We wish to thank the Jason Cruickshank, Bob Gray, and the Cleveland Clinic Athletic Trainers for their support and assistance with data collection. This study was supported by the Edward F. and Barbara A. Bell Family Endowed Chair to JLA.

The protocol outlined below follows the guidelines of the Cleveland Clinic human research ethics committee.
1. Administering the C3 App
<ol>
	<li>Administer the C3 app to all student-athletes at baseline prior to the start of the given athletic season. Administer follow up assessments in the event of a concussive injury. Follow up assessments are reserved for the evaluation of recovery once the individual reports no more than minimal symptoms, so as to prevent symptom provocation as a result of testing. The following protocol is used when administering the C3 app.</li>
	<li>Assess postural sway during performance of the Balance Error Scoring System (BESS) using the inertial sensors native to the digital tablet to collect biomechanical data measuring linear and angular acceleration while the student-athlete completes six 20-second balance stances.</li>
	<li>Ensure that the volume is turned up. Ask the athlete to remove his/her shoes.</li>
	<li>Ask and record the following information:
	<ol>
		<li>&#34;If you were to kick a ball, what leg would you use?&#34;. Record individual&#39;s answer as their &#34;dominant foot&#34;.</li>
		<li>&#8220;Have you had an ankle or knee injury from which you haven&#39;t fully recovered in the last six months?&#8221; Record if injury affected dominant or non-dominant ankle or knee.</li>
		<li>Record if the athlete is wearing any sort of brace on his/her dominant or non-dominant knee or ankle.</li>
		<li>Record the surface on which the testing is being conducted.</li>
		<li>Record the footwear used for testing (socks are preferred).</li>
	</ol>
	</li>
	<li>Affix digital tablet onto individual&#39;s sacrum using a custom belt.</li>
	<li>Inform athlete that his/her balance will be tested. Instruct athlete to remain in the designated stance for the entire 20-second trial with his/her hands on hips and eyes closed. Instruct the athlete to get back into the correct position as quickly as possible if he/she loses his/her balance. Verify that the athlete understands the instructions, and ask him/her to stand with his/her feet together (demonstrate double limb stance, Figure 2a).
	<ol>
		<li>Once the athlete is in the proper stance, tap Start to begin the 5-second countdown that signalizes the start of the 20-second trial.</li>
		<li>During the 20-second trial, count the number of errors committed. Errors include any of the following: Hands off hips; opening eyes; step, stumble, or fall; lifting toe or heel off the ground; bending more than 30 degrees at the waist; staying out of position for greater than 5 seconds.</li>
		<li>Record the number of errors committed during the balance trial.</li>
	</ol>
	</li>
	<li>For the second trial, instruct athlete to stand on his/her non-dominant foot (Figure 2b). Repeat steps 1.4.1 to 1.4.3.</li>
	<li>For the third trial, instruct athlete to stand heel to toe in tandem stance, with the non-dominant foot in the back (Figure 2c). Repeat steps 1.4.1 to 1.4.3.</li>
	<li>For the fourth trial, instruct athlete to stand with feet together, identical to the first stance, but on a foam pad, (Figure 2d). Repeat steps 1.4.1 to 1.4.3.</li>
	<li>For the fifth trial, instruct athlete to stand on his/her non-dominant foot, identical to the second trial, but on a foam pad (Figure 2e). Repeat steps 2.4.1 to 2.4.3.</li>
	<li>For the sixth trial, instruct athlete to stand stand heel to toe in tandem stance identical to the third trial, but on a foam pad (Figure 2f). Repeat steps 2.4.1 to 2.4.3.</li>
</ol>
2. Assessment of Static and Dynamic Vision
<ol>
	<li>Static Vision
	<ol>
		<li>Use the length of the belt to measure 5 feet to position the digital tablet and participant at the correct distance, 5 feet apart.</li>
		<li>Holding the digital tablet at eye level, instruct the participant to read the 5 letters displayed from left to right (refer to instructions as shown in Figure 3).</li>
		<li>Record the correct number of letters the participant was able to read.</li>
		<li>If the participant correctly identified 3 or more letters, repeat steps 2.1.2 and 2.1.3 once smaller optotypes are presented.</li>
		<li>If the participant identifies 2 or fewer correctly, proceed to step 2.2.</li>
	</ol>
	</li>
	<li>Dynamic Vision
	<ol>
		<li>Play the sample metronome tone and demonstrate proper head movement, rotating right to left, approximately 20 degrees of cervical rotation in each direction (envisioning movement from 10 to 2 on a horizontal clock dial). Ask the participant to demonstrate the proper head rotation, keeping with the metronome.</li>
		<li>Initiate trial, ensure participant is rotating head properly while optotypes are presented. Instruct participant to read the 5 letters displayed from left to right while continuing to rotate head left to right to the beat of the metronome. If the participant stops moving his/her head to read the letters, press Redo Trial.</li>
		<li>Record the correct number of letters the participant was able to read.</li>
		<li>If the participant correctly identified 3 or more letters, repeat steps 2.2.2 and 2.2.3 once smaller optotypes are presented.</li>
		<li>If the participant identifies 2 or fewer correctly, proceed to next module.</li>
	</ol>
	</li>
</ol>
3. Assessment of Information Processing Assessment using Simple and Choice Reaction Time Paradigms14
<ol>
	<li>Simple Reaction Time (SRT) (Figure 4a)
	<ol>
		<li>Display the instruction screen and instruct the participant to place his/her index finger from the dominant hand on the Touch and Hold button. Once the stimulus (light) turns from yellow to green, instruct the participant to release the button and touch the green light as quickly as possible.</li>
		<li>Observe the participant complete the practice trial, ensuring that he/she understands the directions and is able to complete the task within the allotted time (100-500 ms).</li>
		<li>Observe the participant complete 25 valid trials without errors within the allotted time (100-500 ms per trial).</li>
	</ol>
	</li>
