Development of an iPhone application for sideline concussion testing

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Professional athletes are taking concussion very seriously, and missed play due to concussion is no longer stigmatized. One fortuitous consequence is increased awareness of the detrimental effects of concussion among student athletes. Whereas professional athletes have access to formal in-competition evaluation and out-of-competition monitoring programs, the majority of student athletes, especially at the middle school and high school levels, do not. The authors therefore set out to create an easy-to-use iPhone application for sideline concussion testing and serial monitoring of these at-risk athletes.

Abbreviations used in this paper: app = application; CDC = Centers for Disease Control; CSV = comma-separated values; SCAT2 = Sport Concussion Assessment Tool 2.

Professional athletes are taking concussion very seriously, and missed play due to concussion is no longer stigmatized. One fortuitous consequence is increased awareness of the detrimental effects of concussion among student athletes. Whereas professional athletes have access to formal in-competition evaluation and out-of-competition monitoring programs, the majority of student athletes, especially at the middle school and high school levels, do not. The authors therefore set out to create an easy-to-use iPhone application for sideline concussion testing and serial monitoring of these at-risk athletes.

Much of the current discussion regarding sports-related concussion is focused on prevention and return-to-play guidelines. This is appropriate, because prevention of the initial injury and subsequent reinjury is of paramount importance. The model concussion prevention legislation, Washington State's Zachery Lystedt Law, incorporates 3 key aspects, as follows: 1) athletes, parents, and coaches are required to receive yearly concussion education; 2) an athlete suspected of having a concussion must be removed from competition and not returned to play; and 3) a licensed health care professional must clear the athlete to return to play.3 Implicit is the need for a standardized method to identify the concussed athlete during competition.

To this end, the “Consensus statement on concussion in sport,” generated during the 3rd International Conference on Concussion in Sport was widely published in 2009.2 Germane to the current paper was the recommendation that “Once the first aid issues are addressed, then an assessment of the concussive injury should be made using the SCAT2 or other similar tool.” The SCAT2 “represents a standardized method of evaluating injured athletes aged from 10 years or older.” The SCAT2 can be used for preseason baseline evaluation, and it is available at no charge for distribution and use.

There are, however, barriers to the use of concussion test instruments like SCAT2: namely, lack of awareness and inconvenience. Lack of awareness regarding sports-related concussion and of the availability of standardized testing platforms are being addressed through legislation and campaigns like the CDC's “Heads Up: Concussion in Youth Sports.” The pencil and paper SCAT2 survey is inconvenient to use on the sideline (especially when the weather turns foul), and dissemination of test data is more difficult. A digital format, particularly a smart-phone application, breaches these barriers. In this paper, we report our experience with the development of an iPhone app for concussion testing.

Methods

The app development team included a neurosurgeon (R.A.R.) to provide the medically relevant content, a graphic artist (G.A.C.) to design the user interface, and a computer programmer (N.S.) to translate the vision into the computer's language.

During the planning process, we identified several desirable functions to incorporate into the app, as follows.

  1. SCAT2 elements. The purpose of our app is to help determine if an injured athlete shows signs and symptoms of concussion. We therefore built the app around test elements from the well-established SCAT2 platform.

  2. Ease of use. Because the app will be used to evaluate injured athletes in the heat of battle, it has to be easy to use.

  3. Multiple uses. Many school boards, particularly in rural areas, have budget and personnel limitations that make it difficult to implement a concussion-testing platform like ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing). We planned an app that could be used for preseason baseline evaluations, in-competition testing, and postconcussion monitoring.

  4. Data transmission. The data generated from our app are compiled in the CSV format so that it can be directly entered into a database or spreadsheet program.

  5. Adaptability. Although the app is currently based on SCAT2, we anticipate that other sideline concussion test strategies will be validated in the future. We wanted the flexibility to add this functionality to forthcoming versions of the app.

  6. Security and backup. Because the app will store private health information, security is needed to prevent unwanted data access should the device be borrowed, lost, or stolen. To this end we incorporated a login screen requiring a user name and password. There is a quick test feature allowing access to the test elements (but not private health information) in the event of an emergency. Also planned is a synchronizing feature that will back up test data to a Health Insurance Portability and Accountability Act–compliant server hosted by Marquette General Health System.

Next came the graphic design and programming. Throughout this stage, simulated versions of the app were evaluated to be certain that a product consistent with our desired functionality took shape.

Last, the app was submitted to the Apple app store for testing and approval.

Results

The resulting app is named Concussion Test (Fig. 1). There is no charge to download it through the iTunes store.

Fig. 1.
Fig. 1.

