On the Front Lines

January 29, 2015
Athletic trainers need all the assistance they can get in the fight against concussions. Fortunately, there are many new and innovative products that can help them do just that.
By Kristin Maki

Kristin Maki is an Editorial Assistant at Training & Conditioning. She can be reached at: [email protected].


As bodies of research on concussions continue to grow, products to help prevent, diagnose, and treat brain injuries have hit the market. In this article, we take a closer look at some of these advanced products and how they are contributing to the fight against concussions.

Biodex Balance Assessment Program
Objective balance and cognitive testing are important parts of concussion management, as they offer sports medicine professionals a way to evaluate and subsequently monitor an athlete's post-injury condition. By comparing post-injury data to a baseline assessment and/or normative data, athletic trainers can track athletes' recovery for a safe return to play.

"Recent studies have demonstrated that a decreased ability to maintain balance is a hallmark sign of concussion," says Don Gronachan, Director of Physical Medicine Sales at Biodex Medical Systems, Inc. "Research has also shown that separately, current methods of concussion assessment--a graded symptoms checklist, neurocognitive assessment, and objective balance testing--demonstrated sensitivities of 68-, 79-, and 62-percent, respectively. When used together, greater than 90-percent sensitivity was achieved."

The Biodex Balance Assessment Program toolbox includes a software program that takes athletic trainers through baseline testing, post-injury evaluation, and rehabilitation. It includes the modified Clinical Test for Sensory Integration of Balance standardized assessment, which tracks disturbances in balance dysfunction and vestibular issues post-concussion.

The Balance System SD uses a 21.5-inch diameter sensor pad that athletes stand on. It looks like a scale at first glance, with several foot-placement indicator lines on its surface. The pad tilts up to 20 degrees from the horizontal. It includes adjustable handles on the side that can be raised, lowered, or swung out of the way, and a touch-screen monitor. The portable BioSway system uses a static platform and includes a foam pad to stand on for more challenging tests. Both systems provide balance testing with objective documentation, comparisons to normative data, and printed and electronic progress reports. They also offer rehabilitation and protocols to help identify and improve balance problems. Ethernet and USB ports are included for easy printing and connecting with other devices.

"The NCAA, NATA, and other organizations have formulated best practices for concussion management plans," Gronachan says. "These recommendations state that baseline assessments for each student-athlete should be recorded prior to the first practice, and the same assessment tools should be used post-injury at appropriate time intervals. Biodex provides an objective balance assessment device that not only tests for changes in balance, but also estimates the contributions of the visual, vestibular, and somatosensory systems to overall balance."

Concussion Vital Signs
Research has shown that high school and college athletes' brains are still developing. During this time, sustaining a concussion may be one of the greatest risks they encounter on the playing field and therefore must be conscientiously managed. The Web-based concussion management platform Concussion Vital Signs aims to help.

Concussion Vital Signs is a scientifically-based information system that helps clinicians coordinate care, evaluate athletes, and make informed return to play decisions. It includes easily interpreted reports with athletes' raw scores, percentile rankings, and "Validity Indicators" to allow users a quick view of whether a student's effort or performance during the test was valid.

"Concussion Vital Signs was designed to help clinicians and athletic trainers meet the current consensus guidelines for concussion management," says Craig Fitzgerald, Vice President of CNS Vital Signs. "The neurocognitive tests in the assessment platform are validated across numerous peer reviewed medical publications and have been used by over 6,500 clinicians, researchers, hospitals, and academic medical centers in over 52 countries.

"The Web-based platform is optimized to coordinate a continuum of care where doctors and athletic trainers can share information," he continues. "Plus, the administrative console was designed and developed collaboratively with certified athletic trainers and other clinicians to make the evaluation and management of a school-based concussion program as efficient as possible."

Along with these features, Concussion Vital Signs has a lifespan neurocognitive normative database, which enables reliable and valid testing of athletes from ages eight to 90 years old, data collection that allows parents or guardians to enter medical history when it's convenient, an integrated SCAT2 mobile sideline assessment tool for quick concussion screenings, and the ability to capture data with a smart phone or tablet.

The Halo
Recent research is showing that neck strength and flexibility is a factor in concussion prevention. But neck training hasn't always been a simple task. The Halo, a dynamic neck strengthening rotary cable attachment, can change that. The Halo is designed to get a full contraction of the neck's muscles by applying horizontal resistance as the head rotates through exercises.

As its name suggests, the Halo is placed atop the user's head. Made from high-grade aircraft aluminum, it has an adjustable Velcro strap for vertical fit. The device is lined with a bladder that is pumped full of air for a customized fit. And it doesn't take up a lot of space in the weightroom.

