Quantitative Assessment of Balance for Accurate Prediction of Return to Sport From Sport-Related Concussion

Abstract

Background:

Determining when athletes are able to return to sport after sports-related concussion (SRC) can be difficult.

Hypothesis:

A multimodal algorithm using cognitive testing, postural stability, and clinical assessment can predict return to sports after SRC.

Study Design:

Prospective cohort.

Level of Evidence:

Level 2b.

Methods:

Athletes were evaluated within 2 to 3 weeks of SRC. Clinical assessment, Immediate Post Concussion and Cognitive Testing (ImPACT), and postural stability (Equilibrate) were conducted. Resulting data and machine learning techniques were used to optimize an algorithm discriminating between patients ready to return to sports versus those who are not yet recovered. A Fisher discriminant analysis with leave-one-out cross-validation assessed every combination of 2 to 5 factors to optimize the algorithm with lowest combination of type I and type II errors.

Results:

A total of 193 athletes returned to contact sports after SRC at a mean 84.6 days (±88.8). Twelve subjects (6.2%) sustained repeat SRC within 12 months after return to sport. The combination of (1) days since injury, (2) total symptom score, and (3) nondominant foot tandem eyes closed postural stability score created the best algorithm for discriminating those ready to return to sports after SRC with lowest type I error (13.85%) and type II error (11.25%). The model was able to discriminate between patients who were ready to successfully return to sports versus those who were not with area under the receiver operating characteristic (ROC) curve of 0.82.

Conclusion:

The algorithm predicts successful return to sports with an acceptable sensitivity and specificity. Tandem balance with eyes closed measured with a video-force plate discriminated athletes ready to return to sports from SRC when combined in multivariate analysis with symptom score and time since injury. The combination of these factors may pose advantages over computerized neuropsychological testing when evaluating young athletes with SRC for return to contact sports.

Clinical Relevance:

When assessing young athletes sustaining an SRC in a concussion clinic, measuring postural stability in tandem stance with eyes closed combined with clinical assessment and cognitive recovery is effective to determine who is ready to successfully return to sports.