	<li>Choice Reaction Time (CRT) (Figure 4b)
	<ol>
		<li>Display the instruction screen and ask participant to place both index fingers on Touch and Hold buttons.</li>
		<li>After the yellow light is displayed momentarily, a green light (stimulus) and cyan light, serving as a distractor light, are displayed. Ask participant to lift the digit that corresponds with the side in which the green light was presented, and tap the green light as quickly as possible. Remind the participant to keep the digit that corresponds to the cyan distractor light on the Touch and Hold button.</li>
		<li>Observe the participant complete practice trial, ensuring that he/she understands the directions and is able to complete task within the allotted time (100-750 ms).</li>
		<li>Observe the participant complete 25 valid trials without errors within the allotted time (100-750* ms per trial). 
		NOTE: The 500 ms and 750 ms restrictions for SRT and CRT, respectively are lifted post-injury for follow up assessments.</li>
	</ol>
	</li>
</ol>
4. Processing Speed Test15
<ol>
	<li>Initiate the test and instruct the participant to read the instructions provided on the sample testing screen. Instruct the participant to use the symbol key on the top of the screen to complete the test below the symbol key. The symbol key contains symbols in the top row and corresponding digits in the bottom row. The test contains only symbols, requiring the participant to input digits that correspond to the symbol as identified in the key using the keyboard at the bottom of the screen.</li>
	<li>Press the Begin Practice button and observe the participant complete the practice trial according to proper testing procedures.</li>
	<li>Remind participant that the actual test will not provide feedback as to whether the response was &#8220;correct&#8221; or &#8220;incorrect&#8221;, as it did in the practice trial.</li>
	<li>Inform the participant that a new row of symbols will appear once he/she completes the existing row. Instruct the participant to continue to enter corresponding digits until prompted to stop and that the trial will last 2 minutes. Remind the participant that he/she cannot correct an incorrect response, and to complete each response as quickly and accurately as possible.</li>
	<li>Press the Begin Test button to initiate the test. Observe the participant perform the test ensuring correct procedures are followed (Figure 5).</li>
</ol>
5. Assessment of Executive Function and Set Switching
<ol>
	<li>Trail Making Test A
	<ol>
		<li>Instruct participant to read the instructions on the screen, describing the test as a &#8220;connect the dots&#8221; test in which 25 circles corresponding with digits 1-25 must be connected by using the stylus provided (Figure 6a).</li>
		<li>Press Begin Practice and observe participant completing the practice trial, ensuring that he/she maintains contact between the digital tablet and stylus throughout the trial.</li>
		<li>Proceed to test by pressing the Begin Test button. Observe the participant complete the test, ensuring that correct procedures are followed (Figure 6b).</li>
	</ol>
	</li>
	<li>Trail Making Test B
	<ol>
		<li>Instruct participant to read the instructions on the screen, describing the test as a &#8220;connect the dots&#8221; test in which 25 circles corresponding with digits and letters must be connected using the stylus provided. Instruct the participant to begin with the number &#8220;1&#8221;, followed by the letter &#8220;A&#8221;, and continue alternating between numbers and letters, in sequence, &#8220;1&#8221; followed by &#8220;A&#8221;, then &#8220;2&#8221; followed by &#8220;B&#8221;, then &#8220;3&#8221; followed by &#8220;C&#8221;, etc. The test is complete when 25 dots corresponding with numbers and letters are connected.</li>
		<li>Press Begin Practice and observe participant completing the practice trial, ensuring that he/she maintains contact between the digital tablet and stylus throughout the trial (Figure 6c).</li>
		<li>Proceed to test by pressing Begin Test button. Observe the participant complete the test, ensuring that correct procedures are followed (Figure 6d).</li>
	</ol>
	</li>
</ol>
6. Interpretation of C3 App to Guide Clinical Decision-Making
<ol>
	<li>Administer C3 app follow-up assessment if the student-athlete is diagnosed with a concussion20 using procedures outlined in step 1 above. Ensure clearance of cervical spine prior to administration of dynamic visual testing.</li>
	<li>View follow-up performance on all C3 app modules as displayed in Figure 7.</li>
	<li>Determine post-injury performance on radar plot by analyzing each axis (representing a given module) relative to baseline performance, represented by the perimeter of the polygon. The red, yellow, and blue polygons depict performance at various post-injury time points, representing a gradual return to baseline function.</li>
	<li>Based on the clinical exam, performance on C3 app modules, time since injury, athlete&#8217;s history, and other relevant determinants of care, refer to specialty services as outlined in carepath algorithm (Figure 1).</li>
	<li>Field Validation
	<ol>
		<li>Conduct an analysis of C3 app data on a cohort of student-athletes with confirmed concussion. With Cleveland Clinic Institutional Review Board approval and waived consent, C3 app data were obtained for all incident reports completed between July, 2014 through October, 2016, and C3 baseline and follow up assessments completed on student-athletes injured between July, 2013 through December, 2014. Criteria for inclusion were as follows: 1) Presence of baseline C3 assessment, 2) Concussive injury confirmed by Cleveland Clinic physician, 3) Follow-up C3 assessment post-injury.</li>
		<li>Determine post-injury performance on each module of the C3 app by comparing outcomes to baseline performance.
		<ol>
			<li>Analyze data as a function of post-injury phase as defined by the carepath: acute (0-7 days post-injury), subacute (8-20 days post-injury), chronic (&#62;20 days post-injury).</li>
			<li>Stratify student-athletes according to time to recovery (recovered within 3 weeks of injury or recovered in &#62;3 weeks since injury).</li>
		</ol>
		</li>
	</ol>
	</li>
</ol>

