Non-Cognitive Diagnostic Assessment of

TBI/Sports ConcussionBarry D. Jordan M.D., M.P.H. Barry D. Jordan M.D., M.P.H.

Director, Brain Injury ProgramDirector, Brain Injury ProgramBurke Rehabilitation HospitalBurke Rehabilitation Hospital

Associate Professor Clinical NeurologyAssociate Professor Clinical NeurologyWeill Medical College of Cornell UniversityWeill Medical College of Cornell University

Former Chief Medical OfficerFormer Chief Medical OfficerNew York State Athletic CommissionNew York State Athletic Commission

Concussion Evaluation Neurodiagnostic TestingNeurodiagnostic Testing

Neuropsychological Neuropsychological TestingTesting

NeuroimagingNeuroimaging Biomarkers of brain injuryBiomarkers of brain injury Objective Balance Objective Balance

AssessmentAssessment Electrophysiological Electrophysiological

testingtesting Genetic testingGenetic testing Eye tracking techniquesEye tracking techniques

Non-computerized cognitive assessment

Standardized Assessment of Concussion (SAC)Standardized Assessment of Concussion (SAC) Sport Concussion Assessment Tool 2 (SCAT 2)Sport Concussion Assessment Tool 2 (SCAT 2) McGill On-Field Concussion EvaluationMcGill On-Field Concussion Evaluation Maddocks ScoreMaddocks Score Military Acute Concussion Evaluation (MACE)Military Acute Concussion Evaluation (MACE) Standard pencil paper neuropsychological testingStandard pencil paper neuropsychological testing

Neuroimaging Traditional structural Traditional structural

neuroimaging neuroimaging CTCT MRIMRI

Newer structural Newer structural neuroimaging neuroimaging DTIDTI

Functional and metabolic Functional and metabolic scanning scanning PET PET SPECT SPECT fMRI fMRI MRSMRS NIRSNIRS

strong directional dependence of water diffusion

decreased directional dependence of water diffusion

Diffusion anisotropy: fiber tract integrityDiffusion anisotropy: fiber tract integrity

CSTdamaged fiber tract

healthy fiber tract

Fiber Tractography in TBI

Anterior corona Anterior corona radiata and genu of radiata and genu of CCCC

Uncinate fasiculusUncinate fasiculus Cingulum bundle and Cingulum bundle and

body of CCbody of CC Inferior longitudinal Inferior longitudinal

fasciculusfasciculus

a

c

b

d

Figure 2. Diffusion anisotropy maps (a) of a representative boxer (27 yo) and (b) a control (29 yo). Intensity is proportional to anisotropy and color shows the direction. Boxer has decreased FA in genu CC, anterior and posterior limb of IC than those of the normal control. Fiber tracking showed overall less trackable white matter fibers in this boxer’s brain (c) when compared to control (d). The difference in fibers through the corpus callosum is particularly striking.

old study new study

DTI in Boxing

Zhang et al. (2006)49 professional boxers and 19 controls42 boxers had normal conventional MRI7 boxers had NSWM changesNone of the boxers exhibited

neurological signs or symptomsBoxers had decreased FA in the CC and

IC

0.4

0.5

0.6

0.7

0.8

0.9Normals

Boxers

FA splenium FA genu FA post. FA ant. BDav

of CC of CC limb of IC limb of IC (10 -5cm2/s)

DTI and ATBI

Cubon et al 2011Cubon et al 2011 Assessed WM fiber tract integrity 10 Assessed WM fiber tract integrity 10

varsity college athletes and controlsvarsity college athletes and controls Also included moderate and severe TBI Also included moderate and severe TBI

patients and controlspatients and controls Symptomatic 1 month after sports-related Symptomatic 1 month after sports-related

concussionconcussion

DTI and ATBI Cubon et al. 2011 (cont’d)Cubon et al. 2011 (cont’d)