Logo for the Concussion Test app.

In Concussion Test, there are several ways to begin the testing protocol. First, an athlete can be selected from the player roster. In this scenario, an athlete's name and his/her demographic information are stored in the app, along with preseason baseline concussion testing. Second, an athlete's demographic information can be entered right before the concussion test is administered. Third, there is a quick-test option that permits direct entry into the test elements. This is especially helpful if there is a need to evaluate an athlete who is not part of the team. At the end of the test elements, the option of adding the test data to an existing player or to a new player is available.

In addition to general demographic information, the app also stores results of prior concussion tests and the number of previous concussions, general medical information useful in emergency situations, and emergency contact information.

The testing protocol is based on SCAT2 and includes the following elements: concussion symptom survey, modified Maddocks questions, balance test, immediate and delayed word recall, reverse digit recall, and reverse month recall (Fig. 2A and B). To prevent an athlete from memorizing the words and digits through repetitive testing, the app automatically refreshes the word and digits list with each new test. This functionality is not available with the traditional pencil and paper SCAT2.

Fig. 2.
Fig. 2.

Selected screen shots demonstrating several of the app's functions. A: The Reverse Number Recall screen. To avoid memorization, the number sequences change with each new test. B: The Balance Test screen has both a countdown timer and an event timer (tap to count) to record the number of errors made in 20 seconds. C: The Results summary screen. Based on test responses, a recommendation regarding return to play is provided in plain language. There is also the option to assign test results to an existing player or to a new player. D: The email screen. Test results are automatically attached as a CSV file, and can be sent to appropriate members of the traumatic brain injury program team.

At the end of the test, a results screen appears, providing a plain-language summary of the data and recommendations regarding return to competition (Fig. 2C). Test results can then be assigned to an existing player or a new player. An email screen (with the test data attached as a CSV file) permits distribution of results to members of the traumatic brain injury team (Fig. 2D).

This app also features a hospital locator—helpful if the team is competing away from home.

Discussion

Concussion recognition and prevention is not a trivial endeavor. Scientific data support the conclusion that repetitive, mild head injury leads to the late sequelae of chronic traumatic encephalopathy.1 Moreover, it is abundantly clear that the catastrophic second-impact syndrome is both real and preventable.4,5 It is imperative, then, that the concussed athlete be identified (especially when signs and symptoms are subtle), and then allowed to return to play only after resolution of symptoms. These tasks can best be accomplished by combining clinical judgment with a standardized, validated tool.

Through a combination of legislation and awareness programs, concussion assessment tools will be increasingly used. A digital format is advantageous due to easier data collection, analysis, distribution, and storage. A mobile-phone app offers the ideal combination of functionality and portability. We therefore developed an iPhone app to assist with in-competition diagnosis of concussion and to permit the serial evaluations necessary to inform decisions about return to play.

There are several concerns with a mobile platform: cost, potential for abuse, and validity. The Concussion Test app is free. Nevertheless, the lowest-priced iPod Touch is $229.00, so there certainly is a greater expense compared with the pencil and paper SCAT2 survey. We anticipate that the advantages of the digital format compensate for this initial capital expense. Can sideline concussion assessments be maliciously used to return an injured athlete to competition? Sure. However, that would require the test administrator to actively falsify the athlete's answers. The mobile format is no more vulnerable to this than the pencil and paper version.

Last, does a mobile (or digital) version of a pencil and paper survey need to be additionally validated? Our opinion is that as long as the method of presenting the question does not affect the thought processes leading to the answer, then additional validation is unnecessary. For both the pencil and paper SCAT2 survey and our app, an independent party administers the test elements and, therefore, the method of presentation is the same from the perspective of the athlete being tested. Moreover, there really is not a good way to establish concurrent validity between our app and the pencil and paper version. Sequential administration of the 2 surveys could easily result in different answers because concussion signs and symptoms can fluctuate over time. Also, there is often time pressure to complete the testing, rendering administration of 2 complete surveys impractical.

Ours is not the first concussion-related iPhone app. When we began app development 1 year ago (July 2010), a search of the iTunes store for “concussion” yielded no results. Now (July 15, 2011), the same search produces 5 apps:

  • SCAT2, Meeuwisse Consulting Services, free

  • SCAT2, Wayne Hans, $3.99

  • Concussion, SportSafety Lab, free with $4.99 in app purchases

  • Concussion Recognition and Response: Coach and Parent Version, Psychological Assessment Resources, $3.99

  • Play it Safe Concussion Assessment, Concussion Health, free

The first 3 apps are SCAT2-based. The Concussion Recognition and Response app is based on the CDC's “Heads Up: Concussion in Youth Sports” program. The Play it Safe app is based on the Concussion Health program developed by the University of Texas Athletic Department. These apps are all well conceived and executed. Although a detailed review of these apps is beyond the scope of this paper, the growing number of concussion-related iPhone apps is a testament to the feasibility and practicality of the concept.

