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Robertson D, Lempke LB, Lynall RC. Analyzing Dual-Task Paradigms to Improve Postconcussion Assessment and Management. J Sport Rehabil 2024; 33:356-364. [PMID: 38897580 DOI: 10.1123/jsr.2023-0292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 04/06/2024] [Accepted: 04/12/2024] [Indexed: 06/21/2024]
Abstract
CONTEXT Dual-task (simultaneous cognitive-motor activities) assessments have been adapted into reliable and valid clinical concussion measures. However, abundant motor and cognitive variations leave researchers and clinicians uncertain about which combinations elicit the intended dual-task effect. Our objective was to examine differences between commonly employed dual-task motor and cognitive combinations among healthy, college-aged individuals. DESIGN Cross-sectional laboratory study. METHODS Twenty participants (age: 21.3 [2.4] y; height: 176.0 [9.1] cm; mass: 76.0 [16.4] kg; 20% with concussion history) completed 4 motor tasks (gait, tandem gait, single-leg balance, and tandem balance) under 5 cognitive conditions (single task, subtraction, month reversal, spelling backward, and visual Stroop) in a research laboratory. The motor performance outcomes were spatiotemporal variables for gait and tandem gait and center of pressure path length (in centimeters) for single-leg and tandem balance. Cognitive outcomes were response rate (responses/second) and cognitive accuracy. We used separate repeated-measures analyses of variance for each motor and cognitive outcome with post hoc Tukey t tests. RESULTS Gait velocity, gait stride length, and tandem gait velocity demonstrated significant cognitive-motor interactions (P's < .001) such that all dual-task conditions resulted in varyingly slower or shorter movement than single task. Conversely, single-leg balance (P = .627) and tandem balance (P = .434) center of pressure path length did not significantly differ among the dual-task cognitive conditions or relative to single task. Statistically significant cognitive-motor interactions were observed only for spelling backward accuracy (P = .004) and response rates for spelling backward, month reversal, and visual Stroop (P's < .001) such that worse accuracy, but faster response rates, occurred during motor tasks. CONCLUSIONS Gait and tandem gait motor tasks accompanied with spelling backward or subtraction cognitive tasks demonstrated consistently strong dual-task effects and, therefore, may be the best suited for clinical and research use following concussion.
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Affiliation(s)
- Diana Robertson
- UGA Concussion Research Laboratory, Department of Kinesiology, University of Georgia, Athens, GA, USA
- UGA Biomechanics Laboratory, Department of Kinesiology, University of Georgia, Athens, GA, USA
| | - Landon B Lempke
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI, USA
| | - Robert C Lynall
- UGA Concussion Research Laboratory, Department of Kinesiology, University of Georgia, Athens, GA, USA
- UGA Biomechanics Laboratory, Department of Kinesiology, University of Georgia, Athens, GA, USA
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Wilkerson GB, Lansey JC, Noblett CN, Sarris CE. Test-Retest Reliability of Immersive Virtual Reality Measures of Perceptual-Motor Performance. Percept Mot Skills 2023; 130:2484-2504. [PMID: 37776022 DOI: 10.1177/00315125231205322] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
The duration, accuracy, and consistency of responses to various types of stimuli are widely accepted as indirect indicators of the efficiency of brain information processing, but current clinical tests appear to lack sufficient sensitivity to detect subtle impairments. Immersive virtual reality (VR) offers a new means to acquire measures of perceptual-motor responses to moving visual stimuli that require rapid conflict resolution, but their test-retest reliability has not yet been demonstrated. Repeated measures. We analyzed data from 19 healthy young adults who performed a 40-trial VR test on three consecutive days. We focused on response time (RT) and perceptual latency (PL) for eye, neck, arm, and whole-body step displacements involved in executing a reaching/lunging movement in a right or left direction toward a peripherally located virtual target. Measures of RT and PL included a 40-trial mean, an intra-individual variability (IIV) value, and a rate correct score (RCS) that incorporated both response duration and accuracy. Most mean and IIV values for PL and RT demonstrated a positive distributional skew that was substantially reduced by natural logarithm transformation. While a learning effect was evident between sessions 1 and 2 for 7 of 8 mean PL and RT measures, 3-session intraclass correlation coefficient (ICC) values were moderate to excellent for 15 of 16 transformed PL and RT measures (range: .618 to .922). The composite RCS metric did not require transformation for either PL or RT, whose respective 3-session ICC values were .877 and .851. This moderate to excellent test-retest reliability for various VR measures of perceptual-motor function, combined with evidence of their validity from both past and future research, suggest that these measures can advance clinical detection of impaired brain processing and longitudinal assessments of potentially modifiable performance deficiencies.
