Cleveland Clinic Postural Stability Index Norms for the Balance Error Scoring System

Quantitative Assessment of Balance for Accurate Prediction of Return to Sport From Sport-Related Concussion

BACKGROUND

Determining when athletes are able to return to sport after sports-related concussion (SRC) can be difficult.

HYPOTHESIS

A multimodal algorithm using cognitive testing, postural stability, and clinical assessment can predict return to sports after SRC.

STUDY DESIGN

Prospective cohort.

LEVEL OF EVIDENCE

Level 2b.

METHODS

Athletes were evaluated within 2 to 3 weeks of SRC. Clinical assessment, Immediate Post Concussion and Cognitive Testing (ImPACT), and postural stability (Equilibrate) were conducted. Resulting data and machine learning techniques were used to optimize an algorithm discriminating between patients ready to return to sports versus those who are not yet recovered. A Fisher discriminant analysis with leave-one-out cross-validation assessed every combination of 2 to 5 factors to optimize the algorithm with lowest combination of type I and type II errors.

RESULTS

A total of 193 athletes returned to contact sports after SRC at a mean 84.6 days (±88.8). Twelve subjects (6.2%) sustained repeat SRC within 12 months after return to sport. The combination of (1) days since injury, (2) total symptom score, and (3) nondominant foot tandem eyes closed postural stability score created the best algorithm for discriminating those ready to return to sports after SRC with lowest type I error (13.85%) and type II error (11.25%). The model was able to discriminate between patients who were ready to successfully return to sports versus those who were not with area under the receiver operating characteristic (ROC) curve of 0.82.

CONCLUSION

The algorithm predicts successful return to sports with an acceptable sensitivity and specificity. Tandem balance with eyes closed measured with a video-force plate discriminated athletes ready to return to sports from SRC when combined in multivariate analysis with symptom score and time since injury. The combination of these factors may pose advantages over computerized neuropsychological testing when evaluating young athletes with SRC for return to contact sports.

CLINICAL RELEVANCE

When assessing young athletes sustaining an SRC in a concussion clinic, measuring postural stability in tandem stance with eyes closed combined with clinical assessment and cognitive recovery is effective to determine who is ready to successfully return to sports.

Symptom recovery and the relationship between post-injury symptom scores and neurocognitive performance in athletes with sport-related concussion

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.

Quantification of Dual-task Performance in Healthy Young Adults Suitable for Military Use

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.

Development and Validation of a Mobile Application to Detect Visual Dysfunction Following Mild Traumatic Brain Injury

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.

Accelerometric Assessment of Postural Balance in Children: A Systematic Review

The correct development of postural control in children is fundamental to ensure that they fully reach their psychomotor capacities. However, this capacity is one of the least studied in the clinical and academic scope regarding children. The objective of this study was to analyze the degree of implementation of accelerometry as an evaluation technique for postural control in children and how it is being used.

METHODS

A systematic search was conducted in PubMed, SpringerLink, SportsDiscus, Medline, Scopus, and Web of Science with the following terms: balance, postural control, children, kids, accelerometry, and accelerometer.

RESULTS

The search generated a total of 18 articles. Two groups of studies were differentiated: those which exclusively included healthy individuals (n = 5) and those which included children with pathologies (n = 13). Accelerometry is being used in children mainly to assess the gait and static balance, as well as to identify the differences between healthy children and children with developmental disorders.

CONCLUSIONS

Accelerometry has a discrete degree of implementation as an evaluation tool to assess postural control. It is necessary to define a systematic method for the evaluation of postural control in pediatrics, in order to delve into the development of this capacity and its alterations in different neurodevelopmental disorders.

Instrumented balance assessment in mild traumatic brain injury: Normative values and descriptive data for acute, sub-acute and chronic populations

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.

Reliability, Validity and Utility of Inertial Sensor Systems for Postural Control Assessment in Sport Science and Medicine Applications: A Systematic Review

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 .

A Technology-Enabled Concussion Care Pathway Reduces Costs and Enhances Care

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.

Military-Specific Normative Data for Cognitive and Motor Single- and Dual-Task Assessments for Use in Mild Traumatic Brain Injury Assessment

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.

A Mobile Device Dual-Task Paradigm for the Assessment of mTBI

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.