Designing A New Test To Assess The Effect Of Concussion On Soldiers' Cognition

Design and validate a new test or a new battery of tests to assess the effect of concussion sustained during a military deployment on soldiers’ cognition. 

Effects of Concussion on Soldiers

The Committee on Head Injury Nomenclature of the Congress of Neurological Surgeons (1966) explains concussion as, “a clinical syndrome characterized by the immediate and transient posttraumatic impairment of neural function such as alteration of consciousness, disturbance of vision or equilibrium, etc. due to brain stem involvement.” Later the American Academy in Neurology (AAN) (1997) referred to concussion as “any trauma-induced alteration in the mental status that may or may not include the loss of consciousness.” The First International Symposium on Concussion in Sports in Vienna described concussion as a “complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces (2001).”

Concussion may be as a result of direct hit by a blunt object to the skull, neck, or face, or any other part of the physique that in turns conveys a spontaneous force to the brain. The concussion leads to neuropathological changes in the brain however, the impact is mainly manifested in the functional capacity of the brain other than any structural changes in the head. There may not necessarily be loss of consciousness registered after the concussion as the clinical and cognitive symptoms will resolve sequentially (Giza & Hovda, 2001).

Barr, et al. (2008) states the effects of concussion as having compromised cognitive functionality, reduced stability, and subjective post-concussive symptoms. A study on the impact of concussion conducted on college football players revealed that players suffering from concussion showed 85.2% complained of headaches, 77% had balance problems, and 69.4% reported feeling of reduced cognitive function at the time of the accident. The evidence from the research suggested that players suffering from subjective post concussive grievances and empirically evaluated cognitive function impairment and stability related issues tend to recover fast from the injury, balance issues are sorted within five days, full cognitive functions resume functionality within a week of the injury.

Traumatic brain injury (TBI) is prevalent in the U.S. military. Research by the Defense and Veterans Brain Injury Center (DVBIC) indicates that between 2000 and 2011, 220, 430 soldiers had suffered from Traumatic Brain Injury (TBI) of which 169,209 of these cases were classified as concussions. However, just like in civilians, concussion might be problematic to detect and can be perplexing to manage. This is because during standard imaging it shows no abnormalities, moreover; both signs and symptoms of concussion are subtle (Iverson, Langlois, McCrea, & Kelly, 2009; Ling, Bandak, Armonda, Grant, & Ecklund, 2009).

As of 2003, there were approximately 300,000 cases of concussion related to sports reported. This number however is believed to be an understatement as many of the cases go unreported or due to the lack of awareness of the constituents of concussive symptoms. However, the cognitive functions of the athletes after a concussion are what are employed to determine the suitability to return to play and the various rehabilitation strategies (Aubry, et al., 2002). The normal procedure or established protocol of evaluating the cognitive functions of the brain after a concussion is the short battery of Neuropsychological Test. This compares the performance of the athlete pre-concussion period and post-concussion period. The scores between the two periods are what are used to speak of the mental status during the post-concussion period. Nevertheless, this method has gained considerable attention with many raising issues regarding the methodology itself. Issues raised involve the setting in which the test occurs and the potential effect of other factors such as age and learning difficulty has on the results of the NP test (Duhaime, et al., 2012; Barr, McCrea, & Randolph, 2008; Giza & Hovda, 2001).

Challenges in Detecting Concussion in Soldiers

Early diagnosis of a concussion remains a priority in order to prescribe the suitable remedy and instituting management practices and avoid the premature deployment to battle zones. The presence of cognitive impairment following an accident leading up to the concussion are made by a medical practitioner. Moreover, where the practitioner has no access to any baseline date, the judgment made is based on the athlete’s performance relative to normative data (Aubry, et al., 2002). It is relatively easier where the practitioner has access to baseline data as it becomes easier to compare the possible changes in cognitive functions based on the scores. The method has gained prominence and is advocated for by neuropsychologists and neurologists involved in sports medicine. Neuropsychological testing has being successfully deployed in sport related brain trauma injuries as a clinical measure for identifying the initial affect and track the recovery progress. The results are often used to make critical decision regarding whether or not to resume play (Aubry, et al., 2002; Barr, McCrea, & Randolph, 2008).