Increased mean diffusivity (MD) among Increased mean diffusivity (MD) among athletes c/w controls in several WM tracts in athletes c/w controls in several WM tracts in the left hemispherethe left hemisphereInferior/superior longitudinal fasciculusInferior/superior longitudinal fasciculusFronto-occipital fasciculiFronto-occipital fasciculiRetrolenticular part of internal capsuleRetrolenticular part of internal capsulePosterior thalamic and acoustic radiationsPosterior thalamic and acoustic radiations

DTI and ATBI

Cubon et al. 2011Cubon et al. 2011 No difference in fractional anistropy No difference in fractional anistropy

(FA) between athletes and controls(FA) between athletes and controls FA decreased with the level of severityFA decreased with the level of severity MD may be more sensitive in detecting MD may be more sensitive in detecting

mild injury and FA more sensitive in mild injury and FA more sensitive in detecting more severe injurydetecting more severe injury

DTI and ATBI

fMRI and TBI

Jantzen et al. (2004)Jantzen et al. (2004) Prospective investigation of 8 collegiate Prospective investigation of 8 collegiate

football players had preseason fMRI scans football players had preseason fMRI scans obtained during a finger sequencing taskobtained during a finger sequencing task

4 players experienced a concussion during the 4 players experienced a concussion during the season and had a f/u fMRI within 1 week of the season and had a f/u fMRI within 1 week of the injury and the 4 controls had a /f/u at the end of injury and the 4 controls had a /f/u at the end of the seasonthe season

Concussed players had marked increased Concussed players had marked increased activation in the areas of the parietal, lateral activation in the areas of the parietal, lateral frontal and cerebellar regionsfrontal and cerebellar regions

fMRI and TBI

Brain Metabolism is Related to Recovery

Over 200 High School Athletes Studied using fMRITested w/in 7 days of concussion and at point of clinical recovery

Hyperactivation predicts CLINICAL recovery time

Resolution of hyperactivation correlates with recovery on ImPACT

Lovell et al., Neurosurgery, 2007

SPECT

Referred population of 17 professional boxersReferred population of 17 professional boxers 14 (82%) had abnormal SPECT scans14 (82%) had abnormal SPECT scans

7 cases with frontal lobe hypoperfusion7 cases with frontal lobe hypoperfusion 3 cases with temporal lobe hypoperfusion3 cases with temporal lobe hypoperfusion 1 case temporoparietal hypoperfusion1 case temporoparietal hypoperfusion 1 case with frontoparietal hypoperfusion1 case with frontoparietal hypoperfusion 1 case with diffuse diminished perfusion in an 1 case with diffuse diminished perfusion in an

irregular and patchy distributionirregular and patchy distribution 1 case bilateral cortical thinning1 case bilateral cortical thinning

SPECT Scanning

SPECT scanning

PET Scanning

PET

19 boxers c/w 8 normal controls SPM 19 boxers c/w 8 normal controls SPM analysisanalysis

8 hypometabolic areas8 hypometabolic areas Bilateral posterior parietal lobes that Bilateral posterior parietal lobes that

extended to the lateral occipital lobesextended to the lateral occipital lobes Bilateral frontal lobesBilateral frontal lobes Bilateral cerebellar hemispheresBilateral cerebellar hemispheres Posterior cingulate cortexPosterior cingulate cortex

Decreased Glucose Uptake Among Boxers (SPM and ROI)

Posterior cingulate Bilateral parietal-

occipital cortices Bilateral frontal

cortices (Broca’s area) Cerebellum

PET/SPECT IN MTBI Umilie et al. 2002Umilie et al. 2002

20 patients with MTBI and persistent 20 patients with MTBI and persistent PCS underwent neuropsychological PCS underwent neuropsychological testing and PET or SPECTtesting and PET or SPECT

19 (95%) had neurobehavioral deficits19 (95%) had neurobehavioral deficits 18 (90%) had abnormal dynamic imaging 18 (90%) had abnormal dynamic imaging

on PET or SPECTon PET or SPECT

PET/SPECT IN MTBI Umile et al (2002) (cont’d)Umile et al (2002) (cont’d)

75% - temporal lobe abnormalities75% - temporal lobe abnormalities 30% - frontal lobe abnormalities30% - frontal lobe abnormalities 40% - nonfrontotemporal abnormalities40% - nonfrontotemporal abnormalities

