Utilizing Technology for Performance Assessment and

Concussion Management

Presented by

Louann Kuntz, ATC, PT, DPT, MEd

Purpose

• To educate athletic trainers about diagnostic tools available to assess concussion, postural control, and sports injury risk.

• To demonstrate how the assessment of postural control can assist with return to play decisions after a concussion.

• To learn about diagnostic tools available to the athletic trainer to aid in assessment of the concussed athlete and assessing sports performance.

• Up to 3.8 million sports or recreation-related concussions occur in the US each year. (Langlois, 2006)

• Individuals with a history of concussion are at an increased risk of sustaining a subsequent concussion. (Guskiewicz, 2003)

• Duration of symptoms are highly variable lasting several minutes to days, weeks, months, or longer. (Guskiewicz et al, 2003), (Field et al, 2003)

Magnitude of the Problem

Magnitude

• No “gold standard” exists for concussion assessment.

• Symptoms or deficits that continue beyond three months may be a sign of post concussion syndrome. (Kashluba et al, 2006)

• Return to play time frames are highly variable and multifactoral. (Herring et al, 2011)

• With proper diagnosis and management, most patients with MTBI recover fully. (Kushner,

1998)

Children and Adolescents

• Research shows that recovery time may be longer for children and adolescents.

Quantifying Postural Instabilities

• Most concussions do not involve the loss of consciousness.

• Detect the symptoms (including postural instability) and determine how long the symptoms last rather than grading the severity of the concussion based on loss of consciousness. (Cantu, 2001)

Quantifiable Postural Instability

• Zurich Consensus Statement on Concussion: (McCrory et al., 2009)

o Postural stability tests should be considered reliable and valid in assessing motor components of neurologic functioning.

• Postural stability assessment may enhance clinical management of concussed athletes. (Guskiewicz, 2003; McCrea et al., 2003; McCrory et al., 2009)

• Postural control testing often reveals deficits even when symptoms are not apparent. (Cavanuagh et al, 2006)

Why Use Technology?

• “The lack of objective and quantifiable information on which to base a return-to-play decision after a mild TBI poses a quandary for sports medicine clinicians.” (Guskiewicz, 2001)

• Clinicians are beginning to manage mild TBI utilizing alternative means of identifying deficits after a suspected head injury.

• Use of technology may help to prevent premature return to competition and subsequent serious injury. (McCrea M et al, 1998;

Guskiewicz et al, 2001; Guskiewicz KM, 2003; Notebaert AJ, et al, 2005)

Balance Assessment

• Balance is the ability to maintain equilibrium by positioning the center of gravity over the base of support. (Murray et al, 1975)

• 49% of your balance comes from the ankles. (Tinnetti, 1994)

• Athletes with cerebral concussion demonstrated acute balance deficits, likely the result of not using information from the vestibular and visual systems effectively. (Guskiewicz et al., 2001)

• Complete recovery of postural control has become an important criteria for return to play.

Objective Assessment of Postural Stability and Balance

BALANCE MASTER BY NEUROCOM BESS TEST

Equilibrate by Balance Engineering

• Portable system that uses force plate technology and cameras to capture a full body assessment. - Remember 49% from the

ankles. What about the other 51%?

• Generate objective data and compares to age specific normative data.

Equilibrate System

Equilibrate Sample Report

Clinical Observation and Use of Technology

• Postural control may not be fully observable.

• Use of technology such as Balance Engineering’s Equilibrate System may provide objective quantifiable data.

• An evidence-based approach to concussion management is presented with a specific focus on return-to-play issues.

Manual Muscle Testing

• RW Bohannon in 2005 demonstrated that dynamometry is superior to manual muscle testing.

• Grading strength may be unreliable. (Bohannon,

RW. 2005)

• We may be missing or placing athletes at risk.

Case Study - 11 Year Old 11 Months After Injury

• Sustained concussion with loss of consciousness.

