Sunday, October 20, 2013

Real improvements in concussion treatment

The CDC reports that approximately 200,000 sports-related concussed athletes per year end up in US emergency rooms.  The total number of sports-related concussions is five times that figure.  Whether the patients end up in EDs or not, our diagnosis and treatment of these traumatic brain injures is substandard compared to what might be possible. 

I recently heard an excellent story about cooperation between the Cleveland Clinic and the Allegheny Health Network to enhance the diagnosis and treatment of concussed athletes and others.  The work being done has great potential to reduce the danger of concussed players returning too soon to the game and to prioritize post-concussion treatment. And it is based on iPads and apps.

The presentation was by Jay Alberts of the Cleveland Clinic--where the development work took place--and Keith Lejeune, Vice President of Innovation Deployment at AHN. It turns out that the accelerometer and gyroscope in the iPad makes concussion assessment possible. But the program starts before any injury occurs.  This story from radio station WESA explains.

C3 Logix is a new, innovative concussion evaluation technology that provides on site data collection at the time of injury, to better aid physicians in diagnosis and treatment. The program is loaded into an iPad and before the season starts, athletes perform a series of neurocognitive tests. The program tracks the athlete’s visual reflexes and their ability to focus on moving objects. Results of these baseline tests can then be compared to data logged in incident reports at the time of suspected brain injury.

After an injury, by having the patient wear the Ipad on a belt, you can watch minor variations in movement and balance that are indicative of whether the brain has recovered fully. Feeding data directly into the electronic medical record, this electronic format enhances understanding of cognitive and motor declines for a concussed patient.

The app on the Ipad creates an avatar to help visualize the balance issues being faced by the concussion victim. You can thereby show this to coaches and parents, too, to help them understand the extent of the injuries.The radio story explains:

The information that C3 Logix provides is key because the athletic trainer or doctor doesn’t have to rely solely on the testimony of an injured player, whose main priority might be returning to play.

During the recovery period, the neurocognitive tests are also repeated  to monitor improvement over time. It turns out that patterns or recovery vary widely among patients. Patients can be referred to physical therapists or speech therapists as data indicate ongoing need. Previously, treatment was based on the "Rest and Pray" model. The empirical result of this has been much more use of extended care (e.g., PTs) than previously would have been the practice.

Compare this to the usual assessment.  An athlete is injured.  The trainer takes care of the person at the site.  Later, the patient shows up for follow-up, but the initial information collected by the trainer is not highly quantified, and it is certainly not captured in the EMR. There is no way for the follow-on caregiver to know the extent of the injury at the start, much less compare the athlete to his or her baseline conditions.  Even the work-up at the ED or clinic fails to produce and capture for future comparison a highly quantifiable version of the facts.

Spread of this approach is proceeding apace.  WESA reports:

C3 Logix is currently used at more than 50 schools in northeast Ohio and has been used to assess more than 7,000 athletes in the past year. Athletic trainers at Allegheny Health Network began baseline testing with the system this month, and there are plans to expand the C3 Logix program to all 14 school districts that receive their training services. The system is also being used at Robert Morris University and by the Pittsburgh Riverhounds soccer team.

Here's a descriptive video story from KDKA television:

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