Eye tracking to help determine concussion severity

Using an eye-tracking method may help spot concussions and help determine their severity.

A new eye-tracking method might help determine the severity of concussions, researchers report.They said the simple approach can be used in emergency departments and, perhaps one day, on the sidelines at sporting events.

"Concussion is a condition that has been plagued by the lack of an objective diagnostic tool, which in turn has helped drive confusion and fears among those affected and their families," said lead investigator Dr. Uzma Samadani. She is an assistant professor in the departments of neurosurgery, neuroscience and physiology at NYU Langone Medical Center in New York City.

"Our new eye-tracking methodology may be the missing piece to help better diagnose concussion severity, enable testing of diagnostics and therapeutics, and help assess recovery, such as when a patient can safely return to work following a head injury," she explained in an NYU news release.

According to researchers, it's believed that up to 90 percent of patients with concussions or blast injuries have eye movement problems. But the current method of assessing eye movement is asking a patient to track a doctor's finger, Samadani said.

The new method was originally developed by Samadani and her colleagues to assess eye movement in U.S. military personnel believed to have concussion or other types of brain injuries.

The researchers compared 75 trauma injury patients and a control group of 64 healthy people. The movements of the participants' pupils were tracked while they watched a music video for a few minutes.

Thirteen trauma patients who hit their heads and had CT scans showing new brain damage, and 39 trauma patients who hit their heads and had normal CT scans, were much less able to coordinate their eye movements than trauma patients who hadn't hit their heads and those in the control group.

The more severe the concussion, the worse a patient's eye movement problems, according to the study. Results were published online Jan. 29 in the Journal of Neurotrauma.

Dr. M. Sean Grady, chair of the neurosurgery department at the University of Pennsylvania's Perelman School of Medicine in Philadelphia, said, "The importance of this study is that it establishes a reliable test and a 'biological' marker for detecting concussion." He was not involved in the study.

"Since concussion can occur without loss of consciousness, this can be particularly important in sideline evaluations in athletics or in military settings where individuals are highly motivated to return to activity and may minimize their symptoms. More work is needed to establish its sensitivity and specificity, but it is very promising," Grady said.

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Concussions in the U.S. - Some helpful information on brain injury

This article explains all about concussion in the U.S., how to treat them, and common misconceptions about concussions.

Concussion, sometimes referred to as mild traumatic brain injury, is one of the most commonly encountered sports injuries. Studies vary but rates are estimated at two million sport related concussions per year in the United States. It is also commonly believed that these are under reported injuries due to lack of recognition of the concussion and the desire of athletes to not miss time from their activity.

Research has led to change in our approach to treatment of the injuries. New guidelines do not use a set time away from activity and emphasize a gradual return to play. While concussions often occur from direct contact to the head or face, they may also occur from rotational forces without contact such as a tumbling fall. Although research continues to help understand what happens to the brain in a concussion, it appears that the neurons (brain cells) sustain a small injury that creates an "energy crisis." This generally lasts 7-10 days and physical or cognitive activity during this time period may worsen symptoms and prolong recovery. ...

Collision sports (football, hockey, etc.) generally have the highest overall rates of concussion; however, they can be seen in all sporting activity. Fortunately, the overall rates of concussions are relatively low even in collision sports. Certain risk factors are associated with an increased risk of concussion or prolonged recovery. Genetics, gender, playing position, migraines, history of multiple concussions and mental disorders (depression, anxiety and ADHD) all may play a role in how an athlete is affected by a concussive injury.

However it is still unclear how much influence each of these factors has on an individual athlete's risk. The diagnosis of a concussion can be complex as the signs and symptoms of concussions can be found in many other conditions and there is not a singular test we can use to determine if a concussion has occurred. Sometimes the diagnosis is very straight forward, for example when there has been a brief loss of consciousness, but many times the changes seen in the athlete are very subtle. The diagnosis of a concussion is mainly based on the history and physical examination. Symptoms of a concussion may include headache, dizziness, nausea/vomiting, amnesia, brief loss of consciousness and inability to concentrate. These symptoms may last for several days to a few weeks.

Imaging, CT scan or MRI, rarely indicate concussions, unless there is a finding on examination that suggests a structural injury ( e.g. bleeding or swelling). Newer computerized tests may add value in some cases, but these tests are not used to diagnose concussions and it is unclear if using these tests improve the outcomes of concussed athletes. Previous grading scales used symptoms at the time of the concussion to determine the severity of the concussion. New guidelines now suggest that we not grade concussions at all and that we only determine that a concussion has occurred. The reasoning for this lies in newer research that shows symptoms at the time of the initial injury do not correlate with the severity of the injury and recovery time. Additionally, grading does not change our treatments as resting until symptoms have resolved is the initial treatment regardless of the injury.

Treatment

When an athlete is suspected of having a concussion, they should be removed immediately from competition. Symptoms should be monitored and the athlete should not be returned to competition until they are evaluated by a qualified medical professional. This evaluation should occur as soon as possible. The athlete should be monitored closely for several hours after a concussion. It is important to stress that both physical and mental rest speed the recovery of concussions. It is okay for the athlete to sleep and should avoid over stimulation such as video games or loud crowded activities. Athletes may need to stay out of school or have modified class schedules.