• Patient self reports feeling normal @ 11 months

• Physician reports - Occasional headaches

- Cranial nerves II through XII intact

- No ataxia

- No dysdiadochokinesis

- Negative pronator drift

- Tandem stance only a few seconds

- Finger to nose fluid

Plantarflexion Dorsiflexion

Knee Extension Knee Flexion

Objective Testing Versus Manual Muscle Testing

Objective Strength

• Plantar flexion R =10.7 lbs; L = 9.7lbs

– Right is 10.9% greater

• Dorsi flexion R = 7.7lbs; L = 7.8lbs

– Left is .7% greater

• Knee Extension R = 40.6lbs; L = 32.6

– Right is 24.5% greater

• Knee Flexion R = 22.7lbs; L = 19.8lbs

– Right is 14.3% greater

Functional and Objective Strength Testing

• Rapid Toe Tapping 10 Seconds

• Normal = 47 reps – Right 36 reps

– Left 29 reps (dyskinesia noted)

• Dorsi flexion

– Left .7% greater

• Plantar flexion

– Right 10.9% greater

• Correlates to poor strength on Left

Functional and Objective Strength Testing

• Sit to Stand 30 sec. Normal 30 in 30 sec. – 12/10/11 = 21 reps

– Right Knee extension is 24.5% greater

Equilibrate Initial Scores 11 Months After Concussion

Equilibrate Assessment

TEST TYPE 12/21/12

Age

Group

Norms

Percent

of Norm

Two feet Eyes Open (EO) 95.81 95.32 +1%

Two feet Eyes Closed (EC) 73.43 94.24 -28%

Right foot EO 27.19 90.31 -232%

Right Foot EC 16.68 71.93 -331%

Left foot EO 30.71 90.31 -194%

Left foot EC 39.11 71.93 -84%

Right foot forward EO 84.68 95.05 -12%

Right foot forward EC 73.14 91.88 -26%

Left foot forward EO 90.14 95.05 -5%

Left foot forward EC 68.36 91.88 -34%

• Poor performance on all but one test types.

• Needed upper extremity support for single leg tasks.

• Additionally patient had weakness in bilateral plantar flexors and headache induced with sit to stand 30 second test.

1 Month Later BTE Primus Isometric Testing

• Dorsi flexion

–Left 100.7% increase

–Right 31.7% increase

BTE Primus Isometric Testing

• Plantar flexion

–Left 83.1% increase

–Right 150.4% increase

BTE Primus Isometric Testing

• Knee Extension

–Left = 45.3% increase

–Right = 19.6% increase

BTE Primus Isometric Testing

• Knee Flexion

–Left = 42.6% increase

–Right = 37.7% increase

Equilibrate Scores

Results After 1 Month

TEST TYPE 12/21/12 1/31/12 % Change

Two feet Eyes Open (EO) 95.81 94.65 -1%

Two feet Eyes Closed (EC) 73.43 89.95 22%

Right foot EO 27.19 84.88 212%

Right Foot EC 16.68 69.66 318%

Left foot EO 30.71 87.63 185%

Left foot EC 39.11 69.31 77%

Right foot forward EO 84.68 95.58 13%

Right foot forward EC 73.14 87.11 19%

Left foot forward EO 90.14 93.75 4%

Left foot forward EC 68.36 91.95 35%

• Significant performance improvement.

• UE support not needed in single leg stance.

• Bilateral plantar flexors improved dramatically 98% on the left and 168% on the right.

• 30 second sit to stand improved from 21 up to 35 reps.

2nd Concussion Occurred

• Sent for Equilibrate testing

Foot Etch Comparisons Two Feet Eyes Open

Initial concussion

12/21/11

11 month after inj.

2nd Concussion

3/21/12

Discharge

6/11/12

(3mo. Later)

Foot Etch Comparisons Left Ft. Fwd EO and Right Ft. Fwd. EO

Discharge

6/11/12

2nd Concussion Evaluation

3/16/12

Equilibrate Scores After 2nd Injury

Unable to perform

Technology and Evidence Based Data

• Quantifying postural stability may help us better manage our athletes to keep them safe and make educated decisions based on evidence for return to play.

