Increasing news media coverage of concussion in contact sports has prompted interest from healthcare providers to address a growing need for services in this area. Existing balance centers are uniquely positioned to use their specialized training and instrumentation to respond to this opportunity.
There are estimates of more than three million concussions per year in the United States resulting from contact sports, with a substantial percentage for children under the age of 19. Concussion is a serious injury, with potentially serious consequences if not properly managed.
Concussion management programs are being implemented for many contact sports. The best programs incorporate pre-season screening in three areas: an inventory of symptoms, a measure of cognitive function, and an assessment of balance. If a suspected concussion occurs, these measures are used as a baseline for comparison of post-injury assessment. An injured athlete with marked changes in any of these three areas is not allowed to return to play until their assessments return to baseline values.
There are unique problems with concussion management. An athlete may not recognize symptoms or may conceal a symptom because he or she wants to return to play. If the balance is evaluated with an observational test, it may not be sensitive enough to detect changes in ability. Cognitive function testing provides valuable data, but if used as the sole objective measure, it may not be sensitive enough to protect all athletes.
There is increased risk of serious consequences if a second concussion occurs before recovery is complete, and that risk is higher still for younger athletes up to age 24. Under-reporting of symptoms due to lack of awareness or incentive to conceal the injury makes the need for sensitive, objective measures more acute. Balance performance can be measured with computer-based systems that provide objective data to increase the effectiveness of a screening program. When combined with objective data from cognitive function tests, the concussion management program will be using the best available approach due to increased sensitivity to detect post-injury changes.
No two concussions are alike, and recovery times can vary widely regardless of the severity of the injury. Objective measures of balance and cognitive function are often used to track recovery, and are incorporated in rehabilitation programs to treat concussion.
A Growth Opportunity
The additional training and instrumentation used in balance centers can be applied to concussion management, and that creates a growth opportunity. If the staff is trained and equipped to provide objective measurement of balance performance, they can provide an essential component to enhance concussion management programs in local schools and club sports.
What is often missing from screening programs is a procedure to follow when a post-injury change is detected. Referrals should be made to healthcare providers trained and experienced in concussion. Rehabilitation for balance and vestibular impairments is often part of treatment plan for concussion, and balance centers can offer these specialized services. This represents an opportunity to develop referrals for a balance center for additional evaluation and therapy.
What components should be considered?
− Participation in pre-season screening. Balance screening, using portable computer-based systems and specialized protocols like the COBALT can be added to supplement existing preseason screening for health and cognitive function.
− Post-Injury protocol. If sideline testing suggests a possible concussion, the person providing first-line care (athletic trainer, team physician, coach, etc.) needs to know what to do and where to refer the athlete for follow-up. A balance center can offer services to meet that need. It will require planning the appropriate procedure for those referrals. For example, a brief clinical protocol like COBALT can confirm or rule out a change in balance performance relative to baseline. If COBALT results confirm a change, referral for more detailed medical evaluation and follow-up cognitive function testing is indicated. The next step in that process is a more comprehensive balance evaluation and possible rehabilitation
− Concussion protocol. If the athlete is referred for comprehensive evaluation, the balance center should plan a protocol in advance. Consider including a complete history, Computerized Dynamic Posturography, dynamic vision testing for VOR, and referral for audiologic evaluation, neuro-optometry and neuro-psychology evaluations.
− Return to Play (RTP) decision planning. The RTP decision is best left to the physician managing the patient’s care. Pre-planning the objective measures that will be needed to support the physician’s decision will help.
− Plan for Timeliness. This is essential for scheduling an athlete for a post-injury protocol, and communicating results to physicians and families. Professional and administrative staff will need procedures in place to schedule post-injury protocols, ideally within a day or two of the appointment request.
If the balance center has the staff and resources available, adding services for concussion can be considered a hub and spoke model. The hub is likely already established, equipped with specialized clinical systems and staff with additional training in balance. Participation in pre-season testing can be developed as a spoke, or another point of entry into the balance center system. Balance screening not only adds a marketing contact, it also can be developed as a fee-for-service revenue generator, billed on a per-person basis or by group subscription by a team or school. It also can provide a platform for educating athletes and their families, and reinforcing the need for referral if problems are found.
Good balance is fundamental to sports performance. Balance screening protocols for concussion management programs not only establish individual baseline performance levels, but they also often identify other unresolved orthopedic issues or areas where balance might be improved. The data generated can be valuable for the athletes and their trainers and coaches in setting training targets for better performance in their chosen sport.
Benefits for the Balance Center
− High Visibility. This can be promoted as a response to a community need and a public health issue. Because concussion is frequently in the news, a program extension to address the issue is newsworthy! The public relations effort may provide an opportunity to raise awareness about the balance center mission in addition to concussion management.
− Establish a positive relationship with the medical community. If a balance center can provide the objective data to assist with diagnosis, referral and return to play decisions, it can position itself as a high value extension to physician practice. Once the relationship is established, it can be developed and expanded to promote referrals for balance, too.
