher MD in the medial lemniscus (ML) and inferior cerebellar peduncle (ICP), compared to non-soccer athletes. In soccer athletes, lower sway during BESS 2, 5, and 6 was associated with higher FA and lower MD in the corticospinal tract, ML, and ICP. In non-soccer athletes, lower sway during BESS 2 and 4 was associated with higher FA and lower MD in the ML and ICP. BESS 1 was associated with higher FA, and BESS 3 was associated with lower MD in the same tracts in non-soccer athletes. DISCUSSION AND CONCLUSIONS Soccer and non-soccer athletes showed unique relationships between sway and WMO, suggesting that sport-specific exposures are partly responsible for changes in neurological structure and accompanying postural control performance and should be considered when evaluating postural control after injury.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content, available at: http://links.lww.com/JNPT/A472 ).
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Affiliation(s)
- Divya Jain
- Divya Jain and Tara Porfido are considering as co-first authors. Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York City, New York (D.J., N.L.D., A.C., C.E.); Department of Rehabilitation & Movement Sciences, School of Health Professions, Rutgers Biomedical and Health Sciences, Newark, New Jersey (T.P., A.M.B.); School of Health and Rehabilitation Sciences, The Ohio State University College of Medicine, Columbus, Ohio (J.B.C.); Department of Neurology, University of Utah (E.L.D., E.A.W.); George E. Wahlen Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah (E.L.D., E.A.W.); and Abilities Research Center, Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York City, New York (J.T.-M.)
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Crowell MS, Thomasma E, Florkiewicz E, Brindle R, Roach M, Goss D, Pitt W. Validity and Responsiveness of a Modified Balance Error Scoring System Assessment Using a Mobile Device Application in Patients Recovering from Ankle Sprain. Int J Sports Phys Ther 2024; 19:440-450. [PMID: 38576835 PMCID: PMC10987306 DOI: 10.26603/001c.94608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 01/28/2024] [Indexed: 04/06/2024] Open
Abstract
Background Static balance is often impaired in patients after ankle sprains. The ability to identify static balance impairments is dependent on an effective balance assessment tool. The Sway Balance Mobile Application (SWAY App) (Sway Medical, Tulsa, OK) uses a smart phone or tablet to assess postural sway during a modified Balance Error Scoring System (mBESS) assessment and shows promise as an accessible method to quantify changes in static balance after injury. Purpose The primary purposes of this study were to determine the ability to differentiate between those with ankle sprain versus controls (construct validity) and ability to detect change over time (responsiveness) of a mBESS assessment using a mobile device application to evaluate static balance after an acute ankle sprain. Study Design Case-control study. Methods Twenty-two military academy Cadets with an acute ankle sprain and 20 healthy Cadets were enrolled in the study. All participants completed an assessment measuring self-reported function, ankle dorsiflexion range of motion (via the weightbearing lunge), dynamic balance, and static balance. Static balance measured with the mBESS using the SWAY App was validated against laboratory-based measures. Cadets with ankle sprains completed their assessment twice: once within two weeks of injury (baseline) and again after four weeks of rehabilitation that included balance training. Independent and paired t-tests were utilized to analyze differences over time and between groups. Effect sizes were calculated and relationships explored using Pearson's correlation coefficients. Results The mBESS scores measured by the SWAY App were lower in participants with acute ankle sprains than healthy Cadets (t = 3.15, p = 0.004). Injured participants improved their mBESS score measured by SWAY at four weeks following their initial assessments (t = 3.31, p = 0.004; Baseline: 74.2 +/- 16.1, 4-weeks: 82.7 +/- 9.5). The mBESS measured by the SWAY App demonstrated moderate to good correlation with a laboratory measure of static balance (r = -0.59, p \< 0.001). Conclusion The mBESS assessed with a mobile device application is a valid and responsive clinical tool for evaluating static balance. The tool demonstrated construct (known groups) validity detecting balance differences between a healthy and injured group, concurrent validity demonstrating moderate to good correlation with established laboratory measures, and responsiveness to changes in static balance in military Cadets during recovery from an acute ankle sprain. Level of Evidence Level 3.
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Affiliation(s)
- Michael S Crowell
- University of Scranton
- Baylor University - Keller Army Community Hospital Division 1 Sports Physical Therapy Fellowship
| | | | - Erin Florkiewicz
- Baylor University - Keller Army Community Hospital Division 1 Sports Physical Therapy Fellowship
| | | | - Megan Roach
- DoD-VA Extremity Trauma & Amputation Center of Excellence Womack Army Medical Center
| | | | - Will Pitt
- Army-Baylor Doctoral Program in Physical Therapy
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Koshino Y, Akimoto M, Kawahara D, Watanabe K, Ishida T, Samukawa M, Kasahara S, Tohyama H. Inertial Sensor-Based Assessment of Static Balance in Athletes with Chronic Ankle Instability. J Sports Sci Med 2023; 22:36-43. [PMID: 36876176 PMCID: PMC9982532 DOI: 10.52082/jssm.2023.36] [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: 11/29/2022] [Accepted: 12/29/2022] [Indexed: 01/09/2023]
Abstract
The Balance Error Scoring System (BESS), a subjective examiner-based assessment, is often employed to assess postural balance in individuals with chronic ankle instability (CAI); however, inertial sensors may enhance the detection of balance deficits. This study aimed to compare the BESS results between the CAI and healthy groups using conventional BESS scores and inertial sensor data. The BESS test (six conditions: double-leg, single-leg, and tandem stances on firm and foam surfaces, respectively) was performed for the CAI (n = 16) and healthy control (n = 16) groups with inertial sensors mounted on the sacrum and anterior shank. The BESS score was calculated visually by the examiner by counting postural sway as an error based on the recorded video. The root mean square for resultant acceleration (RMSacc) in the anteroposterior, mediolateral, and vertical directions was calculated from each inertial sensor affixed to the sacral and shank surfaces during the BESS test. The mixed-effects analysis of variance and unpaired t-test were used to assess the effects of group and condition on the BESS scores and RMSacc. No significant between-group differences were found in the RMSacc of the sacral and shank surfaces, and the BESS scores (P > 0.05), except for the total BESS score in the foam condition (CAI: 14.4 ± 3.7, control: 11.7 ± 3.4; P = 0.039). Significant main effects of the conditions were found with respect to the BESS scores and RMSacc for the sacral and anterior shank (P < 0.05). The BESS test with inertial sensors can detect differences in the BESS conditions for athletes with CAI. However, our method could not detect any differences between the CAI and healthy groups.
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Affiliation(s)
- Yuta Koshino
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Moeko Akimoto
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Daiki Kawahara
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | | | - Tomoya Ishida
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Mina Samukawa
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
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Parrington L, Brumbach BH, Peterka RJ, King LA. Do sensorimotor control properties mediate sway in people with chronic balance complaints following mTBI? Gait Posture 2022; 96:173-178. [PMID: 35667229 DOI: 10.1016/j.gaitpost.2022.05.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 04/20/2022] [Accepted: 05/19/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Up to 40% of mild traumatic brain injuries (mTBI) can result in chronic unresolved symptoms, such as balance impairment, that persist beyond three months. Sensorimotor control, the collective coordination and regulation of both sensory and motor components of the postural control system, may underlie balance deficits in chronic mTBI. The aim of this study was to determine if the relationship between severity of impairment in chronic (> 3 months) mTBI and poorer balance performance was mediated by sensorimotor integration measures. METHODS Data were collected from 61 healthy controls and 58 mTBI participants suffering persistent balance problems. Participants completed questionnaires (Dizziness Handicap Inventory (DHI), Neurobehavioral Symptom Inventory (NSI), and Sports Concussion Assessment Tool Symptom Questionnaire (SCAT2)) and performed instrumented postural sway assessments and a test of Central Sensory Motor Integration (CSMI). Exploratory Factor Analysis was used to reduce the variables used within the mediation models to constructs of impairment (Impairment Severity - based on questionnaires), balance (Sway Dispersion - based on instrumented postural sway measures), and sensorimotor control (Sensory Weighting, Motor Activation and Time Delay - based on parameters from CSMI tests). Mediation analyses used path analysis to estimate the direct effect (between impairment and balance) and indirect (mediating) effects (from sensorimotor control). RESULTS Two out of three sensorimotor integration factors (Motor Activation and Time Delay) mediated the relationship between Impairment Severity and Sway Dispersion, however, there was no mediating effect of Sensory Weighting. SIGNIFICANCE These findings have clinical implications since rehabilitation of balance commonly focuses on sensory cues. Our findings indicate the importance of Motor Activation and Time Delay, and thus a focus on strategies to improve factors related to these constructs throughout the rehabilitative process (i.e., level of muscular contractions to control joint torques; response time to stimuli/perturbations) may improve a patient's balance control.
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Affiliation(s)
- Lucy Parrington
- Department of Neurology, Balance Disorders Laboratory, Oregon Health & Science University, Portland, USA; National Center for Rehabilitative Auditory Research (NCRAR), VA Portland Health Care System, Portland, USA; Department of Dietetics, Human Nutrition and Sport, School of Sport and Exercise Science, La Trobe University, Melbourne, Australia
| | - Barbara H Brumbach
- Biostatistics & Design Program, Oregon Health & Science University, Portland, USA
| | - Robert J Peterka
- Department of Neurology, Balance Disorders Laboratory, Oregon Health & Science University, Portland, USA; National Center for Rehabilitative Auditory Research (NCRAR), VA Portland Health Care System, Portland, USA
| | - Laurie A King
- Department of Neurology, Balance Disorders Laboratory, Oregon Health & Science University, Portland, USA; National Center for Rehabilitative Auditory Research (NCRAR), VA Portland Health Care System, Portland, USA.
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Rodrigues LA, Santos EGR, Santos PSA, Igarashi Y, Oliveira LKR, Pinto GHL, Santos Lobato BL, Cabral AS, Belgamo A, Costa e Silva AA, Callegari B, Souza GS. Wearable Devices and Smartphone Inertial Sensors for Static Balance Assessment: A Concurrent Validity Study in Young Adult Population. J Pers Med 2022; 12:jpm12071019. [PMID: 35887516 PMCID: PMC9316197 DOI: 10.3390/jpm12071019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 06/17/2022] [Accepted: 06/18/2022] [Indexed: 11/25/2022] Open
Abstract
Falls represent a public health issue around the world and prevention is an important part of the politics of many countries. The standard method of evaluating balance is posturography using a force platform, which has high financial costs. Other instruments, such as portable devices and smartphones, have been evaluated as low-cost alternatives to the screening of balance control. Although smartphones and wearables have different sizes, shapes, and weights, they have been systematically validated for static balance control tasks. Different studies have applied different experimental configurations to validate the inertial measurements obtained by these devices. We aim to evaluate the concurrent validity of a smartphone and a portable device for the evaluation of static balance control in the same group of participants. Twenty-six healthy and young subjects comprised the sample. The validity for static balance control evaluation of built-in accelerometers inside portable smartphone and wearable devices was tested considering force platform recordings as a gold standard for comparisons. A linear correlation (r) between the quantitative variables obtained from the inertial sensors and the force platform was used as an indicator of the concurrent validity. Reliability of the measures was calculated using Intraclass correlation in a subsample (n = 14). Smartphones had 11 out of 12 variables with significant moderate to very high correlation (r > 0.5, p < 0.05) with force platform variables in open eyes, closed eyes, and unipedal conditions, while wearable devices had 8 out of 12 variables with moderate to very high correlation (r > 0.5, p < 0.05) with force platform variables under the same task conditions. Significant reliabilities were found in closed eye conditions for smartphones and wearables. The smartphone and wearable devices had concurrent validity for the static balance evaluation and the smartphone had better validity results than the wearables for the static balance evaluation.