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Drs. Alberts and Linder have filed intellectual property protecting the Cleveland Clinic Concussion mobile application. The remaining authors have nothing to disclose.

The development and implementation of the concussion carepath served numerous purposes in our health system&#39;s transformation toward value-based care1,2,3. The algorithm of care was critical in guiding clinical decision-making, and was supported by standardized, biomechanical outcomes in the form of the C3 app, which was used by all members of the interdisciplinary concussion team. These standardized outcomes provided qualifi...

The practice of medicine and the delivery of health care are undergoing a fundamental transformation from volume to value1, driven by payers, hospitals, clinicians, and patients. Health care delivery is challenged by the lack of standardization, interoperability of systems, communication of information, and the coordination of services. These deficiencies complicate effective continuity of care that often result in unnecessary services and have been identified as primary sources of rising health care costs1,2. By contrast, coordinated disease- or condition-specific care has been shown to optimize outcomes while minimizing costs2. In a coordinated care model, patients with a given condition are managed by an experienced, interdisciplinary team according to best practice guidelines, and are referred to the right provider at the right time2.
In efforts to transform clinical practice from a primarily volume-based to a value-based model, the Cleveland Clinic embarked on an enterprise-wide initiative to standardize clinical practice along disease lines through the development and implementation of clinical carepaths3. A care pathway is defined as a standardized approach for the mutual decision-making and organization of care processes for a well-defined group of patients over a well-defined time4. The underlying tenet of a care pathway is standardization of care. The expectation is that with evidence-based care pathways and interdisciplinary care teams, standardization and best practice will be achieved over time, venue and provider resulting in improved efficiency, effectiveness, and value2. With the inclusion of validated outcomes, there is a built-in mechanism for iterating the carepath over time to further refine and improve patient care.
Concussion was identified as a condition in which the potential to streamline care and optimize patient management was significant. While concussive injuries are typically not life-threatening, their effects can be severe and debilitating, with direct and indirect costs estimated at $83 billion annually5. It is estimated that 80-90% of individuals with concussion recover within 7-14 days of injury6,7. However, consensus on the management of the 10-20% of individuals with persistent symptoms is lacking, and evidence supporting or refuting the efficacy of rehabilitation, medical interventions or the diagnostic value of imaging in individuals with post-concussive symptoms is sparse. Multiple consensus statements indicate that an interdisciplinary team approach is optimal to treat concussion6,8,9,10. In 2011, work on the Cleveland Clinic Concussion Carepath11, shown in Figure 1, was initiated. Our primary goal was to create a standardized, evidence-informed approach to the identification, evaluation and management of individuals with concussion. An interdisciplinary team of providers collaborated in the development of the carepath, building consensus based on available evidence in the literature and expert clinical opinion. Physician groups that were represented included: sports medicine, neurology, neurosurgery, rehabilitation medicine, neuroradiology, emergency medicine, primary care, pediatrics and family medicine. The carepath team also included athletic trainers (AT&#39;s), physical therapists (PT&#39;s), speech therapists, occupational therapists, nurses, and neuropsychologists. Finally, computer scientists and research scientists provided technical guidance and software development. The carepath algorithm, documentation template, and outcomes were developed over a course of 15 months from 2011 to 2012. To ensure appropriateness of outcome measures, the C3 application assessment modules were simultaneously being validated12,13,14,15,16.
The evidence-based Cleveland Clinic concussion carepath depicted in Figure 1 was developed to identify individuals with concussion on a trajectory of typical and delayed recovery, and specifically for the latter group, to create clear and objective criteria for referral to specialty services. Standardized outcome measures were established and proposed to be collected across disciplines. In an effort to facilitate utilization and compliance with the standardized evaluation and documentation requirements of the carepath, the Cleveland Clinic Concussion (C3) app was developed, tested, and deployed. The aim of this project is to 1) describe the development and implementation of the Concussion Carepath, 2) to demonstrate the integration of technology in the form of a mobile application to enable the carepath and guide clinical decision-making, and 3) to present preliminary data on the responsiveness of the C3 app in detecting change in neurological function post-concussion. We hypothesized that utilizing the C3 app would improve interdisciplinary communication aide in clinical decision making.

