Again, thanks for the committee and AMSSM and the group here for having me today. I'll start with the mic here, and we'll move it up for Andrew as we go. We've got a tall group today for concussion talks, so I'm going to talk about baseline testing. You can see as we move forward into sideline management and such and rehab. I've been at Duke. I'm a family medicine trained, and I've been there for 20 years. T. Mormon's here, one of my good colleagues and forever, so good to see a bunch of friendly faces as well. But I've been there now for 20 years, and I'm their head medical team physician. So in the morning, I'm with you guys and the ortho folks, and then in the afternoon, I go over to the training room and see all our athletes for their primary care needs. Disclosures, BOA is nothing here. Sway Medical is a concussion app that we use at Duke, and so I'll talk about it, but it's definitely nothing that I just, because you'd want to know, what do we do at Duke, right? If I didn't say what we did, that would be kind of weird. But I do like the app, and I'll talk a little bit about how we use it compared to what else is available. We'll go over the components of testing, timing, setting, you know, when do you do it, what are the different settings, and then what kind of different leagues, from high school to pro leagues, kind of what are they doing, so you kind of have an idea of kind of what's available, what are people doing, and then maybe some of the future of what we look at for testing. When you think about the components of testing, obviously the history is important. System score, we'll talk about each of these separately. Cognitive reaction times, probably if you look at a lot of the cognitive testing with, you know, impact or other things, those are probably one of the more important aspects of it, is reaction times, and probably the most valid and reproducible of the cognitive testing balance. There's many different ways to do that. Cervical screen and then VOMS, our vestibular testing is also a very important component that's come online in the last, you know, five to seven years. Then there's always some component, and as a primary care folks, you know, we've got to remember pre-season testing is an educational component as well, right? This is a time, if you look at a symptom score, you look at things, you can kind of address some of those things to help into the season. So if they do, either to prevent concussion or when they do get one, how can you treat it more effectively? Other things that are kind of coming online is vision tracking. There's a lot of different things out there that needs more data. They're all fairly expensive, and so we need to get more data to see, gosh, how to use it, you know, what are good ways to do so. King Divick's probably been the one that's been out there the longest. They started with the paper cards, cardboard cards that we still use at Duke because it was very inexpensive. It used to be $40 for those cards, and now they don't sell them anymore, and so now it's a, that was a whole long email or discussion I could have with you offline, but, you know, now it's just the iPad app, and it's $20 an athlete. So for Duke, that would be, you know, we have 700 athletes or so on walk-ons and everything else. It would be about $14,000 a year for King Divick, which is really expensive for athletic departments to do something like that for a one-test kind of component. So you just have to think about it. I'm not saying don't use it, or there's actually been some decent data for it, but just you got to look at your resources and what you have for some of these things. Again, Andrew talked more about sideline things, but some of the same tests we do for baseline. Obviously, you're going to do a baseline, and then you're going to use that when they get a concussion. So this is from Kim and AMSSM, our consensus statement, and if you look at a lot of things we do, and this is separately looking at what you're looking at with reliability, it's not that great. You have to take things in a separate, on-their-own kind of thing. It's when you maybe combine them, we can get a little better as far as that. Again, King Divick may be the best there out of them, but, you know, symptoms are very subjective, right, compared to the athlete, even the SAC of doing the cognitive testing, you know, best balance testing is very subjective. So what's some of the reliability when you look at baseline testing and some of the articles? And I have the articles there. I didn't want to go over study after study. It's for 10 minutes. That gets it too detailed, but I have them, so if anybody wants the articles, I have them on my drive. I can give them to you. Email me. I have my email at the end. I'm happy to forward them to you if you want, you know, I just didn't want to, like, drag down the thing with study after study, but I do have those for those that want to look at some more of the data in more detail. SCAT-5, if you look at it together with all the components, there is some decent data to show it is, you know, and there's, you know, some good studies to show it's probably pretty good. Impact near the computer-based testing is probably not as good. There's been some really test-retest reliability issues with them. I think, you know, impact, when it came out in the early 2000s, it was the first objective thing we really had, so I think everybody, you know, went on it right away, you know, and so it kind of really got the market before the science, and so I think that's, you know, again, I'm not necessarily an anti-computer testing person, but I'm just saying you just got to know your limitations, and we'll talk about that a little bit. Again, we use the Sway app. You do, it does, what I like about that, I think the reliability gets better. Again, the studies are small, need more data with it, with that, is that it does the three tests in a row, so you get better reliability. It's also using the phone accelerometer and the phone components versus like a best test where somebody's watching somebody, that subjectivity, so I think you have more objectivity with using that kind of thing with that, so that's why I like it anyway. So what if you don't have a baseline, right? There's a lot of times in our concussion clinic we don't have a baseline for these folks either. It was an invalid test. We've had that too, where the kids did an impact or something, but then nobody looked at the result and saw it was an invalid test when they took it. Things get lost. A lot of youth leagues, right, they don't have any money, nobody's getting baseline testing in youth leagues for a lot of things, especially a lot of youth soccer leagues and things with that, and again, the normative values, you know, there