Though pediatric concussion is an incredibly common injury (nearly 2 million occur each year in the United States), it remains a difficult condition to diagnose. In 2019, we still rely mainly on symptom scores and patient history, with the subjectivity that accompanies self-report, to make the diagnosis.
The Minds Matter Concussion team of researchers and clinicians are working to develop objective methods to diagnose the condition, in order to facilitate improved clinical care and targeted, individualized therapies. Led by our research program co-leads, Drs. Christina L Master and Kristy Arbogast, we have embarked on a large, NIH-funded study evaluating several device-based measures of injury, with the hope of improving our diagnostic capabilities.
Comparing Measures of Balance
We recently published an article in the journal Medicine & Science in Sports & Exercise (ref 1) comparing one of these device-based measures, a biomechanical force plate device, with two clinical tests of balance:
- The Modified Balance Error Scoring System (mBESS), which is a standardized exam performed by many providers on the sideline as part of the Sport Concussion Assessment Tool, 5th Edition (SCAT-5)
- Complex Tandem Gait, an evaluation of gait developed here at Children’s Hospital of Philadelphia Sports Medicine and Performance Center by Drs. Matthew Grady and Christina Master.
In this study, we found that, overall, each test possessed moderate discriminatory ability. The two clinical tests performed similarly and as good as-- if not slightly better than-- the device-based measure.
Also, we found the Complex Tandem Gait, a graded test of increasing difficulty whereby the subject walks with his or her feet in tandem for five steps forward and backward, with eyes both open and closed, possessed individual components that were both highly specific (e.g., having a subject walk forward with his or her eyes open yielded a specificity of 99 percent for ruling in a concussion) and highly sensitive (e.g., having a subject walk backward with his or her eyes closed yielded a sensitivity of 81% for ruling out concussion).
Take Home for Health Care Professionals
In prior studies, we found that the Complex Tandem Gait is readily adopted outside of the specialty sports medicine world; here at CHOP, we have instituted it in our routine practice in both the primary care as well as the emergency department setting (ref 2 and 3).
Providers in all settings should use balance testing, in combination with evaluation of visio-vestibular and oculomotor function, to help diagnose concussion following head injury. The clinical test for balance is quick, easy to learn, and implementable outside of the specialty world.
While device-based measures are increasing in frequency, and are an appealing method to evaluate concussion, this study shows that clinical measures of balance perform as well as, if not better than, the device-based measures in distinguishing concussed patients.
- Clinical and Device-based Metrics of Gait and Balance in Diagnosing Youth Concussion. Corwin DJ, McDonald CC, Arbogast KB, Mohammed FN, Metzger KB, Pfeiffer MR, Patton DA, Huber CM, Margulies SS, Grady MF, Master CL. Med Sci Sport Exer. 2019.
- Use of the Vestibular and Oculomotor Examination for Concussion in a Pediatric Emergency Department. Corwin DJ, Propert KJ, Zorc JJ, Zonfrillo MR, Wiebe DJ. Am J Emerg Med. 2019; 37(7): 1219-1223.
- Improving Primary Care Provider Practices in Youth Concussion Management. Arbogast KB, Curry AE, Metzger KB, Kessler RS, Bell JM, Haarbauer-Krupa J, Zonfrilo MR, Breiding MJ, Master CL. Clin Pediatr (Phila). 2017; 56(9): 854-865.
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