Next Level… In Concussion Care

14 Aug

As an athletic trainer – an opinionated one at that – I struggle with all the “bells-and-whistles” in this conundrum that is the concussion issue.  If you have visited here or heard me speak you undoubtedly know that mismanagement of concussions is the true issue of this complex paradigm.  Yes, we need to know when a concussion occurs to begin the process in the right direction; however, this can be accomplished by simply making sure you have a trained medical professional on hand when the need arises.  Getting an athletic trainer to cover the most at risk sports at the most at risk times is a great start (and in the authors opinion is the only choice if you want to have collision sports).  Short of that, education over-education is necessary for everyone: players, coaches, parents, officials, teacher etc. to properly identify and accept the nature of concussion in sport – it is a risk.

Even having an allied medical professional, like an athletic trainer (AT) at practices and games does not stop the injury from occurring.  In fact, many products that may claim reduction in concussions or “possible concussions” are toying with fraud; at the very least they are practicing deceptive marketing.  The point being, once we identify a concussion how do we and who do we send the injury to, to avoid the rest of the iceberg lurking under the surface of the water?  Moreover, what tools do we have that can help get the right prognosis, treatment and recovery for the injured (and there are many out there)?

I feel there is a new product (I am not a paid endorser, nor have I been given compensation for this article/opinion) now hitting the market that may get us closer to the panacea that we are all hoping for (note I said “closer”).  Although it may have been presented as some big secret; the C3 Logix: Comprehensive Concussion Care system is not a secret rather it is something I feel is a “game changer” for concussion care.  It is not the be-all-end-all and DOES NOT replace an athletic trainer (rather enhance the AT) but, in my humble opinion it is a system that has the potential to address the areas where we are lagging.  C3 Logix is the next level.  C3 Logix was invented at the Cleveland Clinic and is being sold by Just Go Products.

Currently we encourage baseline testing of the brain and its systems to have some form of objective data to compare to after an injury, the most widely used are computer based neurocognitive test batterys – ImPACT being the most known and used.  These type of tests are tools used to help with return to play decisions; by looking at the baseline results compared to the post-injury tests.  However these applications have limitations, namely they only look at brain processing function (including reaction time).  There are other tests that can be delivered in conjunction with these computer based platforms to assess other, as important, portions of the complex that is the brain and its functioning such as: balance, vestibular functioning, motor function and vision.  This is where C3 Logix trumps what we currently have at our finger tips – it has what we currently have PLUS all of the above.

Certainly the gold standard for concussion assessment and management delivers on all portions, but until now it has been a piecemeal process (recently ImPACT has partnered with another company to encompass the balance portion).  Unless, of course you have been using the SCAT3 as your baseline and post test instrument; this paper and pencil test envelopes all the process and was developed in a collaborative effort during the International Concussion Symposiums.  This still presents a problem as different testers may observe and score differently on the portion of the SCAT3 that deals with balance; the BESS Test.  Furthermore, there is not a portion of SCAT3 that deals with vestibular functioning or vision other than subjective questions and answers.

Having as much comprehensive information for a doctor to make return to play decisions, that is as standard and objective as possible is a win-win situation for everyone: players, parents, athletic trainers and doctors to name a few.  C3 Logix I feel can and will deliver on this.

Take a quick look at the C3 Logix Overview and tell me it does not have what we all have been looking for in a single testing battery.  Now, remember that passing a test like the C3 Logix or other testing platforms does not automatically mean return to play; these are not “clearance devices”, they are tools used to make the most informed decision about the management of concussion – the true problem of the concussion crisis.

A quick analogy would be talking to a mechanic over the phone about a weird noise your car is making and giving them a ton of subjective data, even letting them listen over the phone.  A good mechanic can probably drill down to a preliminary diagnosis, but would you just let them service your car based on that alone?  Probably not, you would feel much more comfortable with them (and hoping they don’t up sell you with made up problems) getting in the vehicle and taking it for a test drive and getting a true feel, along with hooking it up to a diagnostic machine.  That is how C3 Logix can be viewed.

Other benefits of this next level thinking is that the baselines provide three important components to me – as well should most of you;

  1. The test is about 20 minutes, max – this beats ImPACT by about 15-20 minutes, but behind Axon Sports.  Remember there are added components to the other platforms.
  2. Although it may add to the time of the test, this platform provides a one-on-one testing environment with the tester (most cases the athletic trainer for baseline and doctor in follow-ups).  Not only does this eliminate the distractions of mass testing in a computer lab it allows for trust to be built.
  3. Sandbagging or deliberate non-performance on the test (in the hopes of getting back quicker – a real and present danger in all testing) is dealt with immediately.  Trials on each component of the test where this can happen will not count and must be redone if this is detected by the software.  This is similar to Axon Sports software that rejects baselines that have not met minimum requirements.  Currently with ImPACT the tester has to look at results to make this determination – labor intensive.