Increased evidence sourced from sports medical practice (Guskiewicz, et al., 2003; McCrea, Guskiewicz, & Randolph, 2009)and animal run tests (Giza & Hovda, 2001) prove that potential cases of concussion risk increased possibility of a repeat scenario of the concussion within the first ten days of receiving the concussion. Injuries sustained during training are often mild and trainees often go unchecked due to failure to report and in real combat situations, those with mild concussions quickly resume full duty status. This highlights the importance of understanding the impact on the cognitive and the physical functions of the brain associates with the concussion especially with the increased chances of reoccurring (Schatz & Sandel, 2013).

Neuropsychological tests are essential in the identification, management, and evaluation of concussion cases and assist in giving the green light for normal functioning of the patients. However, the neuropsychological tests are prone to the human aspect (McCrea, Guskiewicz, & Randoplh, 2009). Factors such as depression, stress, fatigue, sleep deprivation, malingering, fear, increased pressure environment and an understatement of the symptoms to avoid appearing weak may influence the results of the tests. I propose using tools that combine science and technology therefore eliminating some of the human factors. One of the key challenges in adequately responding to concussion is in the recognition of the fact that a recruit may have sustained a head injury and should be taken off practice until further investigation are carried out (Barr, McCrea, & Randolph, 2008). As seen earlier chances of a concussion reoccurring are relatively high often meaning the difference between life and death. The presence of a skilled medic, senior officer, or a certified health care provider on the battlefront facilitates health evaluation of the injured soldier. However, their presence is not always guaranteed due to inaccessibility of the soldiers, failed rescue missions, or KIA or MIA soldiers. The decision to have a trainee excused from training comes from the high above. Additional obstruction to the diagnosis of concussion is that the symptoms may not manifest for some hours following the injury, as a result serious manifestation of the symptoms may occur up to 24hours after the impact occurred  (Duhaime, et al., 2012).

Proposed Research

Science has over the years shown diversity in the manner in which concussions manifest itself in the brain making it impossible to rely on a single assessment tool focusing on single subsystem with an aim of establishing inconsistency in the functioning of the brain. This necessitates a blended assessment approach taking into consideration cognition and emotive aspects of the brain, balance, and aculomotor functions (Giza & Hovda, 2001).

The technology I am proposing involves attaching impact sensors on the headgear of recruits. The impact sensors are expected to record the forces transmitted to the head during collision. They can help detect linear and rotational forces applied to the skull. The sensors will record and transmit in real time the number and severity of hits on the head over time. The relevant people will be alerted once the hits reach a certain threshold. Several side-line assessments are accessible to help with the recognition of concussion symptoms during training, influencing the decision on whether the trainee will resume training or not (Aubry, et al., 2002).

Participants: I propose using the recruits being recruited for training. The procedure will be two faced whereby some of the recruits will participate voluntarily whereas for some it will be involuntary. The Neuropsychological test will be carried out as it has already proved its value in diagnosing concussions.

Design: this will be a longitudinal study where the data collected for the subjects will be observed through the training period and once after they have left training and in active duty. The controlled subjects who are the voluntary group will be exposed to stressful conditions, sleep deprivation, and strenuous activities to factor in how such affects the results. Pre-test measures will have being conducted on the army football team and those already in active combat situations.

Materials: besides having a professional diagnose the concussion using a Neuropsychological test, I will need impact sensors such as the Gforcetracker, i1 Biometrics, BlackBox Biometrics, and X2 Biosystems’ xPatch. In collaboration with neurologists, we will identify the appropriate threshold level of force. The impact sensors will report remotely to a reporting software so we will need hand held mobile devices and computers.

Procedure: The impact sensors will be attached to the helmet or the patches placed on the neck or behind the year. While calibrating the threshold of impact, the age of the recruit must be put into consideration.

