Technology’s role in concussion testing

Consequences of concussion 

Fortunately for many, the symptoms associated with concussion seem to be relatively short-lived. Whilst these symptoms can be disconcerting at the time, a return to normal function, particularly amongst those without a history of head trauma often occurs within two to three weeks. 

However, for athletes that have suffered a number of head impacts, longer term issues are increasingly reported. Much of the literature regarding longer term health problems has focused on neurodegenerative disease such as Altzhimers and other forms of dementia. Generally, distortions in cognitive function linked to minor head injury, such as concussion, seem to occur gradually. The symptoms of Chronic traumatic encephalopathy (CTE) for example, include short term memory loss, fluctuations in mood, including anxiety as well as difficulty thinking and concentrating. The nature of these changes often make identifying any differences difficult in day to day life. Often they can be passed over, masked or attributed to many other factors.  

When do changes start to occur?

Despite the consequences of repeated head impacts becoming more apparent in later life, researchers are looking for signs of shorter term changes to help predict longer term issues. As concussion is a form of brain injury, it would be expected that even after recovery from primary symptoms, some minor form of cognitive or executive function fluctuation may remain, like scar tissue on graze. However, the research investigating alterations in cognitive or executive function amongst young, healthy athletes presents a confusing picture. Often no issues are found during follow up assessments after concussive impacts. In fact, frequently athletes continue to perform well in comparison to control groups who have had no concussion history. 

The comparable results between groups could be an indication of full recovery amongst those who have suffered concussion. However, researchers are beginning to question this. A belief is emerging that issues may lie with tests and their lack of sensitivity. Subtle changes, particularly in young healthy athletes seem difficult to detect, particularly if, as is regularly the case, a battery of quality normative data for those individuals isn’t available for contrast. This means between group comparisons are drawn i.e those that have suffered a concussion are compared to those that have not. 

Between group testing can fail to reflect a true before and after picture of the individual. They could have experienced a minor drop in function, yet still fall within normative values. Therefore interpretation of the impact of a concussion is harder to infer directly. Other procedural concerns have been highlighted when seeking to interpret results. A focus on more cognitive rather than executive function testing could be a reason for discrepancies. This may mean that while cognition isn’t significantly affected, executive function could be.     

Recent research 

A team from the Universite de Montreal, Canada investigated the inconsistencies in results. To do this, they ran a meta-analysis of 19 studies. They examined the responses amongst young athletes with a history of concussion, relative to controls that had never experienced a sport related concussion.

‍Their analysis showed that while no differences were detected in cognitive function, a number of declines in executive function could be detected amongst those with a history of concussion. They concluded that “tests which assess executive function might be more sensitive to long term alterations of sport related concussion”. 

Whilst cognitive testing yielded no significant differences between the two groups, two areas of caution were raised when interpreting these findings. Firstly, athletes with concussion histories can perform well on standardised tests via compensatory mechanisms. They also highlight that a subgroup of athletes may well suffer from cognitive impairment, but due to the nature of the trials, these ‘within group’ differences can be hidden within the results.    

Another issue key point is that the testing generalises to a nonathlete population. The subjects examined in this analysis were college level athletes. It is entirely reasonable to expect that a population that combines high athletic and academic abilities could register better cognitive scores than age matched adults even after some negative alterations. 

Testing

As more information emerges linked to sport related concussion, the importance of testing amongst players and athletes becomes ever more significant. Establishing a baseline not just for concussion recovery, but for normal cognitive and executive function is an important area of investigation. This seems particularly relevant for young athletes and researchers interested in this area. Starting to build a ‘brain’ profile as early as possible will allow tracking of normative changes in development as well as more data upon which to compare and contrast any concerning changes.    

Across professional sport, physical and medical screenings are routine. New signings must pass a medical, pre-season fitness assessments gauge player progress and injury recovery tests support return-to-play strategies. Concussion awareness has also led to baseline cognitive function assessments in many contact sports. However, the focus of these assessments and subsequent tests is on the diagnosis of, and recovery from, concussion. They are not focused, or in many cases designed, to detect mild and subtle changes in cognitive and executive function over time. 

Much is still to be understood in relation to the effects of concussion. Sports that expose athletes to repeated head impacts and injuries are under scrutiny to do more to protect players. Even if alterations in cognitive and executive function are minimal and don't present practical consequences at the time, an understanding of changes could help with treatment and education to protect players later in life. Therefore an increased testing regime to help detect these alterations needs to be evaluated as a serious provision across elite high impact sport.   

The case for technology 

As part of the HITIQ suite of products the COVR virtual reality assessment promises to be the most advanced concussion assessment tool of its kind. Clinical trials are underway with a host of independent universities across the world, drawing on the expertise of global leaders in the concussion, neuroscience and medical fields. 

Despite understanding of concussion and its consequences rapidly expanding, almost without exception, scientific research calls for further investigation as part of their conclusions. The widespread adoption of COVR will open the door for more testing and data generation. 

A move from current pen and paper or computer based programmes to a fully immersive VR concussion assessment system has a number of advantages. 

COVR introduces the unique ability to change cognitive testing into a fully immersive game. To get an accurate understanding of a person’s cognitive ability testing needs to sustain attention, otherwise measurement of cognition can be affected. Creating a fun, engaging environment keeps players focused on the task at hand, getting results that are more accurate than when players are not engaged.

COVR is designed to be a consistent, self-enclosed environment. Cognitive testing generally requires a trained neuropsychologist or psychometrist to administer. While task instructions are scripted, differences between how the scripts are read by administrators can affect test performance. COVR simplifies this process by providing written and verbal instructions in a consistent, accessible way. Where the test is performed also plays a large part in accuracy of measurement. Cognitive testing is more accurate in a quiet room where the person taking the test feels at ease. Conversely, performing tests in a crowded stadium will negatively impact performance. COVR helps minimise the impact of environment by limiting what players see and hear, providing the best quality results in any situation. 

Unlike standard cognitive tests, COVR is able to measure response times with pin-point, millisecond accuracy. Generally during a testing session, pen and paper testing methods are used, with measurement of reaction times, which are important for measuring brain processing speed, accomplished using a stopwatch. COVR is able to measure reaction times in fractions of a second, making more accurate recordings and allowing for better examination of brain health.

Unlike other computerised tests, because COVR is VR based measurement of how players play the games is also possible. COVR tracks player movements in real time, giving greater insights into player performance, strategies and directness in how they respond to the games.

The combination of immersive environments, pin-point accuracy and motion tracking makes COVR a completely unique and accurate way to measure cognitive performance. 

Technology such as COVR will allow sport to move past simple concussion detection and focus on long term athlete welfare. It will catalyse the creation of player concussion or head impact profiles and support enhanced pre and post injury comparisons. The classification of impacts via the HITIQ impact classifier will also allow purposeful between group comparisons. This will help develop recovery and longer term prognosis insights. 

Conclusion 

The need for increased understanding of the consequences of multiple head impacts and concussion continues. To be able to develop insight, more data and greater accuracy in testing is needed. The development of COVR signifies a major leap forward in the ability to gather and analyse concussion data. 

Our aim is to provide a best-in-class detection system that will enable quicker and more accurate detection of cognitive and executive function issues. COVR offers the means to a better future for athletes. With more accurate data, meaningful individual and group comparison will revolutionise the measurement, management and mitigation of sport related concussion, keeping athletes safer both on the pitch and in later life.