Correlations between neuropsychological Correlations between neuropsychological testing could be established but not testing could be established but not consistentlyconsistently

Postulated that there was a temporal lobe Postulated that there was a temporal lobe vulnerability to TBIvulnerability to TBI

Magnetic Resonance Spectroscopy

Provides in vivo neurochemical informationProvides in vivo neurochemical information Metabolites Metabolites

N-aceytlaspartate (NAA): neuron specific metabolite N-aceytlaspartate (NAA): neuron specific metabolite and is a marker on neuronal healthand is a marker on neuronal health

Choline (Cho): marker of inflammationCholine (Cho): marker of inflammation Creatine (Cr): stable brain metabolite and a marker of Creatine (Cr): stable brain metabolite and a marker of

cellular energy statuscellular energy status Myo-inositol: glial markerMyo-inositol: glial marker Lactate: indirect indicator of ischemia/hypoxiaLactate: indirect indicator of ischemia/hypoxia

Can detect areas of neuronal dysfunction in the absence of Can detect areas of neuronal dysfunction in the absence of detectable structural injurydetectable structural injury

Magnetic Resonance Spectroscopy

Vagnozzi et al. 2008Vagnozzi et al. 2008 Compared 14 concussed athletes (4 boxers) Compared 14 concussed athletes (4 boxers)

with 5 controlswith 5 controls3 days after concussion observed a 3 days after concussion observed a

decrease in the NAA/Cr ratio that decrease in the NAA/Cr ratio that resolved after 30 daysresolved after 30 days

Concluded that concussion opens a Concluded that concussion opens a temporal window of metabolic imbalancetemporal window of metabolic imbalance

MRS

Magnetic Resonance Spectroscopy

Henry et al. 2009Henry et al. 2009 Compared 12 concussed athletes with 12 Compared 12 concussed athletes with 12

non-concussed athletes 24-36 hrs post non-concussed athletes 24-36 hrs post concussionconcussionConcussed athletes had more symptomsConcussed athletes had more symptomsConcussed athletes had decreased NAA in Concussed athletes had decreased NAA in

the prefrontal and motor corticesthe prefrontal and motor cortices

Near Infrared Spectroscopy (NIRS) Non-invasive technique for evaluating Non-invasive technique for evaluating

cerebral blood volume and oxygenationcerebral blood volume and oxygenation Technology is based on the transmission and Technology is based on the transmission and

absorption of near-infrared light as it passes absorption of near-infrared light as it passes through tissuethrough tissue

Role in the diagnosis of concussion has been Role in the diagnosis of concussion has been limitedlimited

May be more useful in the identification of May be more useful in the identification of intracranial hematomasintracranial hematomas

NIRS Leon-Carrion et al 2010Leon-Carrion et al 2010

Used an infrascanner NIRS device to Used an infrascanner NIRS device to calculate optical density in brain regionscalculate optical density in brain regions

35 TBI patients admitted into Neuro ICU35 TBI patients admitted into Neuro ICU Detected Detected

90% of extra-axial hematomas90% of extra-axial hematomas88.9% of intra-axial hematomas88.9% of intra-axial hematomas93% of nonsurgical hematoma (< 25 ml)93% of nonsurgical hematoma (< 25 ml)

Infrascanner NIRS device

NIRS Cote et al. 2006Cote et al. 2006

Monitored cerebral hemodynamics during acute Monitored cerebral hemodynamics during acute exercise following concussion in 14 male university exercise following concussion in 14 male university hockey playershockey players

Cerebral oxygenation was reduced up to 35% on day Cerebral oxygenation was reduced up to 35% on day 1 following concussion1 following concussion

Blood volume increased immediately following a Blood volume increased immediately following a concussion at rest and during exercise at day 1 and concussion at rest and during exercise at day 1 and returned to baseline by day 7returned to baseline by day 7

Concluded that there is an increased demand for Concluded that there is an increased demand for oxygenated blood following concussionoxygenated blood following concussion

