Interpreting Clinical Reaction Time Change and Recovery After Concussion: A Baseline Versus Norm-Based Cutoff Score Comparison

Context Preseason testing can be time intensive and cost prohibitive. Therefore, using normative data for postconcussion interpretation in lieu of preseason testing is desirable. Objective To establish the recovery trajectory for clinical reaction time (RTclin) and assess the usefulness of changes from baseline (comparison of postconcussion scores with individual baseline scores) and norm-based cutoff scores (comparison of postconcussion scores with a normative mean) for identifying impairments postconcussion. Design Case-control study. Setting Multisite clinical setting. Patients or Other Participants An overlapping sample of 99 participants (age = 19.0 ± 1.1 years) evaluated within 6 hours postconcussion, 176 participants (age = 18.9 ± 1.1 years) evaluated at 24 to 48 hours postconcussion, and 214 participants (age = 18.9 ± 1.1 years) evaluated once they were cleared to begin a return-to-play progression were included. Participants with concussion were compared with 942 control participants (age = 19.0 ± 1.0 years) who did not sustain a concussion during the study period but completed preseason baseline testing at 2 points separated by 1 year (years 1 and 2). Main Outcome Measure(s) At each time point, follow-up RTclin (ie, postconcussion or year 2) was compared with the individual year 1 preseason baseline RTclin and normative baseline data (ie, sex and sport specific). Receiver operating characteristic curves were calculated to compare the sensitivity and specificity of RTclin change from baseline and norm-based cutoff scores. Results Clinical reaction time performance declined within 6 hours (18 milliseconds, 9.2% slower than baseline). The decline persisted at 24 to 48 hours (15 milliseconds, 7.6% slower than baseline), but performance recovered by the time of return-to-play initiation. Within 6 hours, a change from baseline of 16 milliseconds maximized combined sensitivity (52%) and specificity (79%, area under the curve [AUC] = 0.702), whereas a norm-based cutoff score of 19 milliseconds maximized combined sensitivity (46%) and specificity (86%, AUC = 0.700). At 24 to 48 hours, a change from baseline of 2 milliseconds maximized combined sensitivity (64%) and specificity (61%, AUC = 0.666), whereas a norm-based cutoff score of 0 milliseconds maximized combined sensitivity (63%) and specificity (62%, AUC = 0.647). Conclusions Norm-based cutoff scores can be used for interpreting RTclin scores postconcussion in collegiate athletes when individual baseline data are not available, although low sensitivity and specificity limit the use of RTclin as a stand-alone test.

ANXIETY, FEAR, AND MOVEMENT FOLLOWING SPORTS-RELATED CONCUSSION: HOW DOES KINESIOPHOBIA CORRELATE TO SYMPTOMS AND REACTION TIME?

Background: Fear of pain with movement, also known as kinesiophobia, has been widely studied in various musculoskeletal injuries, yet little is known about its relationship to concussion. Given that concussion can negatively affect neuromuscular control and anxiety, re-integration into sports following a concussion may be associated with kinesiophobia. Hypothesis/Purpose: Our primary purpose was to examine kinesiophobia, among youth athletes with concussion compared to uninjured controls. Secondarily, we sought to examine correlations between kinesiophobia with concussion symptom severity and reaction time. We hypothesized adolescents with concussion would demonstrate greater kinesiophobia compared to controls. Additionally, we hypothesized that greater kinesiophobia would be correlated with higher symptom severity and slower reaction times. Methods: We conducted a repeated measures study of 48 youth athletes. Participants were evaluated at two time points. The concussion group was assessed within 14 days of injury and once cleared for return to play (RTP) by physician. The control group was tested initially and again approximately 28 days later. Participants completed Tampa Scale of Kinesiophobia (TSK), Post-Concussion Symptom Inventory (PCSI), and clinical reaction time (CRT) assessments. We compared mean group differences and assessed the correlation of TSK with PCSI and CRT, at each assessment. Results: We included 26 participants with a concussion and 16 controls (Table 1). The concussion group reported significantly greater TSK scores at the initial assessment (38.0±5.6 vs. 29.3±6.9; p<0.001; Figure 1) and a significantly greater proportion of “high” TSK scores (>36) compared to controls (69% vs. 19%; p = 0.004; Table 1). At the follow-up assessment, there were no significant between group differences in TSK scores (32.8±7.0 vs. 30.4±7.5; p=0.35; Figure 1), or the proportion of “high” TSK scores (38% vs. 25%; p=0.51; Figure 1). TSK scores were significantly and moderately correlated with PCSI for the concussion group at both assessments (r=0.53; p=0.006 at visit 1, r=0.47; p=0.01 at visit 2; Figure 2), but not for controls (Figure 2). Furthermore, TSK scores were significantly and moderately correlated with CRT for the concussion group (r=0.50; p=0.01; Figure 2), but not controls (r= -0.26; p=0.37; Figure 2) at the follow-up assessment. Conclusion: Adolescents recovering from concussion commonly reported high kinesiophobia at initial concussion assessment, while many no longer reported high kinesiophobia when given RTP clearance. Furthermore, kinesiophobia was significantly correlated with self-reported concussion symptoms and clinical reaction time scores. The correlation between kinesiophobia and reaction time suggests a perception-behavior relationship with post-concussion movement deficits may exist. Tables/Figures: [Table: see text][Figure: see text][Figure: see text]

