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.