are, if you don't have those, there's a lot of normative values available for SCAT-5 and other things, so if you don't have that baseline test, you can at least compare it to those same age and sex with that. Again, computerized testing, all the apps have that built in. And then there's even some data out there, what's the usefulness of baseline testing, right, like some things like sleep and other things, maybe they had poor sleep that night, so crummy tests that are bagging the baseline, like there's a lot of issues with baseline testing too that you could really say maybe, you know, yeah, you want that on that same person is better, but normative values maybe aren't that horrible to use actually compared to some of that, because again, the circumstances could be maybe very different compared to that versus, you know, after they're taking the tests from their baseline test after an injury, so it's not all, you know, so clean as usual in medicine, right? Again, history, this is just the main thing to really think about, you know, again, that pre-season education and knowing their previous concussions, how long did it take them to get better before, all those kind of things can maybe help you hopefully prevent the next one, and so that's where you really got to look at those things and also look at that symptom score, because, you know, I've had kids that are low 20s for their baseline symptom score because they have a lot of other things going on, so you're going to know that's kind of the range you're looking for to get back to. If you didn't know that, and they keep sticking at 20, you keep thinking they're not better, you know, then you're spinning your wheels a little bit, so it's really important to know those things. Again, symptom score, mostly it's under 10, it's usually not zero, but some, a lot of kids just put zero because they don't, aren't even paying attention, they don't care, they just want to get it done, right, as far as that, but, you know, look at those, and if you could kind of figure out maybe some areas, and I'll put on here, again, it's very busy, don't worry about reading all this, this is from our AMSSM statement, but I just want to circle all those, there's those main areas of each component, so if there's, you know, a lot of high ocular symptoms or vestibular symptoms, like there's one area we can really focus on headaches or cognitive things, that's an area that you can really hone in on to help them with their, when they come to that baseline component, so there's just all those different areas, again, you can get it from the consensus statement and look at it in better detail. Again, sleep patterns, they've, you know, sleep-deprived people act like they have a concussion when they take testing, so looking at all those things, right, how many kids, you know, the night before or something, they did their baseline, they're coming in from out of town and just, they do their baseline right away and maybe it wasn't the best or they're sick or something like that, so those are things to look at. Cognitive testing, again, a lot of them, the computer options, again, impact's by far the most common, you also have concussion vital signs, which is free, so you can do it for high schools or middle schools, maybe that, you know, money-wise, that's another consideration that you can do, we've done that for some of our local high schools, have them use that versus impact testing, and those are just the different domains that impact will test, just so you have an idea of, like, what is impact, what does it, you know, kind of do, those are all the kind of areas it's trying to test, and I would say even in the interpretation of it, you know, it's always better to even have a neuropsychologist probably try to interpret some of these things for you, again, there's a, you know, also pen and paper kind of ones as well, and we have our neuropsychologists do, testing our athletes, it's a 45-minute battery they do with our Duke athletes, so it's much better, much more sensitive, they read it, once they have an injury, they redo their test, and so that's much better than doing a computer test, if you look at a lot of the, SCAT 5 went to a 10-word list too, so that's something to look at, there's been some data to say a 10-word list is probably better than the 5, and so there's going to be, I think, more and more things coming out to go to that 10-word list versus the 5, so that's something to kind of be on the lookout for as well, again, just know your limitations with computerized testing, again, sensitivity and sensitivities all over the map, again, a lot of the early data was from the folks that made impact, so you got to look at some of the other ones as well, and again, check validity of baseline, there's some stuff, you know, again, a lot of the validity, you know, again, the trainers are just trying to get through all the baselines, they don't check them, you know, I'm not blaming them, they're busy, they're overworked or whatever else and they just didn't check to see whether they were all valid, and then you get a concussion, you look at it, well, then it's not, you can't really use it, so, balance testing, obviously the first thing, you know, Kevin Guskowitz and those guys at UNC came out with the best, and the balance testing on the foam pad, and then the modified best came with some of the consensus statements that came out of that, so it's probably the most common thing, but again, there's a lot of subjectivity with some of the grading of that, which is, it's still a good component, tandem gates doesn't cost anything other than, you know, time, and most of the, you can just do it, it's like, right, the alcohol kind of screen, you know, right, it's just walking a line as fast as you can back and forth, and there's some nice data, it's about 10 to 12 seconds, it's usually average for most people, and so, you know, if you can do that, you need to do, like, there on the trials, like, four trials in a row to kind of get theirs, what's their fastest, you know, so again, it's just a, it's a labor thing, that's not free, but as far as a yearly cost, that's something you can easily do, the Sway app is, again, it does similar stances to the best, but you're just holding their phone up to them when they're doing those different postures, the SOT test is, not many people use that, and it's expensive, but there's just another screen that you can do, quick cervical screen, right, always think about that for headaches or other things, cognitive issues from cervical things can happen, so think of those things, and for prevention programs, VOMS, again, the vestibular exam has been something that's really been shown to be very important, and Mucha and the folks up at Pittsburgh came up with