<table><tbody><tr><td>Foam Balance Pad</td><td>Airex, Sins, Switzerland</td><td></td><td>dense foam balance pad used during balance testing</td></tr><tr><td>iPad Digital Table</td><td>Apple</td><td></td><td></td></tr></tbody></table>

development and implementation of a multi-disciplinary technology enhanced care pathway for youth and adults with concussion

The evidence-informed standardization of care along disease lines is recommended to improve outcomes and reduce healthcare costs. The aim of this project is to 1) describe the development and implementation of the Concussion Carepath, 2) demonstrate the process of integrating technology in the form of a mobile application to enable the carepath and guide clinical decision-making, and 3) present data on the utility of the C3 app in facilitating decision-making throughout the injury recovery process. A multi-disciplinary team of experts in concussion care was formed to develop an evidence-informed algorithm, outlining best practices for the clinical management of concussion along three phases of recovery &#8211; acute, subacute, and post-concussive. A custom mobile application, the Cleveland Clinic Concussion (C3) app was developed and validated to provide a platform for the systematic collection of objective, biomechanical outcomes and to provide guidance in clinical decision-making in the field and clinical environments. The Cleveland Clinic Concussion app included an electronic incident report, assessment modules to measure important aspects of cognitive and motor function, and a return to play module to systematically document the six phases of post-injury rehabilitation. The assessment modules served as qualifiers within the carepath algorithm, driving referral for specialty services as indicated. Overall, the carepath coupled with the C3 app functioned in unison to facilitate communication among the interdisciplinary team, prevent stagnant care, and drive patients to the right provider at the right time for efficient and effective clinical management.

To investigate change in neurologic function following concussion, baseline and follow-up C3 assessments were analyzed in 181 student-athletes injured during the 2013-2014 athletic seasons. Detailed demographics of the 181 injured athletes are shown in Table 1. Data were stratified into two groups: those who recovered within three weeks of injury (N=92) and those who were still symptomatic three weeks after injury (N=89). When comparing the first post-injury assessments, ...

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Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion

A multidisciplinary carepath to standardize disparate concussion care was developed and implemented at the Cleveland Clinic. The Cleveland Clinic Concussion (C3) mobile application was used to enable the carepath through biomechanical outcomes characterizing cognitive and motor function. Patient outcomes improved while cost of care was reduced following implementation.

The evidence-informed standardization of care along disease lines is recommended to improve outcomes and reduce healthcare costs. The aim of this project ...

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6.6K Views.  Cleveland Clinic Foundation. Deze technologie maakt de objectieve kwantificering van de meervoudige symptomen van een hersenschudding, en laat meerdere aanbieders om deze technologie te gebruiken om informatie te delen over de neuro-prestaties van een individu. Een van de voordelen van deze technologie is dat het ons in staat stelt om objectief te kwantificeren de meervoudige symptomen van een hersenschudding. Zo kan het saldo dat doorgaans op een zeer subjectieve manier wordt geëvalueerd, nu worden gekwantificeerd met ...