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Affiliation(s)
| | - Enzo Gabriel Rocha Santos
- Instituto de Ciências Exatas e Naturais, Universidade Federal do Pará, Belém 66050-540, Brazil; (E.G.R.S.); (G.H.L.P.)
| | | | - Yuzo Igarashi
- Núcleo de Medicina Tropical, Universidade Federal do Pará, Belém 66050-540, Brazil; (L.A.R.); (Y.I.)
| | - Luana Karine Resende Oliveira
- Instituto de Ciências da Saúde, Universidade Federal do Pará, Belém 66050-540, Brazil; (L.K.R.O.); (B.L.S.L.); (A.A.C.e.S.); (B.C.)
| | - Gustavo Henrique Lima Pinto
- Instituto de Ciências Exatas e Naturais, Universidade Federal do Pará, Belém 66050-540, Brazil; (E.G.R.S.); (G.H.L.P.)
| | - Bruno Lopes Santos Lobato
- Instituto de Ciências da Saúde, Universidade Federal do Pará, Belém 66050-540, Brazil; (L.K.R.O.); (B.L.S.L.); (A.A.C.e.S.); (B.C.)
| | - André Santos Cabral
- Centro de Ciências Biológicas e da Saúde, Universidade do Estado do Pará, Belém 66087-670, Brazil;
| | - Anderson Belgamo
- Departamento de Ciência da Computação, Instituto Federal de São Paulo, Piracicaba 08021-090, Brazil;
| | - Anselmo Athayde Costa e Silva
- Instituto de Ciências da Saúde, Universidade Federal do Pará, Belém 66050-540, Brazil; (L.K.R.O.); (B.L.S.L.); (A.A.C.e.S.); (B.C.)
- Instituto de Ciências da Educação, Universidade Federal do Pará, Belém 66050-540, Brazil
| | - Bianca Callegari
- Instituto de Ciências da Saúde, Universidade Federal do Pará, Belém 66050-540, Brazil; (L.K.R.O.); (B.L.S.L.); (A.A.C.e.S.); (B.C.)
| | - Givago Silva Souza
- Núcleo de Medicina Tropical, Universidade Federal do Pará, Belém 66050-540, Brazil; (L.A.R.); (Y.I.)
- Instituto de Ciências Biológicas, Universidade Federal do Pará, Belém 66050-540, Brazil;
- Correspondence: ; Tel.: +55-91-982653131
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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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Salchow-Hömmen C, Skrobot M, Jochner MCE, Schauer T, Kühn AA, Wenger N. Review-Emerging Portable Technologies for Gait Analysis in Neurological Disorders. Front Hum Neurosci 2022; 16:768575. [PMID: 35185496 PMCID: PMC8850274 DOI: 10.3389/fnhum.2022.768575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 01/07/2022] [Indexed: 01/29/2023] Open
Abstract
The understanding of locomotion in neurological disorders requires technologies for quantitative gait analysis. Numerous modalities are available today to objectively capture spatiotemporal gait and postural control features. Nevertheless, many obstacles prevent the application of these technologies to their full potential in neurological research and especially clinical practice. These include the required expert knowledge, time for data collection, and missing standards for data analysis and reporting. Here, we provide a technological review of wearable and vision-based portable motion analysis tools that emerged in the last decade with recent applications in neurological disorders such as Parkinson's disease and Multiple Sclerosis. The goal is to enable the reader to understand the available technologies with their individual strengths and limitations in order to make an informed decision for own investigations and clinical applications. We foresee that ongoing developments toward user-friendly automated devices will allow for closed-loop applications, long-term monitoring, and telemedical consulting in real-life environments.
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Affiliation(s)
- Christina Salchow-Hömmen
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Matej Skrobot
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Magdalena C E Jochner
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Schauer
- Control Systems Group, Technische Universität Berlin, Berlin, Germany
| | - Andrea A Kühn
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Berlin School of Mind and Brain, Charité-Universitätsmedizin Berlin, Berlin, Germany
- NeuroCure Clinical Research Centre, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases, DZNE, Berlin, Germany
| | - Nikolaus Wenger
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Saalfield J, Piersol KL, Monaco R, Womack J, Weismiller SA, Esopenko C, Todaro SM, Conway FN, Brostrand K, Buckman JF. Comparison of Concurrent and Same-Day Balance Measurement Approaches in a Large Sample of Uninjured Collegiate Athletes. Int J Sports Phys Ther 2022; 17:228-236. [PMID: 35136692 PMCID: PMC8805106 DOI: 10.26603/001c.31178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Measures of postural stability are useful in assisting the diagnosing and managing of athlete concussion. Error counting using the Balance Error Scoring System (BESS) is the clinical standard, but has notable limitations. New technologies offer the potential to increase precision and optimize testing protocols; however, whether these devices enhance clinical assessment remains unclear. PURPOSE To examine the relationships between metrics of balance performance using different measurement systems in uninjured, healthy collegiate athletes. STUDY DESIGN Cross-sectional. METHODS Five hundred and thirty uninjured collegiate athletes were tested using the C3Logix app, which computes ellipsoid volume as a measure of postural stability during the six standard BESS conditions, while concurrently, errors were manually counted during each condition per standard BESS protocols. The association between concurrently measured ellipsoid volumes and error counts were examined with Spearman's correlations. From this sample, 177 participants also performed two double-leg conditions on the Biodex BioSway force plate system on the same day. This system computes Sway Index as a measure of postural stability. The association of ellipsoid volume (C3Logix) and Sway Index (Biodex) was examined with Spearman's correlations. Individual-level data were plotted to visually depict the relationships. RESULTS C3Logix ellipsoid volume and concurrently recorded error counts were significantly correlated in five of the six BESS conditions (rs:.22-.62; p< 0.0001). C3Logix ellipsoid volume and Biodex Sway Index were significantly correlated in both conditions (rs=.22-.27, p< 0.004). However, substantial variability was shown in postural stability across all three measurement approaches. CONCLUSION Modest correlation coefficients between simultaneous and same-day balance assessments in uninjured collegiate athletes suggest a need to further optimize clinical protocols for concussion diagnosis. LEVEL OF EVIDENCE 2b.
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Affiliation(s)
- Jessica Saalfield
- Department of Kinesiology and Health, Rutgers University, New Brunswick, NJ, USA
| | - Kelsey L Piersol
- Department of Kinesiology and Health, Rutgers University, New Brunswick, NJ, USA
| | | | - Jason Womack
- Department of Family Medicine & Community Health, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA; Department of Athletics, Rutgers University, New Brunswick, NJ, USA
| | - Scott A Weismiller
- Dept. of Internal Medicine, Penn State Health, Milton S. Hersey Medical Center, Hershey, PA, US
| | - Carrie Esopenko
- Department of Rehabilitation and Movement Sciences, Rutgers Biomedical and Health Sciences, Newark, NJ, USA
| | - Sabrina M Todaro
- Center of Alcohol and Substance Use Studies, Rutgers University, New Brunswick, NJ, USA
| | - Fiona N Conway
- Steve Hicks School of Social Work, University of Texas at Austin, Austin, TX, USA
| | - Kyle Brostrand
- Robert Wood Johnson Barnabas Health - Rutgers Sports Medicine, Rutgers University, New Brunswick, NJ, USA
| | - Jennifer F Buckman
- Department of Kinesiology and Health, Rutgers University, New Brunswick, NJ, USA; Center of Alcohol and Substance Use Studies, Rutgers University, New Brunswick, NJ, USA
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Higginson CI, Valenti M, Ibrahim K, Knarr BA, Ryan R, Higginson JS. Neuroticism and Extraversion Are Related to Changes in Postural Stability During Anatomically-Related Cognitive Tasks. J Mot Behav 2021; 54:401-409. [PMID: 34657579 DOI: 10.1080/00222895.2021.1988504] [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: 10/20/2022]
Abstract
The relationship between personality and postural stability has received little attention. This study addressed whether neuroticism and extraversion correlate with changes in postural stability while performing cognitive tasks related to brain regions selectively associated with neuroticism and extraversion. Thirty-two adults stood on a foam mat in tandem stance and completed a 2-back task and a weather prediction task (WPT). As predicted, higher neuroticism was related to increased dual task sway during the 2-back task, r = 0.40, p = 0.023, and lower extraversion was related to increased dual task sway during the WPT, r = -0.43, p = 0.013, suggesting that personality is related to postural stability in healthy young adults and that personality could be considered in the prediction and treatment of individuals with balance difficulties.
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Affiliation(s)
| | - Marisa Valenti
- Department of Psychology, Loyola University Maryland, Baltimore, MD, USA
| | - Karlie Ibrahim
- Department of Psychology, Loyola University Maryland, Baltimore, MD, USA
| | - Brian A Knarr
- Department of Biomechanics, University of Nebraska Omaha, Omaha, NE, USA
| | - Rob Ryan
- Department of Psychology, Loyola University Maryland, Baltimore, MD, USA
| | - Jill S Higginson
- Department of Mechanical Engineering, University of Delaware, Newark, DE, USA
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Linder SM, Lear A, Linder J, Lake A, Brier C, McGrath M, Cruickshank J, Figler R, Alberts JL. Symptom recovery and the relationship between post-injury symptom scores and neurocognitive performance in athletes with sport-related concussion. JOURNAL OF CONCUSSION 2021. [DOI: 10.1177/20597002211018063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction A multi-domain approach to concussion assessment has been recommended that includes self-reported symptom severity in addition to neurocognitive tests and measures of postural stability. The relationship between subjective self-reported symptoms and objective measures of cognitive function in the post-injury state is not well understood. The aims of the study were to determine symptom severity throughout the post-injury continuum of care and the association between symptom severity and performance on measures of neurocognitive function. Methods An observational cohort study was conducted on 1257 high school and collegiate athletes (67% male and 33% female) who had sustained a concussion. Student-athletes were included in the study if they had a healthy baseline assessment and at least one follow-up injury assessment utilizing the Cleveland Clinic Concussion Application (C3 App). Symptom severity was assessed during the acute (0–7 days post-injury), subacute (8–20 days post-injury), and post-concussive (≥21 days post-injury) phases. Neurocognitive performance was assessed using the following measures: Simple Reaction Time (SRT), Choice Reaction Time (CRT), Processing Speed Test (PST), Trail Making Test A (TMT-A), and Trail Making Test B (TMT-B). To determine the relationship between symptom severity and neurocognitive test performance, athletes were stratified into two groups for comparison: symptom score ≤7 or >7, utilizing the 27-item graded symptom checklist within the C3 App. Neurocognitive performance was analyzed with separate linear mixed effect models for each module to compare within-phase differences. Significance for each module at each phase was tested at P < .05 and adjusted for multiple comparisons. Results Median symptom severity during the acute post-injury phase was 10 declining to 2 during the subacute and post-concussive phases. Performance on each of the C3 App modules (SRT, CRT, PST, Trails A, and Trails B) were significantly better in athletes reporting a symptom score of ≤7 compared to those reporting a symptom score >7 at each of the post-injury phases (P < 0.05 on all comparisons). Conclusions Symptomatic athletes performed worse on all measures of neurocognitive function, regardless of time from injury. While symptoms alone should not be used to determine recovery, our data indicate that symptom severity may aide in deciding when to initiate post-injury neurocognitive testing to determine readiness for treatment progression.
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Affiliation(s)
- Susan M Linder
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA
- Department of Physical Medicine and Rehabilitation, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Concussion Center, Cleveland Clinic, Cleveland, OH, USA
| | - Aaron Lear
- Cleveland Clinic Akron General Sport Medicine, Akron, OH, USA
| | - Joseph Linder
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA
| | - Adam Lake
- Cleveland Clinic Concussion Center, Cleveland Clinic, Cleveland, OH, USA
| | - Corey Brier
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Morgan McGrath
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA
| | - Jason Cruickshank
- Cleveland Clinic Concussion Center, Cleveland Clinic, Cleveland, OH, USA
| | - Richard Figler
- Cleveland Clinic Concussion Center, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Sports Health, Cleveland Clinic, Cleveland, OH, USA
| | - Jay L Alberts
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Concussion Center, Cleveland Clinic, Cleveland, OH, USA
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11
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Penko AL, Linder SM, Miller Koop M, Dey T, Alberts JL. Quantification of Dual-task Performance in Healthy Young Adults Suitable for Military Use. Mil Med 2021; 186:58-64. [PMID: 33499500 DOI: 10.1093/milmed/usaa404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/18/2020] [Accepted: 10/01/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Dual-task performance, in which an individual performs two tasks simultaneously, is compromised following mild traumatic brain injury (mTBI). Proficient dual-task performance is essential in a military setting for both military member safety and execution of skilled tasks. To address the unique needs of military members, a portable dual-task assessment was developed incorporating an auditory dual-task task as a novel assessment module utilizing mobile-device technology. The aim of this study was to develop and validate a dual-task mobile device-based application that accurately quantifies cognitive and motor function. MATERIALS AND METHODS Fifty, healthy, military-age civilians completed three cognitive tasks in single- and dual-task conditions with eyes open and closed: visual Stroop, auditory Stroop at 1.5- and 2.5-second stimulus presentation, and number discrimination. All dual-task conditions required the maintenance of postural stability while simultaneously completing a cognitive task. RESULTS There were no differences between single- and dual-task conditions for cognitive performance on any of the tests, and a ceiling effect was observed for the visual Stroop and auditory Stroop 1.5-second stimulus presentation (P > .05). Significant differences in postural stability were observed between the eyes-open and eyes-closed conditions in all single- and dual-task conditions (P < .01). Significant differences in postural stability were observed between the eyes-open single-task condition and all dual-task conditions (P < .01). CONCLUSIONS Based on the performance of healthy young adults, the number discrimination task may be optimal for detecting subtle changes in dual-task performance. The detected differences found between the eyes-open and eyes-closed conditions provide discriminatory value and insight into the reliance of vision of postural stability performance. While dual-task cognitive performance was not observed in this healthy population, individuals with mTBI may exhibit decreased dual-task performance. The independent evaluation of cognitive and motor function under dual-task conditions has the potential to transform the management and treatment of mTBI.
