Figure 1. Biodex BioSway for baseline and post-injury postural sway determination and post-concussion rehabilitation.

Figure 1. Biodex BioSway for baseline and post-injury postural sway determination and post-concussion rehabilitation.

The epidemic that is concussion in sports continues to affect many of us and has trickled down from the professional and college fields to the youth sports that many of us played. The majority of physical therapists will not have the opportunity to work with the post-concussed professional or collegiate athlete, but all of us can positively affect the incidence of concussion in youth sports leagues through education, comprehensive baseline concussion testing, and post-concussion management as rehabilitation specialists. The technologies available to us in this area of practice continues to grow and evolve.

Building a Concussion Management Program

Developing a comprehensive concussion management program for a clinic begins with the foundation of baseline testing and offering it to underserved youth sports leagues. This begins to build community relationships and solidify a therapist’s expertise in the area of concussion management. The latest research shows that a baseline testing program should include assessment of multiple systems affected by a head injury to more accurately determine when an athlete is truly ready for return to play. The three components that my practice assesses in baseline testing are balance, oculomotor, and cognitive systems. The technologies available to test these areas are numerous.

The disintegration of the balance system after concussion is based on the research of numerous colleagues, including those by Kevin Guskiewicz, PhD, ATC, and his team at UNC Chapel Hill. Postural sway abnormalities can now be quantified using several technologies, including stationary, portable, and even iPhone applications. I use the Biodex Medical Systems BioSway unit, by Biodex Medical Systems Inc, Shirley, NY, for in-office and on-location baseline balance assessments (Figure 1).

Biodex also makes a stationary model called the Balance System SD that has a dynamic platform for more sophisticated testing and vestibular training. With either unit, the clinician can perform a Modified Clinical Test for the Sensory Integration of Balance (mCTSIB). Both units are designed to test the sensory process by compromising the somatosensory, visual, and vestibular components used to control and then measure postural sway. This objective data can be compared to preinjury status after a concussion and can help determine when an athlete has returned to a preinjury level of postural sway control, which is commonly affected following a head injury. In addition, these units are frequently used in the clinic during post-concussion rehabilitation in training postural sway and challenging the vestibular and visual systems often affected by head trauma.

Figure 2. AlterG antigravity treadmill used for safe early vestibular ocular reflex  training and gaze stabilization, as well as aerobic conditioning.

Figure 2. AlterG antigravity treadmill used for safe early vestibular ocular reflex
training and gaze stabilization, as well as aerobic conditioning.

For a high level of portability in a device that can easily be taken on the field or sideline to measure postural sway, there is the iPhone application called SWAY. This system, created by Sway Medical LLC, Tulsa, Okla, utilizes the built-in motion sensors of the iPhone, iPad, or iPod Touch devices to measure postural sway utilizing a proprietary motion analysis algorithm. The company has increased the scope of its software, and now includes reaction time and symptom tracking, which are also important components of concussion management. Other technologies on the market that target balance assessment and management include the Proprio, by Decatur, Ill-based company Perry Dynamics, and the NeuroCom SMART EquiTest from Natus Medical Inc, San Carlos, Calif. Micromedical Technologies, Chatham, Ill, is also a manufacturer of technologies used to treat dizziness and balance disorders.

The latest technology receiving attention in the media and in research arenas is the measurement of oculomotor control and the impact of this system following a concussion. The King-Devick Test (K-D test) from King-Devick Test LLC, headquartered in Terrace, Ill, was developed in 1976 by Alan King and Steven Devick, who were optometrists looking for a way to measure saccadic eye movements and its impact on reading ability. Saccades are defined by Webster’s dictionary as “a small rapid jerky movement of the eye especially as it jumps from fixation on one point to another (as in reading).”

In 2011, researchers began looking at the K-D test as a rapid sideline assessment screening tool for concussion, and now it has been examined in numerous peer-reviewed studies as a tool to measure suboptimal brain function. The test works by measuring the time it takes to read aloud single-digit numbers that are arranged on a series of three cards. The test can be delivered using an iPad, laptop, or computer as well as the old-fashioned way of large index cards. The total time it takes to read the series of numbers is recorded and measured against testing post-concussion. The majority of the research puts the cutoff score of greater than 5 seconds compared to preinjury values as being positive for concussion, and should help prevent the athlete from returning to play too soon and risking catastrophic injury or even death.