Here are some screen shots:

SACSAC pg 3

SAC

C3 Simple RT #1C3 Choice RT

Static VA #1C3 Dynamic VA

C3 Trails #5

Balance #1

The “polygon” view of recovery is very nice to see and simple to explain, it also pinpoints exact areas that need addressed.  This can be extremely valuable when looking for the right rehabilitation professional (vestibular, balance, etc.) for treatment.Being so new, there is not normative data quite yet, but I have been assured it is on its way soon – allowing for assessment of injured athletes/people who did not take a baseline.  There are other aspects to also highlight;

  • Being cloud based, a test can be performed elsewhere and then reviewed by whomever is within the patients care.
  • The application works offline, so in areas of horrible or no up-link availability you can perform the test then the info is stored until it can be sent to the cloud, then its off the device, making it HIPAA compliant.

Certainly there will be research done on this application by independent groups that will find faults and problems with it, as has been done with other applications.  However internal research, particularly with the most exciting aspect – in my opinion – the balance assessment (because of its objective nature) has been very strong, comparing it against the gold standard of the Neurocom (SOT Test).  Here is the C3 NATA 2013 Cleveland Clinic Concussion Poster for your viewing.

I freely admit that I have not had hands on with this product quite yet, still working up the funding to get it, but it is indeed on my short list.  I honestly feel the C3 Logix brings us forward in concussion care and is above and beyond what is currently available.  I am interested in hearing your thoughts on this.

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13 Responses to “Next Level… In Concussion Care”

  1. joe bloggs August 14, 2013 at 10:42 #

    I think Cleveland Clinic is a fine institution, but I am deeply concerned that there seems to be a lack of scientific evidence that the application is valid. It seems well packaged just prematurely marketed like so many products coming to market. Much like the SCAT, it seems to simply be given the benefit of the doubt.

    With respect to balance testing, there is a body of evidence that is developing that suggests vestibular injuries may not account for the entire picture as balance may also reflect pathophysiological issues.

    • Dustin Fink August 14, 2013 at 21:03 #

      Joe,

      You know I agree with your concerns, its in market now and will be a learning process like others… I don’t believe I have seen it marketed as a clearance device… The reason I am impressed is that most good clinics use a multifaceted approach that includes all of this… Rather than have different tests that can be “graded/scored” by different people this allows for a much better big picture…

      I agree with balance and vestibular, in fact I am starting to trend to blood pressure and other factors, but this may be the best “all in one” out there…

    • Dustin Fink August 14, 2013 at 21:05 #

      Joe,

      I have also been given this information to pass along to you regarding some validity stuff…

      —–

      I noticed a comment that suggests there wasn’t enough data yet. The person probably doesn’t realize that this system has been in place for 3 seasons and over 8,000 athletes have used it at over 70 schools and that C3 Logix has processed over 475 well characterized concussions (meaning baseline, incident report, post event tests, return-to-play protocol). That is a very strong sample size.

      —–

      • joe bloggs August 15, 2013 at 06:16 #

        Pass this back. Sample size is good but we need to know how the experiment was conducted. When will the results go into press so its concurrent validity can be assessed independently. It should illustrate how each element preformed against benchmark.

        I too think all in one is a good idea.

  2. Kids SRC Doc August 15, 2013 at 23:45 #

    Isn’t the price tag on this about $7500 (not including the tests)? That will price out the majority of high schools.

    • Dustin Fink August 16, 2013 at 11:05 #

      I believe there is a one time fee and a per user, per year fee, then the tests… I think initially with the purchase of an iPad or two it may be expensive… But with all things it boils down to money…

      Personally if you were to invest money, it should be with an athletic trainer first. Then bells and whistles and tools to follow…

      I do think this is more for a clinic based system, as a vast majority of AT’s and MD’s come from hospitals/clinics. This is where the buying power should be. And honestly, shouldn’t the practitioners be in control of concussions?