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Affiliation(s)
- Amanda L Penko
- Cleveland Clinic, Department of Biomedical Engineering, Cleveland, OH 44195, USA
| | - Susan M Linder
- Cleveland Clinic, Department of Biomedical Engineering, Cleveland, OH 44195, USA
| | - Mandy Miller Koop
- Cleveland Clinic, Department of Biomedical Engineering, Cleveland, OH 44195, USA
| | - Tanujit Dey
- Cleveland Clinic, Department of Biomedical Engineering, Cleveland, OH 44195, USA
| | - Jay L Alberts
- Cleveland Clinic, Department of Biomedical Engineering, Cleveland, OH 44195, USA
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12
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Linder SM, Koop MM, Tucker D, Guzi K, Gray DC, Alberts JL. Development and Validation of a Mobile Application to Detect Visual Dysfunction Following Mild Traumatic Brain Injury. Mil Med 2021; 186:584-591. [PMID: 33499531 DOI: 10.1093/milmed/usaa360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/11/2020] [Accepted: 09/22/2020] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Following mild traumatic brain injury, visual dysfunction is a common occurrence, yet the condition often goes undiagnosed. A mobile application was developed to measure aspects of visual acuity and oculomotor function. The aim of this project was to validate the newly developed suite of outcomes conducive for use in the field to detect visual dysfunction. MATERIALS AND METHODS A custom mobile application was developed on an Apple iPad using iOS operating system software version 11.0 in Objective C to measure near point of convergence (NPC), distance visual acuity, reading fluency, and self-rated convergence insufficiency (CI). To determine construct validity, 50 healthy young adults were administered NPC and distance visual acuity assessments using the iPad and standard clinical approaches. A ruler measurement was obtained simultaneous to the iPad NPC measurement to determine measurement accuracy. All testing was administered by a licensed optometrist and the order of testing (iPad versus clinical) was randomized. RESULTS The correlation coefficient between the iPad and clinical measurements of NPC was 0.893, while iPad and ruler measurement was 0.947. Modest accordance was found between iPad and wall chart measures assessing distance visual acuity. A ceiling effect was evident with use of a wall chart to determine distance visual acuity. Healthy young adults scored a mean (SD) of 13.0 (7.4) on the Convergence Insufficiency Symptom Survey. Reading fluency was highly variable with a mean (SD) of 291 (119) words per minute. CONCLUSIONS iPad measures of NPC were highly correlated with clinical measures, while visual acuity measured with the iPad showed modest correlation. Nonetheless, the suite of visual assessments provide value as screening tools, and when used in combination with reading fluency assessment and self-reported CI may be effective in identifying visual dysfunction following mild traumatic brain injury.
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Affiliation(s)
- Susan M Linder
- Department of Physical Medicine and Rehabilitation, Cleveland Clinic, Cleveland, OH 44195, USA.,Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Mandy Miller Koop
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Diane Tucker
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Karen Guzi
- Department of Emergency Medicine, Cleveland Clinic, Cleveland, OH 44195, USA.,Case Western Reserve University School of Nursing, Samson Pavilion, Cleveland, OH 44106, USA
| | - Daniel C Gray
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Jay L Alberts
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH 44195, USA.,Department of biomedical engineering and the center for Neurologic Restoration, Cleveland Clinic, Cleveland, OH 44195, USA
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13
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Parrington L, Popa B, Martini DN, Chesnutt JC, King LA. Instrumented balance assessment in mild traumatic brain injury: Normative values and descriptive data for acute, sub-acute and chronic populations. JOURNAL OF CONCUSSION 2020. [DOI: 10.1177/2059700220975605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Often the Balance Error Scoring System (BESS) is used to assess balance during a clinical evaluation of a patient presenting with mild Traumatic Brain Injury (mTBI). Although recent research has shown the benefits of using inertial sensor measures such as the Root Mean Square (RMS) of the acceleration in place of clinical scoring, few normative data are available for clinicians to reference. The purpose of this paper was to provide normative data collected using wearable sensors for healthy controls across three age groups, as well as providing cohort data for mTBI participants across three stages following injury (acute, sub-acute and chronic). The RMS in the Medio-Lateral direction (ML RMS sway) of each condition (double stance – DS; single stance – SS; and tandem stance – TS) was extracted per participant for analysis. The average ML RMS sway across all conditions was also calculated (ML RMS-Av). Percentiles were calculated to provide normative data, and two multivariate general linear models were used to evaluate differences between 1) non-athlete controls, athlete controls, and athletes with acute mTBI, and 2) non-athletic cohorts of control, sub-acute and chronic mTBI groups across young, middle-aged, and older adults. Model 1 revealed athletes with acute mTBI had more ML RMS sway than athlete controls the for the DS condition ( p < 0.001), but no differences with non-athlete controls. Athlete controls also had less ML RMS sway for the SS condition and ML RMS-Av ( p ≤ 0.022) compared with non-athlete controls. Model 2 revealed less ML RMS sway in the control group than the sub-acute and chronic mTBI groups for DS ( p ≤ 0.004), but no differences between the sub-acute and chronic group, while more ML RMS sway occurred in the chronic group compared with the control and sub-acute groups for the TS condition and ML RMS-Av ( p ≤ 0.013). Older adults had more ML RMS sway than young and middle-aged adults for SS, TS and ML RMS-Av ( p ≤ 0.019), while there were no differences between the young and middle-aged adults. Normative values presented here can help increase the practical application of instrumented balance assessment of mTBI patients through wearable sensors. ML RMS sway in the DS condition provided the clearest distinction between control and mTBI groups, but we caution that young adult athletes need to be assessed against athletic peers in the absence of baseline normative values. In non-athlete cohorts, age and gender norms may not be necessary to consider when assessing DS performance; however, age may be an important factor to consider when accessing norms for other stance conditions or the average performance across all conditions.
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Affiliation(s)
- Lucy Parrington
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
- Veterans Affairs Portland Health Care System, Portland, OR, USA
| | - Bryana Popa
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
- OHSU-PSU School of Public Health, Portland State University, Portland, OR, USA
| | - Douglas N Martini
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
- Veterans Affairs Portland Health Care System, Portland, OR, USA
| | - James C Chesnutt
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
- Department of Orthopedics & Rehabilitation and Family Medicine, Oregon Health & Science University, Portland, OR, USA
- Rebound Orthopedics and Neurosurgery, Portland, OR, USA
| | - Laurie A King
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
- Veterans Affairs Portland Health Care System, Portland, OR, USA
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Reliability, Validity and Utility of Inertial Sensor Systems for Postural Control Assessment in Sport Science and Medicine Applications: A Systematic Review. Sports Med 2020; 49:783-818. [PMID: 30903440 DOI: 10.1007/s40279-019-01095-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Recent advances in mobile sensing and computing technology have provided a means to objectively and unobtrusively quantify postural control. This has resulted in the rapid development and evaluation of a series of wearable inertial sensor-based assessments. However, the validity, reliability and clinical utility of such systems is not fully understood. OBJECTIVES This systematic review aims to synthesise and evaluate studies that have investigated the ability of wearable inertial sensor systems to validly and reliably quantify postural control performance in sports science and medicine applications. METHODS A systematic search strategy utilising the PRISMA guidelines was employed to identify eligible articles through ScienceDirect, Embase and PubMed databases. In total, 47 articles met the inclusion criteria and were evaluated and qualitatively synthesised under two main headings: measurement validity and measurement reliability. Furthermore, studies that investigated the utility of these systems in clinical populations were summarised and discussed. RESULTS After duplicate removal, 4374 articles were identified with the search strategy, with 47 papers included in the final review. In total, 28 studies investigated validity in healthy populations, and 15 studies investigated validity in clinical populations; 13 investigated the measurement reliability of these sensor-based systems. CONCLUSIONS The application of wearable inertial sensors for sports science and medicine postural control applications is an evolving field. To date, research has primarily focused on evaluating the validity and reliability of a heterogeneous set of assessment protocols, in a laboratory environment. While researchers have begun to investigate their utility in clinical use cases such as concussion and musculoskeletal injury, most studies have leveraged small sample sizes, are of low quality and use a variety of descriptive variables, assessment protocols and sensor-mounting locations. Future research should evaluate the clinical utility of these systems in large high-quality prospective cohort studies to establish the role they may play in injury risk identification, diagnosis and management. This systematic review was registered with the International Prospective Register of Systematic Reviews on 10 August 2018 (PROSPERO registration: CRD42018106363): https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=106363 .
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15
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Prim JH, Favorov OV, Cecchini AS, Scherer MR, Weightman MM, McCulloch KL. Clinical Utility and Analysis of the Run-Roll-Aim Task: Informing Return-to-Duty Readiness Decisions in Active-Duty Service Members. Mil Med 2020; 184:e268-e277. [PMID: 30690450 DOI: 10.1093/milmed/usy425] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 03/12/2018] [Accepted: 12/10/2018] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The Assessment of Military Multitasking Performance (AMMP1) consists of six dual-task and multitask military-relevant performance-based assessments which were developed to provide assistance in making return-to-duty decisions after concussion or mild traumatic brain injury (mTBI.) The Run-Roll-Aim (RRA) task, one component of the AMMP, was developed to target vulnerabilities following mTBI including attention, visual function, dynamic stability, rapid transition, and vestibular function. One aim of this study was to assess the known-group and construct validity of the RRA, and additionally to further explore reliability limitations reported previously. MATERIALS AND METHODS A cross-sectional study consisting of 84 Active Duty service members in two groups (healthy control - HC and individuals experiencing persistent mTBI symptoms) completed neurocognitive tests and the RRA. The RRA task requires a high level of mobility and resembles military training activities in a maneuver that includes combat rolls, fast transitions, obstacle avoidance, and visual search. Observational and inertial sensor data were compared between groups and performance across four trial times was compared within groups. Correlations between RRA results and neurocognitive test scores were analyzed. RESULTS Simple observational measures (time, errors) did not differ between groups. Spectral power analysis of the inertial sensor data showed significant differences in motor performance between groups. Within group one-way ANOVAs showed that in HC trial 1, time was significantly different than trials 2,3 and 4 (F(3,47) = 4.60, p < 0.01, Tukey HSD p < 0.05) while the mTBI group showed no significant difference in time between trials. During testing individuals with mTBI were less likely to complete the multiple test trials or required additional rest between trials than HCs (χ2 = 10.78, p < 0.01). Small but significant correlations were seen with two neurocognitive tests of attention and RRA performance time. CONCLUSION While observational scores were not sensitive to group differences, inertial sensor data showed motor performance on the forward run, combat roll, and backward run differed significantly between groups. The RRA task appeared challenging and provoked symptoms in the mTBI group, causing 8 of 33 mTBI participants to stop the task or require additional rest between trials while none of the HC participants had to stop. Individuals with mTBI demonstrated slower learning of the complex motor sequence compared to HCs who had significant improvement after one trial of RRA. Complex novel training maneuvers like RRA may aid clinicians in informing return to duty decisions.
