It’s easy to get completely caught up in new technologies that provide objective data medical professionals can use in conjunction with their assessment of mild traumatic brain injury (mTBI).
But it’s important to have a good understanding of today’s mTBI assessment landscape – the existing tools and their limitations, as well as practitioners’ concerns and hopes.
Toward that end, we spoke recently with clinician Ashley Long, PhD, LAT, ATC, and Andy Massey, an athletic training consultant and ATC (athletic trainer certified) spotter for the NFL.
In her role as the concussion clinic coordinator for Mt. Olive Family Medicine Center in North Carolina, Ashley is on the front lines of mTBI assessment, diagnosis and treatment. She outlined the comprehensive three-pronged protocol used by her clinic:
A neurocognitive test assesses the patient’s verbal and visual memory, reaction times and processing speed. This is usually given as a paper-and-pencil or on-line test.
A clinician-led vestibular ocular motor screening checks the patient’s eye movements and head movements, looking for return of symptoms.
A balance test measures the patient’s ability to balance in a variety of positions, including standing with eyes closed and feet together and then on one foot and the other foot.
Ashley stressed the important of using a multidimensional approach to assessing mTBI. “Concussions can affect different parts of the brain and contribute to so many different deficits that you can’t just check one facet of a patient’s cognitive or physical performance. We need to provide an objective assessment the physician can rely on during diagnosis and treatment.”
Technologies that can provide accurate measurements are a critical part of the process, Ashley said, as are baseline tests and a thorough understanding of the patient’s overall history. “Previous orthopedic injuries, learning disabilities, visual issues, balance impairment, any number of issues can affect accurate assessment.”
A person’s motivation also can sometimes affect TBI assessments. “You never live and die by the test,” Ashley said. If something seems off, further investigation and a discussion with the physician are warranted.
A comprehensive assessment protocol can provide benefits beyond helping the physician with a diagnosis. With objective test results, tentative patients can understand that they’re ready to return to the field, and eager or motivated patients can realize they need to hold back a little longer, Ashley said.
Although he once relied on subjective assessments, the doctor Ashley works with will no longer clear anyone without objective data to support a return to play or to the classroom. “When the data reflects your observation, it gives you confidence in your decisions,” she said.
Now that the comprehensive protocol is the norm in their practice, they’ve seen time to return to play (RTP) increase overall among their patients.
Considering that development, objective assessments also have become a useful component of community education programs to help parents, fans, coaches and players understand why a star player might have to sit out longer than anyone wants. “Quality of care isn’t always everyone else’s primary concern,” Ashley noted.
Because mTBI is multidimensional by nature, the clinician said she doesn’t expect to ever have just one tool that could immediately diagnose concussions.
But that hasn’t kept companies from trying.
In his work as an athletic training consultant and certified athletic trainer, Andy Massey has seen a growing interest in creating objective data that can be used in conjunction with a professional’s assessment and diagnosis of TBI.
He’s also seen a wide range of new and emerging technologies, including devices that look at eye movement, shape and behavior as well as interactive systems that track body movement and integrate performance and training aspects into the technology.
Some involve virtual reality (VR), and Andy experienced first-hand some of the issues related to that technology. Although a life-long fan of roller coasters and amusement parks, Andy said taking the test in the VR created unsteadiness, and that caused slight motion sickness. The fact that VR can induce dizziness in even just a few people becomes problematic in measuring brain function, since vertigo is sometimes a symptom of concussion.
“Technologies like these start creating different environments that are counter-productive to useful results,” Andy said.
Another issue revolves around the time involved in using the new technologies, which can take 4 or 5 minutes. “While the health and safety of the athlete is the concern, time is critical in making playing status decisions, especially in timed sports and sports that do not allow free substitution. You need a technology that provides objective data quickly and easily.”
Ease-of-use is a critical issue when game-time decisions need to be made on the sidelines, he said. “Being portable and user-friendly is key. In a game situation, a concussion is definitely the hardest call there is. The more data, the better.”