"Most weightrooms have a problem with space," says Mike Jolly, CEO and Founder of Mission Competition Fitness, which manufactures the Halo. "Four-way neck machines have a huge footprint, so a gym won't usually have more than one or two of them. Then coaches run into timing problems--how do you get a whole football team through a neck workout if you only have one or two pieces of equipment?

"The Halo solves this problem," he continues. "They're inexpensive and have no footprint, so facilities can have several. If there's a post in the weightroom, all a coach has to do is hook up a couple of Halos to it using bungee cords. If you picture the spokes of a bicycle wheel, you could have a group of players attached to the post with bungee cords working out their necks. If you have an adjustable cable machine, the Halo works great with that."

By applying horizontal resistance on the neck muscle groupings as they contract, the Halo helps build strength and flexibility. Recent research has found that both increased neck strength and flexibility will dissipate the force of head impacts.

"As an athlete's head snaps back after a hit, he can slow that down if he has a strong neck," says Jolly. "If you can slow that blow down with a strong neck, the brain is less likely to bounce off of the skull. And if an athlete has good range of motion in the neck, there's more time to slow the hit down in the first place, before you get the bouncing effect. In doing so, not only might a concussion be prevented, but also the sub-concussive blows that can do a lot of damage over time."

Impact Sensing Mouthguard
By embedding sensors inside its Impact Sensing Mouthguard, i1 Biometrics aims to help athletic trainers determine the location and level of impact sustained by athletes. The device uses sensors placed inside a VistaMaxx plastic mouthguard, which is fully functional with a tight fit on the upper teeth and sturdier than standard ethylene vinyl acetate (EVA) boil-and-bite guards.

The i1 Biometrics Impact Sensing Mouthguard does not prevent concussions. Instead, it informs athletic trainers that an athlete has experienced an impact that may have caused a concussion. Athletic trainers can then use field tests to look for any signs of a concussion and/or compare test results to baseline levels obtained before the season.

The sensored mouthguard fits tightly onto the upper teeth of the athlete. Because the upper teeth are rigidly attached to the skull, the mouthguard can accurately measure skull movement and calculate the acceleration and deceleration experienced by the brain. Data is recorded and transmitted in real time to a laptop or mobile device off the field. When an impact exceeds a predetermined G-force level, an alarm goes off on the connected device to alert an athletic trainer of a sizeable impact.

"In 2008, the Zurich Consensus said that hits greater than 60-G in linear force are more likely to cause concussion," says Jesse Harper, Vice President of Sales at i1 Biometrics. "Thus, when we ship the system, that's where the threshold is set. But the alert level is completely modifiable for each athlete.

"As more research is done, or if the athletic trainer would like to be alerted to lesser hits--for example, with an athlete who's recovering from an injury--they can adjust the threshold," he continues. "So far, everything has been geared toward linear acceleration since that's what the research has been able to collect. But we've added a gyroscope to our sensors so we can measure the rotational force as well. We're looking forward to seeing how this will help improve the research and protect athletes going into the future."

Data is also kept in a cloud storage system for later retrieval. "One of the biggest challenges for athletic trainers is that they're very busy on the sideline," says Harper. "They're taping, icing, and working with their athletes, so they can't see everything that's happening on the field. This mouthguard allows them to capture and receive information about the magnitude and location of head impacts that occur on the field--even if no one sees them happen."

Presagia Sports' Athlete Electronic Health Records
Whether it's dealing with medical records or assessments, paperwork is a tedious necessity for athletic trainers. By integrating medical records, treatment plans, and sideline assessment capacities, Athlete Electronic Health Records by Presagia Sports allow athletic trainers to access and update information conveniently. The Web-based system gives athletic trainers the ability to track every aspect of injuries and illnesses--from a cold all the way to a concussion diagnosis and subsequent recovery process.

"Assessing athletes for concussions is an essential piece of any athletic trainer's job," says Mitchell Slutsken, Director of Presagia Sports. "Along with the athlete's health risk, there's a legal risk. If you're at an away game and an athlete gets injured, the athletic trainer may not have all of the baseline scores handy to make an informed return to play decision. With our system, that information is accessible from a smartphone or tablet--so you can complete an electronic SCAT2 with our system and it will automatically calculate the scores--and you will be able to compare them to the athlete's baseline right away. Not only does it allow an informed decision, but it will show that you use a consistent method across the board."

Along with this functionality, if the assessments indicate that a concussion has occurred, the system has a standardized letter to print and give to the athlete on the spot. In it, basic information about concussions and their treatment is given. Similarly, you can send notifications to the team's other medical personnel, alerting them about the concussion. "There are obviously certain things that need to be kept private, and the system supports HIPAA compliance," Slutsken says. "But it enables users to share this important information with other authorized personnel so that they in turn can make better treatment and medication decisions."

