Technology alone won’t save sports from the risk of brain injury but there’s a race to deliver products that help identify concussion when it happens on the field.
Innovators are increasingly looking to cram clinical testing into mobile devices that help identify concussive events and aid better health outcomes.
Some of these are already available, others are preparing to launch. Still more are undergoing clinical trials to prove their efficacy.
Whether a tool that measures forces on the head or brain activity, blood patterns and cognitive response, or even a simple symptom checker, every sporting club across the country could soon have some form of verification aid in their first aid kit.
“We’re just at the tip of the iceberg of this injury,” says Keith Thomas.
Thomas is no stranger to contact sports. He played more than 250 first-class games of Australian Football – mostly at the Norwood Football Club in South Australia, but also across two seasons at Fitzroy in the VFL. After 10 years as an AFL club CEO, his focus has turned to running a concussion management technology startup called Spark.
“From a physiological point of view, the level of understanding that the medical fraternity is gathering now about how severe concussions can be both in the immediate short-term and longer-term is growing, and will continue to grow,” Thomas says.
“Player welfare becomes a really important part of this, and I think culturally, we’re already seeing very significant shifts in the attitudes of sporting participants and codes towards the injury where, in my day, it was very much ‘shake it off, and get on with it’.
“But the really significant shift that is going to occur, undoubtedly, is that the objective measure of this injury will happen. It’s already happening.”
Thomas’s company has completed a set of clinical trials among amateur footballers and is poised to undertake another trial of FDA-approved diagnostic technology already used in the US Military and healthcare system. His hope is to adapt the technology for a wearable diagnostic system for sports participants.
With near uniformity, clinicians, researchers, entrepreneurs, participants and bystanders want to see the guesswork taken out of concussion diagnosis and management, especially in community sports where professional expertise is often replaced by volunteer awareness.
In response to community demand, there’s a fast-growing industry seeking to provide technology that delivers objective data that can aid concussion and mild Traumatic Brain Injury assessment, and management.
App-lying a checklist
What emerges in discussions with professionals working in the field is that knowledge of mTBI and concussion is nascent. But as knowledge grows, effectively educating first-contact health professionals like GPs, as well as the people and caregivers that will encounter the injury, remains a challenge.
At the elite level, where trained healthcare professionals are more likely to be found staffing the bench, the Sport Concussion Assessment Tool (SCAT5) assessment is used. Here, a doctor or physio can use this detailed, standardised tool to evaluate whether a concussion has been experienced by a player removed from the arena.
“We’re already seeing very significant shifts in the attitudes of sporting participants and codes towards the injury where, in my day, it was very much ‘shake it off, and get on with it’.”
For non-professionals, the Concussion Recognition Tool (CRT5) can help identify possible concussions. The point here, however, is that it’s not a technical diagnostic tool: it can merely indicate signs and symptoms of trauma, and help non-professionals recommend clinical follow-up.
Professor Vicki Anderson is a paediatric neuropsychologist at Murdoch Children’s Research Institute. She worked on the development of the Headcheck app: a straightforward smartphone program now recommended by the AFL as part of its player registration process. It adapts elements of these assessment tools to help individuals, particularly parents, identify potential symptoms of concussion.
A person displaying symptoms is then recommended to get clearance from a GP or emergency department. This is useful, says Anderson, because it helps to give clarity to appropriate action for an individual or caregiver to take.
“At the moment, lots of families use lots and lots of health care,” she says.
“They go to multiple, different people who tell them multiple, different things, and they just get really confused and more distressed.”
The simple interface is designed to be user-friendly – the type of application that anyone can pick up and use intuitively. It’s also helpful in community sports, particularly where volunteers without health training can use it to determine the likelihood of a player concussion and support them in follow-up actions.
“Our tech team tell us, and I think it’s good information, is that if you’re going to do something at a community level, it has to be simple, it has to be engaging, and not take too long,” Anderson says.
“Of course, there are lots of things that we can do that are very in-depth, but we can’t deliver those at community level because the community won’t engage with them.”
So through a simple app, the signs and symptoms of suspected concussion can be understood and followed with actions to address it.
For those wanting a greater level of detail, there’s a burgeoning tech industry with suppliers looking to offer sports products that give as good an indicator of concussion as possible.
Headwear for healthcare
One such prominent technology emerging out of Western Australia is HitIQ. It’s a simple pitch: a mouthguard that measures force.
Using a tiny sensor embedded in the guard, the HitIQ uploads impact data to an app that can be monitored post-activity by its wearer.