Additional Exergames to Regular Tennis Training Improves Cognitive-Motor Functions of Children but May Temporarily Affect Tennis Technique: A Single-Blind Randomized Controlled Trial

This study evaluated the effects of an exergame program (TennisVirtua-4, Playstation Kinect) combined with traditional tennis training on autonomic regulation, tennis technique, gross motor skills, clinical reaction time, and cognitive inhibitory control in children. Sixty-three children were randomized into four groups (1st – two exergame and two regular trainings sessions/week, 2nd – one exergame and one regular training sessions/week, 3rd – two regular trainings sessions/week, and 4th – one regular training session/week) and compared at baseline, 6-month immediately post intervention and at 1-year follow-up post intervention. At 6-month post intervention the combined exergame and regular training sessions revealed: higher breathing frequency, heart rate (all ps ≤ 0.001) and lower skin conductance levels (p = 0.001) during exergaming; additional benefits in the point of contact and kinetic chain elements of the tennis forehand and backhand technique (all ps ≤ 0.001); negative impact on the shot preparation and the follow-through elements (all ps ≤ 0.017); higher ball skills (as part of the gross motor skills) (p &lt; 0.001); higher percentages of clinical reaction time improvement (1st −9.7% vs 3rd group −7.4% and 2nd −6.6% vs 4th group −4.4%, all ps ≤ 0.003) and cognitive inhibitory control improvement in both congruent (1st −20.5% vs 3rd group −18.4% and 2nd −11.5% vs 4th group −9.6%, all ps ≤ 0.05) and incongruent (1st group −19.1% vs 3rd group −12.5% and 2nd group −11.4% vs 4th group −6.5%, all ps ≤ 0.001) trials. The 1-year follow-up test showed no differences in the tennis technique, clinical reaction time and cognitive inhibitory control improvement between groups with the same number of trainings per week. The findings support exergaming as an additional training tool, aimed to improve important cognitive-motor tennis skills by adding dynamics to the standardized training process. Caution should be placed to planning this training, e.g., in a mesocycle, since exergaming might decrease the improvement of specific tennis technique parts of the trainees. (ClinicalTrials.gov; ID: NCT03946436).

Clinical Reaction Time After Concussion: Change From Baseline Versus Normative-Based Cutoff Scores

Context: Pre-season testing is often used to establish baseline scores for post-concussion interpretation. However, pre-season testing can be time-intensive and cost-prohibitive, in which case normative data may be used for post-injury interpretation. Objective: To compare change from baseline and normative-based cutoff scores in interpreting clinical reaction time (RTclin) following concussion. Design: Prospective case-control study. Setting: Multi-site study with testing completed in university athletic training rooms. Patients or Other Participants: An overlapping sample of 99 participants (age=19.0±1.1 years) evaluated within 6 hours post injury, 176 participants (age 18.9±1.1 years) evaluated 24–48 hours post injury, and 214 participants (18.9±1.1 years) evaluated at the time they were cleared to begin a return-to-play progression. Concussion participants were compared to 942 control participants (age=19.0±1.0 years) who did not sustain a concussion during the study period but completed preseason baseline testing one year apart. Main Outcome Measures: At each time point, follow-up RTclin (i.e., post injury or year 2) was compared to individualized year 1 preseason baseline RTclin and to normative baseline data (i.e., sex- and sport-specific). Receiver operating characteristic curves were used to compare sensitivity and specificity of RTclin change from baseline and normative-based cutoff scores. Results: Within 6h, change from baseline of 16ms maximized combined sensitivity (52%) and specificity (78%, AUC=0.702), while normative-based cutoff scores of 19ms maximized combined sensitivity (45%) and specificity (86%, AUC=0.700). At 24–48h, change from baseline of 2ms maximized combined sensitivity (64%) and specificity (61%, AUC=0.666), while normative-based cutoff scores of 0ms maximized combined sensitivity (63%) and specificity (62%, AUC=0.647). Conclusions: Normative-based cutoff scores can be used for interpreting RTclin scores following concussion when individualized baseline data is not available, although low sensitivity and specificity may limit clinical use as a stand-alone test.