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Affiliation(s)
- Julianna H Prim
- Curriculum in Human Movement Science, Department of Allied Health Sciences, University of North Carolina at Chapel Hill, 3070 Bondurant Hall, 321 S. Columbia St. Chapel Hill, NC
| | - Oleg V Favorov
- Department of Biomedical Engineering, University of North Carolina at Chapel Hill, NC
| | - Amy S Cecchini
- Intrepid Spirit Clinic, Contractor for The Geneva Foundation, Fort Bragg, NC
| | - Matthew R Scherer
- Clinical and Rehabilitative Medicine Research Program, U.S. Army Medical Research and Materiel Command, Fort Detrick, MD
| | | | - Karen L McCulloch
- Division of Physical Therapy, Department of Allied Health Sciences, School of Medicine, University of North Carolina at Chapel Hill, NC
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16
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Alberts JL, Modic MT, Udeh BL, Zimmerman N, Cherian K, Lu X, Gray R, Figler R, Russman A, Linder SM. A Technology-Enabled Concussion Care Pathway Reduces Costs and Enhances Care. Phys Ther 2020; 100:136-148. [PMID: 31584666 DOI: 10.1093/ptj/pzz141] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 12/21/2018] [Accepted: 05/05/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND The standardization of care along disease lines is recommended to improve outcomes and reduce health care costs. The multiple disciplines involved in concussion management often result in fragmented and disparate care. A fundamental gap exists in the effective utilization of rehabilitation services for individuals with concussion. PURPOSE The purpose of this project was to (1) characterize changes in health care utilization following implementation of a concussion carepath, and (2) present an economic evaluation of patient charges following carepath implementation. DESIGN This was a retrospective cohort study. METHODS A review of electronic medical and financial records was conducted of individuals (N = 3937), ages 18 to 45 years, with primary diagnosis of concussion who sought care in the outpatient or emergency department settings over a 7-year period (2010-2016). Outcomes including encounter length, resource utilization, and charges were compared for each year to determine changes from pre- to post-carepath implementation. RESULTS Concussion volumes increased by 385% from 2010 to 2015. Utilization of physical therapy increased from 9% to 20% while time to referral decreased from 72 to 23 days post-injury. Utilization of emergency medicine and imaging were significantly reduced. Efficient resource utilization led to a 20.7% decrease in median charges (estimated ratio of means [CI] 7.72 [0.53, 0.96]) associated with concussion care. LIMITATIONS Encounter lengths served as a proxy for recovery time. CONCLUSIONS The implementation of the concussion carepath was successful in optimizing clinical practice with respect to facilitating continuity of care, appropriate resource utilization, and effective handoffs to physical therapy. The utilization of enabling technology to facilitate the collection of common outcomes across providers was vital to the success of standardizing clinical care without compromising patient outcomes.
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Affiliation(s)
- Jay L Alberts
- Department of Biomedical Engineering, Cleveland Clinic Foundation, 9500 Euclid Avenue, ND-20, Cleveland, OH 44195 (USA); Center for Neurological Restoration, Cleveland Clinic Foundation; Office of Clinical Transformation, Cleveland Clinic Foundation; and Concussion Center, Cleveland Clinic Foundation
| | - Michael T Modic
- Office of Clinical Transformation, Cleveland Clinic Foundation
| | - Belinda L Udeh
- Office of Clinical Transformation, Cleveland Clinic Foundation; and Neurological Institute Center for Outcomes Research, Cleveland Clinic Foundation
| | | | - Kay Cherian
- Department of Biomedical Engineering, Cleveland Clinic Foundation
| | - Xiaoyang Lu
- Office of Clinical Transformation, Cleveland Clinic Foundation
| | - Robert Gray
- Concussion Center, Cleveland Clinic Foundation
| | | | | | - Susan M Linder
- Department of Biomedical Engineering, Cleveland Clinic Foundation; and Concussion Center, Cleveland Clinic Foundation
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Krause DA, Anderson SE, Campbell GR, Davis SJ, Tindall SW, Hollman JH. Responsiveness of a Balance Assessment Using a Mobile Application. Sports Health 2020; 12:401-404. [PMID: 31961240 DOI: 10.1177/1941738119888656] [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 Balance assessment is used by clinicians as part of athlete concussion screening. The King-Devick (K-D) Balance app is designed to provide an objective balance assessment value. The purpose of this study was to investigate the responsiveness of a balance assessment using the K-D Balance app. HYPOTHESIS The K-D Balance app will demonstrate acceptable responsiveness for balance assessment. STUDY DESIGN Repeated-measures study. LEVEL OF EVIDENCE Level 5. METHODS A convenience sample of 25 participants between the ages of 20 and 25 years completed testing procedures. A battery of balance tests using the K-D Balance app on an iPhone were conducted 1 week apart. After a 5-minute warm-up, 3 stances were assessed: double leg, tandem right, and tandem left. The K-D Balance app guided the test positions and test times. A value representing movement was generated by the app algorithm. Analysis included descriptive statistics along with intraclass correlation coefficient and minimal detectable change (MDC). RESULTS The median score of the K-D test was 0.5 for session 1 and 0.4 for session 2. The ICC was 0.42 (95% CI, 0.04-0.70), and the MDC was 1.58. CONCLUSION The MDC value of 1.58 represents the threshold of meaningful change in balance, as measured with the K-D Balance app. CLINICAL RELEVANCE Clinicians can use the results of this study to objectively assess changes in balance over time using the K-D Balance app.
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Affiliation(s)
- David A Krause
- Mayo Clinic Program in Physical Therapy, Mayo Clinic College of Medicine and Science, Rochester, Minnesota.,Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota
| | - Sarah E Anderson
- Mayo Clinic Program in Physical Therapy, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Graeme R Campbell
- Mayo Clinic Program in Physical Therapy, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Samson J Davis
- Mayo Clinic Program in Physical Therapy, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Samuel W Tindall
- Mayo Clinic Program in Physical Therapy, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - John H Hollman
- Mayo Clinic Program in Physical Therapy, Mayo Clinic College of Medicine and Science, Rochester, Minnesota.,Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota
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Rachitskaya A, Yuan A, Davidson S, Streicher M, DeBenedictis M, Rosenfeldt AB, Alberts J. Computer-Assisted Immersive Visual Rehabilitation in Argus II Retinal Prosthesis Recipients. Ophthalmol Retina 2020; 4:613-619. [PMID: 31937474 DOI: 10.1016/j.oret.2019.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/07/2019] [Accepted: 11/08/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE The field of retinal prostheses is expanding. However, the best approach to training and assessing the functional benefit of postoperative vision has not been established. The purpose of this single-center prospective interventional case series was to evaluate the feasibility and effectiveness of using the Computer Assisted Rehabilitation Environment (CAREN) system as a visual rehabilitation tool in Argus II patients. DESIGN Single-center prospective interventional case series (clinicaltrials.gov identifier, NCT03444961). PARTICIPANTS Four Argus II recipients (3 men and 1 woman). METHODS Eight visual rehabilitation sessions using the CAREN system (twice weekly for 4 weeks). MAIN OUTCOME MEASURES Baseline and postintervention assessments consisted of visual function, mobility, and balance tests. RESULTS All patients successfully completed training on the CAREN system. While the Argus II device was active, walking speed increased from baseline to immediately after the intervention on flat and undulating surfaces and while localizing objects by 20%, 10%, and 18%, respectively. An improved ability to complete the timed up and go test successfully was observed. CONCLUSIONS Novel methods of visual rehabilitation for retinal prostheses recipients, such the CAREN system, are feasible and may result in improved ability to use the Argus II while performing functional tasks. Immersive technology may provide a solution for the standardization of effective rehabilitation approaches to augment retinal prosthesis performance. Heterogeneity of results indicates that a larger sample size would be beneficial.
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Affiliation(s)
- Aleksandra Rachitskaya
- Cole Eye Institute, Department of Ophthalmology, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Alex Yuan
- Cole Eye Institute, Department of Ophthalmology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Sara Davidson
- Neurological Institute, Center for Neurological Restoration, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Matthew Streicher
- Neurological Institute, Center for Neurological Restoration, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Meghan DeBenedictis
- Cole Eye Institute, Department of Ophthalmology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Anson B Rosenfeldt
- Lerner Research Institute, Department of Biomedical Engineering, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jay Alberts
- Neurological Institute, Center for Neurological Restoration, Cleveland Clinic Foundation, Cleveland, Ohio; Lerner Research Institute, Department of Biomedical Engineering, Cleveland Clinic Foundation, Cleveland, Ohio; Office of Clinical Transformation, Cleveland Clinic Foundation, Cleveland, Ohio
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McGrath MK, Linder SM, Koop MM, Zimmerman N, Ballantyne MAJ, Ahrendt DM, Alberts JL. Military-Specific Normative Data for Cognitive and Motor Single- and Dual-Task Assessments for Use in Mild Traumatic Brain Injury Assessment. Mil Med 2020; 185:176-183. [PMID: 32074318 DOI: 10.1093/milmed/usz261] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Military personnel and civilian athletes are both at risk for mild traumatic brain injury. However, these groups are unique in their training and typical daily activities. A fundamental gap in the evaluation of military personnel following mild traumatic brain injury is the lack of military-specific normative reference data. This project aimed to determine if a separate normative sample should be used for military personnel on their performance of the Cleveland Clinic Concussion application and a recently developed dual-task module. METHODS Data were collected from healthy military personnel (n = 305) and civilians (n = 281) 18 to 30 years of age. Participants completed the following assessments: simple and choice reaction time, Trail Making tests A&B, processing speed test, single-task postural stability, single-task cognitive assessment, and dual-task assessment. RESULTS Civilian participants outperformed military service members on all cognitive tasks under single- and dual-task conditions (P ≤ 0.04). The military group outperformed civilians on all postural stability tasks under single- and dual-task conditions (P ≤ 0.01). CONCLUSION Differences in cognitive performance and postural stability measures may be influenced by demographic differences between military and civilian cohorts. Thus, military-specific normative datasets must be established to optimize clinical interpretation of Cleveland Clinic Concussion assessments.
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Affiliation(s)
- Morgan K McGrath
- Department of Biomedical Engineering, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195
| | - Susan M Linder
- Department of Biomedical Engineering, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195
| | - Mandy Miller Koop
- Department of Biomedical Engineering, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195
| | - Nicole Zimmerman
- Quantitative Health Sciences, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195
| | - Maj Aaron J Ballantyne
- Division of Adolescent and Young Adult Medicine, Brooke Army Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234
| | - Dale M Ahrendt
- Division of Adolescent and Young Adult Medicine, Brooke Army Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234
| | - Jay L Alberts
- Department of Biomedical Engineering, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195
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20
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Use of Wearable Sensor Technology in Gait, Balance, and Range of Motion Analysis. APPLIED SCIENCES-BASEL 2019. [DOI: 10.3390/app10010234] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
More than 8.6 million people suffer from neurological disorders that affect their gait and balance. Physical therapists provide interventions to improve patient’s functional outcomes, yet balance and gait are often evaluated in a subjective and observational manner. The use of quantitative methods allows for assessment and tracking of patient progress during and after rehabilitation or for early diagnosis of movement disorders. This paper surveys the state-of-the-art in wearable sensor technology in gait, balance, and range of motion research. It serves as a point of reference for future research, describing current solutions and challenges in the field. A two-level taxonomy of rehabilitation assessment is introduced with evaluation metrics and common algorithms utilized in wearable sensor systems.