BIOMARKERS

S100S100ββ Neuron specific enolase Neuron specific enolase

(NSE)(NSE) Glial fibrillary acidic protein Glial fibrillary acidic protein

(GFAP)(GFAP) Tau (cleaved tau, phospho Tau (cleaved tau, phospho

tau, total tau)tau, total tau) Neurofilament light protein Neurofilament light protein

(NFL)(NFL) Microtubular associated Microtubular associated

protein 2 (MAP2)protein 2 (MAP2)

CK-BBCK-BB Spectrin breakdown Spectrin breakdown

productsproducts ββ amyloid protein (A amyloid protein (Aββ)) Apolipoprotein (Apoe)Apolipoprotein (Apoe) Myelin basic protein Myelin basic protein

(MBP)(MBP) Ubiquitin C-terminal Ubiquitin C-terminal

hydrolase L1 (UCH-L1)hydrolase L1 (UCH-L1)

S100 β

Most extensively studied serum biomarkerMost extensively studied serum biomarker Variable relationship between S100Variable relationship between S100ββ and and

outcome following MTBIoutcome following MTBI Needs to collected within 4 hours of injuryNeeds to collected within 4 hours of injury There are extracranial sources of S100There are extracranial sources of S100ββ

S100 β

Hasselbatt et al 2004Hasselbatt et al 2004 18 marathon runners 18 marathon runners

without brain injurywithout brain injury Found an increase in Found an increase in

postrace serum S100postrace serum S100ββ from extracranial from extracranial sources sources

No significant change No significant change in GFAPin GFAP

Biomarkers of ATBI in Boxing Zetterberg et al. (2006)Zetterberg et al. (2006)

14 amateur boxers and 10 healthy controls14 amateur boxers and 10 healthy controls CSF analysis 7-10 days and 3 months post boutCSF analysis 7-10 days and 3 months post bout

Neurofilament light protein (NFL)Neurofilament light protein (NFL)Total tau (T-tau)Total tau (T-tau)Phosphorylated tau (P-tau)Phosphorylated tau (P-tau)Glial fibrillary acidic protein (GFAP)Glial fibrillary acidic protein (GFAP)ββ amyloid protien (A amyloid protien (Aββ))

Assessed the number and severity of the hits by interviewAssessed the number and severity of the hits by interview

Biomarkers of ATBI in Boxing

Zetterberg et al. (2006) (cont’d)Zetterberg et al. (2006) (cont’d) Increases in NFL, T-tau, and GFAP post bout Increases in NFL, T-tau, and GFAP post bout

compared to levels post 3 months of restcompared to levels post 3 months of rest NFL and GFAP were higher in boxers post bout NFL and GFAP were higher in boxers post bout

compared to controlscompared to controls No difference in biomarkers between boxers at 3 No difference in biomarkers between boxers at 3

months and controls except for NFL (remained months and controls except for NFL (remained elevated)elevated)

P-tau and AP-tau and Aββ were not elevated were not elevated Concluded that amateur boxing was associated Concluded that amateur boxing was associated

with neuronal and astroglial injurywith neuronal and astroglial injury

Balance and Agility Testing

Balance Error Scoring system (BESS)Balance Error Scoring system (BESS) Sensory Organization Test (SOT)Sensory Organization Test (SOT) Gait TestingGait Testing Virtual RealityVirtual Reality Instrumented Agility TaskInstrumented Agility Task

Balance Error Scoring System

Hands lifted off iliac crestHands lifted off iliac crest Opening eyesOpening eyes Step, stumble or fallStep, stumble or fall Moving hip more than 30 Moving hip more than 30

degrees of flexion or abductiondegrees of flexion or abduction Lifting forefoot or heelLifting forefoot or heel Remaining out of testing Remaining out of testing

position for more than 5 position for more than 5 secondsseconds

Balance Error Scoring System

Several studies have identified BESS Several studies have identified BESS deficits ranging from 3-5 days post deficits ranging from 3-5 days post concussion when compared to baseline and concussion when compared to baseline and controls controls

The best sensitivity is at the time of injuryThe best sensitivity is at the time of injury

Sensory Organization Test (SOT)