• Dynamometer testing vs. manual muscle testing.

• Deficits may be revealed that where not previously apparent.

Case Study

• A 16 year old male

• Concussed 4 times:

• Initial: Oct. 2009

• 2nd: Jan. 2010

• 3rd: Oct. 2010

• 4th: Jul. 2011

• 5 weeks after 4th concussion athlete underwent Equilibrate testing

Equilibrate Results

Injured athlete vs. his twin brother

Wojciechowski, JC. Use of Equilibrate System as a Diagnostic Tool for Concussion; and for Tracking Recovery after

Incident.- A Case Study. Henrietta, NY. 2011.

Equilibrate Testing

Testing Results: Weeks 5-11 Post Trauma

Wojciechowski, JC. Use of Equilibrate System as a Diagnostic Tool for Concussion; and for Tracking

Recovery after Incident.- A Case Study. Henrietta, NY. 2011.

Professional Ice Hockey Player

Division I Male Basketball

Dirt Bike Rider

Gagnon, JP. Concussion In Sports: An Educational In-Service With Case Study. Utica College 2012.

How Is This Technology Being Used?

• Balance and Concussion Assessment

• Balance Training and Rehabilitation

• Sports Performance Assessment

• ACL/Orthopedic Rehabilitation

- Pre-hab and Rehab

• Upper Extremity Rehabilitation

• Closed Chain UE Rehabilitation

• Low Back Rehabilitation

Other Uses of Equilibrate for Sports Performance Testing

Why Is Balance Important?

• Predictor of injury

– In a study by McGuine et al, 210 high school subjects were tested.

– Subjects with poor balance (high sway) suffered seven times more ankle sprains.

• “A number of studies have found that poor balance ability is significantly related to an increased risk of ankle injuries.” (Hrysomallis, 2007)

Where Is This Technology Being Used?

• Professional athletics

• Naval Special Warfare Development Group

• Veteran’s Affairs

• Colleges

• High schools

• Private practices

More Examples

Oregon Shift Test

Injury Identification or Deficiency

SI Joint Dysfunction Healthy SI Joint

More Uses

Visual Cueing With Targets

As Simple Or As Complex As You Want

Creative Application of Technology

Control and Proprioception

References 1. McCrea M, Kelly JP, Randolph C, et al. Standardized assessment of concussion (SAC):

on-site mental status evaluation of the athlete. J Head Trauma Rehabil. 1998;13(2):27–35.

2. Guskiewicz KM. Postural stability assessment following concussion: one piece of the puzzle. Clin J Sport Med. 2001;11(3):182–189.

3. Guskiewicz KM. Assessment of postural stability following sport related concussion. Curr Sports Med Rep. 2003;2(1):24–30.

4. Notebaert AJ, Guskiewicz KM. Current trends in athletic training practice for concussion assessment and management. J Athl Train. 2005;40(4):320–325.

5. Murray M, Seireg A, Sepic S. “Normal Postural Stability and Steadiness: Quantitative Assessment”. The Journal of Bone and Joint Surgery, 1975; 57A, pp 510 - 516.

6. Sahler CS, Greenwald BD. Traumatic brain injury in sports: a review. Rehabil Res Pract. 2012:659652. doi: 10.1155/2012/659652.

7. McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. British Journal of Sports Medicine. 2005;39(4):196–204.

8. Cantu RC (2001). "Posttraumatic Retrograde and Anterograde Amnesia: Pathophysiology and Implications in Grading and Safe Return to Play". Journal of Athletic Training 36 (3): 244–248.

9. Freeman MR, Dean ME, Hanham IF. The etiology and prevention of functional instability of the foot. J Bone Joint Surg. 1965; 47B(4):678-85.

