Bara Alsalaheen

Measurement error in the Immediate Postconcussion Assessment and Cognitive Testing (ImPACT): systematic review

Objective:To review the literature on the reliability of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). Design:Systematic review of the relevant literature in PubMed, CINAHL, and PSYCHINFO. Studies were evaluated using the STROBE instrument and custom developed items. Results:Search yielded 5 943 articles. Ten studies met the inclusion criteria and were reviewed. With the exception of processing speed, all composite scores consistently exhibited poor to moderate reliability (ie, intraclass correlation coefficient <0.80). When considering 2 time points, participants who were misclassified as experiencing a “reliable change” in any score ranged between 5% and 26% for verbal memory, 2.2% and 19.6% for visual memory, 4% and 24% for processing speed, and 4% and 23.2% for reaction time. Conclusions:The Pearson r correlation coefficient and average measures intraclass correlation coefficient may be inappropriately utilized to examine the reliability of ImPACT scores. Given the poor to moderate reliability of most ImPACT scores, clinicians should be cautious when ImPACT is used as a criterion for medical clearance to return to play after concussion. Because of its widespread use in concussion-related clinical research, researchers must exercise due diligence when utilizing ImPACT to evaluate outcomes after concussion or to validate other outcome measures.

Validity of the Immediate Post Concussion Assessment and Cognitive Testing (ImPACT).

BackgroundThe immediate post concussion assessment and cognitive testing (ImPACT) is the most widely used concussion assessment tool. Despite its popularity, it is unclear if validation studies for the ImPACT test covered all aspects of validity to support its widespread use in research and clinical practice.ObjectiveThe purpose of this report is to review literature surrounding the validity and the utility of the ImPACT test.Data sources and appraisalA systematic review of relevant studies in PubMed, CINAHL, and PsycINFO was carried out. Studies were evaluated using the STROBE (strengthening the reporting of observational studies in epidemiology) or the STARD (standards for reporting of diagnostic accuracy) criteria.ResultsThe literature search yielded 5968 studies. Sixty-nine studies met the inclusion criteria and were included in the qualitative review. Although the convergent validity of ImPACT was supported, evidence of discriminant and predictive validity, diagnostic accuracy and responsiveness was inconclusive. The utility of the ImPACT test after acute symptom resolution was sparse. The review found many factors influenced the validity and utility of ImPACT scores.ConclusionClinicians must consider the benefit of ImPACT testing for their patients on a case-by-case scenario and must take the psychometric properties of the test into account when interpreting results.

Performance of High School Adolescents on Functional Gait and Balance Measures

Purpose: To describe the performance of high school adolescents during common functional gait and balance measures used in vestibular physical therapy. Methods: A cross-sectional study of 91 participants determined their performance on the Activities-specific Balance Confidence (ABC) scale, Dynamic Gait Index, Functional Gait Assessment, Timed “Up and Go” (TUG), Five Times Sit to Stand (FTSTS) test, tests of gait speed (GS), and the Balance Error Scoring System. In a subset of this sample, GS, TUG, and the FTSTS were repeated twice to examine test-retest reliability. Results: The measures of GS, TUG, and FTSTS were normally distributed. The Activities-specific Balance Confidence, Dynamic Gait Index, and Functional Gait Assessment exhibited a ceiling effect. The timed measures exhibited moderate to good reliability. Conclusions: These performance scores may provide end points for discharge from vestibular physical therapy. However, clinicians should be aware of the ceiling effect exhibited by some measures.

King-Devick Test reference values and associations with balance measures in high school American football players.

The King‐Devick test appears to be a promising tool in screening for concussions. However, limited evidence exists on the baseline associations between the K‐D test and age and baseline screening tools used after concussion. Additionally, there are no published reference values for the K‐D test in high school football players. The K‐D test, the Balance Error Scoring System, and the Limits of Stability (LOS) test were administered to 157 high school football players. Additionally, a subsample of 62 participants completed the test twice to examine the reliability of K‐D test. There was no relationship between the K‐D test and the BESS, or the reaction time and directional control of LOS test. Students aged between 16 and 18 years demonstrated faster K‐D test performance compared to students between 13 and 15 years of age. However, there was no association between K‐D test and history of concussion. The reliability of the K‐D test was (ICC2,1 = 0.89), and the minimal detectable change was 6.10 s. Normative reference values for high school football players are presented in this study.

Reliability and concurrent validity of instrumented balance error scoring system using a portable force plate system.

