Variability of the modified Balance Error Scoring System at baseline using objective and subjective balance measures

Multisystem recovery after sport-related concussion in adolescent rugby players: a prospective study protocol

INTRODUCTION

Sport-related concussion is one of the most common injuries in adolescent rugby players with evidence of prolonged recovery in some concussed athletes. Concussion is a complex pathophysiological process that can affect a variety of subsystems with multifactorial presentation. Most research on adolescents recovery after concussion focuses on neurocognitive functioning and symptom outcomes over the short term. There is a need to explore concussion recovery over time across multiple subsystems in adolescent rugby players.

METHODS AND ANALYSIS

This prospective study will use sensorimotor and oculomotor outcomes in adolescent male and female rugby players aged 16-18 years. Players will be recruited from school or club rugby teams across the province of Ulster. Baseline assessment will be undertaken at the start of the playing season and will include questionnaires, Quantified Y Balance Test and Pupillary Light Reflex. Players who sustain a concussive event will be reassessed on all outcomes at 3 days, 7 days, 14 days, 23 days, 90 days, 180 days and 365 days postconcussion. For serial outcome data, we will examine response curves for each participant and make comparisons between known groups. We will use logistic regression to explore any association between demographic variables and recovery. The strength of the predictive model will be determined using R2, p values and ORs, with 95% CIs.

ETHICS AND DISSEMINATION

Ethical approval has been granted for this study from Ulster University Research Ethics Committee (REC/14/0060). This study will be published in an open-access research journal on completion.

TRIAL REGISTRATION NUMBER

ACTRN12622000931774p.

The Implementation of a Return-to-Play Protocol with Standardized Physical Therapy Referrals in a Collegiate Football Program: PT's Role in Return-to-Play, A Clinical Commentary

Sport-related concussions (SRCs) are multi-faceted injuries requiring coordinated care for return-to-play (RTP). Although the number of concussions in collegiate football is increasing annually, there is poor standardization among RTP protocols. Recent evidence suggests there is an increased risk of lower extremity injury, neuropsychiatric consequences, and re-injury after SRC, and risk factors for a prolonged recovery from SRC have also been identified. Evidence demonstrates a faster RTP and improved outcomes with early physical therapy intervention; however, this is not yet common practice in the treatment of acute SRC. There is little guidance available on the development and implementation of a multidisciplinary RTP rehabilitation protocol for SRC that incorporates standardized physical therapy. By describing an evidence-based RTP protocol with standardized physical therapy management, and measures taken to implement this protocol, this clinical commentary aims to identify steps in treating SRC that can be used to improve recovery. The purpose of this commentary is to: a) survey the current state of standardization of RTP protocols in collegiate football; b) highlight the development and implementation of a RTP protocol with standardized physical therapy referral and management in an NCAA Division II collegiate football program; and c) describe results of a full-season pilot study, including time to evaluation, time to RTP, rate of re-injury or lower extremity injury, and the clinical significance of protocol implementation.

Level of Evidence

Level V.

Is the Sport Concussion Assessment Tool 5th Edition a useful concussion assessment tool in head‐injured patients presenting to the emergency department?

OBJECTIVE

Concussion is a common ED complaint, but diagnosis is challenging as there are no validated objective measures. Use of concussion tools derived from sports medicine is common, but these tools are not well validated in ED settings. The aim of this study was to assess the ability of the Sport Concussion Assessment Tool 5th Edition (SCAT5) to identify concussion in ED patients presenting following head injury.

METHODS

We conducted a prospective observational study of head-injured adult patients presenting to ED between March and July 2021. ED diagnosis of concussion was used as the diagnostic standard, and we assessed the diagnostic performance of the SCAT5 test and its three subsections (Standardised Assessment of Concussion (SAC), Post-Concussion Symptom Scale (PCSS) and Modified Balance Error Scoring System (mBESS)) against this.

RESULTS

Thirty-two head-injured participants were enrolled, 19 of whom had a discharge diagnosis of concussion, alongside 17 controls. Median time for SCAT5 testing was 21 (interquartile range 16-27) min. Fifteen (30.6%) participants were interrupted during testing. Area under the curve (AUC) (95% confidence interval) for the SAC, PCSS and mBESS were 0.51 (0.34-0.68), 0.92 (0.84-0.99) and 0.66 (0.47-0.85), respectively. Sensitivity and specificity of sections were as follows: entire SCAT5 (100.0%, 20.0%), SAC (48.1%, 60.0%), PCSS (89.7%, 85.0%) and mBESS (83.3%, 58.8%). Using PCSS alone would have identified 17 of 19 concussions.

CONCLUSION

The SCAT5 test had a low specificity, was long and was frequently interrupted. We suggest it is not an ideal assessment to use in ED. The PCSS score performed well and was easy to complete. It may be useful as a standalone tool to simplify ED concussion identification.

