A significant challenge in the diagnosis and management of athletes and military personnel with concussion is the diverse background, training,
clinical management approach and outcomes used by the multidisciplinary team of clinicians involved. Further challenging the continuity of care is the disparity of resources and access to technology and electronic health records available in the various settings in which concussion care and management occur—from the field to the emergency department and, finally, the clinical setting.
Effective care of concussion requires the coordination of both clinical resources and handoffs between providers (Broglio et al. 2014). A fundamental difficulty in this coordination is the use of discipline-specific measures of motor and cognitive function. In our research we used motor-control principles in the design of motor and cognitive assessments, and quantified the tests using objective biomechanical measures.
A Concussion App
Many mobile devices come equipped with a suite of inertial sensors (e.g., a linear accelerometer and gyroscope) as well as a capacitive touch screen, and so are ideally suited to transition from expensive electronic notebooks to handheld data collection systems. Using these capacities, we developed the Cleveland Clinic Concussion (C3) app to document injury in the field, facilitate the objective evaluation of the multiple domains of neurologic function affected by concussion, and document the return to play rehabilitation process. The C3 app contains an incident report module, five assessment modules for evaluating various aspects of neurologic function, and a return to play module (Alberts and Linder 2015; Alberts et al. 2015).
Operationally, athletes or military personnel complete a baseline evaluation at the beginning of a season or as part of their medical intake. The baseline data are used as a comparison for subsequent data collection sessions to guide treatment and return to play decisions by a multidisciplinary treatment team. If participants do not have a baseline, their information is expressed against age- and gender-based normative values. The assessments measure performance on the following tasks:
- a comparison of times to complete two trail making tests,
- one- and two-choice simple reaction times,
- the six Balance Error Scoring System (BESS) stances (Guskiewicz et al. 2001),
- the Graded Symptom Checklist,1 and
- memory and processing speed.
Collectively, these modules allow for the systematic documentation of the injury and an objective measurement of the signs and symptoms associated with the injury over time. All of these data are then linked to a return to play module in which the athletic trainer or other member of the provider team systematically increases the aerobic demands of activity while monitoring symptoms and eventually creates simulated practice and game activities to aid in determining whether the athlete is ready to return to play. The ability to document and share the documentation related to the progression is critical from a patient management perspective as well as a medical-legal perspective.
The radar plot in figure 1 illustrates assessment based on these modules for a concussion patient in the days and weeks after injury. The perimeter of the polygon represents the baseline level on each of the domains evaluated. The red polygon represents the level of function in these domains approximately 48 hours after injury, the yellow polygon 10 days after, and blue 16 days postinjury.
In this case, the athlete has recovered in terms of symptoms and performance on tests evaluating neurocognitive functioning, but his balance, based on objective biomechanical data, is not back to normal. Because the patient is more than 14 days postinjury and has lingering postural instability, he would be considered a candidate for vestibular therapy. The vestibular therapist has access to the technology and the previous postural stability assessments, facilitating both the handoff between providers and the development of an effective rehabilitation plan of care.
To date, we have baseline tested more than 30,000 athletes and characterized more than 6,000 athletes with concussion using the C3 technology and concussion care path (Alberts and Linder 2015).
Beyond the App: Care Coordination
Technology is great, but its use requires people. We have been fortunate to have clinical buy-in and acceptance.
An important tenet of clinical care is to get the patient to the right provider at the right time. Figure 2 shows the number of concussion patient visits and rehabilitation sessions (encounters) from 2010 to 2014 (red lines, left axis). Rehab encounters initially were very low in 2010, but there was a significant increase in 2013 and 2014, when the care path and C3 technology were released.
Importantly, as shown in figure 2 (blue line, right axis), the number of days to the first rehabilitation visit after seeing a physician decreased from more than 250 in 2010 to approximately 23 in 2014. Thus technology is helping to get the patient to the right provider at the right time.
Health care is undergoing a transition from volume to value; typically value is the quotient of outcomes over cost. Significant effort has gone into evaluating and attempting to reduce cost as a method of improving value. Enabling providers with affordable technology not only decreases cost but also, importantly, improves patient outcomes through a more efficient path of return to play or referral to specialty care. Both outcome and cost data are being evaluated in this model. It is hypothesized that the cost of care will decrease as unnecessary visits to other providers are reduced, unnecessary imaging is eliminated, and outcomes improve.
From a best practices perspective, a multifactorial assessment that includes a baseline helps to facilitate the return to play and the all-important return to learn process. Our approach combines immediate evaluation to discern any suspected concussion with postinjury serial assessments, and uses those assessments to assist in both clinical pattern recognition and treatment. Moreover, the mobile aspect of the system facilitates the engagement of the parent, coach, and school administrators that is critical for the safety and care of athletes.
Alberts JL, Linder SM. 2015. The utilization of biomechanics to understand and manage the acute and long-term effects of concussion. Kinesiology Review 4(1):39–51.
Alberts JL, Thota A, Hirsch J, Ozinga S, Dey T, Schindler DD, Koop MM, Burke D, Linder SM. 2015. Quantification of the balance error scoring system with mobile technology. Medicine and Science in Sports and Exercise 47(10):2233–2240.
Broglio SP, Cantu RC, Gioia GA, Guskiewicz KM, Kutcher J, Palm M, Valovich McLeod TC, National Athletic Trainers’ Association. 2014. National Athletic Trainers’ Association position statement: Management of sport concussion. Journal of Athletic Training 49(2):245–265.
Guskiewicz KM, Ross SE, Marshall SW. 2001. Postural stability and neuropsychological deficits after concussion in collegiate athletes. Journal of Athletic Training 36(3):263–273.
This checklist is modelled after the Sport Concussion Assessment Tool, 3rd edition (SCAT3), available at http://bjsm.bmj.com/content/47/5/259.full.pdf+html.