When the sports program at Utah State University talks about taking bases, they don't mean the bags a batter tags running to home plate. Instead, these are special base measurements that will be taken from every USU student this year.
The computerized dynamic posturography protocol is aimed at spotting vestibular injury and other subtle changes that can result from previous concussions. If the study team there is successful, USU's research may actually mean less reliance on the system in the future.
Why? If a good correlation can be shown between this method, the SMART EquiTest, and the Balance Error Scoring System (BESS), the data will validate what researchers have long suspected: that the low-cost, low-tech BESS really is a dependable assessment, said John Ribera, PhD, the director of audiology for USU's department of communicative disorders and deaf education. That's a finding that would benefit not just his campus in Logan, but other institutions that want to rate the readiness of kids and young adults to take the field, before and after a knock to the head.
History has shown that technological development alone “is the wrong altar at which to worship,” said Richard E. Gans, PhD, the founder and chief executive officer of the American Institute of Balance. Relying on a $100,000 piece of technology to diagnose vestibular dysfunction is “not going to happen,” at least not on a large scale, he said.
At a time when concussion prevention is being debated, with some scientists asserting that no helmet or mouth guard is capable of offering completely safe protection, some coaches are still loathe to call such head trauma even mild traumatic brain injury (TBI). But Dr. Ribera and his colleagues have no such hesitation. TBI, he pointed out, has been a fairly silent epidemic, despite the headline-generating acknowledgment of the disorder by players in the National Football League. Even now, high school team members often feel compelled to go back into games after a hit to the headthat may have them “seeing stars,” he said. In fact, that is one of the problems—concussive events are still trivialized with terms describing how a player “got dinged” or the way in which a human collision on the field “rang a bell,” when what really happened was a severe, injurious blow to the head.
A UNIQUE PROTOCOL
About three-fourths of the TBIs that occur each year are concussions, according to the federal Centers for Disease Control and Prevention. In one study in which children and young adults with or without a history of concussive injury were compared, the two groups differed strikingly in simple verbal tasks, such as their ability to recall sentences. These and other investigations have intensified the focus on young players, who, it is asserted, may be more prone to lingering effects because their brains are still developing. Approximately 40 percent of those who suffer TBIs also develop a cluster of symptoms that range from memory lapses to headaches and dizziness. Known as post-concussion syndrome, cognitive changes may be most dramatic, according to data from the National Institute of Neurological Disorders and Stroke.
Many athletes with mild to moderate head injuries experience such deficits, which may surface as inattentiveness. The ability to concentrate or even plan ahead may become difficult, and decisions that require even minimal problem solving can seem overwhelming to these individuals. Such situations led Dale Mildenberger, the head athletic trainer at USU, to begin looking for these signs years ago—and he found them.
“I am not a crusader,” he said. But as a former ambulance driver who put himself through college by rushing medical transport vehicles to scenes of carnage, “it really bothered me that some athletes would get their heads slammed into the ground and then somebody would hold up two fingers, and say ‘how many?’ like that was a good way to make the determination,” said Mr. Mildenberger, who is also an adjunct associate professor of sports medicine at the university. “It was completely without science.”
As it turned out, Dr. Ribera had similar laments. “It takes time to heal that brain,” he said, noting that the organ in its semi-solid state is like three pounds of Jell-o slapping up against the skull, even when the head is surrounded by a helmet. It was out of these concerns that the collaboration between the university's sports and audiology programs, which also includes the Emma Eccles Jones College of Education & Human Services at USU, was born. The program seems to be unique among universities in its specific protocol as well.
The SMART EquiTest is being used to provide a way to chart the variations that can arise from individual differences, Dr. Ribera said. When recovery is underway, it can be used to gauge how therapy is succeeding, measurements that can be used to track the deficits that need to be targeted for return to baseline, he noted. Because this is the first year the 400-plus athletes at the school are being tested, results are not yet available.
The way in which the ability to think arises in the brain — particularly a developing one — is still not fully understood, said Bradley Schlaggar, MD, PhD, the A. Ernest and Jane G. Stein Associate Professor of Developmental Neurology at Washington University in St Louis. Magnetic resonance imaging used to study functional connectivity in the resting state shows that some processes appear under local control by certain brain regions, while others begin to expand into other, more distant sites, he said during a lecture at the annual meeting of the American Neurological Association in San Diego in September. This growth in cross-brain connection is essential for any mind to reach its potential, and injury can interrupt it disastrously.
Maria Luisa Gorno-Tempini, MD, PhD, a neurologist at the Memory and Aging Center at the University of California, San Francisco, said in another presentation that damage to these connections can cause imbalances that impair the most basic functions such as acquisition of language and speaking.
Nobody has to explain that to George Visger, a former NFL player and current environmental consultant, who now lives in northern California. “If I don't write things down, they will be gone. My short-term memory is shot,” said Mr. Visger, who earned a biology degree after he quit playing football. “I was going to be the greatest NFL player ever,” he said. “I was all knuckles-in-the-ground. I loved tackling.”
But he played games he cannot remember. “There was one where I was given smelling salts I bet 25 times,” he said. “People tell me how great it was that I could … go back to school, but I wonder where would I be now if I had just concentrated on academics and not played football?”
EXPANDING PATIENT CARE
Hopefully students at USU will never have to ask themselves that question. The posturography system there is mandatory for all players because it “is a functional test, which we can use to isolate [physical] systems to see problems,” Dr. Ribera said. Theoretically, it can be used to screen players at risk. “We pretty much know what the normal response should be at 20 years old and up,” he said. “Is it fair to have that quarterback who has that kind of thing happen [on a weekend] have to take a test the following Monday?”
It's also likely that some players will already have post-concussive problems before they begin college ball; many having been playing in sports leagues since elementary school. Spotting brain injury often is difficult. A trip to the emergency department may mean imaging, but frequently there is no fracture of bone or any obvious sign. Even the scans are clear, Dr. Ribera pointed out.
No one test is ever truly diagnostic verification, cautioned Dennis Dolny, PhD, the principal investigator of the project and head of health, physical education, and recreation at USU. The decision surrounding an athlete's ability to play is “100 percent medical,” and team physicians and other doctors make that call. “We do feel this [posturography] will give a more complete profile,” Dr. Dolny said. In the future, this application is planned for use in the semi-rural USU community, where it could help with the growing elderly population, he added.
Dr. Gans observed that collaboration with other health professionals — physical therapists, neurologists, rehabilitation specialists — will solidify the future of audiology by involving audiologists in the continuum of patient care that requires that expertise. Audiology must become part of the established health care community to thrive in the next decade, he said.
“While technology is helpful, now more than ever, especially for our bright young AuDs, we need to be big thinkers, not merely technicians,” Dr. Gans said.
* Read the CDC Injury Factbook at http://1.usa.gov/CDCinjuryFacts.
* Learn more from NINDS about postconcussion syndrome at http://1.usa.gov/NINDSinjury.
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