C3 Logix: Practical Application and Use (It’s Freaking Awesome)

13 Nov

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?

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10 Responses to “C3 Logix: Practical Application and Use (It’s Freaking Awesome)”

  1. Jason Viel November 13, 2013 at 14:21 #

    Dustin,

    Great to hear your input on this product I was very interested to hear how it worked. You said that the only downfall would be amount of time to test mass baselines but with help that can be overcome. My question would be how much would it cost to be able to effectively baseline test 75-100 kids. I would love to be able to do this because it sounds like it “will be” better and tests more aspects of concussion in one swoop but am concerned, with having about 300 athletes to baseline test every year, about cost and the amount of help I would need. Can you elaborate on that for me? If you dont want to do it hear feel free to email me. Thanks

    • Dustin Fink November 13, 2013 at 14:31 #

      Jason,
      Great question…

      I hope that Just Go will answer this as well; but I think you could figure this…
      – Purchase of C3 (comes with belt and pad)
      – three iPads (may already have)
      – one end user
      – one licensing fee
      – per use fee for the other two iPads

      I don’t know the exact price, but if your med director were to purchase they could recoup the cost through office visits… This is where I have a little disagreement on the pricing, because if you are stand alone at a HS you will have to figure it all to overhead…

      I am guessing a start up you are looking for would be anywhere from $1000ish (if you own the iPads already) to north of $2500…

      I am not as versed in the cost aspect…

      One iPad for station 1 and two iPads at station two… I would imagine that if you are doing 100 with this type of set up you are looking at about 4-5 hours total… Not too bad, really… For what you are getting…

      • Jason Viel November 13, 2013 at 14:50 #

        Thanks Dustin,

        The closer I get to the end of the school year the more I will push for this from my clinic and school standpoint. I think my clinic can use this I am trying to get a vestibular rehab aspect started in our PT clinics so that we can push kids who are 1 week out with symptoms still occurring in and started on some of the vestibular rehab and I think I can push the clinic on this to use this as a progressing or not progressing benchmark and maybe defer costs and use the PT’s for help in Baseline testing. Again thanks for everything you do.

      • Dustin Fink November 16, 2013 at 10:44 #

        Greetings Dustin,

        I hope this helps, sorry it took so long. The internet coverage is real patchy here. Also, if anyone has any direct questions regarding pricing I’m happy to work with them directly. At this time we have a couple of pricing models one is for schools and universities and the other is for hospitals and clinics. So we have some pricing models, but try to tailor a pricing model to fit into each institution so that the medical staff can utilize C3 as freely as possible. That means we hope each team/school/institution will baseline all of there athletes yearly, perform as many follow assessments deemed necessary by their protocols, and login into the cloud to review and extract as much data as possible to make highly accurate medical decisions. With that being said, our overall goal is to provide seamless Comprehensive Concussion Care (C3) to each and every athlete no matter their location or economic means.

        A typical school/university in a closed network (Non-clinic or hospital):
        One time installation fee: $995 for someone like David to fly out and do a training session.
        User Fee: $100/year for ATC
        C3 Kit: $150/Kit Balance Belt, Stylus, Carrying Case, and Airex Pad
        Baseline Assessment: $6.25/baseline or $5/participant or athlete; which ever is greater
        Follow Up Assessment:
        Unlimited and free

        However, at this time we’re making some concessions for groups that are becoming the early adopters. Which is very typical of any new product being released.

        Hospital, Concussion Clinic, or Outreach Program: (These groups can achieve reimbursements from Insurance)
        Each institution has a tailored pricing model, but their fees are heavily weighted on follow-up assessments which are reimbursable. The goal in doing this is to get medical institutions like the Cleveland Clinic to adopt C3 Logix and implement it into their concussion protocols and outreach programs. Once this is achieved, medical groups can then give C3 Logix to ALL of their schools so that EVERY athletes is covered with the best concussion care possible.

        Cheers,

        Jason Schonhoff
        Western Territory Principal
        Just Go Products
        4483 Via Bianca Ave
        Las Vegas, NV 89141
        http://www.justgoproducts.com
        Sent from my iPhone

  2. Kids SRC Doc November 13, 2013 at 21:08 #

    That’s my downside to C3 – the cost factor. With schools on such limited budgets, it is tough to get this stuff through.

    Also, in my experience, I have not had great luck with pushing kids 7 days out into neurovestibular therapy – I have found 10-14 days to be much more ideal & helpful. 1 week is still quite acute and they often cannot do the exercises well.

    • Dustin Fink November 14, 2013 at 00:02 #

      Cost will always be a factor for schools… I always advocate that if you don’t have an AT, but are willing to spend money that is where the funds should be directed first… Then on to items such as this…

      I really want this to be as accessible to as many parties as possible…

  3. Dan November 13, 2013 at 22:08 #

    The basic science behind the C3 product seems encouraging. I have reviewed the reliability and validity testing data provided by the Cleveland Clinic group/developers. Mostly presented as posters (not yet in peer review journals), these data seem solid.

  4. Chase Curtiss November 15, 2013 at 21:44 #

    Dustin, any concerns about the product being marketed without the appropriate regulatory clearance as a medical device? The FDA clearly states that this type of mobile medical application should be regulated:

    “Apps that use a mobile platform to record response time and accuracy of patients completing a cognitive task and/or automatically score or interpret cognitive testing results”

    and

    “Apps that use the built-in accelerometer or other similar sensors in a mobile platform to monitor the user’s movement to determine conditions such as sleep apnea, sleep phase, fall detection, or detect motion related to other conditions or diseases or to measure heart rate”

    (http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm263340.htm)

    Unless concussion is not actually a medical condition, which seems to me to be the biggest problem, the shake it off mentality. With lives at risk and with all the lawsuits associated with concussions, it would seem to me that the appropriate standards being met would be a big deal.

    Of course my opinion is very biased, but I think should at least be reasonably considered.

    Would love to see your review of Sway Balance, our FDA cleared diagnostic and much more affordable product at $199 with no straps and on smartphone or tablet.

    • Chase Curtisd November 16, 2013 at 11:14 #

      Seems to me the most important question that should be asked. The regulations are clear. The appropriate oversight is to ensure a safe and effective tool for screening or diagnostic. “I don’t care” is likely not the best answer in the unfortunate case of litigation proceedings.

      • Dustin Fink November 16, 2013 at 11:32 #

        Shouldn’t the developer be worried about the red tape and certs of a product? So my “I don’t care” is not one of non-importance in the sense of the need. My “I don’t care” was qualified as an end user… There are plenty of self use apps that don’t have the FDA approval. If they are not used for diagnostic reasons, and charted that way, does it matter?

        If I as a practitioner place in my reports, “possible concussion” why would it matter what I used. My most powerful tool I have, my clinical experience and mind is not FDA approved (although it should be, ha)!

        I think the steps you and your product took were great, thank you. I would have thought that all applications would have had to jump through the ringers… Is ImPACT, your partner, FDA approved? I honestly don’t know…

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