Video: Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion

An Investigation of the Effects of Sports-related Concussion in Youth Using Functional Magnetic Resonance Imaging and the Head Impact Telemetry System

One of the most commonly reported injuries in children who participate in sports is concussion or mild traumatic brain injury (mTBI)1. Children and youth involved in organized sports such as competitive hockey are nearly six times more likely to suffer a severe concussion compared to children involved in other leisure physical activities2. While the most common cognitive sequelae of mTBI appear similar for children and adults, the recovery profile and breadth of consequences in children remains largely unknown2, as does the influence of pre-injury characteristics (e.g. gender) and injury details (e.g. magnitude and direction of impact) on long-term outcomes. Competitive sports, such as hockey, allow the rare opportunity to utilize a pre-post design to obtain pre-injury data before concussion occurs on youth characteristics and functioning and to relate this to outcome following injury. Our primary goals are to refine pediatric concussion diagnosis and management based on research evidence that is specific to children and youth. To do this we use new, multi-modal and integrative approaches that will:
 1.Evaluate the immediate effects of head trauma in youth 
2.Monitor the resolution of post-concussion symptoms (PCS) and cognitive performance during recovery 
3.Utilize new methods to verify brain injury and recovery
To achieve our goals, we have implemented the Head Impact Telemetry (HIT) System. (Simbex; Lebanon, NH, USA). This system equips commercially available Easton S9 hockey helmets (Easton-Bell Sports; Van Nuys, CA, USA) with single-axis accelerometers designed to measure real-time head accelerations during contact sport participation 3 - 5. By using telemetric technology, the magnitude of acceleration and location of all head impacts during sport participation can be objectively detected and recorded. We also use functional magnetic resonance imaging (fMRI) to localize and assess changes in neural activity specifically in the medial temporal and frontal lobes during the performance of cognitive tasks, since those are the cerebral regions most sensitive to concussive head injury 6. Finally, we are acquiring structural imaging data sensitive to damage in brain white matter.

This article provides an overview of a multi-modal approach to mild traumatic brain injury diagnosis and recovery in youth. This approach combines neuropsychological testing with functional magnetic resonance imaging and the Head Impact Telemetry System to monitor the relationship between head impacts and brain activity during cognitive testing.

One of the most commonly reported injuries in children who participate in sports is concussion or mild traumatic brain injury (mTBI)1. Children and youth ...

Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care

The Institute of Medicine has targeted patient-centeredness as an important area of quality improvement. A major dimension of patient-centeredness is respect for patient's values, preferences, and expressed needs. Yet specific approaches to gaining this understanding and translating it to quality care in the clinical setting are lacking. From a patient perspective quality is not a simple concept but is best understood in terms of five dimensions: technical outcomes; decision-making efficiency; amenities and convenience; information and emotional support; and overall patient satisfaction. Failure to consider quality from this five-pronged perspective results in a focus on medical outcomes, without considering the processes central to quality from the patient's perspective and vital to achieving good outcomes. In this paper, we argue for applying the concept of fair process in clinical settings. Fair process involves using a collaborative approach to exploring diagnostic issues and treatments with patients, explaining the rationale for decisions, setting expectations about roles and responsibilities, and implementing a core plan and ongoing evaluation. Fair process opens the door to bringing patient expertise into the clinical setting and the work of developing health care goals and strategies. This paper provides a step by step illustration of an innovative visual approach, called photovoice or photo-elicitation, to achieve fair process in clinical work with acquired brain injury survivors and others living with chronic health conditions. Applying this visual tool and methodology in the clinical setting will enhance patient-provider communication; engage patients as partners in identifying challenges, strengths, goals, and strategies; and support evaluation of progress over time. Asking patients to bring visuals of their lives into the clinical interaction can help to illuminate gaps in clinical knowledge, forge better therapeutic relationships with patients living with chronic conditions such as brain injury, and identify patient-centered goals and possibilities for healing. The process illustrated here can be used by clinicians, (primary care physicians, rehabilitation therapists, neurologists, neuropsychologists, psychologists, and others) working with people living with chronic conditions such as acquired brain injury, mental illness, physical disabilities, HIV/AIDS, substance abuse, or post-traumatic stress, and by leaders of support groups for the types of patients described above and their family members or caregivers.

This paper illustrates an innovative visual approach (photovoice or photo-elicitation) to achieve fair process in clinical care for patients living with chronic health conditions, illuminate gaps in clinical knowledge, forge better therapeutic relationships, and identify patient-centered goals and possibilities for healing.

The Institute of Medicine has targeted patient-centeredness as an important area of quality improvement. A major dimension of patient-centeredness is ...