Reliability and validity criteria

By counting and measuring the velocity of the hits suffered in the head, we will gain valuable data that will help in the prevention of concussion progressing to a full-blown brain damage. If the test is reliable, I expect to see high correlation between the data collected from the impact sensors and the conventional neuropsychological tests. The higher the impact recorded the same will reflect in the sideline measures of psychomotor functions, working memory, cognitive, and decision-making process. The same results are expected to be observed during the test-retest reliability having factored in the human aspect of the test established by the control group. The results should resonate with those of the pre-tests.

1. Recruits who will have transmitted higher numbers and severity to the head will have a slower response in their cognitive functions
2. Soldier in real combat situations will be transmitting higher numbers and severity especially those in volatile areas such as Afghanistan and Iraq than those in training
3. Soldiers who have surpassed a given threshold will transmit a repeat episode of the same over time since those who have suffered are at a heightened risk of suffering another brain injury

Conclusion

Despite the advancement in technology in terms of weapons and body armor, the brain remains prone to non-penetrating injuries such as collisions and explosions during combat (Orcutt, 2016). Practically, the scores from the neuropsychological tests potentially reflect on the general status of the patient. The tests are designed to capture and evaluate the functioning of the brain making the inclusion of the system related errors in the test scores an impediment in the psychometric accuracy of the test (National Research Council, 2014; Schatz & Sandel, 2013; Barr, McCrea, & Randolph, 2008). The major challenge of diagnosing concussion with technology is that there is no specific subsystem of the brain that is universally affected by the concussion. Different cases have different impacts with some complaining of severe headaches, deregulated sleep, cognitive or emotional issues, and balance and equilibrium (Giza & Hovda, 2001).

References

Aubry, M., Cantu, R., Dvorak, J., Baumann, T. G., Johnston, K., Kelly, J., & al., e. (2002). Summary and agreement statement of the ?rst International Conference, Vienna. British Journal of Sports Medicine , 3(6), 6-10.

Barr, W., McCrea, M., & Randolph, &. C. (2008). Neuropsychology of sports related injuries. In J. Morgan, & &. J. Ricker, Textbook of clinical neuropsychology (pp. 660-678). New York: Oxford University Press .

Duhaime, A., Beckwith, J., Maerlender, A., McAllister, T., Crisco, J., Duma, S., . . . Greenwald, &. R. (2012). Spectrum of acute clinical characteristics of diagnosed concussions in college athletes wearing instrumented helmets. Journal of Neurosurgery, 12(5), 547-559.

Giza, C., & Hovda, &. D. (2001). The neurometabolic cascade of concussion. Journal of Athletic Training, 36, 228-235.

Guskiewicz, K., Mcrea, M., Marshall, S., Cantu, R., Randolph, C., Barr, W., & al, e. (2003). Cumulative effects associated ith recurrent concussion in collegiate football players. Journal of the American Medical Association, 290(19), 2549-2555.

Iverson, G., Langlois, J., McCrea, M., & Kelly, J. (2009). Challenges associated with post-deployment screening for mild traumatic brain injury in military personnel. The Clinical Neuropsychologist, 23, 1299–1314.

Ling, G., Bandak, F., Armonda, R., Grant, G., & Ecklund, J. (2009). Explosive blast neurotrauma. Journal of Neurotrauma, 26, 815–825.

McCrea, M., Guskiewicz, K., & Randoplh, &. C. (2009). Effects of symptom free waiting period on clinical outcome and risk of reinjury after sport-related concussion. Neurosurgery, 65(5), 876-883.

National Research Council. (2014). Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. In R. Graham, F. Rivara, & M. F. al, Institute of Medicine. Washington DC: National Academic Press.

Orcutt, M. (2016, June 9). Is This the Diagnostic Tool We’ve Been Waiting for in Concussion Testing? Retrieved from MIT Technology Review : https://www.technologyreview.com/s/601619/is-this-the-diagnostic-tool-weve-been-waiting-for-in-concussion-testing/

Schatz, P., & Sandel, &. N. (2013). Sensitivity and specificity of the online version of ImPACT in high school and collegiate athletes. American Journal of Sports Medicine, 41(2), 321-326