Using mHealth to Tackle the Concussion Conundrum

By Eric Wicklund, mHealth Intelligence

mHealth tools, ranging from apps to headgear the occasional robot, are changing the way schools and youth sports leagues check for concussions in their athletes.

It’s not uncommon these days for a high school or college physical trainer to have a tablet stowed alongside the bandages, water bottles and aspirin. When an athlete suffers a hard hit to the head, the trainer can call up an app that helps measure visual processing, cognitive perception, coordination and memory.

“Professional athletes have doctors on the sideline to test them for concussion symptoms, but students and amateur athletes don’t have that luxury,” says David Eagleman, a professor of psychiatry and behavioral sciences at the Stanford University School of Medicine who founded the mHealth company BrainCheck in 2014. “BrainCheck makes it easy for them to measure their cognitive function on a normal day and then measure changes after an incident or blow to the head. It’s a tremendous tool for athletes and trainers to be aware of these changes that are often subtle and can be missed.”

High-profile concussion cases in professional sports, especially the NFL and NHL, have raised awareness of the devastating health effects of hard and repeated hits to the head. But schools and youth leagues are feeling the pressure as well. The American Journal of Sports Medicine reports that one in five high school athletes sustains a concussion each year – and almost 40 percent of them continue to play after that hit. And a 2013 study estimated that high school football players are twice as likely to sustain a concussion as a college or professional player.

That makes inexpensive and easy-to-use mobile health tools all the more valuable. Sometimes all that’s needed is a good video link to a doctor at the nearest hospital.

In Mississippi, roughly a dozen high schools are partnering with the University of Mississippi Medical Center to provide concussion evaluation services on the sidelines during football games. High school staff (only three of the schools have a trainer) are equipped with a tablet and video-conferencing app that links them to UMMC’s doctors.

“To diagnose a concussion is based mainly on talking to the player and seeing how they’re acting,” Brian Tolleson, MD, one of the doctors at the other end of the video link, told MSNewsNow during a 2015 interview. “It’s not necessarily a physical exam where you need to put your hands on the player.”

“You’ll never prevent a concussion,” Lee Jenkins, executive director of the Mississippi Brain Injury Association, added. “But the thing is you can prevent a second concussion which is when the real danger comes in.”

For more advanced concussion testing, BrainCheck is one of several mHealth companies developing online platforms that test cognitive function. Vizzario, Oculogica and SyncThink are developing or using eye-tracking technology to assess visual attention following a concussive hit. Sonde Health uses audio analysis technology developed at MIT to develop “vocal biomarkers” of mental health disorders, including the lasting effects of a concussion. And imPACT Applications markets a pair of devices, called imPACT (Immediate Post-Concussion Assessment and Cognitive Testing) and imPACT Pediatric, that test reaction time, word recognition and non-verbal problem solving in adults and children who have suffered hits to the head.

imPACT is now partnering with the Dignity Health Foundation, Dignity Health’s Barrow Neurological Institute, the California Interscholastic Foundation and the San Francisco 49ers to launch a mHealth-based concussion testing program in five pilot schools in the San Francisco area. Another 20 area high schools will be using the Dignity Health Concussion Network’s online and app-based educational tools to educate students, coaches, staff and parents on the effects of a concussion.

“This program is necessary to help correct major misunderstandings that most of the population has about concussions,” Jávier Cardenas, MD, director of the Barrow Concussion and Brain Injury Center in Phoenix, said in a release announcing the partnership. “For example, many people believe that a head injury is only a concussion if there is a loss of consciousness, but 90 percent of concussions do not present with that symptom at all. This program empowers athletic directors and coaches to take an injured player out of the game and gives athletes the tools to speak up when something doesn’t feel quite right.”

Robotics companies, meanwhile, are marketing their telemedicine platforms to high schools, colleges and professional sports teams looking for a real-time link to a specialist on the sidelines. Northern Arizona University deploys Vecna’s four-foot-tall VGo robot on the sidelines during football games to provide an instant link to neurologists at the Mayo Clinic in Phoenix.

“Through those two seasons there were 11 players who had suspected concussions and were assessed on-site as well as remotely, using standardized tools,” Mayo neurologist Amaal Starling, MD, said in a story prepared by Vecna. Of those 11 players, she said, nine were diagnosed with a concussion.

“I do see this as a huge tool and advancement for the smaller colleges as well as the high schools,” Starling added. “I think it’s important that every high school have a dedicated athletic trainer who has easy access to a neurologist who can evaluate brain dysfunction.”

In a nod to patient engagement, there’s a fashion element as well. Sports apparel manufacturers like Nike, UnderArmour and Reebok have been or are working on headgear, such as skullcaps and headbands, that can measure the concussive impact to a user’s head or even analyze biometric data and a user’s moods to check for erratic behavior.

Then there’s BioDirection, an Arizona startup that is developing the Tbit, a mobile device that tests a drop of a user’s blood for protein biomarkers released into the bloodstream following a concussion. The company envisions a day when a player can be tested for a concussion in 90 seconds – as easily as a diabetic pricks his or finger to test blood-glucose levels.

“We are addressing an enormous, global unmet medical need with a truly amazing technical platform,” Brian McGlynn, the company’s founding executive vice president and CTO, said in press release announcing the company’s filing of pre-submission information with the U.S. Food and Drug Administration. “Tbit’s ability to quantitatively measure protein biomarkers associated with brain injury at ng/mL concentrations offers the potential to aid in concussion prognosis and unbiased return to play/activity decision making. Tbit is the first step in rapid and affordable, real-time data to improve diagnosis and patient safety.”

Some healthcare providers are gathering data from concussion patients to study side effects and ongoing health issues.

“Concussion is experienced by more than 4 million Americans each year,” says Laura Balcer, MD, the co-director of NYU Langone’s Concussion Center and co-principal investigator in a study, launched last December, that is gathering data from concussion patients using the Concussion Tracker app and Apple’s ResearchKit platform. “Using new technologies, we can now evaluate a potentially large percentage of this population across the country to gain daily insights about concussion, and employ data in ways we previously could not. For instance, this data could enable us to understand daily symptom profiles for patients for the first time.”

The NFL also recognizes the value of mHealth in its efforts to deal with concussions. The NFL Players Association and Harvard University are using ResearchKit in TeamStudy, an app-based study designed to measure the short- and long-term effects faced by NFL athletes.

“Traditionally, we study participants in one location, failing to capture their real-life, day-to-day experience — for example, understanding things like pain and daily activity,” Alvaro Pascual-Leone, MD, chief of cognitive neurology at Beth Israel Deaconess Medical Center in Boston and principal investigator in the study, said in a release issued by the NFL. “Using ResearchKit, we will be able to quickly identify patterns that could lead to treatments for health conditions faced by former NFL players.”

Neurological testing remains one of the hot topics in mHealth innovation and contests across the country. Among the winners of the 2016 Cleveland Medical Hackathon was Reflexion Interactie Technologies, a startup developed by three Case Western Reserve University students that uses a mobile-optimized online screening program to help non-professional athletes and athletic programs to conduct weekly screening programs.

mHealth experts say these platforms have applications far beyond the sports field. They could be adapted to test cognitive function in people dealing with many types of neurological issues, including Alzheimer’s, Parkinson’s, stroke and dementia.

“Concussion and dementia are massive problems in desperate need of better solutions,” says George McLendon, former provost at Rice University and an early investor in BrainCheck, which recently secured $3 million in funding to expand its platform to senior care.