Balanced approach

Balanced approach

With an increased awareness of the dangers concussions pose to football players from the NFL down to Pee Wee football, the NCAA now requires all Division I member institutions to have a concussion management plan in place for its student athletes to employ policies to reduce and treat occurrences of brain injury.

Lamar University head athletic trainer Josh Yonker said he is committed to doing everything he can to keep his athletes safe after a suspected concussion.

“Essentially, in a concussion, you have an impact on the brain,” said Yonker. “The brain is not tight against the skull, and so in an impact, it will hit against the inside of the skull and kind of bounce back and forth. That can lead to memory loss, light sensitivity, nausea and the other symptoms of a concussion. We have to make sure that an athlete’s brain has returned to normal before we put them back out there because an elevation in heart rate or blood pressure can negatively affect their brain and their recovery.”

At the suggestion of Audiology Program Director Vicky Dionne, Yonker came up with a redesigned plan for Lamar athletes at risk for concussion, which he implemented prior to the 2012 Lamar football season, utilizing the Neurocom balance machine that the Department of Speech and Hearing Sciences purchased in 2009 for its Speech and Hearing Clinic patients.

“Lamar’s new concussion management plan says that if any player is suspect at all of having a potential concussion or a hit that was hard enough, they don’t play in that game,” said Dionne. “They’re benched; no questions asked.”

The new comprehensive plan is designed to provide Lamar student athletes the cutting-edge care necessary for such an injury. The plan ensures that no athlete returns to the field of play without being fully cleared of the injury.

“The subjective nature of post-concussive symptoms makes the decision of allowing athletes to return to play extremely difficult,” said Dionne. “The use of objective cognitive function and postural balance testing is becoming more standard practice in sports medicine to determine when players are ready to return to the field.”

Yonker’s plan centers on baseline testing in two areas prior to play or practice. The first is ImPACT Testing, which is a computer-generated cognitive exam administered by the athletic department that each player takes prior to the season.

“The ImPACT exam is a computerized neuropsychology test,” Yonker said. “Ten words are flashed and the (test takers) have to remember those 10 words. Distracters, such as shapes and lines, are flashed, and then the (test takers) have to go back and make sure they remember those words. It measures reaction time, as well.”

The second baseline exam is a vestibular balance exam called Computerized Dynamic Posturography, which is conducted on specialized equipment, the Neurocom SMART Balance Master. After suffering a concussion, the player will take the exams again, and baseline measures will be compared to post-injury readings. After the symptoms are gone, and the player has returned to baseline values, an athlete will begin the process of returning to full practices and games.

“The baseline numbers are based on age, height and weight,” Dionne said.

The system utilizes a dynamic 18-inch by 18-inch dual forceplate with rotation capabilities to measure the vertical forces exerted by the patient’s feet, and a moveable visual surround; it provides objective assessment and retraining of the sensory and voluntary motor control of balance with visual biofeedback on either a stable or unstable support surface and in a stable or dynamic visual environment, according to Neurocom’s website. 

The Neurocom SMART Balance Master cost Lamar around $130,000, Dionne said. The Department of Speech and Hearing Sciences used Higher Education Assistance Funds as well as clinic revenue to help pay for the equipment, according to Dionne. In addition to the cost of the machine, the department also has to pay audiologists to interpret the data from the concussion test results. And the costs are well worth it, Dionne said.

“The idea here on campus is that they are student athletes — they’re students first,” she said. “If they are going to incur brain injuries, that’s definitely going to impact their ability to be a student, and so that’s got to take priority over everything. There is no money on the line here as far as salaries, so it’s really nice to say the student isn’t playing and we’re going to protect them.”

The tests are of no charge to the athletes because they are Lamar students and help audiologists determine where an athlete’s dizziness is coming from, Dionne said.

“We have to determine if the dizziness is coming from the ear or if it’s coming from the brain,” she said.

An athlete is first placed in a harness to prevent them from falling. The Computerized Dynamic Posturography test the audiology clinic then performs on athletes or patients with a suspected concussion utilizes the Sensory Organization Technique (SOT), which identifies abnormalities in the patient’s use of the three sensory systems that contribute to postural control: somatosensory, visual and vestibular. According to Neurocom’s website, during the SOT, useful information delivered to the patient’s eyes, feet and joints is effectively eliminated through calibrated “sway referencing” of the support surface and/or visual surround, which tilt to directly follow the patient’s anteroposterior body sway.

There is also a Motor Control Test (MCT) given, which assesses the ability of the automatic motor system to quickly recover following an unexpected external disturbance.

“With the MCT, the plate (of the Neurcom machine) will move backwards or forwards in different increments, said Rae Guerrero, an audiology intern who works in the concussion management program at Lamar. “We’re checking (the patient’s) reaction time; people who have concussions can have a slow reaction time, so it gives us a good indicator if that was affected by a concussion.”

An Adaptation Test is also administered to assess a patient’s ability to minimize sway when exposed to surface irregularities and unexpected changes in support surface inclination.

“Instead of (the plate) going backwards or forwards, it goes up or down,” Guerrero said.“It checks their ankle strategy and their reaction time.”

The next test is the Weight Bearing Squat, in which the patient is instructed to maintain equal weight on the two legs while standing erect and then squatting in three positions of knee flexion.

“(The patient) will slowly bend down a little bit (from a standing position) at a time at different degrees like they’re doing a squat (exercise) all the way to a sitting position,” Guerrero said. “We’re checking their weight distribution and if they rely on one leg more than the other, which can help tell if an injury may have occurred.”

Finally a Unilateral Stance test is given, which quantifies postural sway velocity with the patient standing on either the right or left foot on the forceplate, with eyes open and with eyes closed. The length of each trial is 10 seconds.

“They’ll stand on one leg at a time, first with their eyes open and then with their eyes closed.” she said. “We looked to see if anything is affected at that point also.”

After the tests are performed, the results are given to the physician and athletic trainers, who then determine whether an athlete is healthy enough to return to play.

“The importance of a measured return to play has become evident over the years, as coming back too quickly leaves an athlete vulnerable to a second or third concussion in a short amount of time,” said Yonker. “This can lead to far more dangerous conditions, both short term and long term.”

Yonker said the athletic department wouldn’t have been able to afford the Neurocom and that he appreciated Dionne’s efforts in informing him about the technology already available on campus.

“I had this piece of equipment in our clinic that was being underused, and I had students that needed to learn how to use it,” Dionne said. “And (Yonker) wanted more for his athletes.”

“The implementation of this collaborative program between Lamar audiology and athletics has made Lamar University a leader in the Southland Conference for player safety,” said Jason Henderson, Lamar’s athletic director.

To date, about 300 Lamar athletes have had baseline measures obtained, six Lamar football players had post-concussion testing and management and four Lamar volleyball players received post-concussion testing and management.

“The two sports that have the highest rate of concussions across the NCAA are actually women’s basketball and women’s soccer,” Yonker said.

Yonker said all athletes that are in a contact sport and pole-vaulters are required to take baseline testing. Dionne said that the concussion testing is available to non-Lamar students for a fee. For more information, contact the Lamar audiology department at (409) 880-8171 or e-mail Dionne at vickie [dot] dionne [at] lamar [dot] edu.