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Richmond SB, Dames KD, Shad JM, Sutherlin MA, Fling BW. Setting boundaries: Utilization of time to boundary for objective evaluation of the balance error scoring system. J Sports Sci 2019; 38:21-28. [DOI: 10.1080/02640414.2019.1677378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Sutton B. Richmond
- Department of Health and Exercise Science, Colorado State University, Fort Collins, CO, USA
| | - Kevin D. Dames
- Kinesiology Department, State University of New York Cortland, Cortland, NY, USA
| | - Joanna M. Shad
- Department of Health and Exercise Science, Colorado State University, Fort Collins, CO, USA
| | - Mark A. Sutherlin
- Kinesiology Department, State University of New York Cortland, Cortland, NY, USA
| | - Brett W. Fling
- Department of Health and Exercise Science, Colorado State University, Fort Collins, CO, USA
- Molecular, Cellular, & Integrative Neuroscience Program, Colorado State University, Fort Collins, CO, USA
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Abstract
OBJECTIVE To examine and describe normative values for an objective, mobile measure of postural stability commonly used in concussion assessments, SWAY Balance (SWAY Medical, Tulsa, Oklahoma). DESIGN Retrospective analysis of baseline balance assessments in a healthy pediatric population. SETTING Baseline assessments completed by certified athletic trainers at an outpatient concussion center or sports medicine offices in Philadelphia, PA and surrounding suburban Pennsylvania and New Jersey or during an athletic trainer's baseline assessment of collegiate athletes at a National Collegiate Athletic Association (NCAA) Division-II University in Fort Lauderdale, FL. PARTICIPANTS Test results of a sample of 466 athletes aged 5 to 18 years were included. INTERVENTIONS The SWAY Balance test was administered using a mobile device on all participants as part of a standard preseason, baseline evaluation, following the standard evaluation protocol. MAIN OUTCOME MEASURES Baseline SWAY Balance mobile assessment balance and reaction time scores, age and sex effects, were examined. RESULTS Normative scores are described, with results stratified into 4 age groups (5-9, 10-12, 13-17, and 18 years old). Balance scores, overall and within each individual stance score, improved with the age of the participants. Sex effects on balance were only seen in single-leg stances, with females outperforming males. Reaction time was found to be faster in males and improved with age, peaking at 13 to 17 years old and slowing in 18-year-olds. CONCLUSIONS Normative, age-specific SWAY Balance test results provided are of clinical use as references in the concussion assessments of pediatric athletes.
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Pinho AS, Salazar AP, Hennig EM, Spessato BC, Domingo A, Pagnussat AS. Can We Rely on Mobile Devices and Other Gadgets to Assess the Postural Balance of Healthy Individuals? A Systematic Review. SENSORS 2019; 19:s19132972. [PMID: 31284455 PMCID: PMC6651227 DOI: 10.3390/s19132972] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 06/29/2019] [Accepted: 07/02/2019] [Indexed: 12/21/2022]
Abstract
The consequences of falls, costs, and complexity of conventional evaluation protocols have motivated researchers to develop more effective balance assessments tools. Healthcare practitioners are incorporating the use of mobile phones and other gadgets (smartphones and tablets) to enhance accessibility in balance evaluations with reasonable sensitivity and good cost–benefit. The prospects are evident, as well as the need to identify weakness and highlight the strengths of the different approaches. In order to verify if mobile devices and other gadgets are able to assess balance, four electronic databases were searched from their inception to February 2019. Studies reporting the use of inertial sensors on mobile and other gadgets to assess balance in healthy adults, compared to other evaluation methods were included. The quality of the nine studies selected was assessed and the current protocols often used were summarized. Most studies did not provide enough information about their assessment protocols, limiting the reproducibility and the reliability of the results. Data gathered from the studies did not allow us to conclude if mobile devices and other gadgets have discriminatory power (accuracy) to assess postural balance. Although the approach is promising, the overall quality of the available studies is low to moderate.
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Affiliation(s)
- Alexandre S Pinho
- Movement Analysis and Rehabilitation Laboratory, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS 90050-170, Brazil
- Health Sciences Graduate Program, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS 90050-170, Brazil
| | - Ana P Salazar
- Movement Analysis and Rehabilitation Laboratory, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS 90050-170, Brazil
- Rehabilitation Sciences Graduate Program, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS 90050-170, Brazil
| | - Ewald M Hennig
- Institute of Health & Biomedical Innovation (IHBI), Queensland University of Technology (QUT), Kelvin Grove, Brisbane QLD 4059, Australia
| | - Barbara C Spessato
- Movement Analysis and Rehabilitation Laboratory, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS 90050-170, Brazil
- Rehabilitation Sciences Graduate Program, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS 90050-170, Brazil
| | - Antoinette Domingo
- School of Exercise and Nutritional Sciences, San Diego State University, San Diego, CA 92182-7251, USA
| | - Aline S Pagnussat
- Movement Analysis and Rehabilitation Laboratory, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS 90050-170, Brazil.
- Health Sciences Graduate Program, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS 90050-170, Brazil.
- Rehabilitation Sciences Graduate Program, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS 90050-170, Brazil.
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Wood TA, Hsieh KL, An R, Ballard RA, Sosnoff JJ. Balance and Gait Alterations Observed More Than 2 Weeks After Concussion: A Systematic Review and Meta-Analysis. Am J Phys Med Rehabil 2019; 98:566-576. [PMID: 31219809 DOI: 10.1097/phm.0000000000001152] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to systematically review and quantitatively synthesize the existing evidence of balance and gait alterations lasting more than 2 wks after concussion in adults. DESIGN A systematic review was conducted through PubMed, CINAHL, SPORTDiscus, and Web of Science. Investigations must include adult participants with at least one concussion, were measured for 14 days after injury, and reported balance or gait measures. Balance error scoring system scores, center of pressure sway area and displacement, and gait velocity were extracted for the meta-analysis. RESULTS Twenty-two studies were included. Balance alterations were observed for 2 wks after concussion when participants were tested with eyes closed, for longer durations of time, and with nonlinear regulatory statistics. The meta-analysis of center of pressure sway area with no visual feedback indicated that concussed individuals had greater sway area (P < 0.001). Various gait alterations were also observed, which may indicate that concussed individuals adopt a conservative gait strategy. The meta-analysis revealed that concussed participants walked 0.12 m/sec (P < 0.001) and 0.06 m/sec (P = 0.023) slower in single and dual-task conditions, respectively. CONCLUSIONS Subtle balance and gait alterations were observed after 2 wks after a concussion. Understanding these alterations may allow clinicians to improve concussion diagnosis and prevent subsequent injury.
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Affiliation(s)
- Tyler A Wood
- From the Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, Illinois (TAW, KLH, RA, JJS); Brown School, Washington University, St. Louis, Missouri (RA); and Division of Intercollegiate Athletics, University of Illinois at Urbana-Champaign, Champaign, Illinois (RAB)
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Pitt W, Chou LS. Reliability and practical clinical application of an accelerometer-based dual-task gait balance control assessment. Gait Posture 2019; 71:279-283. [PMID: 31125835 DOI: 10.1016/j.gaitpost.2019.05.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 05/10/2019] [Accepted: 05/11/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Gait balance control assessment using whole body center of mass (COM) kinematic measures in concussed individuals reveals persistent balance deficits up to two months post-injury. A reliable and clinically practical gait balance control assessment leveraging similar kinematic measures is necessary to improve concussion assessment and management. RESEARCH QUESTION Can peak accelerations collected during a dual-task (DT) gait assessment from a single low back placed accelerometer be measured reliably on different days, by different raters, in different environments, and be practically applied in a Division One (D1) athletics program? METHODS A single accelerometer placed on the low back over the L5 vertebra was utilized with a DT gait analysis protocol. Twenty (10 F) healthy participants performed the assessment in a laboratory and non-laboratory environment, on two separate days, and with two different raters. Eight gait event specific peak accelerations along three orthogonal axes were collected. In addition, data were collected from a cohort of 14 D1 female soccer players during a single assessment to explore the practical clinical application. RESULTS Cronbach's α values for the eight metrics ranged from 0.881 to 0.980 and ICC values from 0.868 to 0.987. Average assessment time for the 14 D1 female athletes was 8.50 ± 0.58 min, and significant differences between walking conditions were identified for Vert Accel 1 (p < .01), Vert Accel 2 (p = .01), and A-P Accel (p < .01). SIGNIFICANCE High Cronbach's α and ICC values coupled with a short assessment time and sensitivity to differences in gait balance control indicate our testing apparatus and protocol are both reliable and clinically practical. Additionally, gait event specific peak accelerations from a single accelerometer can detect subtle changes in gait balance control and may facilitate improvements in sport-related concussion diagnosis and return to activity decision making.
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Affiliation(s)
- Will Pitt
- Motion Analysis Laboratory, Department of Human Physiology, University of Oregon, Eugene, OR, USA
| | - Li-Shan Chou
- Motion Analysis Laboratory, Department of Human Physiology, University of Oregon, Eugene, OR, USA.
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Kinematic Metrics from a Wireless Stylus Quantify Tremor and Bradykinesia in Parkinson's Disease. PARKINSONS DISEASE 2019; 2019:6850478. [PMID: 31061696 PMCID: PMC6466869 DOI: 10.1155/2019/6850478] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 02/19/2019] [Accepted: 02/21/2019] [Indexed: 12/04/2022]
Abstract
A fundamental challenge in the clinical care of Parkinson disease (PD) is the current dependence on subjective evaluations of tremor and bradykinesia. New technologies offer the ability to evaluate motor deficits using purely objective measures. The aim of this study was to develop and evaluate the efficacy of a wireless stylus (Cleveland Clinic Stylus) with an embedded motion sensor to quantitatively assess tremor and bradykinesia in patients with PD with subthalamic nucleus (STN) deep brain stimulation (DBS). Twenty-one subjects were tested in various on and off DBS conditions while holding the Cleveland Clinic Stylus while at rest, maintaining a postural hold, and during a movement task. Kinematic metrics were calculated from the motion sensor data, including 3D angular velocity and 3D acceleration data, and were compared between the on and off conditions. Generalized estimating equations (GEEs) were used to determine the relationship between kinematic metrics and MDS-Unified Parkinson's Disease Rating Scale Motor III (UPDRS-III) subscores. Kinematic metrics from the rest and postural tasks were significantly related to the UPDRS-III subscores of tremor (p < 0.001 for all metrics), and kinematic metrics from the movement task were significantly related to the UPDRS-III subscore of bradykinesia (p < 0.001 for 3/7 metrics). Kinematic metrics (7/9) showed a significant effect of stimulation setting (range: p < 0.03– < 0.0001) across the three tasks, indicating significant improvements from DBS in these measures. The Cleveland Clinic Stylus provided quantitative kinematic measures of tremor and bradykinesia severity and detected significant improvements in these measures from medication and DBS therapy. This low-cost, easy-to-use tool can provide objective measures that will improve clinical care of PD patients by providing a more reliable and objective evaluation of movement symptoms, disease progression, and effects of therapy in and outside the clinical setting.
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Houston MN, Hoch MC, Malvasi SR, Peck KY, Svoboda SJ, Cameron KL. Level of Agreement Between Human-Rated and Instrumented Balance Error Scoring System Scores. Ann Biomed Eng 2019; 47:2128-2135. [PMID: 31011917 DOI: 10.1007/s10439-019-02274-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/15/2019] [Indexed: 11/27/2022]
Abstract
Clinicians have used the Balance Error Scoring System (BESS) to quantify postural control for concussion management. However, the reliability of the human rated BESS has varied prompting the development of instrumented BESSs. A cross-sectional design was used to determine the level of agreement (LOA) between human rated and instrumented BESS scores. Sixty participants completed the BESS on video. An instrumented mat was used to quantify BESS errors while a live human rater simultaneously scored the BESS. A second human rated BESS performance via video. Bland-Altman LOA analyses evaluated agreement between scoring methods (Mat-Human, Mat-Video, Video-Live) for each stance. Mean biases between scores, for each stance, with 95% confidence intervals (95%CIs) were calculated. Agreement between scoring methods was not assessed for the Firm-Double-Limb stance because very few errors were recorded. Agreement between both human raters and the mat was poor based on mean bias estimates > ± 1 and/or wide 95%CIs for all stances including BESS-Total. Agreement between the human raters was better, having displayed consistently smaller mean bias estimates and tighter 95%CIs for all stances and BESS Total. As a result, human rated and instrumented BESS scores may not be comparable. One method should be used to measure BESS errors for consistency.