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Affiliation(s)
- Gary B Wilkerson
- Graduate Athletic Training Program, University of Tennessee at Chattanooga, Chattanooga, TN, USA
| | | | - Courtney N Noblett
- Graduate Athletic Training Program, University of Tennessee at Chattanooga, Chattanooga, TN, USA
| | - Caroline E Sarris
- Graduate Athletic Training Program, University of Tennessee at Chattanooga, Chattanooga, TN, USA
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3
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Lempke LB, Caccese JB, Syrydiuk RA, Buckley TA, Chrisman SPD, Clugston JR, Eckner JT, Ermer E, Esopenko C, Jain D, Kelly LA, Memmini AK, Mozel AE, Putukian M, Susmarski A, Pasquina PF, McCrea MA, McAllister TW, Broglio SP, Master CL. Female Collegiate Athletes' Concussion Characteristics and Recovery Patterns: A Report from the NCAA-DoD CARE Consortium. Ann Biomed Eng 2023:10.1007/s10439-023-03367-y. [PMID: 37751028 DOI: 10.1007/s10439-023-03367-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/07/2023] [Indexed: 09/27/2023]
Abstract
Concussion has been described in the United States (US) collegiate student-athlete population, but female-specific findings are often underrepresented and underreported. Our study aimed to describe female collegiate student-athletes' initial injury characteristics and return to activity outcomes following concussion. Female collegiate student-athletes (n = 1393) from 30-US institutions experienced a concussion and completed standardized, multimodal concussion assessments from pre-injury through unrestricted return to play (uRTP) in this prospective, longitudinal cohort study. Initial injury presentation characteristics, assessment, and return to activity outcomes [<48-h (acute), return to learn, initiate return to play (iRTP), uRTP] were collected. We used descriptive statistics to report injury characteristics, return to activity outcomes, and post-injury assessment performance change categorization (worsened, unchanged, improved) based on change score confidence rank criteria across sport contact classifications [contact (n = 661), limited (n = 446), non-contact (n = 286)]. The median (25th to 75th percentile) days to return to learn was 6.0 (3.0-10.0), iRTP was 8.1 (4.8-13.8), and uRTP was 14.8 (9.9-24.0), but varied by contact classification. Across contact levels, the majority experienced worse SCAT total symptom severity (72.8-82.6%), ImPACT reaction time (91.2-92.6%), and BSI-18 total score (45.2-51.8%) acutely relative to baseline, but unchanged BESS total errors (58.0-60.9%), SAC total score (71.5-76.1%), and remaining ImPACT domains (50.6-66.5%). Our findings provide robust estimates of the typical female collegiate student-athlete presentation and recovery trajectory following concussion, with overall similar findings to the limited female collegiate student-athlete literature. Overall varying confidence rank classification was observed acutely. Our findings provide clinically-relevant insights for athletes, clinicians, researchers, and policymakers to inform efforts specific to females experiencing concussion.
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Affiliation(s)
- Landon B Lempke
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI, USA.
- Exercise and Sport Science Initiative, University of Michigan, Ann Arbor, MI, USA.
- , 830 North University Avenue, Suite 4000, Ann Arbor, MI, 48109, USA.
| | - Jaclyn B Caccese
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA
| | - Reid A Syrydiuk
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI, USA
| | - Thomas A Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA
| | - Sara P D Chrisman
- Division of Adolescent Medicine, University of Washington, Seattle, WA, USA
| | - James R Clugston
- Departments of Community Health Family Medicine and Neurology, University of Florida, Gainesville, FL, USA
| | - James T Eckner
- Department of Physical Medicine & Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Elsa Ermer
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Carrie Esopenko
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Divya Jain
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Louise A Kelly
- Department of Exercise Science, California Lutheran University, Thousand Oaks, CA, USA
| | - Allyssa K Memmini
- Department of Health, Exercise & Sports Sciences, University of New Mexico, Albuquerque, NM, USA
| | - Anne E Mozel
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Adam Susmarski
- Department of Orthopedics and Sports Medicine, United States Naval Academy, Annapolis, MD, USA
| | - Paul F Pasquina
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Michael A McCrea
- Center for Neurotrauma Research, Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Thomas W McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Steven P Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI, USA
| | - Christina L Master
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Orthopaedics and Sports Medicine, Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Lempke LB, Ermer E, Boltz AJ, Caccese J, Buckley TA, Cameron KL, Chrisman SPD, D'Lauro C, Eckner JT, Esopenko C, Hunt TN, Jain D, Kelly LA, Memmini AK, Mozel AE, Putukian M, Susmarski A, Pasquina PF, McCrea MA, McAllister TW, Broglio SP, Master CL. Initial Mild Traumatic Brain Injury Characteristics and Recovery Patterns Among Females Across the United States Military Service Academies: A Report from the NCAA-DoD CARE Consortium. Ann Biomed Eng 2023:10.1007/s10439-023-03374-z. [PMID: 37743459 DOI: 10.1007/s10439-023-03374-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/15/2023] [Indexed: 09/26/2023]