Abstract Objectives: The Balance Error Scoring System (BESS) is a commonly used test in adolescents and young adults. Affordability and portability of newer force plates has led to instrumentation of many clinical balance tests including the BESS. Despite the higher precision of force plate measures compared with clinical scoring, it is unclear if the instrumented BESS demonstrate concurrent validity and reliability when compared with the original BESS. The purpose of this study was to examine the reliability and concurrent validity of instrumented BESS testing using a commercially available force plate system. Methods: Thirty-six participants participated in the initial testing day (17 male/19 female, M = 15.9 years, SD = 1.5 years). The test–retest sample consisted of 26 participants who completed the same testing procedure after 1 week. For all testing sessions, participants performed the BESS while standing on a portable force plate system. Number of errors and sway velocity were obtained. Concurrent validity was established through correlation analysis examining the relationship between the original and the instrumented BESS scores. Reliability was established using Intraclass Correlation Coefficient (ICC3,1) computed for the instrumented and the original BESS. Results: A significant moderate relationship exists between the total scores of the original and the instrumented BESS (rs = 0.54, p = 0.001). Despite a range of reliability scores for the different conditions in the instrumented BESS (ICC3,1 = 0.19–0.61) and the clinically scored BESS (ICC3,1 = 0.13–0.71), the reliability score for the total test score was the same for the instrumented and the clinical test (ICC3,1 = 0.74). Conclusion: Although the instrumented BESS may appear to demonstrate concurrent validity against the original BESS, instrumentation did not improve its reliability. Future research should examine if the instrumented BESS demonstrates validity against laboratory level force plates and if it is able to overcome the ceiling effect reported for the clinical BESS test.

Validity and Reliability of the Vestibular/Ocular Motor Screening and Associations With Common Concussion Screening Tools:

Background: Sustaining a concussion commonly results in vestibular impairments that may be associated with balance deficits. To screen for vestibular impairments after a concussion, the Vestibular/Ocular Motor Screening (VOMS) tool was developed. The relationship between the VOMS and other concussion screening tools, such as the Balance Error Scoring System (BESS) and King-Devick (K-D), have not been explored. Hypotheses: (1) VOMS would provide reliable results and not provoke symptoms in healthy adolescents and (2) VOMS test items would measure related aspects of vestibular function that are not measured through the BESS or K-D. Study Design: Cross-sectional, descriptive. Level of Evidence: Level 4. Methods: A total of 105 healthy adolescents (53 male, 52 female; mean age, 15.4 years) completed the VOMS, BESS, and K-D tests. A subsample of 21 adolescents (16 male, 5 female; mean age, 15.5 years) completed the VOMS twice. Results: The median total symptom score for all 7 VOMS items was 0 (0-5). The majority of the individual VOMS test items total symptom scores demonstrated a significant correlation with each other (rs = 0.25-0.66, P < 0.02). The individual VOMS items did not demonstrate a significant relationship to the BESS or K-D. VOMS items demonstrated high agreement in total symptom scores between testing trials, with near point convergence (NPC) distance demonstrating an intraclass correlation coefficient (ICC) of 0.95 (95% CI, 0.89-0.98; P < 0.001). The MDC95 (minimal detectable change with 95 confidence) for NPC distance was 4 cm. Conclusion: The VOMS did not provoke vestibular symptoms in healthy adolescents. The VOMS items measured unique aspects of vestibular function other than those measured by the BESS or K-D with good reliability. Clinical Relevance: Clinicians should consider implementing the VOMS as part of a comprehensive concussion assessment if vestibular impairment is suspected. If NPC distance is measured twice, a difference of >4 cm would be considered real change outside of measurement error.

Reliability and Construct Validity of Limits of Stability Test in Adolescents Using a Portable Forceplate System

OBJECTIVE To examine the reliability, convergent, and discriminant validity of the limits of stability (LOS) test to assess dynamic postural stability in adolescents using a portable forceplate system. DESIGN Cross-sectional reliability observational study. SETTING School setting. PARTICIPANTS Adolescents (N=36) completed all measures during the first session. To examine the reliability of the LOS test, a subset of 15 participants repeated the LOS test after 1 week. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Outcome measurements included the LOS test, Balance Error Scoring System, Instrumented Balance Error Scoring System, and Modified Clinical Test for Sensory Interaction on Balance. RESULTS A significant relation was observed among LOS composite scores (r=.36-.87, P<.05). However, no relation was observed between LOS and static balance outcome measurements. The reliability of the LOS composite scores ranged from moderate to good (intraclass correlation coefficient model 2,1=.73-.96). CONCLUSIONS The results suggest that the LOS composite scores provide unique information about dynamic postural stability, and the LOS test completed at 100% of the theoretical limit appeared to be a reliable test of dynamic postural stability in adolescents. Clinicians should use dynamic balance measurement as part of their balance assessment and should not use static balance testing (eg, Balance Error Scoring System) to make inferences about dynamic balance, especially when balance assessment is used to determine rehabilitation outcomes, or when making return to play decisions after injury.

