1. April 18, 2015 Ithaca College Ithaca, NY Upstate Concussion Center and Motion Analysis Laboratory at the Institute for Human Performance, Upstate Medical University, Syracuse, NY Christopher Neville, PhD, PT Director of Research – Concussion Management Program Associate Professor Upstate Medical University Department of PT Education, Orthopedic Surgery, and Physiology Brian Rieger, PhD Director Concussion Management Program Claudine Ward, MD Medical Director – Concussion Management Program 1

2. Concussion ED visits for concussion increased 62% between 2001 and 2009 (CDC 2011) 1.6 and 3.8 million sports-related concussions each year in the US 49+ states have laws directing response to suspected concussion 2

3. However…. Current diagnosis and management of concussion is largely driven by self-reported symptoms and expert opinion 3

4. Crucial Point… The appropriate management of sport-related concussion, specifically determining better objective determinants is critical and constantly evolving. 4

5. Current Trends Insufficient evidence for age or level of competition on risk Sex: Greater Males in sports but risk and sex varies by sport. Risk greater for females in soccer or basketball Sport: American football and Australian rugby greater risk than other sports BMI> 27kg/m 2 and training time less than 3 hrs weekly Helmets have a protective effect (no superior helmet). Insufficient data on soccer headgear. Giza, 2013 5

6. 6

7. Current Tools Post-concussive symptom scale or graded symptom checklist Standardized Assessment of Concussion (SAC) (sensitivity 80-94%, specificity 76-91%) Neuropsychological Testing: (sensitivity 71-88%) Balance Error Scoring System (BESS): (sensitivity 34- 64%, specificity 91%) Combination of self-report, cognitive, and balance – 89%-96% (Broglio, 2007) 7

8. Dual Task- Cognition and Balance Together Functional in nature If not given specific instructions about which task to prioritize, then the brain must decide to unconsciously prioritize Competition for attention Register-Mihalik, 2013 8

9. Balance Central Nervous System Manages and Interprets Signals from the Vestibular, Visual, and Somatosensory Systems 9

10. Balance using IMU 10

11. Cognition 11

12. Stroop Color Word Test (T1) 12

13. Stroop Test (T2) 13

14. Stroop Test (T3) 14

15. Measuring Postural Stability with an Inertial Sensor: Concurrent Validity and Sensitivity Christopher Neville, PT, PhD, Brian Rieger, PhD, Caleb Ludlow, DPT Student 15

16. Methods 16 IMU – Captures Acceleration at 250Hz Forceplate – Captures movement of the COP at 1000Hz Kinematic Movement of the L4L5 Segment at 120Hz

17. Balance Test Conditions 1.TLEO- Standing feet together, hands on hips, with eyes open 2.TLEC- Standing feet together, hands on hips, with eyes closed 3.TSEO- Tandem stance (dominant foot forward), hands on hips, with eyes open 4.TSEC- Tandem stance (dominant foot forward), hands on hips, with eyes closed 5.TLEOfp- Standing feet together, hands on hips, with eyes open, on a foam-pad 6.TLECfp- Standing feet together, hands on hips, with eyes closed, on a foam-pad 7.TSEOfp- Tandem stance (dominant foot forward), hands on hips, with eyes open, on a foam-pad 8.TSECfp- Tandem stance (dominant foot forward), hands on hips, with eyes open, on a foam-pad 17

18. Validation Initial Validation (Bivariate Correlations to FP = 0.79; to Kinematics= 0.89) 6

19. Sensitivity 9 Firm SurfaceFoam Surface Two LegsTandem StanceTwo LegsTandem Stance Eyes Open Eyes Closed

20. Root Mean Squared Figure 2. The magnitude of dispersion (RMS) for the Inertial Sensor across 8 balance tests 20

21. Centroid Frequency Centroid frequency of the Inertial Sensor acceleration across the 8 balance tests 21

22. Case Based Application: Utilizing the Mi Sensor, we were able to collect balance scores for baseline testing for a college football team. We collected the same measures of balance collected in our validation study with the addition of two cognitive tasks performed in tandem stance while recording the balance during those tasks. We then were able to compare these scores to Balance Error Scoring System (BESS) score testing which is a part of the mandated balance testing for New York collegiate football players. Over the course of the season one of the members on the football team unfortunately sustained a concussion. We however, were able to track his progress as he recovered from his concussion. The subject was an 18 year old African American male who is a dual sport athlete. He reported no history of concussions, no prior orthopedic injuries, and that he was not currently on any kind of medication. 22

23. Bess Error Scoring System Table 2. BESS Scores for this recently concussed individual 23

24. Symptoms 24

25. Mi balance Injury Date: 10/21/2014 25

26. Progress after concussion Figure 4. Tracking balance scores across time and condition 26

27. Reliability and Effects of Intentional Effort Manipulation on Balance Tested under Dual-Task Christopher Neville, PT, PhD, Ryan Charboneau, BA, Grace McIntosh, DPT Student 27

28. Balance Reliability 28 0.88 0.83 0.91 0.89 0.86 0.92 0.86 0.71 Range: 0.71-0.92

29. Dual Task Reliability 29 0.950.90 0.91 0.92

30. Malingering Case Scenario Automobile accidents are a fact of life and can happen to anyone. We are interested in your opinion of how people would fake or exaggerate symptoms after an automobile accident. We would like you to imagine that you were driving to the store at night about six months ago when another car turned into you. You were knocked out for a while and when you woke up you were in the hospital. Imagine that you had to stay in the hospital for a week or two to recover. Try to imagine that you had this accident about six months ago and you have decided to fake or exaggerate symptoms to get more insurance money. If you can make your symptoms seem real, you will make a lot of money. If it seems you are faking, you probably won’t get much. 30

31. TSEO 31 Cognition Dual-Task Balance Conditions

32. Trial 1-TSEO 32 Trial 2-TSEO Malingering - TSEO

33. 33 TSEODual-Task Dual (Triple?)-Task Malingering TSEO-Malingering

34. 34 Questions? Christopher Neville, PT,PhD Caleb Ludlow, DPT Student Grace McIntosh, DPT Student