Abstract
Mild traumatic brain injury (mTBI) has been described in the United States (US) military service academy cadet population, but female-specific characteristics and recovery outcomes are poorly characterized despite sex being a confounder. Our objective was to describe female cadets' initial characteristics, assessment performance, and return-to-activity outcomes post-mTBI. Female cadets (n = 472) from the four US military service academies who experienced a mTBI completed standardized mTBI assessments from pre-injury to acute initial injury and unrestricted return-to-duty (uRTD). Initial injury presentation characteristics (e.g., delayed symptoms, retrograde amnesia) and return-to-activity outcomes [i.e., return-to-learn, initiate return-to-duty protocol (iRTD), uRTD] were documented. Descriptive statistics summarized female cadets' injury characteristics, return-to-activity outcomes, and post-mTBI assessment performance change categorization (worsened, unchanged, improved) relative to pre-injury baseline using established change score confidence rank criteria for each assessment score. The median (interquartile range) days to return-to-learn (n = 157) was 7.0 (3.0-14.0), to iRTD (n = 412) was 14.7 (8.6-25.8), and to uRTD (n = 431) was 26.0 (17.7-41.8). The majority experienced worse SCAT total symptom severity (77.8%) and ImPACT reaction time (97.0%) acutely < 24-h versus baseline, but unchanged BESS total errors (75.2%), SAC total score (72%), BSI-18 total score (69.6%), and ImPACT verbal memory (62.3%), visual memory (58.4%), and visual motor speed (52.5%). We observed similar return-to-activity times in the present female cadet cohort relative to the existing female-specific literature. Confidence ranks categorizing post-mTBI performance were heterogenous and indicate multimodal assessments are necessary. Our findings provide clinically relevant insights to female cadets experiencing mTBI across the US service academies for stakeholders providing healthcare.
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Affiliation(s)
- Landon B Lempke
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI, USA.
- Exercise and Sport Science Initiative, University of Michigan, Ann Arbor, MI, USA.
- , 830 North University Avenue, Suite 4000, Ann Arbor, MI, 48109, USA.
| | - Elsa Ermer
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Adrian J Boltz
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI, USA
| | - Jaclyn Caccese
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA
| | - Thomas A Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA
| | - Kenneth L Cameron
- Keller Army Hospital and United States Military Academy, West Point, NY, USA
| | - Sara P D Chrisman
- Division of Adolescent Medicine, University of Washington, Seattle, WA, USA
| | - Christopher D'Lauro
- Department of Behavioral Science and Leadership, United States Air Force Academy, USAF Academy, El Paso County, CO, USA
| | - James T Eckner
- Department of Physical Medicine & Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Carrie Esopenko
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tamerah N Hunt
- Department of Health Sciences and Kinesiology, Georgia Southern University, Statesboro, GA, USA
| | - Divya Jain
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Louise A Kelly
- Department of Exercise Science, California Lutheran University, Thousand Oaks, CA, USA
| | - Allyssa K Memmini
- Department of Health, Exercise & Sports Sciences, University of New Mexico, Albuquerque, NM, USA
| | - Anne E Mozel
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Adam Susmarski
- Department of Orthopedics and Sports Medicine, United States Naval Academy, Annapolis, MD, USA
| | - Paul F Pasquina
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Michael A McCrea
- Center for Neurotrauma Research, Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Thomas W McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Steven P Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, MI, USA
| | - Christina L Master
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Orthopaedics and Sports Medicine, Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Lempke LB, Oldham JR, Passalugo S, Willwerth SB, Berkstresser B, Wang F, Howell DR, Meehan WP. Influential Factors and Preliminary Reference Data for a Clinically Feasible, Functional Reaction Time Assessment: The Standardized Assessment of Reaction Time. J Athl Train 2023; 58:112-119. [PMID: 35476022 PMCID: PMC10072093 DOI: 10.4085/1062-6050-0073.