Ask your health care provider for more specific recommendations. Returning the athlete to play starts when the athlete is symptom free. It will take 3-7 days for full return to sports (depending on the sport) with an athlete gradually increasing their activity level every 24 hrs. Returning to class can occur over the same timeframe and athletes should be monitored as well for any increase or recurrence of symptoms. Activity can surface underlying concussion symptoms and athletes should be instructed to notify their coach, trainer or physician if they redevelop any symptoms during the recovery period. This process allows faster and safer return to sporting activity. Computerized neuropsychological testing is sometimes used to help monitor an athlete's progress but is never used on its own to determine a diagnosis or an athlete's readiness to return to play. There are many common misconceptions about concussive injuries.

The following are several myths about concussion:

Every athlete who sustains a hard hit must have a concussion. Although our knowledge about the forces involved in concussion is improving we still have not found a level of force that definitely causes a concussion. At times high forces do not cause an injury and relatively lower ones may. This means that we should not overact to every head impact but also need to listen to athletes who complain of concussive like symptoms after any head contact. Because there is no known force level for concussion in-helmet devices that are marketed to consumers as "concussion alarms," they are not recommended as they will likely lead to both over and under diagnosis of concussive injuries.

Better helmets and mouth guards will prevent concussions. Unfortunately there is no good scientific evidence that helmets of any type (hard shells, soft-padded or head bands) or mouth guards can prevent or reduce the risk of concussions. Hard helmets can reduce the risk of more serious head injuries (bleeding, skull fractures etc.) and should be worn in high risk sports. Mouth guards can prevent dental injuries and should be worn for sports with a high risk of these injuries. Helmet-add ons additionally are not effective in concussion prevention and using these will generally void any warranties associated with the helmet. Risk reduction may be possible in some settings with rule changes (e.g. no hitting from behind in hockey) and behavior changes (e.g. tackling technique in football).

Once you have a concussion you will always be more susceptible to having another one. While there appears to be an increased risk of recurrence in the first few weeks after a concussive injury it is unclear what factors may influence the risk of another injury in the future. Despite being a commonly held belief there is no evidence to suggest that athletes develop a decreasing force threshold after each injury. A few small studies have found the opposite....

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Neck injuries versus concussions

Concussions and neck injuries have similar symptoms, so diagnosing and differentiating these conditions is often difficult.

Athletes and others reporting cognitive difficulties after a head injury are usually diagnosed as having had a concussion. But is it really a concussion? A new study published by University at Buffalo medical faculty finds that many of the same symptoms are common to concussions and to injuries to the neck and/or balance system, known collectively as cervical/vestibular injuries.

The research was based on responses about symptoms from 128 patients -- some of whom were professional athletes -- who were being treated at UB's Concussion Management Clinic in the School of Medicine and Biomedical Sciences.

It was published online ahead of print last week in the Clinical Journal of Sport Medicine.

The purpose of the study was to determine how to distinguish between concussion injury and neck injury, based on symptoms.

"Based on our research, we conclude that some patients who have been told they've suffered a concussion, and whose symptoms persist for several months may actually have suffered a neck injury, rather than a concussion, or in addition to a concussion," says John J. Leddy, MD, clinical professor in the UB Department of Orthopaedics and senior author.

He embarked on the study based on his experience as director of the UB Concussion Management Clinic.

"I'd seen enough patients in our clinic, some previously diagnosed with post-concussion syndrome, who continued to experience symptoms even after passing our treadmill test, which indicates full recovery from concussion," says Leddy, who sees patients through UBMD, the physician practice plan of the UB medical school.

"The symptoms for both conditions are so nonspecific that it's really hard to make a diagnosis based on them," Leddy continues, "so we had to find another way to discriminate between them."

To determine which of the respondents had probably sustained a concussion and which more likely had a neck injury, the UB researchers used the graded treadmill test developed by Leddy and co-author Barry Willer, PhD, UB professor of psychiatry.

"The treadmill test helps us make a first delineation between what I call physiologic concussion and other possible causes of cognitive symptoms," says Leddy.

"Because a concussion is a brain injury, we thought that cognitive symptoms would be more likely associated with concussions," he says. "Surprisingly, that didn't turn out to be the case. People who have had neck injuries can also have problems with concentration and with memory. They feel like they're in a fog, which is exactly what people report after concussion."

Symptoms reported by both groups were headache, dizziness, blurred vision, poor concentration and memory deficits.

Patients in both groups filled out a detailed questionnaire concerning their symptoms. These responses were then correlated to their treadmill test results. "Then we did some sophisticated statistical analysis," says Leddy. "Even when we looked at the data in multiple ways, there was really no way to separate out the two groups based on their symptom patterns alone."

Determining which condition a patient has experienced is critical, Leddy explains, because courses of treatment are very different.

"The treatment for a neck injury is actually to be more active, to do physical and vestibular therapy, to have a more active intervention, whereas after a concussion, exercise must begin slowly and incrementally after a period of rest," he says.