Vision Training Methods for Sports Concussion Mitigation and Management

There is emerging evidence supporting the use vision training, including light board training tools, as a concussion baseline and neuro-diagnostic tool and potentially as a supportive component to concussion prevention strategies. This paper is focused on providing detailed methods for select vision training tools and reporting normative data for comparison when vision training is a part of a sports management program. The overall program includes standard vision training methods including tachistoscope, Brock&#8217;s string, and strobe glasses, as well as specialized light board training algorithms. Stereopsis is measured as a means to monitor vision training affects. In addition, quantitative results for vision training methods as well as baseline and post-testing *A and Reaction Test measures with progressive scores are reported. Collegiate athletes consistently improve after six weeks of training in their stereopsis, *A and Reaction Test scores. When vision training is initiated as a team wide exercise, the incidence of concussion decreases in players who participate in training compared to players who do not receive the vision training. Vision training produces functional and performance changes that, when monitored, can be used to assess the success of the vision training and can be initiated as part of a sports medical intervention for concussion prevention.

This paper describes a protocol to conduct, quantitatively monitor, and assess the success of vision training initiated as part of a sports medical management program including intervention for concussion prevention and performance enhancement.

There is emerging evidence supporting the use vision training, including light board training tools, as a concussion baseline and neuro-diagnostic tool ...

Behavior

Development of an Audio-based Virtual Gaming Environment to Assist with Navigation Skills in the Blind

Audio-based Environment Simulator (AbES) is virtual environment software designed to improve real world navigation skills in the blind. Using only audio based cues and set within the context of a video game metaphor, users gather relevant spatial information regarding a building's layout. This allows the user to develop an accurate spatial cognitive map of a large-scale three-dimensional space that can be manipulated for the purposes of a real indoor navigation task. After game play, participants are then assessed on their ability to navigate within the target physical building represented in the game. Preliminary results suggest that early blind users were able to acquire relevant information regarding the spatial layout of a previously unfamiliar building as indexed by their performance on a series of navigation tasks. These tasks included path finding through the virtual and physical building, as well as a series of drop off tasks. We find that the immersive and highly interactive nature of the AbES software appears to greatly engage the blind user to actively explore the virtual environment. Applications of this approach may extend to larger populations of visually impaired individuals.

Audio-based Environment Simulator (AbES) is virtual environment software designed to improve real world navigation skills in the blind.

Audio-based Environment Simulator (AbES) is virtual environment software designed to improve real world navigation skills in the blind. Using only audio ...

Collecting Saliva and Measuring Salivary Cortisol and Alpha-amylase in Frail Community Residing Older Adults via Family Caregivers

Salivary measures have emerged in bio-behavioral research that are easy-to-collect, minimally invasive, and relatively inexpensive biologic markers of stress. This article we present the steps for collection and analysis of two salivary assays in research with frail, community residing older adults-salivary cortisol and salivary alpha amylase. The field of salivary bioscience is rapidly advancing and the purpose of this presentation is to provide an update on the developments for investigators interested in integrating these measures into research on aging. Strategies are presented for instructing family caregivers in collecting saliva in the home, and for conducting laboratory analyses of salivary analytes that have demonstrated feasibility, high compliance, and yield quality specimens. The protocol for sample collection includes: (1) consistent use of collection materials; (2) standardized methods that promote adherence and minimize subject burden; and (3) procedures for controlling certain confounding agents. We also provide strategies for laboratory analyses include: (1) saliva handling and processing; (2) salivary cortisol and salivary alpha amylase assay procedures; and (3) analytic considerations.

We demonstrate: (1) procedures for collection of salivary samples in cognitive impaired older adults by family caregivers in the home setting, (2) procedures for measuring stress activity via salivary cortisol and alpha amylase, and (3) representative profiles. Protocols that allow researchers to study stress-linked processes advance our understanding of biological sensitivity and susceptibility.

Salivary measures have emerged in bio-behavioral research  that are easy-to-collect, minimally invasive, and relatively inexpensive  biologic markers of ...

A Multi-Modal Approach to Assessing Recovery in Youth Athletes Following Concussion

Concussion is one of the most commonly reported injuries amongst children and youth involved in sport participation. Following a concussion, youth can experience a range of short and long term neurobehavioral symptoms (somatic, cognitive and emotional/behavioral) that can have a significant impact on one&#8217;s participation in daily activities and pursuits of interest (e.g., school, sports, work, family/social life, etc.). Despite this, there remains a paucity in clinically driven research aimed specifically at exploring concussion within the youth sport population, and more specifically, multi-modal approaches to measuring recovery. This article provides an overview of a novel and multi-modal approach to measuring recovery amongst youth athletes following concussion. The presented approach involves the use of both pre-injury/baseline testing and post-injury/follow-up testing to assess performance across a wide variety of domains (post-concussion symptoms, cognition, balance, strength, agility/motor skills and resting state heart rate variability). The goal of this research is to gain a more objective and accurate understanding of recovery following concussion in youth athletes (ages 10-18 years). Findings from this research can help to inform the development and use of improved approaches to concussion management and rehabilitation specific to the youth sport community.