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Affiliation(s)
- Megan N Houston
- John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Hospital, United States Military Academy, 900 Washington Road, West Point, NY, 10996, USA.
| | - Matthew C Hoch
- Sports Medicine Research Institute, University of Kentucky, Lexington, KY, USA
| | - Steven R Malvasi
- John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Hospital, United States Military Academy, 900 Washington Road, West Point, NY, 10996, USA
| | - Karen Y Peck
- John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Hospital, United States Military Academy, 900 Washington Road, West Point, NY, 10996, USA
| | | | - Kenneth L Cameron
- John A. Feagin Jr. Sports Medicine Fellowship, Keller Army Hospital, United States Military Academy, 900 Washington Road, West Point, NY, 10996, USA
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Linder SM, Cruickshank J, Zimmerman NM, Figler R, Alberts JL. A technology-enabled electronic incident report to document and facilitate management of sport concussion: A cohort study of youth and young adults. Medicine (Baltimore) 2019; 98:e14948. [PMID: 30946318 PMCID: PMC6455956 DOI: 10.1097/md.0000000000014948] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Despite the widespread awareness of concussion across all levels of sport, the management of concussion from youth to college is inconsistent and fragmented. A fundamental gap contributing to inconsistent care is the lack of a scalable, systematic approach to document initial injury characteristics following concussion. The purpose of this study was to determine differences in injury profiles and management of youth, high school, and college athletes using a mobile application for incident report documentation.A cohort study was conducted in which concussion electronic incident report data from 46 high schools and colleges, and Cleveland Clinic ambulatory concussion clinics were gathered and analyzed.In sum, 1421 (N = 88 youth, N = 1171 high school and N = 162 college) athletes with sport-related concussions were included.Despite the relative absence of red flags, youth athletes had a greater probability of being sent to the emergency department than high school and collegiate athletes. Over 60% of athletes were removed from play immediately post-injury. Injury recognition was delayed in 25% of athletes due to delayed symptom reporting (20% of males, 16% of females) or delayed symptom onset (5% of males, 9% of females). A significantly greater incidence of red flags was evident in males, and in high school and collegiate athletes compared to youth athletes.The high frequency of youth athletes sent to the emergency department, despite the absence of red flags, may be a reflection of inadequate medical coverage at youth events, ultimately resulting in unnecessary utilization of emergency medicine services. The relatively high incidence of delayed injury reporting implies that additional educational efforts targeting student-athletes and the utilization of resources to improve injury detection are warranted. The systematic collection of injury-related demographics through the electronic mobile application facilitated interdisciplinary communication and improved the efficiency of managing athletes with concussion.
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Affiliation(s)
| | | | | | | | - Jay L. Alberts
- Department of Biomedical Engineering
- Cleveland Clinic Concussion Center
- Office of Clinical Transformation
- Center for Neurological Restoration, Cleveland Clinic, Euclid Avenue, Cleveland, Ohio, USA
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Linder SM, Koop MM, Ozinga S, Goldfarb Z, Alberts JL. A Mobile Device Dual-Task Paradigm for the Assessment of mTBI. Mil Med 2019; 184:174-180. [DOI: 10.1093/milmed/usy334] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/15/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
Research Objective
Dual-task performance, in which individuals complete two or more activities simultaneously, is impaired following mild traumatic brain injury. The aim of this project was to develop a dual-task paradigm that may be conducive to military utilization in evaluating cognitive-motor function in a standardized and scalable manner by leveraging mobile device technology.
Methods
Fifty healthy young adult civilians (18–24 years) completed four balance stances and a number discrimination task under single- and dual-task conditions. Postural stability was quantified using data gathered from iPad’s native accelerometer and gyroscope. Cognitive task difficulty was manipulated by presenting stimuli at 30, 60, or 90 per minute. Performance of cognitive and balance tasks was compared between single- and dual-task trials.
Results
Cognitive performance from single- to dual-task paradigms showed no significant main effect of balance condition or the interaction of condition by frequency. From single- to dual-task conditions, a significant difference in postural control was revealed in only one stance: tandem with eyes closed, in which a slight improvement in postural stability was observed under dual-task conditions.
Conclusion
The optimal dual-task paradigm to evaluate cognitive-motor performance with minimal floor and ceiling effects consists of tandem stance with eyes closed while stimuli are presented at a rate of one per second.
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Affiliation(s)
- Susan M Linder
- Cleveland Clinic, Department of Biomedical Engineering, 9500 Euclid Avenue, Cleveland, OH
| | - Mandy Miller Koop
- Cleveland Clinic, Department of Biomedical Engineering, 9500 Euclid Avenue, Cleveland, OH
| | - Sarah Ozinga
- Cleveland Clinic, Department of Biomedical Engineering, 9500 Euclid Avenue, Cleveland, OH
| | - Zachary Goldfarb
- Cleveland Clinic, Department of Biomedical Engineering, 9500 Euclid Avenue, Cleveland, OH
| | - Jay L Alberts
- Cleveland Clinic, Department of Biomedical Engineering, 9500 Euclid Avenue, Cleveland, OH
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Miller Koop M, Rosenfeldt AB, Alberts JL. Mobility improves after high intensity aerobic exercise in individuals with Parkinson's disease. J Neurol Sci 2019; 399:187-193. [PMID: 30826715 DOI: 10.1016/j.jns.2019.02.031] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 02/18/2019] [Accepted: 02/20/2019] [Indexed: 11/16/2022]
Abstract
Emerging literature indicates aerobic exercise improves the motor symptoms associated with Parkinson's disease (PD). However, the impact of aerobic exercise on functional locomotor performance has not been evaluated systematically. The aim of this project was to determine the impact of an 8-week high intensity aerobic exercise intervention on Timed Up and Go (TUG) performance in PD. Fifty-nine participants with idiopathic PD completed 24 aerobic exercise sessions over 8 weeks. Two modes of exercise were utilized: forced (FE) and voluntary (VE). A mobile application was used to gather biomechanical data for the characterization of the TUG subtasks: Sit-Stand, Gait, Turning, and Stand-Sit. Participants were assessed in an off medication state at: 1) baseline, prior to any exercise intervention, and 2) after completion of exercise treatment. At baseline, the VE group completed the TUG in 9.41 s, while the FE group completed the TUG significantly faster in 8.0 s. Following the exercise intervention, the VE group decreased TUG time to 8.9 s (p < .01). Both exercise groups demonstrated significant improvements in Turning Velocity, time of Gait phase and Stand-Sit duration. Overall mobility in participants with PD was significantly improved after high intensity aerobic exercise training. Improvements in turning and gait speed, and in Stand-Sit times indicate exercise is effective in improving functional aspects of mobility that are often associated with falls and quality of life measures. These results support the use of high intensity aerobic exercise for improvements in functional lower extremity performance in a PD population.
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Affiliation(s)
- Mandy Miller Koop
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Anson B Rosenfeldt
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Jay L Alberts
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States of America; Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, United States of America; Cleveland Clinic Concussion Center, Cleveland Clinic, Cleveland, OH, United States of America.
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Houston MN, Peck KY, Malvasi SR, Roach SP, Svoboda SJ, Cameron KL. Reference values for the Balance Error Scoring System as measured by the Tekscan MobileMat™ in a physically active population. Brain Inj 2018; 33:299-304. [PMID: 30501390 DOI: 10.1080/02699052.2018.1552021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES The Balance Error Scoring System (BESS) is commonly used to measure postural stability; however, it has demonstrated inconsistent reliability values when administered by humans. The Tekscan MobileMat™ was developed to automate the assessment of BESS errors and eliminate rater subjectivity. The objective of this study was to report reference values for the BESS, as measured by the MobileMat™, and examine the effect of sex, concussion history, and competitive sport level on BESS performance. METHODS Four hundred and forty participants performed the BESS on the MobileMat™. Participants were asked to maintain each stance with their eyes closed for 20 s. The MobileMat™ was used to quantify the number of errors. RESULTS Concussion history (p = 0.279-0.979) and competitive sport level (p = 0.422-0.979) did not affect BESS performance. Males performed significantly better than females for the single-limb foam stance (p = 0.032). No sex differences were detected for the other BESS stances or BESS total score (p = 0.067-0.744). CONCLUSIONS Previously reported reference values in collegiate athletes and adolescents were slightly higher thus highlighting the value in establishing population norms and in developing new technologies to objectively quantify BESS performance. Furthermore, sex, concussion history, and competitive sport level do not appear to influence BESS performance as measured by the MobileMat™.
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Affiliation(s)
- Megan N Houston
- a John A. Feagin Jr. Sports Medicine Fellowship, Department of Orthopaedic Surgery , Keller Army Community Hospital , West Point , NY , USA
| | - Karen Y Peck
- a John A. Feagin Jr. Sports Medicine Fellowship, Department of Orthopaedic Surgery , Keller Army Community Hospital , West Point , NY , USA
| | - Steven R Malvasi
- a John A. Feagin Jr. Sports Medicine Fellowship, Department of Orthopaedic Surgery , Keller Army Community Hospital , West Point , NY , USA
| | - Sean P Roach
- a John A. Feagin Jr. Sports Medicine Fellowship, Department of Orthopaedic Surgery , Keller Army Community Hospital , West Point , NY , USA
| | - Steven J Svoboda
- b Department of Orthopaedic Surgery , Lafayette Centre Orthopaedics and Sports Medicine, MedStar Georgetown University Hospital , Washington , DC , USA
| | - Kenneth L Cameron
- a John A. Feagin Jr. Sports Medicine Fellowship, Department of Orthopaedic Surgery , Keller Army Community Hospital , West Point , NY , USA
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LINDER SUSANM, OZINGA SARAHJ, KOOP MANDYMILLER, DEY TANUJIT, FIGLER RICHARD, CRUICKSHANK JASON, ALBERTS JAYL. Cleveland Clinic Postural Stability Index Norms for the Balance Error Scoring System. Med Sci Sports Exerc 2018; 50:1998-2006. [DOI: 10.1249/mss.0000000000001660] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Dey T, Piryatinska A, Woyczynski WA, Ozinga SJ, Alberts JL. Quantifying the Complexity of Time Series With Applications to Postural Balance Studies of Parkinson's Patients. Stat Biopharm Res 2018. [DOI: 10.1080/19466315.2018.1473793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- Tanujit Dey
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Alexandra Piryatinska
- Department of Mathematics and Statistics, San Francisco State University, San Francisco, CA
| | - Wojbor A. Woyczynski
- Department of Mathematics, Applied Mathematics and Statistics, and Center for Stochastic and Chaotic Processes in Science and Technology, Case Western Reserve University, Cleveland, OH
| | - Sarah J. Ozinga
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH
| | - Jay L. Alberts
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH
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Abstract
The Balance Error Scoring System (BESS) is a human-scored, field-based balance test used in cases of suspected concussion. Recently developed instrumented alternatives to human scoring carry substantial advantages over traditional testing, but thus far report relatively abstract outcomes which may not be useful to clinicians or coaches. In contrast, the Automated Assessment of Postural Stability (AAPS) is a computerized system that tabulates error events in accordance with the original description of the BESS. This study compared AAPS and human-based BESS scores. Twenty-five healthy adults performed the modified BESS. Tests were scored twice each by human raters (3) and the computerized system. Interrater (between-human) and inter-method (AAPS vs. human) agreement (ICC(2,1)) were calculated alongside Bland-Altman limits of agreement (LOA). Interrater analyses were significant (p<0.005) and demonstrated good to excellent agreement. Inter-method agreement analyses were significant (p<0.005), with agreement ranging from poor to excellent. Computerized scores were equivalent across rating occasions. LOA ranges for AAPS vs. the Human Average exceeded the average LOA ranges between human raters. Coaches and clinicians may consider a system such as AAPS to automate balance testing while maintaining the familiarity of human-based scoring, although scores should not yet be considered interchangeable with those of a human rater.
