The Concussion Blog

Last year while in Zürich I was approached by a group of people from the Cleveland Clinic and they had a poster they wanted to show me.  It had numbers, graphs and pictures – your normal poster at a conference – but what caught my eye was an iPad strapped on the back of a patient that was measuring movement.  I asked very basic questions and to be frank I was a bit overwhelmed at the entire company I was keeping in Zürich, so the poster was a blur.

After that chance meeting and getting back to the States I really forgot about the project until the spring when I started to hear more about it in the underground.  This testing platform was starting to get noticed and being from one of, if not currently the most, prestigious concussion care centers only helped matters.  I wanted to learn more; and in August that chance finally presented itself as the company selling the C3 Logix, Just Go Products, was able to connect with me for a webinar.

I was very blown away with what they were presenting to me – which is probably what the development team in Zürich was telling me – so much so that I wrote a glowing post on it.  Since that time I have worked hard to find a way to procure the system for use; if nothing more to test it out and see if my perceptions were reality.  This goal of mine finally became a reality, not only was I able to get the iPad needed and the app, C3 even offered to send out a technician (really that may be underselling David, he is a nerd but a very good nerd) to help me get accustomed to it.

This past Friday I scheduled the winter sports concussion testing for my high school; the freshman and juniors that have not already done so completed a popular version of the computer based neurocognitive testing, while the other freshman and juniors along with seniors were up for the “beta test” on the C3 Logix platform.  With the split we had 30 kids going to take the new baseline; with what I knew and was told I scheduled them at intervals starting at 2:45 and planning to be done at 4:00.

I had help that day, not only was David (Cleveland Clinic) there, Stephanie (Just Go Products) was also there to answer questions and lend a hand.  This was not just one guy getting an iPad, belt, foam pad and the app and doing it – although with its ease it is entirely possible.  With that help and eager eyes watching on: team physician, co-working athletic trainer, two college students and a high school student athletic trainer we wrapped up at 4:15.  The process and application of C3 was very simple and took almost a whole two minutes to become proficient with.

The developers have created a baseline only portion of the app for mass testing which helps with the time.  Truly it is designed for multiple iPads and multiple testers to lessen the time a group has to wait.  When mass baseline testing with one person and one iPad it will be necessary for individual testing times.  This will be cumbersome and work intensive for a single individual, which is probably the ONLY negative of the product.  However, you should be reminded that not only are we testing neurocognitive we are testing vision, balance, simple reaction time, choice reaction time and concentration with trail making.  With any product there is trade off’s, in the case of C3 Logix this is a very good trade-off, in my opinion.  As an athletic trainer I would rather spend extra time gathering a plethora of baseline information over the entire scope of concussion management and getting one-on-one time with my athletes; over herding them like cattle and having them perform in a sterile environment with no interaction.  To me, it makes the testing and components of concussion personal, allowing for a connection as practitioner.  It also allows for monitoring during the test to avoid the dreaded “sandbagging”, simple mistakes made making a test invalid and interference with other test takers in a computer lab.  In reality this test takes no longer than the paper and pencil SCAT3, but with more information and immediate feedback.

Back to my experience…

Stephanie gathered the athletes information at intake: name, DOB, sport, handedness, etc.  Once in the system we called in the athlete individually to perform the first station of work: symptom scale, SAC, balance and vision.  Quick aside here; for a true baseline one would assume that the symptom scores should be zero.  After all the athlete should not have any problems related to a concussion and any symptom prior to the baseline should be chalked up to other factors and have no bearing on a concussion in the future.  With symptoms as our guide during a sequale, those would all be back to zero before a return to play.  That being said we opted to skip that module on the test.  Likewise with the SAC; a score of 30 should be expected, especially if we are going to use that portion on the sidelines.  Granted the delayed recall may be tricky, it has been my experience that those doing the SAC as a baseline, given enough time and concentration score 30’s almost every time.  It was decided upon by the team physician and consultation that forgoing the SAC in the interest of time would also be OK.  It should be noted that during a follow-up assessment these modules will be used and relied upon when determining if the athlete is fit – basically forcing the athlete to register perfect on those portions for their baseline return.  As we all should know, none of these alone (or any testing platform) are stand alone return to play devices.  That is why the entire paradigm and scope must be evaluated, which is what C3 Logix delivers.

The first encounter the athlete has with this program is the balance assessment, the BESS test essentially.  Prior to beginning a belt with an iPad holder is affixed to the waist and iPad is clipped in.  The three stances on the ground (in socks) is performed; with a voice counting down from five to inform the athlete to close eyes.  Once started the practitioner can count the errors and inputs them on the iPad before going to the next stance.  Once finished on the ground the athlete moves to the foam pad for the same three stances and counting of errors.  Not only does the test gather the testers errors – inputted by the tester – it also uses the gyroscopes to measure overall movement.  This portion was extremely humbling for the athlete, many comments were made by the kids eluding to the difficulty and realizing this test was “no joke”.  The balance portion definitely got their attention and made the rest of the testing process better in my opinion.  It was quite funny to see the other athletes peering into the gym and making fun of the ones before them only to have them humbled very quickly when it was their turn.  Hearing all of it, I made sure they got the smack-talk returned to them.