      That is a part of the other platforms that has me worried is school/coach control… It should be trained medical pros in charge…

    • Dustin Fink August 16, 2013 at 11:08 #

      Further more if a doc/clinic were to purchase, they can code and get reimbursed for the tests, eventually making it a profit center, like ImPACT is now…

    • Jason August 16, 2013 at 12:01 #

      Greetings Kids SRC Doc; The C3 Logix has a variety of pricing options, depending on the number of athletes, the classification of the client (pro, college, high school, youth) and the actually customer who pays for the baseline assessment and post events assessments. There are “all you can use” prices for teams but there is also a “consumption” based model where you pay only what you use. Keep in mind, many clinics and hospitals perform baseline assessments for the high schools and then use an insurance reimbursement model for the post-event assessments and concussion care services. Under such a model, the high schools actually pay nothing for the use of the technology. So, cost is really not something that should prevent the adoption of this technology. I also understand that C3 Logix is working with funding sources (like grants) to help make the software available to those schools who want it but may not have a hospital system or sports clinic to pay for it.

  3. Scotty August 19, 2013 at 16:38 #

    Always better safe then sorry when it comes to evaluating concussions in my opinion. This is some really interesting information here. Thanks for sharing.

    • C Chulada ATC August 21, 2013 at 15:36 #

      I’ve been in contact with the product rep, who has indicated: “cost is currently about $10,000. It is designed for one to one clinical use, and would most likely be outside the budget of any high school”.

      The baseline is done one to one, so how long would that take a practitioner to baseline a whole team or a whole school? no computer lab at the school, one athlete at a time in the clinic. Not sure how practical that will be for the HS AT, but a great money making idea….

      • Dustin Fink August 21, 2013 at 16:52 #

        Yes a whole team at once will be time consuming, about 20 min/athlete… However, we are talking about as close to a clinical spectrum as you can get. If your gonna find out “full” recovery, then having all that info is necessary…. Timing is no different than using a SCAT as baseline… And why as an athletic trainer wouldn’t you want one to one baselines? Get to know and educate at the same time…

        Often I feel some people are looking for the cheap and easy way out… If we’re going to insist on this complex for recovery we should take the time to test them that way…

        As for pricing; I have expressed my concern with that…

  4. Jason August 28, 2013 at 10:34 #

    1) While some major colleges have an integrated clinical model where staff is large enough and qualified enough to manage both the baseline athlete assessment and post-event athletes assessment in-house, most high school and small colleges use a clinic or hospital system to perform concussion assessments and management – including RTP. In these cases, the costs to the high schools or small colleges (and some larger colleges) for assessments is absorbed by the clinic or hospital. The reality is that most schools who choose to move to C3 Logix’s more comprehensive and integrated tool will see no increased cost. One of the offerings from C3 Logix is also a “mass baseline assessment service,” whereby a team of Cleveland Clinic certified technicians come in with multiple iPads and conduct a preseason assessment of all players.

    The costs for large colleges (500 or more scholarship athletes) to acquire and use C3 Logix is based on a variety of factors (number of athletes, who performs the assessments, amount of hardware, number of certified users, relationship with clinic/team doctor/RTP protocol, etc.). There is no “off the shelf” price for C3 Logix. Price quotes are only provided after consultation with the Head Athletic Trainer/Head of Sports Medicine and or Team Doctor and a certified C3 Logix representative.

    2) One of the other big benefits of C3 Logix is the time savings and mobility factor. Using the iPad as the collection device for administering all of the tests, a trainer or doctor, healthcare assistant, assistant coach, or school nurse can complete the entire, comprehensive test in 18 minutes on average. The other neurocognitive (ImPACT included) tests take 30 – 40 minutes on average. What’s more, the test can be done virtually anywhere (locker room, training room, classroom, sideline, doctor’s office, home, etc.) as it does not require web connectivity. This means that every athlete (regardless of location or ease of access to medical equipment or medical centers) can have the best standard of care using the remote capabilities of C3 Logix.

  5. Albert (Al) Cooper September 22, 2013 at 14:04 #

    Very interesting product. Based on the previous information on the pricing and that it is designed for clinical 1-1 use, have to ask… What’s the difference between having a trained experienced vestibular therapist in a clinical setting with impact testing? It’s appearence is nice on an ipad, however is no different than providing a SCAT Test, and BESS Test. all of this is going to be done in a clinical setting with1-1 treatment anyway.

    Into would like to see the published research on its validity and reliability levels.

    I am not really knocking it, just think this is a newer looking mouse trap. Remember that NASA spent thousands of dollars to invent a pen that could write upside down in space. The Soviets simply replied with using a pencil.

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