A Multi-Modal Approach to Assessing Recovery in Youth Athletes Following Concussion

The overall goal of this procedure is to conduct a multimodal concussion assessment for youth between 10 to 18 years of age in order to inform the development of improved concussion rehabilitation protocols specific to the youth sport community. This is accomplished by first completing demographic and concussion history questionnaires, as well as a post-concussion symptom report. The second step is to measure the resting heart rate variability of each subject.

Next, a thorough assessment consisting of measures of cognition, balance, strength, and agility is completed. The final step is to reassess all subjects who go on to sustain a concussion using the same measures on a repeated schedule in order to track progress and recovery over time. Ultimately, this protocol will provide new insight into how the youth brain and body recover after concussion and can inform the development of a standardized approach to the assessment of performance pre and post-concussion within the youth sport population.

This method can help answer key questions in youth sport concussion, such as determining which approaches to measuring recovery are most appropriate and when youth athletes can return to daily activities after concussion. Demonstrating this procedure are James Murphy, Talia, Dick, Katie, ma, Melissa Penia and Lever Wheel, who are research staff and graduate students within the concussion research Center at Hall Blue Review Kids Rehabilitation Hospital I Prior to the subject's arrival, ensure all equipment is functioning properly, is ready for testing, and that the assessment rooms are free from unnecessary distractions. After reviewing parental and subject consent, measure and record the subject's height and weight, set up the heart rate monitor, strap under the shirt once adjustments are made, and gel is applied, and put the watch on the wrist of the subject.

Next, administer the demographic information form and collect the post-concussion symptom report using the child version of the post-concussion symptom inventory or P-C-S-I-C while the subject is seated. For five minutes, ask the subject to lay supine on a clean sanitized mat quietly without talking. Then turn on the heart rate monitors to record resting state heart rate variability or HRV data, the RR interval function set to on and record the heart rate or HR for 10 minutes.

After 10 minutes, click the lap button on the watch to indicate the end of supine lying. Rest in state HRV data collection. Ask the subject to return to a seated position.

Then click the lap button again to indicate the beginning of resting state seated HRV data collection. Have the subject remain in the seated position for five minutes without talking. End the session by stopping the watch recording function.

Ask the subject to remove the heart rate strap and watch ensure the testing environment is free from distraction. Then ask the subject to sit at an individual cubicle with a personal laptop with a mouse, and administer the immediate post-concussion assessment and cognitive testing or impact. Next, administer the static balance assessment using the modified clinical test of sensory integration of balance or M-C-T-S-I-B by asking the subject to stand on the portable balance system while standing on the balance system force plate.

Ask the subject to complete four ordered conditions, standing with eyes open for 20 seconds, standing with eyes closed for 20 seconds, standing with eyes open on an indexed foam pad for 20 seconds and standing with eyes closed on an indexed foam pad for 20 seconds. Next, ask the patient to stand upright with a straight arm parallel beside the body, palm facing the body, and with a neutral wrist using a dynamometer measure and record hand grip strength in kilograms for each hand by asking the subject to squeeze the grip as hard as he or she can. For three seconds in a neutral upper extremity position, document the dominant hand and complete three consecutive trials for each hand.

Starting with the dominant hand, make a note of the maximum hand grip for each hand out of the three trials taken in a space at least 2.5 meters wide and 15 meters long. Set up the track used to administer the agility motor skills assessment using the A BI challenge assessment, or a BI ca concussion module. The entire course should be prepared prior to testing the subject using tape.

Place two end lines 48 inches long and 10 meters apart. Connect these end lines with a 10 meter straight line that has three inch long markers placed every one meter. Lastly, place a 19 inch by 19 inch square at one end line connecting to the center line.

Begin the a BI ca with jumping jacks. Ask the subject to stand with arms at his or her side and jump into an exposition and then instantly jump back into the starting position. Count how many jumping jacks the subject can do in 15 seconds.

Next, administer the pylon cone obstacle course run. Have the subject run in and outta the pylons. Then run back as fast and safely as possible without touching the pylons and to run straight through the finish line On the five meter line, track time the patient as he or she walks backward, touching each heel to the opposite toe.

On each step in a tandem pattern, clear the pylons from the 10 meter track and place a basket at the start and three beanbags At the end, ask the subject to run along the track and retrieve the beanbags one at a time. Place the beanbag in the basket and to touch his or her foot on the starting line. Upon return until all three beanbag are in the basket, using the 19 inch by 19 inch square on the track, have the subject stand with both feet inside the two parallel lines, and to move one foot outside of the corresponding line, followed by the opposite leg.

Moving outside of the other line, ask the subject to return the first foot inside, followed by the second foot. Ensure the cycle times are consecutive and are performed in a rhythmic fashion with equal times between each step. Ask the subject to repeat this task 10 times without moving forward or backward.

Ask the patient to jump forward from a standing position with both feet as far as possible and to hold the landing for three seconds. Measure and record the distance from the front of the furthest back foot. Ask the subject to repeat this task twice and record the farthest distance achieved.

Collect resting state HRV data, post-concussion symptom data and balance data as described previously, immediately following concussion while the subject is experiencing post-concussion symptoms. If the symptoms are exacerbated during testing, stop the data collection and allow the subject to rest. Follow up with the subject weekly by phone to determine when post-concussion symptoms resolve using P-C-S-I-C and continue to collect these data.

Weekly until post-concussion symptoms have resolved. A single case of a concussed youth who has completed all stages of the protocol is presented to demonstrate recovery trajectories. This assessment indicates a decrease in cognitive and balanced performance immediately following concussion and an increase in post-concussion symptoms.

Although post-concussion symptoms return to baseline levels at four weeks post-concussion, cognitive performance and balanced deficits remain elevated. This graph is an example of total power of resting state HRV data before and after a concussion. The participant demonstrated reduced total power on day one, day two, and day six post-concussion.

This pilot data demonstrates that HRV collection is a feasible option for clinical examination. After watching the video, you should have a good understanding of how to perform a novel and multimodal protocol that can be used to assess recovery in youth athletes following a concussion.