Technical force plate system to assess Technical force plate system to assess balancebalance

Disrupts sensory selection process by Disrupts sensory selection process by altering information from the altering information from the somatosensory and/or visual inputs while somatosensory and/or visual inputs while measuring ability to maintain stancemeasuring ability to maintain stance

Uses 6 different conditionsUses 6 different conditions

Sensory Organization Test (SOT)

SOT appears to be a sensitive in detecting SOT appears to be a sensitive in detecting balance deficits following concussionbalance deficits following concussion

Limited use on the field secondary to size Limited use on the field secondary to size and technology needsand technology needs

May provide a more technical or refined May provide a more technical or refined measure of balance performancemeasure of balance performance

BESS is rapid, easy to administer and BESS is rapid, easy to administer and inexpensiveinexpensive

Postural Stability

Guskiewicz et al. (2001)Guskiewicz et al. (2001) 36 concussed athletes compared with 36 36 concussed athletes compared with 36

matched controlsmatched controls Assessed postural stability using the SOT Assessed postural stability using the SOT

and BESS along with neuropsychological and BESS along with neuropsychological testingtesting

Injured subjects demonstrated postural Injured subjects demonstrated postural stability deficits on both SOT and BESSstability deficits on both SOT and BESS

Postural Stability

Guskiewicz et al. (2001)Guskiewicz et al. (2001) These deficits were significantly worse These deficits were significantly worse

than preseason scores and scores of the than preseason scores and scores of the matched controls on postinjury day 1matched controls on postinjury day 1

Gait AnalysisParker et al 2007Parker et al 2007

Assessed 29 concussed athletes Assessed 29 concussed athletes and 29 uninjured matched and 29 uninjured matched controls controls

Gait was assessed while Gait was assessed while completing a simple mental taskcompleting a simple mental task

At 28 days noted a statistically At 28 days noted a statistically significant difference in gait significant difference in gait stability between concussed stability between concussed athletes compared to controlsathletes compared to controls

Virtual Reality

Slobounov et al 2006Slobounov et al 2006 Assessed balance deficits induced by Assessed balance deficits induced by

visual field motion using a virtual reality visual field motion using a virtual reality environment environment

8 concussed athletes exhibited balance 8 concussed athletes exhibited balance deficits up to 30 days despite having deficits up to 30 days despite having symptoms and neuropsych testing return symptoms and neuropsych testing return to baseline to baseline

Instrumental Agility Test

Johnson et al. (2002)Johnson et al. (2002) Assessed 9 concussed Assessed 9 concussed

athletes and 9 matched athletes and 9 matched controlscontrols

Time to complete an agility Time to complete an agility task on the Cybex reactortask on the Cybex reactor

Although concussed athletes Although concussed athletes had more symptoms than had more symptoms than controls there was no controls there was no difference agility difference agility performanceperformance

Electrophysiological testing

Quantitiative Electroencephalogram Quantitiative Electroencephalogram (QEEG)(QEEG)

Event-related Potentials (ERP)Event-related Potentials (ERP)

Quantitative EEG (QEEG) McCrea et al 2010McCrea et al 2010

Prospective, non randomized study of 396 high Prospective, non randomized study of 396 high school and college football players school and college football players

Included cohorts of 28 concussed athletes and 28 Included cohorts of 28 concussed athletes and 28 matched controlsmatched controls

All underwent preseason baseline testing All underwent preseason baseline testing Postconcussive symptomsPostconcussive symptoms Postural stabilityPostural stability Cognitive functioningCognitive functioning QEEG QEEG

Brain scope NT-1000Brain scope NT-1000 Self contained EEG monitorSelf contained EEG monitor Acquires data from 5 active Acquires data from 5 active

regions of the foreheadregions of the forehead Provides immediate, Provides immediate,

actionable information to actionable information to drive timely medical drive timely medical intervention in many cases intervention in many cases of brain dysfunction, such as of brain dysfunction, such as stroke and concussionstroke and concussion

Quantitative EEG (QEEG) McCrea et al 2010 (cont’d)McCrea et al 2010 (cont’d)