Characterization of cervical neuromuscular response to head-neck perturbation in active young adults

BACKGROUND The majority of studies examining the role of cervical muscles on head-neck kinematics focused on musculoskeletal attributes (e.g. strength). Cervical neuromuscular response to perturbation may represent a divergent construct that has not been examined under various perturbation conditions. This study examined the association between cervical musculoskeletal attributes and cervical neuromuscular response of the sternocleidomastoid (SCM) to perturbation. Furthermore, this study examined the effect of anticipation and preload on the SCM neuromuscular response. METHODS Nineteen participants completed measurement of SCM muscle size, cervical flexion maximal voluntary isometric contraction, and the neuromuscular response of the SCM to cervical perturbation. Cervical perturbation was delivered by dropping a 1.59 kg mass from a loading apparatus. The impulsive load was delivered under four conditions: (1) Anticipated perturbation with no preload (A-NP), (2) Unanticipated perturbation with no preload (U-NP), (3) Anticipated perturbation with preload (A-P), and (4) Unanticipated perturbation with preload (U-P). RESULTS None of the cervical musculoskeletal attributes were correlated with the SCM cervical neuromuscular response. This study demonstrated significant effect of preloading and anticipation on baseline EMG amplitude and EMG onset latency for the SCM. Furthermore, there was a significant effect of preloading on average EMG response amplitude for the SCM. DISCUSSION The findings of this study indicate that cervical neuromuscular response of the SCM is different from musculoskeletal attributes and is influenced by perturbation conditions. These findings provide conceptual support to examine the neuromuscular response of the SCM in mitigating head-neck kinematics.

Concussion Attitudes and Beliefs, Knowledge, and Clinical Practice: Survey of Physical Therapists

Background A concussion is considered a mild traumatic brain injury that may cause physical, cognitive, affective, and sleep dysfunction. Physical therapists have been identified as health care providers involved in the multidisciplinary care of a patient with concussion. Objective The purpose of this study was to describe the current attitudes and beliefs, knowledge, and practice of physical therapists in the treatment of patients with concussion. Methods A 55-question electronic survey divided into 6 sections—(1) demographics, (2) current practice in concussion, (3) youth concussion legislation, (4) attitudes and beliefs toward concussion management, (5) concussion knowledge, and (6) clinical decision making—was developed and distributed online through selected American Physical Therapy Association sections. Results A total of 1,272 physical therapists completed the survey. Seventy percent of the respondents (n=894) reported having concussion training. Although supportive of the role of the physical therapist in the treatment of a person with concussion, the respondents demonstrated less confidence when making return-to-play decisions. Respondents correctly answered, on average, 13 (out of 15) concussion knowledge questions, with gaps exhibited in understanding the clinical utilization of concussion severity scales, the conservative treatment of youth who sustain a concussion, and anticipated normal computed tomography and magnetic resonance imaging after a concussion. When provided with clinical scenarios, respondents were able to recognize when a referral to a physician was indicated; however, they demonstrated variability in identifying a need for vestibular or manual physical therapy. Limitations Convenience sampling was utilized, limiting generalizability of the results of the study to the physical therapy profession as a whole. Conclusion Physical therapists demonstrated a solid foundation of concussion knowledge, but gaps still existed. Future professional development opportunities should be developed to target identified gaps in knowledge and current practice patterns.

Home-based circuit training program for an adolescent female with severe traumatic brain injury: A case report

ABSTRACT Adolescents with traumatic brain injury (TBI) are often discharged from physical therapy (PT) services without transitioning into exertional conditioning programs. Active participation in physical activities with peers at school is essential to achieve a sense of accomplishment and acceptance. Factors such as reduced aerobic fitness and residual gait impairments can lead to limited participation and peer interaction. The purpose of this case report was to describe the impact of home-based circuit training (HBCT) focusing on strength and balance on gait speed (GS), energy expenditure, and functional performance in a 17-year-old female with severe TBI. The participant sustained a TBI from a motor vehicle crash. Although she was ambulatory and independent with the basic activities of daily living following two years of rehabilitation, she presented with activity limitations and participation restrictions at school. The participant performed a 4-week HBCT program developed by a school physical therapist that focused on strength and balance. At the end of 4 weeks, improvements were observed in 6 MWT (change = 79.7 m), GS (change = 0.22 m/s), and the COPM scores (performance score change = 2.8, satisfaction score change = 2.2, MCID = 2). Improvements in functional performance, gait speed, and self-perception of occupational performance were observed following 4-week HBCT. Future clinical trials on short duration, HBCT program for children and young adults with TBI are recommended in order to establish effectiveness of HBCT.