10. Tinetti M, McAvay G, Garret P, et al: A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 331:821-827, 1994.

11. Patel, D. R., & Reddy, V. (2010). Sport-related concussion in adolescents. Pediatric clinics of North America, 57(3), 649–670. doi:10.1016/j.pcl.2010.03.006

12. Kevin M. Guskiewicz, Scott E. Ross, and Stephen W. Marshall. Postural Stability and Neuropsychological Deficits After Concussion in Collegiate Athletes. J Athl Train. 2001 Jul-Sep; 36(3): 263–273.

References Cont.

13. Bohannon RW. Manual muscle testing: does it meet the standards of an adequate screening test? Clin Rehabil. 2005 Sep;19(6):662-7.

14. Langlois, J. A. Rutland-Brown, W., & Wald, M. M. (2006). The epidemiology and impact of traumatic brain injury: A brief overview. Journal of Head Trauma Rehabilitation 21, 375–378.

15. Field M, Collins MW, Lovell MR. Does age play a role in recovery from sports related concussion? A comparison of high school and collegiate athletes. Am J Pediatr. 2003;142:546–553.

16. Balance Engineering | Comprehensive Balance Solutions. (n.d.). Retrieved December 24, 2012, from http://balancengineering.com

17. Guskiewicz, Kevin M. (2003). Assessment of postural stability following sport-related concussion. Current sports medicine reports, 2(1), 24–30.

18. Herring, S. A., Cantu, R. C., Guskiewicz, K. M., Putukian, M., Kibler, W. B., Bergfeld, J. A., Boyajian-O’Neill, L. A., et al. (2011). Concussion (mild traumatic brain injury) and the team physician: A consensus statement--2011 update. Medicine and science in sports and exercise, 43(12), 2412–2422. doi:10.1249/MSS.0b013e3182342e64

19. ImPACT Test: Sample Clinical Report. (n.d.). Retrieved December 7, 2012, from http://impacttest.com/about/sample_report

20. ImPACT-Testing & Computerized Neurocognitive Assessment Tools. (n.d.). Retrieved December 7, 2012, from http://www.impacttest.com/

21. McCrea, M., Guskiewicz, K. M., Marshall, S. W., Barr, W., Randolph, C., Cantu, R. C., Onate, J. A., et al. (2003). Acute effects and recovery time following concussion in collegiate football players: The NCAA concussion study. JAMA: the journal of the American Medical Association, 290(19), 2556–2563. doi:10.1001/jama.290.19.2556

References Cont. 22. McCrory, P., Meeuwisse, W., Johnston, K., Dvorak, J., Aubry, M., Molloy, M., & Cantu,

R. (2009). Consensus statement on concussion in sport - The 3rd international conference on concussion in sport held in Zurich, November 2008. PM & R: the journal of injury, function, and rehabilitation, 1(5), 406–420. doi:10.1016/j.pmrj.2009.03.010

23. Kashluba S, Paniak C, Casey JE. Persistent symptoms associated with factors identified by the WHO Task Force on Mild Traumatic Brain Injury. The Clinical Neuropsychologist. 2008;22:195–208.

24. Alexander MP. Minor traumatic brain injury: A review of physiogenesis and psychogenesis. Seminars in Clinical Neuropsychiatry. 1997;2:177–187.

25. Kushner, David. "Mild traumatic brain injury: toward understanding manifestations and treatment." Archives of Internal Medicine 158.15 (1998): 1617..

26. McGuine, TA; Greene, JJ; Best, T; Leverson, G. Balance As a Predictor of Ankle Injuries in High School Basketball Players. Clinical Journal of Sport Medicine: October 2000 - Volume 10 - Issue 4 - pp 239-244

27. Hrysomallis, Con. Relationship Between Balance Ability, Training and Sports Injury Risk. Sports Medicine: 2007 - Volume 37 - Issue 6 - pp 547-556

28. Gagnon, JP. Concussion In Sports: An Educational In-Service With Case Study. Utica College 2012.

29. Wojciechowski, JC. Use of Equilibrate System as a Diagnostic Tool for Concussion; and for Tracking Recovery after Incident.- A Case Study. Henrietta, NY. 2011.

Demonstration and hands on use the

technology.