This also allows updates about concussions or other injuries to be shared with coaching staffs of multi-sport athletes. "The great thing about an Athlete Electronic Health Record with an integrated concussion assessment tool is that it is equally applicable for a single team, schools or universities with many sports, or even Olympic teams," Slutsken says. "So if you have athletes competing in many places, all of their information is readily accessible, regardless of where they are. Our system is extremely scalable--from high schools all the way to Olympic teams." n


Sidebar: Nutrition for the Brain
Companies that manufacture supplements designed to help brain function provide updates on their products.


Klean Cognitive
Athletes need mental clarity, focus, and acuity to perform at their best. Klean Cognitive by Klean Athlete is a patented, scientifically researched combination of nutrients and antioxidants designed to support the health of an athlete's brain.

Mitochondrial function in the brain cells is damaged from free radicals and oxidative stress associated with extreme physical fitness, diet, and environmental exposures. This leads to fatigued, poor functioning brain cells and lower neurotransmission.

The acetyl-l-carnitine, alpha lipoic acid, and biotin found in Klean Cognitive have been the focus of research by scientist Dr. Bruce Ames, PhD. These ingredients support the mitochondrial function and energy in all living cells.

Klean Cognitive is tested and certified by the NSF Certified for Sport Program. It is a unique patented formula created to provide a safe and effective foundation to live healthy, train smart, and compete at the best possible level.

Klean Athlete formulas are made by Douglas Laboratories, which is backed by more than 50 years of industry leading experience, and is a trusted manufacturer worldwide. To ensure the highest quality products and meet the most rigorous standards, Douglas Laboratories controls its own manufacturing process with outstanding quality control, from start to finish.

The outcome of supplementing with Klean Cognitive is cellular energy to provide a healthy functioning brain. Klean Athlete is the natural way to peak optimal performance.

*These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.


Neuro-Impact
The three tenets outlining brain trauma are prevention, diagnosis, and treatment. We've seen a major advancement in literally every single area EXCEPT the one most critical to athletes: treatment. Neuro-Impact, from Trinity Sports Group, Inc. (TSG), believes athletes are grateful for all that has come from the growing awareness, but no one has yet addressed how to better help athletes through their recovery when a brain injury is sustained.

Neuro-Impact is an effective and safe formula to promote normal neurologic function. It has shown great results in assisting athletes in their recovery from many of the common symptoms associated with participating in contact sports and activities.

The Institute of Medicine posted an article in April 2011 on the potential role of nutrition in the treatment of brain injuries. An independent clinical trial (reviewed for publication) was done by Dr. W. Joe Ford, BS, DC, CCSP, of Vitality Sports Medicine and showed nutrition could be used in the treatment of brain injuries. Dr. Ford is now with the Dallas Stars to provide both chiropractic care and administer Neuro-Impact.

TSG has partnered with a Baylor University Research Team, led by Dr. Rodney Bowden, PhD, to conduct further studies, and awaits grant approval from the Department of Defense to study usage of Neuro-Impact in the military.

Brain recovery support is long overdue. Neuro-Impact is not a cure by any means, but could be a breakthrough in brain recovery, and should be included in all recovery and return to play protocols.


Brain Armor

By Erin Cernkovich Barrett, PhD
Manager, Nutrition Science & Advocacy at DSM Nutritional Products


DHA and EPA are long-chain polyunsaturated fatty acids (LCPUFAs) that are important for competitive athletes. In addition to supporting a healthy heart, DHA has also been shown to reduce inflammation, muscle damage, and muscle soreness induced by exercise. DHA is the primary structural LCPUFA in the brain and a nutrient critical for brain development and cognitive functions throughout life. As such, DHA is being evaluated as a therapy for concussions.

In animal studies, DHA supplementation before or after a head injury was shown to protect the brain from the injury by reducing axonal damage, inflammation, and cell death, and limiting injury-induced brain dysfunction. The brains of supplemented animals look similar to the brains of uninjured animals. Human studies investigating DHA as a therapy for concussion are currently underway.

The limited availability of DHA in foods customarily consumed in the U.S. and other countries with "Western" diets has resulted in an obvious shortfall in DHA intake. A DHA dietary supplement and foods fortified with DHA represent viable options to increase DHA intake.

life'sDHA, from algae, an ingredient made by DSM Nutritional Products, is a vegetarian source of DHA. It is produced in an FDA- and NSF-inspected facility to ensure the highest quality. Currently, life'sDHA is found in over 550 foods and beverages, including Horizon Organic Milk and Minute Maid Pomegranate juice. Supplements around the world, including Brain Armor, also made by DSM Nutritional Products, are powered by life'sDHA.

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