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Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion
Chapters
Summary January 20th, 2019
A multidisciplinary carepath to standardize disparate concussion care was developed and implemented at the Cleveland Clinic. The Cleveland Clinic Concussion (C3) mobile application was used to enable the carepath through biomechanical outcomes characterizing cognitive and motor function. Patient outcomes improved while cost of care was reduced following implementation.
Transcript
This technology enables the objective quantification of the multiple symptoms of concussion, and allows multiple providers to use this technology to share information about the neuro performance of an individual. One of the advantages of this technology is it allows us to objectively quantify the multiple symptoms of concussion. For example, balance which typically is evaluated in a very subjective manner can now be quantified using the accelerometer and the gyroscope within the I-Pad.
Demonstrating how to use the C3 application is Susan Linder, a research physical therapist from my laboratory. To assess postural sway, use a custom belt to affix the digital tablet onto the participant's sacrum. And inform the participant that their balance will be tested.
Instruct the participant to remain in the designated stance for the entire 20 second trial with their eyes closed and ask them to begin with the feet together. Instruct the participant to return to the correct position as quickly as possible if they lose their balance. When the participant is in the proper stance, press Start to begin the five second countdown that signalizes the start of the 20 second trial and record the number of errors committed.
Immediately after completing the first trial, begin the next trial. To assess the participant's static vision holding the digital tablet five feet from the participant at eye level, instruct the participant to read the five letters displayed on the table from left to right and record the number of correct letters that the participant is able to read. To assess the dynamic vision, play a sample metronome tone and rotate the head right to left with approximately 20 degrees of cervical rotation in each direction to demonstrate the proper head movement.
Ask the participant to demonstrate the proper head rotation keeping with the metronome and initiate the trial confirming that the participant is rotating their head properly while the opto types are presented and instructing the participant to read the five letters displayed from left to right while continuing to rotate the head left to right to the beat of the metronome. For a simple reaction time assessment, display the instruction screen and instruct the participant to place their dominant index finger onto the touch and hold button. When the stimulus turns from yellow to green, instruct the participants to release the button and to touch the green light as quickly as possible.
Observe the participant completing the practice trial, confirming that they understand the directions and are able to complete the task within the allotted 100 to 500 milliseconds. Then have the participant complete 25 valid trials without errors within the allotted period. For choice reaction time assessment, have the participant place both index fingers on the touch and hold buttons, and have the participant lift the digit that corresponds with the side on which the green light was presented.
Tapping the green light as quickly as possible without moving the finger on the side of the scion destructor light. Observe the participant completing the practice trial, insuring that they understand the directions, and are able to complete the task within the allotted 100 to 750 milliseconds. Then observe the participant complete 25 valid trials without errors within the allotted time.
For the processing speed test, initiate the test, and instruct the participant to read the instructions provided on the sample testing screen. And to use the symbol key on the top of the screen to complete the test below the symbol key. Inform the participant that a new row of symbols will appear once the existing row is completed, and that they should continue to enter corresponding digits until prompted to stop for the entire two minutes of the trial.
After reminding the participant that they cannot correct an incorrect response, and to complete each response as quickly and accurately as possible, press the begin test button to initiate the test. And confirm that the participant is performing the test correctly. For trail-making Test A, instruct the participant to read the instructions on the screen, describing the test as a connect the dots test in which 25 circles corresponding with digits one through 25, must be connected using the provided stylus.
After having the participant complete a practice trial, press begin test to begin the trial. And confirm that the correct procedures are followed. For trail-making Test B, instruct the participant to read the instructions on the screen, describing the test as a connect the dots test in which 25 circles corresponding with digits and letters must be connected with the stylus.
And instruct the participant to begin with the number one followed by the letter A, alternating with consecutive numbers and letters until all 25 dots have been connected. At the end of the practice trial, press begin test, and observe the participant completing the test, confirming that correct procedures are followed. When all of the trials have been completed, a radar plot of all of the Cleveland Clinic Concussion application modules can be generated.
Here, detailed demographics of the 181 injured participants from this representative trial are shown. The data were stratified into two groups, those who recovered within three weeks of injury, and those who were still symptomatic three weeks after injury. When comparing the first post-injury assessments, a significant difference was observed between the two groups for the simple reaction time, choice reaction time, trail-making test B, and for two of the six balance error scoring system stances for quantifying postural sway.
Suggesting that participants who remained symptomatic performed significantly worse on the C3 modules, measuring information processing, executive function, set switching, and postural stability. Importantly, the participants performed comparably on all modules at baseline, and difference were only observed at follow-up suggesting that the modules are effective in detecting changes in neurologic function as a result of concussive injury. It's important to understand where each student athlete is struggling, so we can refer them to specialists who can actively work on improving their symptoms and deficits.
Several of these tests service screening tools to prevent stagnant care, and insure that we can get these student athletes to their right providers in a timely manner. The advantage of this system is that it brings multiple providers, and the patient and their family onto the same page using data. These objective data help guide return to play decision making, as well as next steps for those individuals who may not be recovering.
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