Next the athlete and tester are seated five feet apart for the vision test (the belt for the balance test is 5′ in length allowing you to use that as your measuring device for the chairs).  With both eyes the athlete has to read increasingly smaller lines of letters, when they can no longer identify three or more the test is ended.  They are not done with vision, now it gets harder; a metronome chimes as the athlete is forced to move their head from the “10-to-2” position while fixing their gaze on the screen.  Again they have to read the letters on the screen, which also get smaller as they complete a line.  I do not believe there to be validation on this type of vision test in determining concussion recovery, but what this test does for me is possibly exacerbate any symptoms while performing a follow-up test.  Until (if) there is validation of this test it serves as a fail-safe and again an attention grabber for the athlete.

When finished with that portion of the test the first station is complete, and the athlete moves to the second station of the baseline; a proctored, self-administered portion that has processing speed, simple reaction time, choice reaction time and trail making.  The athlete is handed the iPad and told to follow the instructions for each portion.  Each athlete I saw/heard loved the interface and ease of use, in fact many commented on how it was like a video game.  The effort/cheating (which is just about impossible with the internal error system in C3 Logix) is monitored by a tester.  If an athlete goes outside the small parameter windows of expected effort the program throws up an error and has the athlete redo what ever they failed on.  This is common with the choice reaction time as the athlete may lift the wrong finger off the iPad.  C3 Logix provides more hand-eye interaction than any other tool on the market currently, making the athlete feel involved.  The constant shifting of test batteries also avoids testing fatigue, with new challenges always waiting.

After the second station is complete the athlete is done with test and most, if not all, taking the test were very humbled by the experience.  In all it took an average of 12 minutes for each athlete to complete (the wrestlers took a bit longer, ha).  The group I tested included the wrestlers, boys basketball and girls basketball.  There were ZERO problems while doing the test as the application worked flawlessly and as testing wore on those that were there observing even wanted to try it out, both as a tester and testee.  I did also have the opportunity to run a baseline the next day on one athlete, I timed it, and it took 19 minutes; for all the modules (didn’t skip symptoms or SAC).  The biggest delay was getting shoes on and off, but the interface and tests themselves didn’t take very much effort.

This was a massive success in my book.  Not only did I get to see a baseline that tested a variety of different domains it was interactive and well liked by the athletes taking the test.  There was 100% agreement that this type of test was preferred over what they had done in the past.  Many noted that they were not as tired or “wore out” after C3 Logix as compared to the mass computer lab testing.

I do not wish injury on anyone, but if we are unfortunate to collect a concussion in this group I am really looking forward to seeing how it stacks up with follow-up tests.  Being only 20 minutes long I think that the injured will prefer this battery over the other options we have at our disposal.  What really intrigues me is the balance assessment post injury; I have advocated using balance as one of the biggest factors in recovery (mainly because you cannot “sandbag/lie” about balance easily).  Another factor I am going to give a whirl is creating a workflow (which will not nor is validated) for a sideline evaluation.  When possible I am going to assess my athletes with the app using balance, simple reaction time and choice reaction time (Addendum: had the opportunity to do that last night as an athlete was elbowed in the face).  I think it will take about eight minutes, give or take, to complete and give me a good picture of how they are doing compared to baseline immediately post injury (it took seven minutes last night – it also confirmed what I believed to be a non-concussion based on those three parameters).

Other interesting notes about C3 Logix: there is an event report portion of the program so you can log all sorts of information about the suspected injury…  it works without internet access and stores information until you can deliver it to the cloud…  my team physician can look in on the program from his office without needing the iPad…  the development team is very responsive to any questions via email and even listen to suggestions (one such suggestion is noting if the balance test was run on the provided foam pad or another analog was used)…  rumors are that a workflow/incident report is being created specifically for emergency room use…

Overall I grade this product as an A-.  The only knock I can find on this is the time it takes to test a subject, which is no-big-deal while doing a follow-up assessment, but can be cumbersome with mass baseline testing.  This can be overcome with help and more devices, which those that can afford it will love.  Certainly, there is not the same rigorous studies of this product versus what is out there now; but the other products started the same way.  I truly believe, as I stated in the previous write-up, that C3 Logix is pushing concussion assessment forward in many ways.  The biggest being that we are now gathering all the tests in one program for ease of use and more precise evaluations.  As many may be aware I am not in the business of regularly promoting anything and often have critical takes on products, in this case I suspend both of those factors.  This is not the panacea, but it sure is darn close.  When stocking my toolbox for concussion care this will be right next to the Phillip’s head screw driver and hammer.  And as one of the kids said; “It’s the balls, Fink.”

C3 Logix is and should be your choice for comprehensive concussion testing.  It may not be easy in terms of resources, but is anything worthwhile in life easy?