This article provides an overview of a multi-modal approach to assessing recovery following concussion in youth athletes. The described protocol uses pre- and post-concussion assessment of performance across a wide variety of domains and can inform the development of improved concussion rehabilitation protocols specific to the youth sport community.

Concussion is one of the most commonly reported injuries amongst children and youth involved in sport participation. Following a concussion, youth can ...

A Neuroscientific Approach to the Examination of Concussions in Student-Athletes

Concussions are occurring at alarming rates in the United States and have become a serious public health concern. The CDC estimates that 1.6 to 3.8 million concussions occur in sports and recreational activities annually. Concussion as defined by the 2013 Concussion Consensus Statement &#8220;may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an &#8216;impulsive&#8217; force transmitted to the head.&#8221; Concussions leave the individual with both short- and long-term effects. The short-term effects of sport related concussions may include changes in playing ability, confusion, memory disturbance, the loss of consciousness, slowing of reaction time, loss of coordination, headaches, dizziness, vomiting, changes in sleep patterns and mood changes. These symptoms typically resolve in a matter of days. However, while some individuals recover from a single concussion rather quickly, many experience lingering effects that can last for weeks or months. The factors related to concussion susceptibility and the subsequent recovery times are not well known or understood at this time. Several factors have been suggested and they include the individual&#8217;s concussion history, the severity of the initial injury, history of migraines, history of learning disabilities, history of psychiatric comorbidities, and possibly, genetic factors. Many studies have individually investigated certain factors both the short-term and long-term effects of concussions, recovery time course, susceptibility and recovery. What has not been clearly established is an effective multifaceted approach to concussion evaluation that would yield valuable information related to the etiology, functional changes, and recovery. The purpose of this manuscript is to show one such multifaceted approached which examines concussions using computerized neurocognitive testing, event related potentials, somatosensory perceptual responses, balance assessment, gait assessment and genetic testing.

There is great variability in an individual&#8217;s risk for concussion and their corresponding recovery. A multifaceted approach to concussion evaluation is warranted; including baseline testing of athletes before participation in sport and timely evaluation post injury. The goal of this protocol is to provide an appropriate multifaceted approach to examine concussions.

Concussions are occurring at alarming rates in the United States and have become a serious public health concern. The CDC estimates that 1.6 to 3.8 ...

Autonomic Function Following Concussion in Youth Athletes: An Exploration of Heart Rate Variability Using 24-hour Recording Methodology

Participation in organized sports makes a significant contribution to youth development, but places youth at a higher risk for sustaining a concussion. To date, return-to-activity decision-making has been anchored in the monitoring of self-reported concussion symptoms and neurocognitive testing. However, multi-modal assessments that corroborate objective physiological measures with traditional subjective symptom reporting are needed and can be valuable. Heart rate variability (HRV) is a non-invasive physiological indicator of the autonomic nervous system, capturing the reciprocal interplay between the sympathetic and parasympathetic nervous systems. There is a dearth of literature exploring the effect of concussion on HRV in youth athletes, and developmental differences preclude the application of adult findings to a pediatric population. Further, the current state of HRV methodology has primarily included short-term (5-15 min) recordings, by using resting state or short-term physical exertion testing to elucidate changes following concussion. The novelty in utilizing a 24 h&#160;recording methodology is that it has the potential to capture natural variation in autonomic function, directly related to the activities a youth athlete performs on a regular basis. Within a prospective, longitudinal research setting, this novel approach to quantifying autonomic function can provide important information regarding the recovery trajectory, alongside traditional self-report symptom measures. Our objectives regarding a 24 h recording methodology were to (1) evaluate the physiological effects of a concussion in youth athletes, and (2) describe the trajectory of physiological change, while considering the resolution of self-reported post-concussion symptoms. To achieve these objectives, non-invasive sensor technology was implemented. The raw beat-to-beat time intervals captured can be transformed to derive time domain and frequency domain measures, which reflect an individual&#39;s ability to adapt and be flexible to their ever-changing environment. By using non-invasive heart rate technology, autonomic function can be quantified outside of a traditional controlled research setting.

We demonstrate a 24 h heart rate recording methodology to evaluate the influence of concussion across the recovery trajectory in youth athletes, within an ecologically valid context.

