The investigators will employ a comprehensive assessment battery to include
vestibular/oculomotor, cognitive, and symptom domains using measures that are consistent
with the NIH/NINDS common data elements (CDE) and current military clinical practice
guidelines (CPG).
Demographic and health history: Subjects will report medical, concussion and health
history at your first visit including medications. Subjects may be asked sensitive
personal and family history information. Subjects have the right to not disclose the
information requested. This medical and concussion history, as well as your date of
clearance/recovery from concussion will be abstracted from the medical record for
research purposes.
Neurolign Dx_100 I-PAS testing:
I-PAS testing will be conducted by placing the I-PAS goggles on the head of a patient and
asking the patient to follow instructions while a set of tests is performed. Each of
these tests simply involves eye motions in response to a target. The I-PAS Goggles are
FDA approved for the diagnosis of mTBI. Individuals will undergo a subset of tests from
the tests listed below.
Tests: Explanation/eye motion Calibration: Adjusting goggles to focus on eyes Gaze
horizontal: Looking right and left Predictive saccade: Looking where a subject knows a
light will appear Horizontal random Saccade: Looking right and left Vertical random
Saccade: Looking up and down Smooth pursuit horizontal: Following an object right and
left smoothly Smooth pursuit vertical: Following an object up and down smoothly Memory
Guided saccade: Remembering where an object appeared and looking Self-Paced saccade:
Self-generated horizontal saccades Anti-saccade: Looking away from an object that appears
(opposite direction horizontally, same magnitude) Optokinetic: Following a moving
textured background Visual reaction time: Time required to respond with a button press to
a visual target Saccade reaction time: Time required to initiate an eye movement to a
visual target Auditory reaction time: Time required to indicate with a button press that
an auditory stimulus was heard Subjective visual vertical: Aligning a line to be
earth-vertical Subjective visual horizontal: Aligning a line to be earth- horizontal
Vergence and pupil tests: Binocular disparity step and sinusoidal pursuit tracking by eye
and pupil Light Reflex Tests: Consensual pupillary response to light.
Vestibular/Oculomotor Tests Vestibular/Ocular Motor Screening (VOMS) The VOMS will be
used to screen for vestibular and oculomotor symptoms and impairment. The VOMS assesses
impairment via patient-reported symptom provocation following each of the following
components: 1) smooth pursuit, 2) horizontal and vertical saccades, 3) convergence, 4)
horizontal and vertical vestibular ocular reflex (VOR) and 5) visual motion sensitivity
(VMS). Patients verbally rate changes in headache, dizziness, nausea and fogginess
symptoms compared to their immediate pre-assessment state on a scale of 0 (none) to 10
(severe) following each VOMS assessment, to determine if any domain provokes symptoms.
Scores on any VOMS item of 2+ reflects a positive screening cut-off for vestibular or
oculomotor impairment (Mucha et al., 2014). Convergence is also assessed in the VOMS
using both symptom report and objective measurement of the near point of convergence (NPC
averaged across 3 trials. NPC values >5 cm reflect a positive clinical screening cut-off.
The VOMS requires limited equipment: a 14 pt font NPC hand held fixation stick,
metronome, and a 1 page paper scoring form. The VOMS requires approximately 5 minutes to
administer and score.
Dynamic Visual Acuity Test (DVAT) To assess vestibulo-ocular reflex function, the
clinical version of the DVAT will be performed. First, the lens-corrected static visual
acuity will be assessed using a standard Snellen or LogMAR eye chart. The lowest line
that all letters can be read will be recorded. For dynamic visual acuity, the patient
will flex their head down 30 deg, then rotate their head in the yaw plane at a frequency
of about 2 Hz and amplitude of 20-30 deg. A metronome will be used to set the frequency.
Again, the lowest line that all letters can be read will be recorded. A loss of greater
than 2 lines suggests an impaired VORThe DVAT takes approximately 5 minutes to
administer.
Visual Vertigo Analog Scale (VVAS) The VVAS assesses how much dizziness (0-10 visual
analog scale) an individual reports for 9 different activities, such as walking through a
supermarket aisle, being in a room with fluorescent lights, going down an escalator,
walking over a patterned floor, etc. A positive result occurs when an individual rates at
least two of the nine items on the VVAS above zero (VVAS positive). The VVAS takes 5
minutes to administer.
Cognitive Immediate Post-concussion Assessment and Cognitive Testing (ImPACT). ImPACT is
a computerized neurocognitive test that includes six modules: 1) verbal memory, 2) design
memory, 3) X's and O's, 4) symbol matching, 5) color matching, and 6) three letter memory
(ImPACT Applications Inc.). These modules are used to form four composite scores: verbal
and visual memory (%), visual motor processing speed (#), and reaction time (RT) (sec).
