Increasing news media coverage of concussions in sports has prompted interest from healthcare providers to address a growing need for services in this area. In addition, slips, trips, and falls in the workplace or home can result in concussions. 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 sports, with a substantial percentage for children under the age of 19; yet only 1 in 9 concussions are captured in data surveillance programs. A concussion is a complex injury with potentially serious consequences if not properly managed. The short- and long-term effects of concussion are often overlooked, ranging from visual impairments, headache, difficulty with cognitive tasks, sleep impairments, mood changes, exercise intolerance, coordination, and balance.
Many states, sports leagues, high schools, and universities have mandated policies and programs for concussion education and management. However, there are unique problems with concussion care because it is often an invisible injury. An athlete may not recognize symptoms or may conceal symptoms because he or she wants to return to play. If balance is evaluated with an observational test, it may not be sensitive enough to detect changes in subtle changes in motor and postural control. Neurocognitive function testing provides valuable data, but if used as the sole objective measure, it may not be sensitive enough to protect all athletes.
The best programs incorporate pre-season screening in three areas: an inventory of symptoms, a measure of neurocognitive function, and an assessment of balance. If a suspected concussion occurs, these measures are used as a baseline for comparison with post-injury assessment. An injured athlete with changes in any of these three areas is not allowed to return to play until their assessments return to baseline values. The best concussion care and management programs involve collaboration between the sports health care team, school environment, parents, and athletes.
There is an 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. Objective data from neurocognitive function tests, computerized balance tests, and computerized vision testing provide information to the interdisciplinary team making return-to-play or return-to-work decisions. Serial computerized balance and dynamic vision testing demonstrate increased sensitivity to detect post-injury changes and track recovery with the best available approach.
No two concussions are alike, and recovery times can vary widely regardless of the severity of the injury and predisposing factors. Objective measures of balance, vision, and neurocognitive function are often used to track recovery and are incorporated into rehabilitation programs to treat concussions.
A Growth Opportunity
The additional training and instrumentation used in balance centers can be applied to concussion management, resulting in a growth opportunity. If the staff is trained and equipped to provide objective measurement of balance and vision performance, they can enhance concussion management programs in local schools and club sports.
Often missing from screening programs, staff should follow a procedure when a post-injury change is detected. Referrals should be made to healthcare providers trained and experienced in concussion. Rehabilitation for balance, vision, and vestibular impairments is often part of the 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?
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Participation in pre-season screening. Balance screening, using portable computer-based systems and specialized protocols like the COBALT and dynamic vision assessment of gaze stability and dynamic visual acuity can be added to supplement existing preseason screening for health and cognitive function.
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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 where to refer the athlete for follow-up. A balance center can meet that need. It’s essential to establish a protocol for those referrals. For example, computerized testing like COBALT and dynamic vision assessment can confirm a change in balance and vision performance. The next step in that process is further evaluation to track progress toward the athlete’s return to the playing field.
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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.
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Return to Play (RTP) decision planning. The RTP decision is best left to the physician managing the patient’s care in coordination with the sports physical therapist or athletic trainer. Pre-planning the objective measures needed to support the physician’s decision will help.
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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 and vision screening not only adds a marketing contact but 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 and the ability to maintain visual focus on a target is fundamental to sports performance. Balance screening protocols for concussion management programs not only establish individual baseline performance levels but also often identify other unresolved orthopedic issues or areas where balance might be improved. The data generated can be valuable for the athletes, their athletic trainers, and coaches in setting training targets for better performance in their chosen sport.
Benefits to the Balance Center
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High Visibility. This can be promoted as a response to a community need and a public health issue. Because concussion is frequently in the media, a program extension to address the issue is newsworthy! The public relations effort may provide an opportunity to raise awareness about the balance center’s mission in addition to concussion management.
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Establish a positive relationship with the medical community. If a balance center can provide 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 a relationship is established, it can be developed and expanded to promote referrals for balance, too.