Participation in organized sports makes a significant contribution to youth development, but places youth at a higher risk for sustaining a concussion. To ...

Objectively Assessing Sports Concussion Utilizing Visual Evoked Potentials

A portable system capable of measuring steady-state visual-evoked potentials (SSVEP) was developed to provide an objective, quantifiable method of electroencephalogram (EEG) testing following a traumatic event. In this study, the portable system was used on 65 healthy rugby players throughout a season to determine whether SSVEP are a reliable electrophysiological biomarker for concussion. Preceding the competition season, all players underwent a baseline SSVEP assessment. During the season, players were re-tested within 72 h of a match for either test-retest reliability or post-injury assessment. In the case of a medically diagnosed concussion, players were reassessed again once deemed recovered by a physician. The SSVEP system consisted of a smartphone housed in a VR-frame delivering a 15 Hz flicker stimulus, while a wireless EEG headset recorded occipital activity. Players were instructed to stare at the screen's fixation point while remaining seated and quiet. Electrodes were arranged according to the 10-20 EEG-positioning nomenclature, with O1-O2 being the recording channels while P1-P2 the references and bias, respectively. All EEG data was processed using a Butterworth bandpass filter, Fourier transformation, and normalization to convert data for frequency analysis. Players SSVEP responses were quantified into a signal-to-noise ratio (SNR), with 15 Hz being the desired signal, and summarized into respective study groups for comparison. Concussed players were seen to have a significantly lower SNR compared to their baseline; however, post-recovery, their SNR was not significantly different from the baseline. Test-retest indicated high device reliability for the portable system. An improved portable SSVEP system was also validated against an established EEG amplifier to ensure the investigative design is capable of obtaining research quality EEG measurements. This is the first study to identify differences in SSVEP responses in amateur athletes following a concussion and indicates the potential for SSVEP as an aid in concussion assessment and management.

A portable system capable of measuring steady-state visual-evoked potentials was developed and trialed on 65 amateur rugby players over 18 weeks to investigate SSVEP as a potential electrophysiological biomarker for concussion. Players' baselines were measured pre-season, with retesting for reliability, concussion, and recovery assessment being conducted within controlled time-periods, respectively.

A portable system capable of measuring steady-state visual-evoked potentials (SSVEP) was developed to provide an objective, quantifiable method of ...

Neuroscience

CHILD Model &#8212; Recapitulating Juvenile Concussion and Long-Term Outcomes in Mice

A Pediatric Concussion Model in Mice: Closed Head Injury with Long-Term Disorders (CHILD)

Concussions and mild traumatic brain injuries (mTBI) during childhood represent a significant health endangerment, with many patients later in life exhibiting debilitating physiological, neurological, and psychosocial outcomes. The cellular and molecular pathophysiological mechanisms are relatively unknown, and this significant gap effectively precludes investigations into specific therapeutic strategies to mitigate chronic sequelae. No single animal concussion model recapitulates all the features reported in human subjects, and current models are designed to answer specific research questions. We set out to develop a juvenile concussion that recapitulates clinical early, and long-term symptomology encountered, termed Closed Head Injury with Long-term Disorder (CHILD). In this model, a concussive force via an electromagnetic impactor is delivered to the head of a lightly anesthetized unrestrained post-natal day 17 (P17) mouse, allowing free rotation of the head. Mice are placed on a tightly stretched tin foil across a stereotactic device, and the impactor is carefully aligned with the targeted cortical region. The electromagnetic impactor facilitates the selection of impact depth, dwell, and duration to determine injury severity. A strength of this model is that it allows head rotation, an important clinical feature. After impact, mice are immediately monitored for righting time and time to explore their environment, followed by their return to their dam. Increasing the severity of concussion results in intracranial bleeds in a subset of mice. Mice can be routinely monitored for behavior and neuroimaging over their lifespan, as desired. Various injury severities mimic the heterogeneous nature of juvenile concussions. The current standard CHILD model exhibits no skull fracture, no observable conventional neuroimaging change (similar to clinical), but leads to progressive and persistent neuronal death, altered diffusion MRI, modified neuronal activity and plasticity, increased gliosis, and progressive behavioral perturbations with age. In summary, this CHILD model mimics the early and long-term features observed in many clinical concussion patients.

Pediatric concussions can result in long-term sequelae with physiological and psychological perturbations. This pediatric concussion mouse model results in long-term neuroinflammation, white matter alterations, and neuronal modifications with behavioral dysfunction. The model can be adapted to differential impact locations or repeated concussions to assess lifetime changes.

Concussions and mild traumatic brain injuries (mTBI) during childhood represent a significant health endangerment, with many patients later in life ...

Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion

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