Leddy notes that more research should be done on larger samples concerning concussion and neck injury.

In the meantime, he says, patients who think they've had a concussion and whose symptoms have not diminished after several months, should instead be examined for neck and vestibular injury by a sports medicine physician, a neurologist or a physiatrist, a specialist in rehabilitation medicine.

"I think a lot of practitioners listen to the symptoms and just chalk it up to concussion," he adds, "but if they also examined the neck in these people, they might discover that a neck injury is involved and that's a treatable problem."

Physical symptoms that may indicate a neck injury include tenderness, muscle spasm, reduced motion and/or reduced cervical proprioception, Leddy explains.

Co-authors with Leddy and Willer are John G. Baker, PhD, UB Department of Nuclear Medicine; Asim Merchant, MD and Jason Matuszak, MD, of the UB Department of Family Medicine; John Picano, an MD candidate at UB and Daniel Gaile, PhD, of the UB Department of Biostatistics.

The UB Concussion Management Clinic is a joint effort between the Department of Orthopaedics and the Department of Psychiatry.

The research was supported by the Robert Rich Family Foundation, the Buffalo Sabres Foundation, the Program for Understanding Childhood Concussion and Stroke, the Ralph C. Wilson Foundation and the National Football League Charities.

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Will sensors be in all helmets by 2015?

A research study is looking into adding sensors into helmets. The results may be strong enough to put sensors into all helmets by 2015.

A pilot program designed to provide more information for concussion research could become more widespread, and put sensors in every helmet by 2015.

According to Tom Pelissero of USA Today, two teams participated in the program for part of last year, and researchers are trying to fine-tune the technology to measure head impact in games.

The work is being done by University of North Carolina researcher Kevin Guskiewicz, who is a member of both league and union safety committees.

“We need a sample of these players across all positions and studying every play type possible,” Guskiewicz said. “So, that’s the next step. Then I hope from there that, if we find (the devices) have utility that could actually help an individual player … my hope would be that we would go league-wide.”

Guskiewicz said the project still needs to be approved by the league and union, and getting that kind of agreement has been an issue in the past.

But he said he was “thrilled” that teams are buying into the idea of collecting data, though hurdles remain.

“I personally believe that there is valuable information to be gained for a player to learn how to perhaps modify his behavior, to track the way in which he’s leading with his head possibly or positioning his body on a certain play type that could help protect him,” Guskiewicz said.

“So, we just sort of have to go through this in a methodical approach to work on the feasibility. This year, I hope that we’re able to move forward with answering some of the questions that we have around potential rules changes, and then the following year, who knows?”

As with most issues, getting players and management to agree to anything is difficult, but if the technology can present a step forward in the accurate diagnosis of concussions and head injuries, then players and the league need to find a way to implement.

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A blood test may help diagnose concussions

This article discusses research that claims that a blood test could be a non-subjective way to diagnose a concussion.

A report Monday in the journal Pediatrics says kids who suffer concussions should lay off reading, homework and video games. By giving their brains a rest, most can recover in 20 to 50 days, about twice as fast as those who keep doing those activities.

We also have news regarding how concussions are diagnosed. Researchers are developing a test that could be a game changer.

Quarterback Taylor Kelly of the Arizona State Sun Devils understands the mindset of college football players when it comes to injuries: They are going to want to keep playing.

"Guys just want to go out and play it, you know?  They don't care if their heads are a little banged up," Kelly said.

Neurologist Dr. Javier Cardenas specializes in brain injury. He says overcoming the reluctance of athletes to admit symptoms is only one of the problems in diagnosing concussions.

"Right now when we identify a concussion it is purely subjective. We look at symptoms. Do they have headaches? Do they have dizziness? There is no objective information. Having something objective is the holy grail of concussion," said Cardenas.

This season, Kelly and his teammates took part in a study trying to find a better way to detect concussion. Riddell, the athletic equipment company, supplied the team with helmets that measure all head impacts during practices and games. Then, after every game, the players gave samples of their blood, saliva and urine.

These are now being analyzed at the Translational Genomics Research Institute in Phoenix to see whether evidence of head trauma shows up in body fluids as a so-called biomarker.

Brain cells contain generic material call microRNA. Normally, tiny spheres containing that material break off and make their way into the spinal fluid, then the bloodstream. During a concussion, the bran actually bounces against the skull, and researchers believe the impact can cause changes in the microRNA, changes they hope can be detected in blood tests.

TGen scientists are comparing the RNA in each player's body fluids with the impact data from his helmet to see if they match up.

"It might be that we can actually protect players. So identify players who are at risk but have them take it easy, sit out more, based how their biomarkers are rising over time," said Kendall Van Keuren-Jenses, a member of the research team.

The scientists have data illustrating how the technology might have helped one of the players in the study.

The graphic shows the head impacts recorded in his helmet over several weeks. One hit was the equivalent of four times the punch b a heavyweight boxer – the hardest impact received by any player in the study. He continued to play, and was diagnosed with a concussion 10 days later.

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