The last component of the baseline testing program and readiness for return to sport is the athlete’s cognitive function. There are numerous computer-based products available to provide objective measurement of memory, processing speed, and reaction time. One that is extremely popular and has been used in research efforts is ImPACT (Immediate Post-Concussion Assessment and Cognitive Tool – In addition to ImPACT is the Cogstate Computerized Cognitive Assessment Tool (CCAT – The CCAT is a simpler model of measuring cognitive function utilizing a series of playing cards on a computer. This tends to be an easier system and faster to complete, especially for the younger athletes. All baseline cognitive testing should be performed in a quiet, comfortable environment since group testing in large computer rooms has demonstrated inconsistent data acquisition in several studies.

Technologies To Further Aid Recovery

Unfortunately, not all concussed athletes recover in the typical 7-to-10-day time frame. Some will be affected by lingering symptoms such as headache, impaired postural sway due to visual and vestibular system disruption, cognitive impairments, and deconditioning following physical and cognitive rest. There are several technologies available to assist in the rehabilitation process. The MultiRadiance Mr4 Super Pulsed Laser, provided by Multi Radiance Medical, Solon, Ohio, is a class IV laser that can be an effective modality for the treatment of cervicogenic headache and occipital migraine. This particular cold laser uses three wavelengths of light resulting in increased vascular activity combined with pulsed wavelengths and low-level electrical stimulation to block C fiber activity. This modality can be safely delivered to the cervical spine and occipital region of the cranium to reduce nerve excitability that may be the source of cervicogenic headache.

LiteCure Medical, Newark, Del, also provides class IV lasers that can be used in the relief of pain associated with migraine headache. Among the lasers LiteCure offers are the LightForce EX, LightForce EXP, LightForce FX, and LightForce Pro. Pivotal Health Solutions, Watertown, SD, also provides cold lasers that can be used to address headaches, such as the class 3B Apollo 2,000 mW Cold Laser.

After a period of physical and cognitive rest, post-concussed athletes should progress through an exertional therapy program with symptom as well as heart rate monitoring to ensure aerobic fitness is being achieved without increasing symptoms. The Polar heart rate monitor, available through Lake Success, NY-based Polar Electro Inc, is a technology to ensure patients are kept in a safe aerobic training range with steady progression to ensure a return to prior fitness levels.

Figure 3. Vision Coach interactive light board for oculomotor retraining and hand-eye coordination. Photo courtesy of A3 Bakersfield.

Figure 3. Vision Coach interactive light board for oculomotor retraining and hand-eye coordination. Photo courtesy of A3 Bakersfield.

Other products useful in the exertional therapy program are the Total Gym by San Diego-based company Total Gym, for whole-body fitness with progressive resistance and core stabilization, as well as various mini trampolines, DynaDisc (available through companies such as Exertools, Petaluma, Calif). BOSU Balance Trainer, BOSU, Ashland, Ohio, and Switzerland-based Airex’s balance pads for progressive balance and vestibular training. Advanced vestibular ocular reflex training while ambulating can be performed safely and effectively in the AlterG antigravity treadmill from AlterG, Fremont, Calif. This sophisticated treadmill can allow progressive forward and backward ambulation while performing visual tracking, coordination, and gaze-stabilization activities required for functional tasks. It can also be used for aerobic fitness with reduced compression on joints for those athletes recovering from lower-extremity injuries concurrently with the concussion (Figure 2, page 21).

The last component of a successful post-concussion rehabilitation program is the integration of vision therapy to control eye movements necessary for return to sport. The Vision Coach ( is an interactive light board used in the training of visual function and oculomotor coordination. This advanced technology can be used for hand-eye coordination and speed training as well as combined with vestibular challenges. The light board has advanced software to vary the training stimuli in addition to recording clinical data.

Testing, Rehab, and Beyond

The future of concussion testing and rehabilitation will evolve with even more innovative technologies that have yet to be discovered. The clinician specializing in concussion management will need to be able to analyze the evidence supporting any new products to determine effectiveness and how the technology will hasten the recovery of those suffering from post-concussion syndrome. PTP

David Bertone, PT, DPT, OCS, is president and founder of db Orthopedic Physical Therapy, with locations in central New Jersey. He also created ConcussionRxcare, a specialized program offering baseline concussion testing, education and rehabilitation. As an adjunct professor at Rutgers, the State University of New Jersey, Bertone teaches DPT students about the physical therapy role in concussion management. For more information, contact [email protected].