By providing coaches, parents, athletes, and health and athletic personnel a comprehensive and easy to use tool to identify and monitor student athletes suspected of having a concussion, smart-phone apps will increase awareness of the dangers of concussion and improve decision making with regard to removal from play and return to play. To paraphrase, there should be no doubt when to sit them out.

Conclusions

Mobile-phone apps, due to their popularity and ease of use, offer an excellent platform to promote wellness and prevention agendas such as concussion recognition and second-impact syndrome prevention. Neurosurgeons can and should use their expertise to help develop medically relevant smart-phone apps. Development of an app is a collaborative and cooperative process, and thus plays to neurosurgeons' strengths.

Disclosure

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author contributions to the study and manuscript preparation include the following. Conception and design: all authors. Drafting the article: Rovin. Critically revising the article: Curaudeau, Sharma. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Rovin. Administrative/technical/material support: Rovin.

This paper will be presented at the Section on Neurotrauma and Critical Care Neurosurgical Forum at the 2011 Congress of Neurological Surgeons Annual Meeting, October 1–6 in Washington, DC.

References

  • 1

    Gavett BEStern RAMcKee AC: Chronic traumatic encephalopathy: a potential late effect of sport-related concussive and subconcussive head trauma. Clin Sports Med 30:179188xi2011

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    • Export Citation
  • 2

    McCrory PMeeuwisse WJohnston KDvorak JAubry MMolloy M: Consensus statement on concussion in sport—the 3rd International Conference on concussion in sport, held in Zurich, November 2008. J Clin Neurosci 16:7557632009

    • Search Google Scholar
    • Export Citation
  • 3

    NFL Health Safety: Lystedt Law Overview (http://nflhealthandsafety.com/zackery-lystedt-law/lystedt-law-overview/) [Accessed September 15 2011]

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    • Export Citation
  • 4

    Thomas MHaas TSDoerer JJHodges JSAicher BOGarberich RF: Epidemiology of sudden death in young, competitive athletes due to blunt trauma. Pediatrics 128:e1e82011

    • Search Google Scholar
    • Export Citation
  • 5

    Wetjen NMPichelmann MAAtkinson JL: Second impact syndrome: concussion and second injury brain complications. J Am Coll Surg 211:5535572010

    • Search Google Scholar
    • Export Citation

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Article Information

Address correspondence to: Richard A. Rovin, M.D., 580 West College Avenue, Marquette, Michigan 49855. email: rarovin@gmail.com.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Logo for the Concussion Test app.

  • View in gallery

    Selected screen shots demonstrating several of the app's functions. A: The Reverse Number Recall screen. To avoid memorization, the number sequences change with each new test. B: The Balance Test screen has both a countdown timer and an event timer (tap to count) to record the number of errors made in 20 seconds. C: The Results summary screen. Based on test responses, a recommendation regarding return to play is provided in plain language. There is also the option to assign test results to an existing player or to a new player. D: The email screen. Test results are automatically attached as a CSV file, and can be sent to appropriate members of the traumatic brain injury program team.

References

  • 1

    Gavett BEStern RAMcKee AC: Chronic traumatic encephalopathy: a potential late effect of sport-related concussive and subconcussive head trauma. Clin Sports Med 30:179188xi2011

    • Search Google Scholar
    • Export Citation
  • 2

    McCrory PMeeuwisse WJohnston KDvorak JAubry MMolloy M: Consensus statement on concussion in sport—the 3rd International Conference on concussion in sport, held in Zurich, November 2008. J Clin Neurosci 16:7557632009

    • Search Google Scholar
    • Export Citation
  • 3

    NFL Health Safety: Lystedt Law Overview (http://nflhealthandsafety.com/zackery-lystedt-law/lystedt-law-overview/) [Accessed September 15 2011]

    • Search Google Scholar
    • Export Citation
  • 4

    Thomas MHaas TSDoerer JJHodges JSAicher BOGarberich RF: Epidemiology of sudden death in young, competitive athletes due to blunt trauma. Pediatrics 128:e1e82011

    • Search Google Scholar
    • Export Citation
  • 5

    Wetjen NMPichelmann MAAtkinson JL: Second impact syndrome: concussion and second injury brain complications. J Am Coll Surg 211:5535572010

    • Search Google Scholar
    • Export Citation

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