Clinical testing was repeated on the day of injury and days 8 Clinical testing was repeated on the day of injury and days 8 and 45 post injury for the concussion and control groupand 45 post injury for the concussion and control group

Injured athletes performed poorer on neuro-cognitive Injured athletes performed poorer on neuro-cognitive testing than controls on the day of injury but not days 8 or testing than controls on the day of injury but not days 8 or 4545

Concussed athletes had abnormal electrical activity noted on Concussed athletes had abnormal electrical activity noted on the day of injury and day 8 but not day 45the day of injury and day 8 but not day 45

Suggested that the duration of physiological recovery may Suggested that the duration of physiological recovery may last longer than observed clinical recoverylast longer than observed clinical recovery

Event-Related Potentials (ERP)

Dupuis et al 2000Dupuis et al 2000 ERP visual oddball paradigm to assess ERP visual oddball paradigm to assess

cerebral activity in 20 college athletes cerebral activity in 20 college athletes with MTBIwith MTBI

Concussed athletes had a decrease in the Concussed athletes had a decrease in the P300 amplitudeP300 amplitude

Presumed to reflect alterations in Presumed to reflect alterations in attentional-cognitive processesattentional-cognitive processes

ERP

ERP

Genes influencing non-sports related TBI outcome

Apolipoprotein E (APOE)Apolipoprotein E (APOE) APOE promotor gene APOE promotor gene Catechol-o-methyltransferase (COMT)Catechol-o-methyltransferase (COMT) Dopamine D2 receptor (DRD2) (ANNK1 gene)Dopamine D2 receptor (DRD2) (ANNK1 gene) InterleukinInterleukin p53p53 Angiotensin converting enzyme (ACE)Angiotensin converting enzyme (ACE) CACNA1ACACNA1A

APOEε4 and TBI Outcome Overall unfavorable outcome (GOS)Overall unfavorable outcome (GOS) Increased duration of posttraumatic unawarenessIncreased duration of posttraumatic unawareness Larger CT documented hematomasLarger CT documented hematomas Increased risk of posttraumatic seizuresIncreased risk of posttraumatic seizures Increased association with cerebral amyloid angiopathyIncreased association with cerebral amyloid angiopathy Greater incidence of autopsy confirmed moderate and Greater incidence of autopsy confirmed moderate and

severe contusionssevere contusions Poorer rehabilitation outcomePoorer rehabilitation outcome Lower cognitive function follow TBILower cognitive function follow TBI Higher association with dementia and subclinical dementia Higher association with dementia and subclinical dementia

among TBI patients assessed long term post injuryamong TBI patients assessed long term post injury

APOE and TBI

Zhou et al (2008)Zhou et al (2008) Meta-analysisMeta-analysis

14 cohort studies14 cohort studiesεε4 allele was not associated with initial 4 allele was not associated with initial

injury severityinjury severityεε4 allele was associated with poorer 4 allele was associated with poorer

outcome at 6 months after injuryoutcome at 6 months after injury

APOE Promoter and TBI Terrell et al. (2008)Terrell et al. (2008)

195 college athletes (football / soccer)195 college athletes (football / soccer) Cross-sectional study investigating the association Cross-sectional study investigating the association

between APOE, APOE promoter, and tau between APOE, APOE promoter, and tau polymorphisms and self reported history of polymorphisms and self reported history of concussion over the previous 8 yearsconcussion over the previous 8 years

3 fold increase in risk of history of concussion in 3 fold increase in risk of history of concussion in those TT genotype of G-219T polymorphism those TT genotype of G-219T polymorphism relative to the GG genotyperelative to the GG genotype

4 four-fold increased risk with self reported history 4 four-fold increased risk with self reported history of concussion associated with LOCof concussion associated with LOC

No association with APOE or tau genotypeNo association with APOE or tau genotype

APOE and ATBI in Sports

Kristman et al. (2008)Kristman et al. (2008) Prospective cohort study of 318 Prospective cohort study of 318

collegiate athletes in various sportscollegiate athletes in various sports Compared concussion rates in athletes Compared concussion rates in athletes

with and without APOE with and without APOE εε4 allele4 allele No association between No association between εε4 allele and 4 allele and

sustaining a concussionsustaining a concussion

APOE and ATBI in Sports Tierney et al. 2010Tierney et al. 2010

196 college athletes (163 male football and 33 female soccer 196 college athletes (163 male football and 33 female soccer players)players)

