At the start of the 2022 season Miami Dolphin’s Tua Tagovailoa sustained two injuries a week apart, leading to changes in the NFL Concussion Diagnosis and Management Protocol to add visible “abnormalities of balance and stability, motor coordination, and impact seizure/fencing response” to the list of concussion signs and symptoms leading to removal from play (1). During the Monday Night Football game on December 12th between the Arizona Cardinals and the New England Patriots, wide receiver DeVante Parker slammed his face into the ground and struggled to get back on his feet and maintain his balance, obvious concussion signs to the most casual observer. He was not removed from the game until fellow wide receiver Nelson Agholar knelt on the field, calling for stop of play to obtain help for his teammate. While these injuries have garnered media and league scrutiny (2) and calls for changes to the NFL’s Concussion Management and Return to Play Guidelines, another question remains:
ARE SIDELINE AND LOCKER ROOM ASSESSMENTS ENOUGH TO MAKE THE RIGHT RETURN TO PLAY DECISIONS?
Can we rely on officials and teammates/ observations, sideline physical exam and athlete-reported symptoms (3) to determine if an athlete can return to the field, or can we objectively measure balance; the neurological postural reflex system; and the intricate control between head, neck, vestibular, and vision systems?
Answer? Both. Concussion management is highly individualized and multidimensional and is best served by an evidence-informed interdisciplinary team approach (4). A sideline clinical exam may be skewed by the individual performing the test, impairments not visible to the eyes, or poor test sensitivity (postural sway is one such factor).
A locker room exam focused on a standard neurological exam and modified BESS balance test may not be sensitive enough to detect impairments in the postural control or visual systems that impact an athlete’s concussion recovery and performance. In a 2021 study of sport and military concussion, the SCAT-3 concussion symptom assessment tool (3) and rapid pen/paper vestibular/ocular-motor screening tool (VOMS) were found to be valid measures to identify and monitor acute concussion recovery progress (4).
HOW CAN TECHNOLOGY CONTRIBUTE TO PRECISION REHABILITATION AND RETURN TO PLAY DECISIONS?
Precise measurements of the body’s postural and vestibular-visual responses aid in designing effective, targeted rehabilitation programs and contribute to clinical decision-making about when an athlete can safely return to play following concussion.
Computerized Dynamic Posturography, first developed by NASA scientists and perfected by Bertec’s engineers, is the gold standard to evaluate both voluntary sensorimotor systems and involuntary postural reflex control of balance. Computerized gaze stability and dynamic visual acuity testing quantify both the velocity and direction of vestibulo-ocular impairments. Immersive virtual reality adds another dimension to target these systems. The COBALT functional balance screening protocol increases the sensitivity of the sideline measures by integrating precise force plate measurements of postural sway with elements of the VOMS and modified BESS (5).
As a specialist in concussion rehabilitation, you can’t treat what you can’t see or measure. Precise computerized dynamic posturography, force plate measurements and computerized vision assessment provide data to design customized rehabilitation programs, show objective improvement over time to aid evidence-based, objective clinical decision-making in determining an athlete’s readiness to return to play following concussion.
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About the Author
Dr. Kristinn Heinrichs, Ph.D., P.T., is a dual Board-Certified neurologic and sports clinical physical therapy clinical specialist; one of the few who is also an Athletic Trainer. As a researcher and international educator, she utilizes an Integrative Rehabilitation approach to solving the most challenging sequelae of traumatic brain injury, visual-vestibular, and orthopedic injuries. She integrates biomechanics and movement science technologies, manual therapies, and mind-body skills into clinical practice to bridge rehabilitation and optimize human performance. She has taught graduate courses in performance analysis in sports, orthopedics, and has coached elite athletes. As a Founding Program Director, she established entry-level Master of Science in Athletic Training and Master of Sports Health Science programs. Dr. Heinrichs holds a PhD in Education and Sports Medicine, a Master of Education in exercise physiology and is a member of the Raven Honor Society at the University of Virginia.
References
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NFL Head, Neck, and Spine Committee’s Concussion Diagnosis and Management Protocol. https://static.www.nfl.com/image/upload/v1665264248/league/moexjmdzy2kvjtqsdpbx.pdf. Accessed on 13 December, 2022.
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https://www.patspulpit.com/2022/12/13/23507805/nfl-nflpa-review-devante-parkers-removal-patriots-cardinals-game Accessed on 13 December 2022
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McCrory, P., Meeuwisse, W., Dvořák, J., Aubry, M., Bailes, J., Broglio, S., Cantu, R. C., Cassidy, D., Echemendia, R. J., Castellani, R. J., Davis, G. A., Ellenbogen, R., Emery, C., Engebretsen, L., Feddermann-Demont, N., Giza, C. C., Guskiewicz, K. M., Herring, S., Iverson, G. L., Johnston, K. M., … Vos, P. E. (2017). Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. British journal of sports medicine, 51(11), 838–847. https://doi.org/10.1136/bjsports-2017-097699
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Ferris, L. M., Kontos, A. P., Eagle, S. R., Elbin, R. J., Collins, M. W., Mucha, A., Clugston, J. R., & Port, N. L. (2021). Predictive Accuracy of the Sport Concussion Assessment Tool 3 and Vestibular/Ocular-Motor Screening, Individually and In Combination: A National Collegiate Athletic Association-Department of Defense Concussion Assessment, Research and Education Consortium Analysis. The American journal of sports medicine, 49(4), 1040–1048. https://doi.org/10.1177/0363546520988098
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Massingale, S., Alexander, A., Erickson, S., McQueary, E., Gerkin, R., Kisana, H., Silvestri, B., Schodrof, S., Nalepa, B., & Pardini, J. (2018). Comparison of Uninjured and Concussed Adolescent Athletes on the Concussion Balance Test (COBALT). Journal of neurologic physical therapy: JNPT, 42(3), 149–154. https://doi.org/10.1097/NPT.0000000000000225