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Kuznetsov NA, Robins RK, Long B, Jakiela JT, Haran FJ, Ross SE, Wright WG, Rhea CK. Validity and reliability of smartphone orientation measurement to quantify dynamic balance function. Physiol Meas 2018; 39:02NT01. [DOI: 10.1088/1361-6579/aaa3c2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Johnston W, O'Reilly M, Coughlan GF, Caulfield B. Inertial Sensor Technology Can Capture Changes in Dynamic Balance Control during the Y Balance Test. Digit Biomark 2018; 1:106-117. [PMID: 32095752 DOI: 10.1159/000485470] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 11/17/2017] [Indexed: 12/11/2022] Open
Abstract
Introduction The Y Balance Test (YBT) is one of the most commonly utilised clinical dynamic balance assessments. Research has demonstrated the utility of the YBT in identifying balance deficits in individuals following lower limb injury. However, quantifying dynamic balance based on reach distances alone fails to provide potentially important information related to the quality of movement control and choice of movement strategy during the reaching action. The addition of an inertial sensor to capture more detailed motion data may allow for the inexpensive, accessible quantification of dynamic balance control during the YBT reach excursions. As such, the aim of this study was to compare baseline and fatigued dynamic balance control, using reach distances and 95EV (95% ellipsoid volume), and evaluate the ability of 95EV to capture alterations in dynamic balance control, which are not detected by YBT reach distances. Methods As part of this descriptive laboratory study, 15 healthy participants completed repeated YBTs at 20, 10, and 0 min prior to and following a modified 60-s Wingate test that was used to introduce a short-term reduction in dynamic balance capability. Dynamic balance was assessed using the standard normalised reach distance method, while dynamic balance control during the reach attempts was simultaneously measured by means of the 95EV derived from an inertial sensor, worn at the level of the 4th lumbar vertebra. Results Intraclass correlation coefficients for the inertial sensor-derived measures ranged from 0.76 to 0.92, demonstrating strong intrasession test-retest reliability. Statistically significant alterations (p < 0.05) in both reach distance and the inertial sensor-derived 95EV measure were observed immediately post-fatigue. However, reach distance deficits returned to baseline levels within 10 min, while 95EV remained significantly increased (p < 0.05) beyond 20 min for all 3 reach distances. Conclusion These findings demonstrate the ability of an inertial sensor-derived measure to quantify alterations in dynamic balance control, which are not captured by traditional reach distances alone. This suggests that the addition of an inertial sensor to the YBT may provide clinicians and researchers with an accessible means to capture subtle alterations in motor function in the clinical setting.
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Affiliation(s)
- William Johnston
- Insight Centre for Data Analytics, University College Dublin, Dublin, Ireland.,School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | - Martin O'Reilly
- Insight Centre for Data Analytics, University College Dublin, Dublin, Ireland.,School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
| | | | - Brian Caulfield
- Insight Centre for Data Analytics, University College Dublin, Dublin, Ireland.,School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
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Zhu M, Huang Z, Ma C, Li Y. An Objective Balance Error Scoring System for Sideline Concussion Evaluation Using Duplex Kinect Sensors. SENSORS 2017; 17:s17102398. [PMID: 29053602 PMCID: PMC5677441 DOI: 10.3390/s17102398] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 10/16/2017] [Accepted: 10/18/2017] [Indexed: 11/16/2022]
Abstract
Sports-related concussion is a common sports injury that might induce potential long-term consequences without early diagnosis and intervention in the field. However, there are few options of such sensor systems available. The aim of the study is to propose and validate an automated concussion administration and scoring approach, which is objective, affordable and capable of detecting all balance errors required by the balance error scoring system (BESS) protocol in the field condition. Our approach is first to capture human body skeleton positions using two Microsoft Kinect sensors in the proposed configuration and merge the data by a custom-made algorithm to remove the self-occlusion of limbs. The standing balance errors according to BESS protocol were further measured and accessed automatically by the proposed algorithm. Simultaneously, the BESS test was filmed for scoring by an experienced rater. Two results were compared using Pearson coefficient r, obtaining an excellent consistency (r = 0.93, p < 0.05). In addition, BESS test–retest was performed after seven days and compared using intraclass correlation coefficients (ICC), showing a good test–retest reliability (ICC = 0.81, p < 0.01). The proposed approach could be an alternative of objective tools to assess postural stability for sideline sports concussion diagnosis.
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Affiliation(s)
- Mengqi Zhu
- School of Mechatronical Engineering, Beijing Institute of Technology, Beijing 100081, China.
| | - Zhonghua Huang
- School of Mechatronical Engineering, Beijing Institute of Technology, Beijing 100081, China.
| | - Chao Ma
- School of Mechatronical Engineering, Beijing Institute of Technology, Beijing 100081, China.
| | - Yinlin Li
- School of Mechatronical Engineering, Beijing Institute of Technology, Beijing 100081, China.
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Brungart D, Schurman J, Konrad-Martin D, Watts K, Buckey J, Clavier O, Jacobs PG, Gordon S, Dille MF. Using tablet-based technology to deliver time-efficient ototoxicity monitoring. Int J Audiol 2017; 57:S25-S33. [DOI: 10.1080/14992027.2017.1370138] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Douglas Brungart
- Walter Reed National Military Medical Center, Bethesda, MD, USA,
| | - Jaclyn Schurman
- Walter Reed National Military Medical Center, Bethesda, MD, USA,
- Army Public Hearing Center, Aberdeen Proving Ground, Aberdeen, MD, USA,
| | - Dawn Konrad-Martin
- United States Department of Veterans Affairs (VA), Office of Rehabilitation Research and Development (RR&D) Services, National Center for Rehabilitative Auditory Research, Portland, OR, USA,
- Department of Otolaryngology/HNS, Oregon Health and Science University, Portland, OR, USA,
| | - Kelly Watts
- DoD Hearing Center of Excellence, Lackland AFB, San Antonio, TX, USA,
- Naval Submarine Medical Research Laboratory, Naval Base New London, Groton, CT, USA,
- Core Business Solutions, Round Rock, TX, USA,
| | - Jay Buckey
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA,
| | | | - Peter G. Jacobs
- Department of Biomedical Engineering School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Samuel Gordon
- United States Department of Veterans Affairs (VA), Office of Rehabilitation Research and Development (RR&D) Services, National Center for Rehabilitative Auditory Research, Portland, OR, USA,
| | - Marilyn F. Dille
- United States Department of Veterans Affairs (VA), Office of Rehabilitation Research and Development (RR&D) Services, National Center for Rehabilitative Auditory Research, Portland, OR, USA,
- Department of Otolaryngology/HNS, Oregon Health and Science University, Portland, OR, USA,
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Ozinga SJ, Koop MM, Linder SM, Machado AG, Dey T, Alberts JL. Three-dimensional evaluation of postural stability in Parkinson’s disease with mobile technology. NeuroRehabilitation 2017; 41:211-218. [DOI: 10.3233/nre-171473] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Sarah J. Ozinga
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA
| | - Mandy Miller Koop
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA
| | - Susan M. Linder
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Concussion Center, Cleveland Clinic, Cleveland, OH, USA
| | - Andre G. Machado
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
| | - Tanujit Dey
- Cleveland Clinic Concussion Center, Cleveland Clinic, Cleveland, OH, USA
- Qualitative Health Services, Cleveland Clinic, Cleveland, OH, USA
| | - Jay L. Alberts
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Concussion Center, Cleveland Clinic, Cleveland, OH, USA
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Fino PC, Peterka RJ, Hullar TE, Murchison C, Horak FB, Chesnutt JC, King LA. Assessment and rehabilitation of central sensory impairments for balance in mTBI using auditory biofeedback: a randomized clinical trial. BMC Neurol 2017; 17:41. [PMID: 28231824 PMCID: PMC5324311 DOI: 10.1186/s12883-017-0812-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 01/26/2017] [Indexed: 11/29/2022] Open
Abstract
Background Complaints of imbalance are common non-resolving signs in individuals with post-concussive syndrome. Yet, there is no consensus rehabilitation for non-resolving balance complaints following mild traumatic brain injury (mTBI). The heterogeneity of balance deficits and varied rates of recovery suggest varied etiologies and a need for interventions that address the underlying causes of poor balance function. Our central hypothesis is that most chronic balance deficits after mTBI result from impairments in central sensorimotor integration that may be helped by rehabilitation. Two studies are described to 1) characterize balance deficits in people with mTBI who have chronic, non-resolving balance deficits compared to healthy control subjects, and 2) determine the efficacy of an augmented vestibular rehabilitation program using auditory biofeedback to improve central sensorimotor integration, static and dynamic balance, and functional activity in patients with chronic mTBI. Methods Two studies are described. Study 1 is a cross-sectional study to take place jointly at Oregon Health and Science University and the VA Portland Health Care System. The study participants will be individuals with non-resolving complaints of balance following mTBI and age- and gender-matched controls who meet all inclusion criteria. The primary outcome will be measures of central sensorimotor integration derived from a novel central sensorimotor integration test. Study 2 is a randomized controlled intervention to take place at Oregon Health & Science University. In this study, participants from Study 1 with mTBI and abnormal central sensorimotor integration will be randomized into two rehabilitation interventions. The interventions will be 6 weeks of vestibular rehabilitation 1) with or 2) without the use of an auditory biofeedback device. The primary outcome measure is the daily activity of the participants measured using an inertial sensor. Discussion The results of these two studies will improve our understanding of the nature of balance deficits in people with mTBI by providing quantitative metrics of central sensorimotor integration, balance, and vestibular and ocular motor function. Study 2 will examine the potential for augmented rehabilitation interventions to improve central sensorimotor integration. Trial registration This trial is registered at clinicaltrials.gov (NCT02748109)
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Affiliation(s)
- Peter C Fino
- Department of Neurology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, L226, Portland, OR, 97239-3098, USA.,Veterans Affairs Portland Health Care System, Portland, Oregon, USA
| | - Robert J Peterka
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA.,National Center for Rehabilitative Auditory Research, Veterans Affairs Portland Health Care System, Portland, Oregon, USA
| | - Timothy E Hullar
- Department of Otolaryngology - Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Chad Murchison
- Department of Neurology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, L226, Portland, OR, 97239-3098, USA
| | - Fay B Horak
- Department of Neurology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, L226, Portland, OR, 97239-3098, USA.,Veterans Affairs Portland Health Care System, Portland, Oregon, USA
| | - James C Chesnutt
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon, USA
| | - Laurie A King
- Department of Neurology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, L226, Portland, OR, 97239-3098, USA. .,National Center for Rehabilitative Auditory Research, Veterans Affairs Portland Health Care System, Portland, Oregon, USA.
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Johnston W, Doherty C, Büttner FC, Caulfield B. Wearable sensing and mobile devices: the future of post-concussion monitoring? Concussion 2017; 2:CNC28. [PMID: 30202569 PMCID: PMC6096439 DOI: 10.2217/cnc-2016-0025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 11/24/2016] [Indexed: 11/28/2022] Open
Affiliation(s)
- William Johnston
- School of Public Health, Physiotherapy & Sports Science, University College Dublin, Ireland.,Insight Centre for Data Analytics, University College Dublin, Ireland.,School of Public Health, Physiotherapy & Sports Science, University College Dublin, Ireland.,Insight Centre for Data Analytics, University College Dublin, Ireland
| | - Cailbhe Doherty
- School of Public Health, Physiotherapy & Sports Science, University College Dublin, Ireland.,Insight Centre for Data Analytics, University College Dublin, Ireland.,School of Public Health, Physiotherapy & Sports Science, University College Dublin, Ireland.,Insight Centre for Data Analytics, University College Dublin, Ireland
| | - Fionn Cleirigh Büttner
- School of Public Health, Physiotherapy & Sports Science, University College Dublin, Ireland.,School of Public Health, Physiotherapy & Sports Science, University College Dublin, Ireland
| | - Brian Caulfield
- School of Public Health, Physiotherapy & Sports Science, University College Dublin, Ireland.,Insight Centre for Data Analytics, University College Dublin, Ireland.,School of Public Health, Physiotherapy & Sports Science, University College Dublin, Ireland.,Insight Centre for Data Analytics, University College Dublin, Ireland
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Doherty C, Zhao L, Ryan J, Komaba Y, Inomata A, Caulfield B. Quantification of postural control deficits in patients with recent concussion: An inertial-sensor based approach. Clin Biomech (Bristol, Avon) 2017; 42:79-84. [PMID: 28110244 DOI: 10.1016/j.clinbiomech.2017.01.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 01/10/2017] [Accepted: 01/12/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study was to quantify postural control ability in a group with concussion compared with a healthy control group. METHOD Fifteen concussion patients (4 females, 11 males) and a group of fifteen age- and sex-matched controls were recruited. Participants were tested during the performance of the three stance variants (bilateral, tandem and unilateral) of the balance error scoring system standing on a force place, while wearing an inertial measurement unit placed at the posterior aspect of the sacrum. FINDINGS The area of postural sway was computed using the force-plate and the '95% ellipsoid volume of sway' was computed from the accelerometer data. Concussed patients exhibited increased sway area (1513mm2 [95% CI: 935 to 2091mm2] vs 646mm2 [95% CI: 519 to 772mm2]; p=0.02) and sway volume (9.46m3s-6 [95% CI: 8.02 to 19.94m3s-6] vs 2.68m3s-6 [95% CI: 1.81 to 3.55m3s-6]; p=0.01) in the bilateral stance position of the balance error scoring system. The sway volume metric also had excellent accuracy in identifying task 'errors' (tandem stance: 91% accuracy [95% CI: 85-96%], p<0.001; unilateral stance: 91% accuracy [95% CI: 86-96%], p<0.001). INTERPRETATION Individuals with concussion display increased postural sway during bilateral stance. The sway volume that was calculated from the accelerometer data not only differentiated a group with concussion from a healthy control group, but successfully identified when task errors had occurred. This may be of value in the development of a pitch-side assessment system for concussion.