The sensor is ultra-sensitive, even capable of registering vocal force from the wearer shouting during a game, though such low-level force is filtered out by the software.
As company founder Mike Vegar tells Cosmos, post-game readings can give participants a snapshot of the force experienced by the head, which might be helpful to match against high-impact moments in a game.
“If you’re going to do something at a community level, it has to be simple, it has to be engaging, and not take too long.”
Professor Vicki Anderson
If a force reading is matched to a potential concussion event, the app then “concierges” the user through recommended actions.
“So if there is an impact that is on the heavy side, we just ask that the caregiver run a symptomology checklist on the child or the user,” Vegar says.
That checklist is an adaptation of the SCAT-5 – the standardised tool for clinical concussion evaluation in athletes over 13 years of age. If enough red flags are raised by undertaking the checklist, the app recommends a clinical assessment for the athlete.
Vegar is also exploring ways to further this process and take the guesswork out of concussion evaluation with an extension product – currently being considered by Australia’s Therapeutic Goods Administration – that aids standardised, nationwide concussions assessment through telehealth referrals.
“Whether somebody’s in the Kimberley, or somebody’s in Tasmania, they’re going to get the exact same standard of care,” Vegar says.
“So it’s a streamlined, standardised care model that we’re offering… and I think that’s really important because in the community is so much fear, uncertainty and doubt because of the variability in care.”
Much of the technology making its way into the concussion management market is built around wearables.
“In the community is so much fear, uncertainty and doubt because of the variability in care.”
Two such products use over-eye headsets to deliver testing.
Neuroflex delivers a long-established form of concussion testing called vestibular ocular motor screening (the unfortunately acronymed ‘VOMS’) in a cutting-edge way.
Typically, VOMS is performed in specialised hospital settings where the participant is delivered a series of visual stimuli. But Dr David Stevens, a sleep health researcher at Flinders University’s Adelaide Institute for Sleep Health and the head of medical and research for Neuroflex, says his headset removes the access barrier for clinicians to assess concussion more readily.
The virtual reality goggles measure the ocular vergence – how parallel your eyes are – after a potential concussion, by measuring how quickly the head and eyes respond to visual stimuli.
Analysis of this data would allow specialist neurological physiotherapists or ophthalmologists to intervene and provide support to patients with data that indicate a concussion has taken place.
This, Stevens says, turbocharges testing that might happen on the sidelines, again invoking the objectivity of tech-based testing.
“We can tell you exactly where the damage has occurred, the severity of damage and any symptomology,” Stevens says.
Condensing hospital-standard assessments into a portable tool for doctors and other specialists is handy, and that’s mainly the audience Neuroflex is targeted at. While Stevens says it’s a feasible product on the sidelines at sporting events, the results should be verified in a clinical setting.
“We do stipulate that for everyone’s safety, and I’m talking physical as well as legal safety, it really should be a clinician-led interpretation of the result, so the right decision is made by the person who has the training to make the decision.”
“It really should be a clinician-led interpretation of the result, so the right decision is made by the person who has the training to make the decision.”
Dr David Stevens
Clinical verification of objective data is a theme of most products on, or entering, the market.
In New South Wales, Dr Adrian Cohen is testing his Nurochek headset with teams across Australia, New Zealand and the US.
When he started trialling technology as part of his foray into the field, he was left unsatisfied by the quality of testing on offer across sporting disciplines.
“The industry is looking for a solution that’s reliable, that’s understandable. And that’s objective,” Cohen says.
In his hunt for objective measures, he turned to transcranial magnetic stimulation – TMS – which records the brain’s electrical signals. He wanted a fast, effective measure that could be performed behind the white line.
His Nurochek headset connects back-of-head electrodes to a PC, while the headset flashes a bright light into the eyes of the patient. Those electrodes form part of an electroencephalogram test to measure the brain’s electrical activity and compare it to normative data using AI.
In contrast to personal baseline comparisons, Nurochek leverages thousands of baselines to identify tests that might significantly deviate from the norm.
This, Cohen points out, is useful for technology that might be used in situations where a baseline doesn’t exist.
“The industry is looking for a solution that’s reliable, that’s understandable. And that’s objective,” Cohen says.
Dr Adrian Cohen
“Even in sport, you may not have done a baseline on a player, but now you can test them the first time you see them,” Cohen says.
“In the emergency room, say someone comes in from a motor vehicle accident, of course you haven’t got a baseline for them because they’re just a member of the public. Now we’ve got the opportunity to be able to test them.”
Up next: Insuring the brain
More on the Science of Concussion in Sport