Balance impairment in patients with moderate-to-severe traumatic brain injury: Which measures are appropriate for assessment?

Left untreated, balance impairment following moderate-to-severe traumatic brain injury (TBI) can be highly debilitating and hinder activities of daily life. To detect impairments, clinicians need appropriate assessment tools. The objective of this study was to evaluate the feasibility and utility of a battery of clinical balance assessments in adults with moderate-to-severe TBI within 6-months of injury. Thirty-seven adults with TBI [Glasgow Coma Scale score ≤ 12 (33 M/4 F) age 18–50 years] participated in balance testing. Assessments included the Balance Error Scoring System (BESS), National Institutes of Health Standing Balance Test (NIH-SBT), Functional Gait Assessment (FGA), Advanced Functional Gait Assessment (FGA-A), Tandem Gait Test (TGT), Berg Balance Scale (BBS), and Walking While Talking Test (WWTT). We identified pronounced ceiling effects on the BBS and FGA, two widely used clinical balance assessments. The NIH-SBT, WWTT, and FGA used in conjunction with the FGA-A, offered versatility in their capacity to assess patients across the balance severity spectrum. This study provides evidence to support a stepwise approach to balance assessment that can be adapted to the broad range of balance ability found in moderate-to-severe TBI.

Dynamic Visual Stimulations Produced in a Controlled Virtual Reality Environment Reveals Long-Lasting Postural Deficits in Children With Mild Traumatic Brain Injury

Motor control deficits outlasting self-reported symptoms are often reported following mild traumatic brain injury (mTBI). The exact duration and nature of these deficits remains unknown. The current study aimed to compare postural responses to static or dynamic virtual visual inputs and during standard clinical tests of balance in 38 children between 9 and 18 years-of-age, at 2 weeks, 3 and 12 months post-concussion. Body sway amplitude (BSA) and postural instability (vRMS) were measured in a 3D virtual reality (VR) tunnel (i.e., optic flow) moving in the antero-posterior direction in different conditions. Measures derived from standard clinical balance evaluations (BOT-2, Timed tasks) and post-concussion symptoms (PCSS-R) were also assessed. Results were compared to those of 38 healthy non-injured children following a similar testing schedule and matched according to age, gender, and premorbid level of physical activity. Results highlighted greater postural response with BSA and vRMS measures at 3 months post-mTBI, but not at 12 months when compared to controls, whereas no differences were observed in post-concussion symptoms between mTBI and controls at 3 and 12 months. These deficits were specifically identified using measures of postural response in reaction to 3D dynamic visual inputs in the VR paradigm, while items from the BOT-2 and the 3 timed tasks did not reveal deficits at any of the test sessions. PCSS-R scores correlated between sessions and with the most challenging condition of the BOT-2 and as well as with the timed tasks, but not with BSA and vRMS. Scores obtained in the most challenging conditions of clinical balance tests also correlated weakly with BSA and vRMS measures in the dynamic conditions. These preliminary findings suggest that using 3D dynamic visual inputs such as optic flow in a controlled VR environment could help detect subtle postural impairments and inspire the development of clinical tools to guide rehabilitation and return to play recommendations.

False Positive Rates and Associated Risk Factors on the VOMS and mBESS in U.S. Military Personnel

CONTEXT

In 2018, the U.S. military developed the Military Acute Concussion Evaluation-2 (MACE-2) to inform acute evaluation of mTBI. However, researchers have yet to investigate false positive rates for components of the MACE-2 including the Vestibular-Ocular Motor Screen (VOMS) and modified Balance Error Scoring System (mBESS) in military personnel.

OBJECTIVE

To examine factors associated with false positives in VOMS and mBESS in U.S. Army Special Operations Command (USASOC) personnel.

DESIGN

Cross-sectional study.

SETTING

Military medical clinic.

PARTICIPANTS

416 healthy USASOC personnel completed medical history, VOMS, and mBESS evaluations.

MAIN OUTCOME MEASURES

False positive rates for the VOMS (2+ on VOMS symptom item, ≥ 5 cm for near point of convergence [NPC] distance) and mBESS (total score >4) were determined using chi-square analyses and independent samples t-tests. Multivariable logistic regressions (LR) with adjusted odds ratios (aOR) were performed to identify risk factors for false positives on VOMS and mBESS. VOMS items false positive rates ranged from 10.6% (smooth pursuits) to 17.5% (NPC). mBESS total score false positive rate was 36.5%.

RESULTS

The multivariable LR model supported three significant predictors of VOMS false positives including age (OR= 1.07, 95% CI= 1.02-1.12, p=0.007), migraine (OR=2.49, 95% CI= 1.29-4.81, p=0.007), and motion sickness history (OR=2.46, 95% CI= 1.34-4.50, p=0.004). Results of the multivariable LR model supported only motion sickness history as a significant predictor (OR=2.34, 95% CI= 1.34-4.05, p=0.002) of mBESS false positives.