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Affiliation(s)
- Cailbhe Doherty
- Insight Centre for Data Analytics, University College Dublin, Dublin, Ireland.
| | - Liang Zhao
- Insight Centre for Data Analytics, University College Dublin, Dublin, Ireland.
| | - John Ryan
- St. Vincent's University Hospital, Dublin, Ireland
| | | | | | - Brian Caulfield
- Insight Centre for Data Analytics, University College Dublin, Dublin, Ireland
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43
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Use of Mobile Device Accelerometry to Enhance Evaluation of Postural Instability in Parkinson Disease. Arch Phys Med Rehabil 2016; 98:649-658. [PMID: 27670925 DOI: 10.1016/j.apmr.2016.08.479] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/21/2016] [Accepted: 08/29/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the accuracy of inertial measurement unit data from a mobile device using the mobile device relative to posturography to quantify postural stability in individuals with Parkinson disease (PD). DESIGN Criterion standard. SETTING Motor control laboratory at a clinic. PARTICIPANTS A sample (N=28) of individuals with mild to moderate PD (n=14) and age-matched community-dwelling individuals without PD (n=14) completed the study. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Center of mass (COM) acceleration measures were compared between the mobile device and the NeuroCom force platform to determine the accuracy of mobile device measurements during performance of the Sensory Organization Test (SOT). Analyses examined test-retest reliability of both systems and sensitivity of (1) the equilibrium score from the SOT and (2) COM acceleration measures from the force platform and mobile device to quantify postural stability across populations. RESULTS Metrics of COM acceleration from inertial measurement unit data and the NeuroCom force platform were significantly correlated across balance conditions and groups (Pearson r range, .35 to .97). The SOT equilibrium scores failed to discriminate individuals with and without PD. However, the multiplanar measures of COM acceleration from the mobile device exhibited good to excellent reliability across SOT conditions and were able to discriminate individuals with and without PD in conditions with the greatest balance demands. CONCLUSIONS Metrics employing medial-lateral movement produce a more sensitive outcome than the equilibrium score in identifying postural instability associated with PD. Overall, the output from the mobile device provides an accurate and reliable method of rapidly quantifying balance in individuals with PD. The portable and affordable nature of a mobile device with the application makes it ideally suited to use biomechanical data to aid in clinical decision making.
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Howell DR, Shore BJ, Hanson E, Meehan WP. Evaluation of postural stability in youth athletes: the relationship between two rating systems. PHYSICIAN SPORTSMED 2016; 44:304-10. [PMID: 27266445 DOI: 10.1080/00913847.2016.1197763] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The Balance Error Scoring System (BESS) has been documented as a useful way to evaluate postural control following sport-related concussions sustained by youth athletes. However, limitations have been reported with its use due to the reliance on visual observation as the primary measurement outcome. The primary purpose of this study was to examine the correlation between the modified BESS (mBESS) as rated by a clinician and a simultaneous analysis performed by an integrated video-force plate system. The secondary purpose was to assess if a history of prior concussion affected postural control. METHODS A group of healthy youth athletes (n = 398; mean age 13.7 ± 2.4 years) completed the mBESS while simultaneously undergoing an integrated video-force plate evaluation to measure postural stability. Spearman rank-order correlations were used to determine the strength of correlation between the 2 rating systems. In addition, performance on the mBESS between those with and without a history of concussion was compared using univariate ANCOVAs. RESULTS A moderately high correlation was found during single-leg stance (ρ = -0.64, p < .001), while a weak correlation was found during tandem stance (ρ = -0.30, p < .001). No postural control differences were found between groups with and without a concussion history. CONCLUSION The video-force plate rating system correlates well with the clinician rating during the single-leg stance of the mBESS, but not during double-leg or tandem stances. A history of concussion did not affect mBESS scores.
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Affiliation(s)
- David R Howell
- a The Micheli Center for Sports Injury Prevention , Waltham , MA , USA.,b Division of Sports Medicine , Boston Children's Hospital , Boston , MA , USA.,c Department of Orthopaedics , Boston Children's Hospital , Boston , MA , USA.,d Brain Injury Center , Boston Children's Hospital , Boston , MA , USA
| | - Benjamin J Shore
- c Department of Orthopaedics , Boston Children's Hospital , Boston , MA , USA.,e Department of Orthopaedic Surgery , Harvard Medical School , Boston , MA , USA
| | - Emily Hanson
- a The Micheli Center for Sports Injury Prevention , Waltham , MA , USA.,b Division of Sports Medicine , Boston Children's Hospital , Boston , MA , USA.,c Department of Orthopaedics , Boston Children's Hospital , Boston , MA , USA
| | - William P Meehan
- a The Micheli Center for Sports Injury Prevention , Waltham , MA , USA.,b Division of Sports Medicine , Boston Children's Hospital , Boston , MA , USA.,c Department of Orthopaedics , Boston Children's Hospital , Boston , MA , USA.,d Brain Injury Center , Boston Children's Hospital , Boston , MA , USA.,e Department of Orthopaedic Surgery , Harvard Medical School , Boston , MA , USA
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Evidence-Based Management of Sport-Related Concussion: Completing the Puzzle. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2016. [DOI: 10.1007/s40141-016-0121-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Rosenfeldt AB, Rasanow M, Penko AL, Beall EB, Alberts JL. The cyclical lower extremity exercise for Parkinson's trial (CYCLE): methodology for a randomized controlled trial. BMC Neurol 2015; 15:63. [PMID: 25902768 PMCID: PMC4415238 DOI: 10.1186/s12883-015-0313-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 04/08/2015] [Indexed: 01/25/2023] Open
Abstract
Background Motor and non-motor impairments affect quality of life in individuals with Parkinson’s disease. Our preliminary research indicates that forced exercise cycling, a mode of exercise in which a participant’s voluntary rate of exercise is augmented on a stationary cycle, results in global improvements in the cardinal symptoms of Parkinson’s disease. The objective of the Cyclical Lower Extremity Exercise (CYCLE) trial for Parkinson’s disease is to determine the effects of forced exercise cycling on motor and non-motor performance when compared to voluntary rate cycling and a non-exercise control group. Additionally, we plan to identify any associated changes in neural activity determined by functional magnetic resonance imaging. Methods/Design A total of 100 individuals with mild to moderate idiopathic Parkinson’s disease will participate in a single-center, parallel-group, rater-blind study. Participants will be randomized 2:2:1 into a forced exercise, voluntary exercise, or no-exercise control group, respectively. Both exercise groups will cycle 3 times per week for 8 weeks at identical aerobic intensities for 40 minutes, but participants in the forced exercise group will cycle 30% faster than their voluntary rate by means of an augmented motorized bicycle. Neuroimaging, clinical, and biomechanical assessments of motor and non-motor performance will be made at baseline both ‘on’ and ‘off’ medication, after four weeks of exercise (midpoint), end of treatment, 4 weeks after end of treatment, and 8 weeks after end of treatment. Discussion CYCLE trial will play a critical role in determining the effectiveness of two different types of aerobic exercise, forced and voluntary, on motor and non-motor performance in individuals with Parkinson’s disease. Additionally, the coupling of clinical, biomechanical, and neuroimaging outcomes has the potential to provide insight into mechanisms underlying change in function as a result of exercise. Trial registration Clinicaltrials.gov registration number NCT01636297.
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Affiliation(s)
- Anson B Rosenfeldt
- Department of Biomedical Engineering, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Matthew Rasanow
- Department of Biomedical Engineering, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Amanda L Penko
- Department of Biomedical Engineering, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA. .,Cleveland FES Center, L Stokes Cleveland VA Medical Center, 10701 East Boulevard, Cleveland, OH, 44106, USA.
| | - Erik B Beall
- Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Jay L Alberts
- Department of Biomedical Engineering, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA. .,Cleveland FES Center, L Stokes Cleveland VA Medical Center, 10701 East Boulevard, Cleveland, OH, 44106, USA. .,Center for Neurological Restoration, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, 44195, USA.
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Alberts JL, Hirsch JR, Koop MM, Schindler DD, Kana DE, Linder SM, Campbell S, Thota AK. Using Accelerometer and Gyroscopic Measures to Quantify Postural Stability. J Athl Train 2015; 50:578-88. [PMID: 25844853 DOI: 10.4085/1062-6050-50.2.01] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Force platforms and 3-dimensional motion-capture systems provide an accurate method of quantifying postural stability. Substantial cost, space, time to administer, and need for trained personnel limit widespread use of biomechanical techniques in the assessment of postural stability in clinical or field environments. OBJECTIVE To determine whether accelerometer and gyroscope data sampled from a consumer electronics device (iPad2) provide sufficient resolution of center-of-gravity (COG) movements to accurately quantify postural stability in healthy young people. DESIGN Controlled laboratory study. SETTING Research laboratory in an academic medical center. PATIENTS OR OTHER PARTICIPANTS A total of 49 healthy individuals (age = 19.5 ± 3.1 years, height = 167.7 ± 13.2 cm, mass = 68.5 ± 17.5 kg). INTERVENTION(S) Participants completed the NeuroCom Sensory Organization Test (SOT) with an iPad2 affixed at the sacral level. MAIN OUTCOME MEASURE(S) Primary outcomes were equilibrium scores from both systems and the time series of the angular displacement of the anteroposterior COG sway during each trial. A Bland-Altman assessment for agreement was used to compare equilibrium scores produced by the NeuroCom and iPad2 devices. Limits of agreement was defined as the mean bias (NeuroCom - iPad) ± 2 standard deviations. Mean absolute percentage error and median difference between the NeuroCom and iPad2 measurements were used to evaluate how closely the real-time COG sway measured by the 2 systems tracked each other. RESULTS The limits between the 2 devices ranged from -0.5° to 0.5° in SOT condition 1 to -2.9° to 1.3° in SOT condition 5. The largest absolute value of the measurement error within the 95% confidence intervals for all conditions was 2.9°. The mean absolute percentage error analysis indicated that the iPad2 tracked NeuroCom COG with an average error ranging from 5.87% to 10.42% of the NeuroCom measurement across SOT conditions. CONCLUSIONS The iPad2 hardware provided data of sufficient precision and accuracy to quantify postural stability. Accuracy, portability, and affordability make using the iPad2 a reasonable approach for assessing postural stability in clinical and field environments.
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Affiliation(s)
- Jay L Alberts
- Department of Biomedical Engineering, Cleveland Clinic, OH;,Center for Neurological Restoration, Cleveland Clinic, OH;,Cleveland Clinic Concussion Center, Cleveland Clinic, OH;,Cleveland Functional Electrical Stimulation Center, L. Stokes Cleveland VA Medical Center, OH
| | - Joshua R Hirsch
- Department of Biomedical Engineering, Cleveland Clinic, OH;,Cleveland Clinic Concussion Center, Cleveland Clinic, OH
| | | | - David D Schindler
- Department of Biomedical Engineering, Cleveland Clinic, OH;,Cleveland Clinic Concussion Center, Cleveland Clinic, OH
| | - Daniel E Kana
- Department of Biomedical Engineering, Cleveland Clinic, OH
| | - Susan M Linder
- Department of Biomedical Engineering, Cleveland Clinic, OH;,Cleveland Clinic Concussion Center, Cleveland Clinic, OH
| | - Scott Campbell
- Department of Biomedical Engineering, Cleveland Clinic, OH;,Cleveland Clinic Concussion Center, Cleveland Clinic, OH
| | - Anil K Thota
- Department of Biomedical Engineering, Cleveland Clinic, OH;,Center for Neurological Restoration, Cleveland Clinic, OH
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