Clinical Reaction-Time Performance Factors in Healthy Collegiate Athletes

Context In the absence of baseline testing, normative data may be used to interpret postconcussion scores on the clinical reaction-time test (RTclin). However, to provide normative data, we must understand the performance factors associated with baseline testing. Objective To explore performance factors associated with baseline RTclin from among candidate variables representing demographics, medical and concussion history, self-reported symptoms, sleep, and sport-related features. Design Cross-sectional study. Setting Clinical setting (eg, athletic training room). Patients or Other Participants A total of 2584 National Collegiate Athletic Association student-athletes (n = 1206 females [47%], 1377 males [53%], and 1 unreported (&lt;0.1%); mass = 76.7 ± 18.7 kg; height = 176.7 ± 11.3 cm; age = 19.0 ± 1.3 years) from 3 institutions participated in this study as part of the Concussion Assessment, Research and Education Consortium. Main Outcome Measure(s) Potential performance factors were sex; race; ethnicity; dominant hand; sport type; number of prior concussions; presence of anxiety, learning disability, attention-deficit disorder or attention-deficit/hyperactivity disorder, depression, or migraine headache; self-reported sleep the night before the test; mass; height; age; total number of symptoms; and total symptom burden at baseline. The primary study outcome measure was mean baseline RTclin. Results The overall RTclin was 202.0 ± 25.0 milliseconds. Female sex (parameter estimate [B] = 8.6 milliseconds, P &lt; .001, Cohen d = 0.54 relative to male sex), black or African American race (B = 5.3 milliseconds, P = .001, Cohen d = 0.08 relative to white race), and limited-contact (B = 4.2 milliseconds, P &lt; .001, Cohen d = 0.30 relative to contact) or noncontact (B = 5.9 milliseconds, P &lt; .001, Cohen d = 0.38 relative to contact) sport participation were associated with slower RTclin. Being taller was associated with a faster RTclin, although this association was weak (B = −0.7 milliseconds, P &lt; .001). No other predictors were significant. When adjustments are made for sex and sport type, the following normative data may be considered (mean ± standard deviation): female, noncontact (211.5 ± 25.8 milliseconds), limited contact (212.1 ± 24.3 milliseconds), contact (203.7 ± 21.5 milliseconds); male, noncontact (199.4 ± 26.7 milliseconds), limited contact (196.3 ± 23.9 milliseconds), contact (195.0 ± 23.8 milliseconds). Conclusions Potentially clinically relevant differences existed in RTclin for sex and sport type. These results provide normative data adjusting for these performance factors.

Perceptual vision training in non-sport-specific context: effect on performance skills and cognition in young females

Although an increasing interest in vision training for sport performance, whether it may have a transfer to sport-specific skills and whether such transfer could be mediated by cognition remain open issues. To enlighten this point, we tested the effect of 6-weeks sport vision training programmes (requiring generic or volleyball-specific motor actions) in non-sport-specific context compared to a third group performing traditional volleyball training in sport-specific context. Fifty-one female volleyball players were randomly assigned to one of three groups. Before and after training period subjects were tested on accuracy of volleyball-specific skills and cognitive performance (clinical reaction time, executive control, perceptual speed). Accuracy of volleyball-specific skills improved after traditional volleyball training with respect to the vision training groups. Conversely, vision training groups improved cognitive performance (clinical reaction time, executive control and perceptual speed), as compared to traditional volleyball training group. Our results have shown that vision training in non-sport-specific context (both generic or with specific motor actions) improved cognitive performance, but seems to be less effective for improving sport-specific skills. These evidences suggest that environment in which exercises were performed plays a key role to improve perception and action in sport-specific skills, supporting the ecological approach to sport learning.

Examining Practice and Learning Effects With Serial Administration of the Clinical Reaction Time Test in Healthy Young Athletes

Context: The clinical reaction time (RTclin) test has been recommended as a valid test for assessing concussion and determining recovery of reaction time function following concussion. However, it is unknown whether repeat assessment, as is used in postconcussion testing, is affected by learning or practice phenomena. Objective: To determine if a practice or learning effect is present with serial administration of the RTclin test. Design: Randomized control trial. Setting: University athletic training clinics. Participants: A total of 112 healthy collegiate athletes (age = 19.46 [1.34] y). Interventions: The control group completed the RTclin test on days 1 and 60. The experimental group completed the RTclin test on days 1, 2, 3, 7, and 60. Main Outcome Measure: Reaction time as measured with the RTclin test. Results: The difference in RTclin test performance from day 1 to day 60 was not significant (mean change = −2.77 [14.46] ms, P = .42, 95% confidence intervals, −6.40 to 0.862) between groups. The experimental group experienced significant improvement (λ = 0.784, F4,49 = 3.365, P = .02, η2 = .216, power = 0.81) with acute repeat testing. However, post hoc analysis did not reveal a significant difference between scores during the 5 test periods. Conclusions: The results suggest serial administration of the RTclin test does not produce a practice or learning effect. Clinicians, however, should be cautious as the results do provide evidence patients may demonstrate improved scores when testing occurs on repetitive days after initial exposure to the test.