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Clinical reaction-time (RT) measures are frequently used when examining patients with concussion but do not correlate with functional movement RT. We developed the Standardized Assessment of RT (StART) to emulate the rapid cognitive demands and whole-body movement needed in sport. OBJECTIVE To assess StART differences across 6 cognitive-motor combinations, examine potential demographic and health history confounders, and provide preliminary reference data for healthy collegiate student-athletes. DESIGN Prospective, cross-sectional study. SETTING Clinical medicine facilities. PATIENTS OR OTHER PARTICIPANTS A total of 89 student-athletes (56 [62.9%] men, 33 [37.1%] women; age = 19.5 ± 0.9 years, height = 178.2 ± 21.7 cm, mass = 80.4 ± 24 kg; no concussion history = 64 [71.9%]). MAIN OUTCOME MEASURE(S) Student-athletes completed health history questionnaires and StART during preseason testing. The StART consisted of 3 movements (standing, single-legged balance, and cutting) under 2 cognitive states (single task and dual task [subtracting by 6's or 7's]) for 3 trials under each condition. The StART trials were calculated as milliseconds between penlight illumination and initial movement. We used a 3 × 2 repeated-measures analysis of variance with post hoc t tests and 95% CIs to assess StART cognitive and movement differences, conducted univariable linear regressions to examine StART performance associations, and reported StART performance as percentiles. RESULTS All StART conditions differed (P ≤ .03), except single-task standing versus single-task single-legged balance (P = .36). Every 1-year age increase was associated with an 18-millisecond (95% CI = 8, 27 milliseconds) slower single-task cutting RT (P < .001). Female athletes had slower single-task (15 milliseconds; 95% CI = 2, 28 milliseconds; P = .02) and dual-task (28 milliseconds; 95% CI = 2, 55 milliseconds; P = .03) standing RT than male athletes. No other demographic or health history factors were associated with any StART condition (P ≥ .056). CONCLUSIONS The StART outcomes were unique across each cognitive-motor combination, suggesting minimal subtest redundancy. Only age and sex were associated with select outcomes. The StART composite scores may minimize confounding factors, but future researchers should consider age and sex when providing normative data.
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Affiliation(s)
- Landon B. Lempke
- Division of Sports Medicine, Boston Children's Hospital, MA
- The Micheli Center for Sports Injury Prevention, Waltham, MA
| | - Jessie R. Oldham
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond
| | - Scott Passalugo
- Division of Sports Medicine, Boston Children's Hospital, MA
- The Micheli Center for Sports Injury Prevention, Waltham, MA
| | - Sarah B. Willwerth
- Division of Sports Medicine, Boston Children's Hospital, MA
- The Micheli Center for Sports Injury Prevention, Waltham, MA
| | | | - Francis Wang
- Harvard University Health Service, Cambridge, MA
| | | | - William P. Meehan
- Division of Sports Medicine, Boston Children's Hospital, MA
- The Micheli Center for Sports Injury Prevention, Waltham, MA
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Single-Leg Hop Stabilization Throughout Concussion Recovery: A Preliminary Biomechanical Assessment. J Sport Rehabil 2023:1-11. [PMID: 36812918 DOI: 10.1123/jsr.2022-0397] [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: 11/09/2022] [Revised: 12/12/2022] [Accepted: 12/19/2022] [Indexed: 02/24/2023]
Abstract
CONTEXT Aberrant movement patterns among individuals with concussion history have been reported during sport-related movement. However, the acute postconcussion kinematic and kinetic biomechanical movement patterns during a rapid acceleration-deceleration task have not been profiled and leaves their progressive trajectory unknown. Our study aimed to examine single-leg hop stabilization kinematics and kinetics between concussed and healthy-matched controls acutely (≤7 d) and when asymptomatic (≤72 h of symptom resolution). DESIGN Prospective, cohort laboratory study. METHODS Ten concussed (60% male; 19.2 [0.9] y; 178.7 [14.0] cm; 71.3 [18.0] kg) and 10 matched controls (60% male; 19.5 [1.2] y; 176.1 [12.6] cm; 71.0 [17.0] kg) completed the single-leg hop stabilization task under single and dual task (subtracting by 6's or 7's) at both time points. Participants stood on a 30-cm tall box set 50% of their height behind force plates while in an athletic stance. A synchronized light was illuminated randomly, queuing participants to initiate the movement as rapidly as possible. Participants then jumped forward, landed on their nondominant leg, and were instructed to reach and maintain stabilization as fast as possible upon ground contact. We used 2 (group) × 2 (time) mixed-model analyses of variance to compare single-leg hop stabilization outcomes separately during single and dual task. RESULTS We observed a significant main group effect for single-task ankle plantarflexion moment, with greater normalized torque (mean difference = 0.03 N·m/body weight; P = .048, g = 1.18) for concussed individuals across time points. A significant interaction effect for single-task reaction time indicated that concussed individuals had slower performance acutely relative to asymptomatic (mean difference = 0.09 s; P = .015, g = 0.64), while control group performance was stable. No other main or interaction effects for single-leg hop stabilization task metrics were present during single and dual task (P ≥ .051). CONCLUSIONS Greater ankle plantarflexion torque coupled with slower reaction time may indicate stiff, conservative single-leg hop stabilization performance acutely following concussion. Our findings shed preliminary light on the recovery trajectories of biomechanical alterations following concussion and provide specific kinematic and kinetic focal points for future research.
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