CONCLUSIONS

There were low false positive rates across VOMS items, which were associated with age, history of mTBI, migraine, and motion sickness. False positives for the mBESS total score were higher (36.5%) and were only associated with a history of motion sickness. These risk factors for false positives should be considered when administering and interpreting VOMS and mBESS components of the MACE-2 in this population.

A Novel Neuropsychological Tool for Immersive Assessment of Concussion and Correlation with Subclinical Head Impacts

Mild traumatic brain injury (mTBI) remains a diagnostic challenge and therefore strategies for objective assessment of neurological function are key to limiting long-term sequelae. Current assessment methods are not optimal in austere environments such as athletic fields; therefore, we developed an immersive tool, the Display Enhanced Testing for Cognitive Impairment and mTBI (DETECT) platform, for rapid objective neuropsychological (NP) testing. The objectives of this study were to assess the ability of DETECT to accurately identify neurocognitive deficits associated with concussion and evaluate the relationship between neurocognitive measures and subconcussive head impacts. DETECT was used over a single season of two high school and two college football teams. Study participants were instrumented with Riddell Head Impact Telemetry (HIT) sensors and a subset tested with DETECT immediately after confirmed impacts for different combinations of linear and rotational acceleration. A total of 123 athletes were enrolled and completed baseline testing. Twenty-one players were pulled from play for suspected concussion and tested with DETECT. DETECT was 86.7% sensitive (95% confidence interval [CI]: 59.5%, 98.3%) and 66.7% specific (95% CI: 22.3%, 95.7%) in correctly identifying athletes with concussions (15 of 21). Weak but significant correlations were found between complex choice response time (processing speed and divided attention) and both linear (Spearman rank correlation coefficient 0.262, p = 0.02) and rotational (Spearman coefficient 0.254, p = 0.03) acceleration on a subset of 76 players (113 DETECT tests) with no concussion symptoms. This study demonstrates that DETECT confers moderate to high sensitivity in identifying acute cognitive impairment and suggests that football impacts that do not result in concussion may negatively affect cognitive performance immediately following an impact. Specificity, however, was not optimal and points to the need for additional studies across multiple neurological domains. Given the need for more objective concussion screening in triage situations, DETECT may provide a solution for mTBI assessment.

Pac-12 CARE-Affiliated Program: structure, methods and initial results

Sport-related concussion has garnered increasing scientific attention and research over the last decade. Collegiate student-athletes represent an important cohort in this field. As such, the Pac-12 CARE-Affiliated Program (CAP) was formed in 2017 as a regional hub of the Concussion Assessment, Research and Education (CARE) consortium. CAP is multisite, prospective, longitudinal study that aims to improve student-athlete health by identifying factors associated with concussion incidence and recovery and using this knowledge to inform best clinical practices and policy decisions. CAP employed a staggered rollout across the Pac-12, with the first four institutions enrolling in fall 2018. After receiving institutional review board (IRB) approval, these institutions began consenting student-athletes to share clinical concussion and baseline data for research purposes. Athletes completed baseline testing that included a medical questionnaire, concussion history and a battery for clinical concussion assessments. Concussed student-athletes were given the same battery of assessments in addition to full injury and return to play reports. Clinicians at each university worked with a data coordinator to ensure appropriate reporting, and the Pac-12 Concussion Coordinating Unit at the University of Colorado Boulder provided oversight for quality control of the data study wide. During year 1, CAP consented 2181 student-athletes and tracked 140 concussions. All research was conducted with the appropriate IRB approval across the participating Pac-12 institutions. Data security and dissemination are managed by the Presagia Sports Athlete Electronic Health Record software (Montreal, Quebec, Canada) and QuesGen Systems (San Francisco, California, USA).

The use of inertial measurement units to assess gait and postural control following concussion

BACKGROUND

Impairments in gait and balance function are typical after concussion. There is evidence that these neuromuscular deficits persist past the typical time of symptom resolution. The ability to quantify these changes in gait and balance may provide useful information when making return to play decisions in clinical settings.

RESEARCH QUESTION

Are changes in gait function and postural control evident across the course of a concussion management program?

METHODS

A retrospective analysis of a convenience sample of 38 patients who were seen for concussion between October 2017 and May 2019 was performed. Gait and balance measures were assessed at their initial clinic visit post-injury and at their clearance visit using inertial measurement units. During dual-task walking trials, the medial-lateral motion of the center of mass and gait velocity were measured. Postural sway complexity and jerk index were measured during both eyes-open and eyes-closed balance trials.