some nice articles and kind of protocols to come up with your vestibular testing with that, and these are all the different areas that you can test for that, and then comparison to injury data, when they have that, again, the King Divick, if you're not aware of what that is, that's the card on the bottom there, and so you read numbers as fast as you can across the screen, probably like most Leduc athletes are in like a 30-second range, the high school kids are probably close to a minute for kind of normal ones that we've seen. As far as that, Mules is another one, Steve Galletta up at NYU kind of developed that too, he helped kind of validate the King Divick, and then when they kind of got a lot more pricey, they were trying to come up with Mules, Mules is like a bunch of pictures on a card, 8x11 cards you can read as fast as you can, and so there's been some validation studies of that too, so that's something that you can look at compared to injury data. Again, the app we use, Sway, I like it, you can do pre-season testing, everybody has their phone, a trainer can send the code out to the kid's phone, they download the app, they can do it, they can watch them, they can all do it right there, so they can watch them, so it's really nice, we can do it in individual, they do have some normative data available, and then in the sideline evaluation, I have all their data on my phone, so it's nice to have it all available there, we still do King Divick, we have the cards and the whole kit on the sideline, again, to compare post-injury testing, but it started out as a balance app to kind of like a best, and it's really moved a lot of these other things that it does, and reaction time I'm getting, just like I would on a computer test, so I like that, and then doing all these other things that it's doing as well, some of the cognitive domains, again, needs more data, again, I'm not here to sell it, this is what we use, and I do like it, so this is kind of what you see when you get the report there, so the gray lines are kind of normative data, and then the colored lines are like their data from their baseline, so you're comparing what they got to their baseline, as long as with normative data at the same time, so that's why, again, I just find it's helpful for me, anyway. Timing, and this is that data out of Steve Brollio, and the guys at the CARE Consortium, DOD, I mean, this is gonna be just a treasure trove of data coming out of these studies, this is one of the best concussion things they've ever done, the thousands upon thousands of injuries that we're finally gonna get instead of smaller studies, so you're just gonna see over the years, more and more data from this, this is one of the earlier ones, and Steve was funny, and he's like, well, I'm sorry to tell you, but it probably was better to have annual baselines versus not, because it's like, when's the timing, you know, do you do it every year, do you do it every, just once in college when they get there, you know, kind of thing, he's like, eh, it's probably better to do it every year, because there was some changes year to year, and so he didn't really say, you know, kind of what tests you have to do, and the NCA says do some for the baseline testing, maybe you don't do all the components or not, I don't, you know, again, it's left a little bit up to that. What is the setting, also, again, a lot of times, just for time's sake, do group versus home testing, or individual testing, obviously individual's the best, but that's the most time intensive, and so most of the things are some kind of group component to it these days, and again, just check for those valid results. So, just quickly, at the end here, let's go through kind of all the different levels of sport, again, middle school to high school, you know, SCAT 5, concussion vital signs, impacts, whatever the, you know, kind of resources the school has, right, and the time by, you know, some of these schools just have their one ATC, right, and they have, you know, 300 athletes or something, so think of that. Check your local state laws, too, I mean, that's very important, right, you got to know what you're required to do for that school, and so that's very important to look at. And the NCAA requires, again, just one component of these as your baseline checklist, and so, again, history of concussion, symptoms, cognitive balance, and again, we determine whether clearance for additional testing, but those are kind of the basics that you need. NFL, pre-season education, modified SCAT, and then they have, you know, their independent neuropsychologists and folks there, and the people on the sideline. NBA, pre-season education, again, modified SCAT, you can see the theme here, MLB, SCAT, and also a seven-day DL list, and then also neurological evaluation as well, which, you know, again, they want to leave a little bit of leeway from team to team. As far as NHL is a little more specific, again, some pre-season education, SCAT-5, no more than five testing at once, I thought was interesting. Impact annually, but if they've had a concussion, then teen neuropsychologists, and one of the nice study here was a difference, you know, especially in NHL, right, not the NBA is getting more international, too, right, but there's English versus non-English language scoring, maybe more normative values when you're looking at difference from those is important as well. FIFA, obviously, they came up with SCAT-5, so they're going to endorse the SCAT-5, and they have the PEED SCAT-5 for those younger folks as well. Again, the military academies, it's similar to NCA, because it's CARE, DOD consortium, which is, again, amazing, you can just see all the schools and academies that are with us, that's why we're getting so much data from these, and again, it's similar to the NCA and what they're testing. Just in a one table, so just what I all said in those, you know, six or seven slides, you can just see most of them, there's some component of the SCAT-5, along with doing, you know, and other resources along with that for most of those leagues. In the future, Paris is coming up for, they've moved it to fall, because of the next fall, because of the COVID stuff, and then more vision, pupil reaction time kind of things, there's some apps and some other things, I think that'll be very interesting, or some sideline things as well. Again, biomarkers and genetics and CT is always on the horizon, too, about, you know, looking at those kind of things as well. So, again, here's my email, if you need any of the articles, I have them, easy to do, here's the references I have, and I can easily send it to anybody that needs them. Thank you.

baseline testing

concussions

cognitive reaction times

vestibular testing

pre-season education