The ImPACT also includes the Post-concussion Symptom Scale (PCSS), which is a 22-item
self-reported symptom severity inventory of somatic, cognitive, affective and
sleep-related symptoms. The ImPACT test takes 20-30 minutes to administer.
Automated Neuropsychological Assessment Measure (ANAM). The ANAM will be used to assess
neurocognitive performance. ANAM is a computerized neurocognitive test that includes
eight test modules: 1) code substitution delayed, 2) code substitution, 3) matching to
sample, 4) mathematical processing, 5) procedural reaction time, 6) simple reaction time,
7) simple reaction time repeated, and 8) go/no go (ANAM v. 4.3; Vista Life Sciences).
These modules are scored based on accuracy, speed, and throughput (accuracy/mean reaction
time). The ANAM takes approximately 20 minutes to administer.
Symptoms Modified Balance Error Scoring System (mBESS) The BESS measures postural
stability and consists of three stances including feet side by side, a tandem stance, and
a single-leg stance on the non-dominant leg. The three stances are performed for 20 sec
each, three on a firm surface and three stances on a dynamic (medium density foam)
surface. All stances are completed with eyes closed and with hands on the iliac crests.
Errors include lifting hands off the iliac crests, opening the eyes, stepping, stumbling,
or falling, moving the hip into more than a 30 degree of flexion or abduction, lifting
the forefoot or heel, or remaining out of the testing position for more than 5 seconds.
Each error equals 1 point, with higher scores indicating worse performance. For the
current study, the investigators will use the modified BESS (mBESS) that consists of the
three stances performed on the firm surface only. Clinical cut-offs for BESS suggest that
a total error score 9 or greater indicates clinical impairment in balance. The mBESS
takes approximately 5-6 minutes to administer.
Dizziness Handicap Inventory (DHI) The DHI is a 25-item self-report measure that examines
dizziness-related handicap. It has good psychometric properties, is not prone to ceiling
or floor effects, has been used in the mTBI population, measures deficits across the
spectrum of impairments, activities and participation, and is brief to complete. Each
item is categorized into one of three domains: functional, emotional, or physical. It was
developed with the help of patients who complained of dizziness and uses a three-item
response scale, "yes/sometimes/no" scored as "4/2/0" respectively. The DHI has good
internal consistency for the total score ( 0.89). The test-retest reliability is high (r
= .97) and it is responsive to change in a vestibular population. The DHI has been
validated in individuals with mTBI. The DHI takes approximately 5 minutes to complete.
Neurobehavioral Symptom Inventory (NSI) Per the recommendations of the JPC-8/CRMRP
Complex Traumatic Brain Injury Rehabilitation Research Clinical Trial Award, the NSI will
be completed by all participants. The NSI is a 22-item (i.e. symptom) scale in which
participants rate the severity of symptoms on a 5-point scale (0 = None, 1 = Mild, 2 =
Moderate, 3 = Severe, 4 = Very Severe) ranging from 0-60.
Behavioral Symptom Inventory-18 (BSI-18) The BSI-18 is an 18-item symptom inventory that
assesses the level of psychological distress during the past 7 days on 18 items. The
BSI-18 yields total global severity index ranging from 0-72, as well as somatic,
depression, and anxiety sub-scale scores. Any sub-scale T-score >63 is reflective of
clinical impairment on that sub-scale. The BSI-18 requires 5 minutes to complete and
score.
Pittsburgh Sleep Quality Index (PSQI) The PSQI will be used to assess sleep quality. The
PSQI is a self-report measure including 18 items that comprise seven component scores: 1)
subjective sleep quality, 2) sleep latency, 3) sleep duration, 4) sleep efficiency, 5)
sleep disturbances, 6) sleep medication usage, and 7) daytime dysfunction. Subscale and
global PSQI scores are calculated, with higher scores indicating poorer sleep quality.
Administered Tests
Total test time will be 85-90 minutes per subject and will be conducted in private exam
rooms or the concussion research lab:
ImPACT/PCSS (20-30 min)
VOMS (5 min)
DVAT (5 min)
VVAS (5 min)
mBESS (5 min)
DHI (5 min)
NSI (5 min)
BSI-18 (5 min)
PSQI (5 min)
ANAM (20 min)
Neurolign Dx_100 I-PAS (15-20 min)
mTBI participants will complete 3 visits; Visit 1 within 10 days of injury, Visit 2 11-30
days post-injury, and Visit 3 31 or more days post-injury.
mTBI and control participants will complete their testing at either the UPMC Concussion
Clinic in a private exam room or the concussion research lab in a research dedicated
environment. No testing will occur in an open, non- confidential, public area.
Control participants will complete 1 visit, completing all of the same assessments with
the I-PAS system, surveys, and neurocognitive testing. Testing for Control participants
will be completed at the concussion research lab in a confidential, dedicated research
setting.
Research Coordinators and Research Assistants and clinical faculty (Co-Is) will complete
the above-listed procedures with mTBI and Control participants.