RESULTS

Paired samples t-tests and Wilcoxon signed rank tests were used to determine whether statistically significant changes occurred for the gait and balance variables, respectively. Medial-lateral sway decreased (4.4 ± 1.3 cm to 4.0 ± 1.2 cm, p = 0.018) and gait velocity increased (0.78 ± 0.23 m/s to 0.91 ± 0.18 m/s, p <  0.001) from initial to clearance testing. Jerk index decreased (6.41 ± 11.06 m²/s⁵ to 5.73 ± 4.28 m²/s⁵, p = 0.031) and (11.87 ± 26.42 m²/s⁵ to 7.87 ± 8.38 m²/s⁵, p = 0.003) from initial to clearance testing for the eyes-open and eyes-closed conditions, respectively. Complexity index increased (2.38 ± 1.08-2.86 ± 0.72, p = 0.010) from initial to clearance testing for the eyes-closed condition. There was no change in complexity index for the eyes-open condition.

SIGNIFICANCE

These preliminary results support the potential use of measures of gait and postural control to assess recovery following a concussion in a clinical setting.

Can Neurocognitive Function Predict Lower Extremity Injuries in Male Collegiate Athletes?

The purpose of this study is to demonstrate whether neurocognitive evaluation can confirm the association between neurocognitive level and postural control and to analyze the relationship between neurocognitive level and acute musculoskeletal injury in male non-net sports athletes. Seventy-seven male non-net sports athletes participated in this study. The Standardized Assessment of Concussion (SAC), Landing Error Scoring System (LESS), Balance Error Scoring System (BESS), and Star Excursion Balance Test (SEBT) were used for testing; we collected data related to injury history for six months after testing. Pearson's correlation analysis, logistic regression, and the independent sample t-test were used for statistical analysis. The correlation between SAC and SEBT results was weak to moderate (p < 0.05). Eleven of the seventy-seven participants experienced acute lower limb injuries. SAC, LESS, BESS, and SEBT results have no effect on the occurrence of acute lower extremity injuries (p > 0.05) and were not statistically different between the injured and non-injured groups (p > 0.05). Therefore, using the SAC score alone to determine the risk factor of lower extremity injuries, except in the use of assessment after a concussion, should be cautioned against.

Responsiveness of a Balance Assessment Using a Mobile Application

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.

Sport-Related Concussion: Evaluation, Treatment, and Future Directions

Sport-related concussion (SRC) is a highly prevalent injury predominantly affecting millions of youth through high school athletes every year. In recent years, SRC has received a significant amount of attention due to potential for long-term neurologic sequelae. However, the acute symptoms and possibility of prolonged recovery account for the vast majority of morbidity from SRC. Modifying factors have been identified and may allow for improved prediction of a protracted course. Potential novel modifying factors may include genetic determinants of recovery, as well as radiographic biomarkers, which represent burgeoning subfields in SRC research. Helmet design and understanding the biomechanical stressors on the brain that lead to concussion also represent active areas of research. This narrative review provides a general synopsis of SRC, including relevant definitions, current treatment paradigms, and modifying factors for recovery, in addition to novel areas of research and future directions for SRC research.

Perceptual-cognitive three-dimensional multiple-object tracking task can help the monitoring of sport-related concussion

Objectives

While the rate of sport-related concussion is increasing, more effective tools are needed to help monitor the diagnosis and return to play of athletes. The three-dimensional multiple-object tracking (3D-MOT) exercise is a perceptual-cognitive task that has shown predictive power towards the dynamic requirements of real-world activities such as sport. This study introduced the use of the 3D-MOT task, along with the Standardized Assessment of Concussion (SAC) and Modified Balance Error Scoring System (M-BESS) tests, for diagnosis and return to play in professional sports.

Methods

Fifty-nine professional athletes were tested with the 3D-MOT, SAC and M-BESS tests at 48 hours following the injury. The same measures were employed to evaluate the return to play following the standard concussion management protocol. The SAC and M-BESS tests were also performed in pre-season (baseline) in 32 out of the 59 athletes.

Results

The injured athletes exhibited poor performance on 3D-MOT at 48 hours post injury compared with return to play (p<0.001) as well as compared with healthy professionals' performance scores (p<0.001). Importantly, learning rate, which participants are thought to have an expert advantage on this perceptual-cognitive task, was totally disrupted at 48 hours post injury compared with healthy professionals (p<0.001). The 3D-MOT performance was also correlated to the total number of symptoms (p=0.020), SAC (p=0.031) and M-BESS (p=0.004) scores at 48 hours. Not surprisingly, SAC and M-BESS tests' usefulness for monitoring concussion was found to be weak, particularly when test performance following the injury was compared to baseline (p=0.056 and 0.349 for SAC and M-BESS, respectively).

Conclusion

3D-MOT could help monitor sport-related concussion in professional athletes. The discussion also covers the critical importance of perceptual-cognitive assessment following concussion in the athletic population.