Multi-center cross sectional study evaluating the association Multi-center cross sectional study evaluating the association carrying 1 or more APOE rare (or minor) alleles (APOE carrying 1 or more APOE rare (or minor) alleles (APOE εε2, 2, APOE APOE εε4 and 4 and T allele of G-219T APOE promoter polymorphism)T allele of G-219T APOE promoter polymorphism) and self reported history of concussion via a questionnaireand self reported history of concussion via a questionnaire

Athletes carrying all 3 rare alleles were 9.8 times more likely to Athletes carrying all 3 rare alleles were 9.8 times more likely to report a previous concussion and concluded that carriers may be at report a previous concussion and concluded that carriers may be at greater risk of concussion greater risk of concussion

Athletes carrying the T allele of the APOE promoter gene were 8.4 Athletes carrying the T allele of the APOE promoter gene were 8.4 more likely to report multiple concussions and concluded that more likely to report multiple concussions and concluded that carriers may be greater risk of multiple concussionscarriers may be greater risk of multiple concussions

Eye tracking technology

ID CoachID Coach King-Devick TestKing-Devick Test

ID Coach Sideline Concussion Tracker

Uses eye-gazing Uses eye-gazing technology to assist technology to assist in the assessment of in the assessment of concussionsconcussions

ID Coach Sideline Concussion Tracker

Player is positioned in front of a monitor and Player is positioned in front of a monitor and focuses on a fixed point while pupil size is focuses on a fixed point while pupil size is analyzedanalyzed

The player is then asked to follow a moving The player is then asked to follow a moving object across the screen without head object across the screen without head movement (baseline eye tracking is movement (baseline eye tracking is established)established)

Blurred/double vision or inability to focus Blurred/double vision or inability to focus may be indicative of concussionmay be indicative of concussion

King-Devick (K-D) Test

Measurement of speed of rapid number namingMeasurement of speed of rapid number naming Reading aloud a series of single digit numbers Reading aloud a series of single digit numbers

on 3 test cards from left to righton 3 test cards from left to right Sum of the 3 test card time scores and the Sum of the 3 test card time scores and the

number of errors are scored.number of errors are scored. Captures impairment of eye movements, Captures impairment of eye movements,

attention, language, and other correlates of attention, language, and other correlates of suboptimal brain functionsuboptimal brain function

King-Devick (K-D) Test

Galetta et al 2011Galetta et al 2011 K-D test was administered to a cohort of K-D test was administered to a cohort of

boxers (n=27) and MMA (n=12) pre and boxers (n=27) and MMA (n=12) pre and post fightpost fight

Also administered the MACEAlso administered the MACE Postfight K-D time scores were Postfight K-D time scores were

significantly higher (worse) for participants significantly higher (worse) for participants who had head trauma (59 vs 41 seconds)who had head trauma (59 vs 41 seconds)

King-Devick (K-D) Test

Galetta et al 2011 (cont’d)Galetta et al 2011 (cont’d) Among those with head trauma, participants Among those with head trauma, participants

with LOC had higher postfight K-D scores with LOC had higher postfight K-D scores than those without LOC (65.5 vs 52.7 seconds)than those without LOC (65.5 vs 52.7 seconds)

Worse postfight scores also correlated with Worse postfight scores also correlated with postfight MACE scorespostfight MACE scores

Suggested that this could serve as a rapid Suggested that this could serve as a rapid sideline screening testsideline screening test

King-Devick (K-D) Test

Conclusions There is no single There is no single

test available to test available to diagnose sports diagnose sports concussionconcussion

Various devices/tests Various devices/tests that may assist in the that may assist in the diagnosisdiagnosis

Remains a clinical Remains a clinical diagnosisdiagnosis

THANK YOU

QUESTIONS?QUESTIONS?