Is COBALT something to identify balance deficits that mCTSIB might not pick up after a concussion?

Answer:

Amy Alexander, PT: “Because athletes start with such high level of balance, usually above general population studies, they have to be really impaired to show up on a static test. Now on the COBALT test, 100% of healthy athletes can do the test, and they do it with a very low error rate. We had just under 600 athletes from age 10 to 25. When we were looking at what does COBALT do and how do athletes do on it, 100% of them can do it.

I only have norms for age 10. I can tell you I’ve done it as young as seven. They don’t do it well, but they can do it. That’s the key, is they can do it. Now in the 10 to 25 year old, across all age groups, over 90% could do it without committing more than one error, so it has a very low error rate. If somebody biffs more than once, or meets error criteria more than once, you already know that’s extraordinary. And that sounds funny, and I write it up like that, and I will educate my athletes that that’s extraordinary. Because, particularly once you get to 16 and 18, it’s 90… In the 19 to 25 year old group, I think it was 100% could do the test without committing more than one error.

So if you come to me as an injured athlete, if you can’t do the test, I already know there’s a problem. In our post-injury study that we submitted to JMPT, 45% of the concussed athletes couldn’t do it on the first try. Of the rest that could, the vast majority had two or more errors. Of the ones that were able to muscle through it and commit only one error, their SWAY scores were much larger. We give them… 25th percentile is our lowest edge of passing, is what we tend to use.

Anyway, what we liked about it is… Our idea around here, we tossed around the phrase, “difficult, but doable.” I say that because it is hard. These athletic trainers that I was teaching a couple weeks ago with Jamie, I made them do it. They were like, “Oh my God, this is really hard.” I go, “yeah, but you’re doing it.” And that’s the key, is they’re doing it. It’s not easy, but that’s the thing that will tease out among athletes. The thing is, as a healthy athlete, there’s going to be some variation in execution, but an injured athlete that’s not got really good kinesthetic aware…like if they’re way off angle, if they think a line looks like this instead of this for head turning… Those sorts of things, those execution errors, they just really, for me, is a highly useful tool.

I have tested healthy athletes or uninjured athletes up through the age of 60 or… I’m sorry, 68 is, I think, the oldest athlete that I ever did. And he was Tai-Chi and a marathon, and he was still a runner, and so that was his fitness, was Tai-Chi and running. So he could do it as well. Did he do it as well as the 25 year old? No, but he could do it.”

Bridgett Wallace, PT, DPT: “Prior to COBALT in 19, Kevin Guskiewicz and colleagues, certainly taking the lead in concussion management through the NATA, National Athletic Trainers Association, came out with the BESS test, which is widely used among athletic trainers and is difficult, but doable. For those, however, that also are really doing the VOMS, that research showed that the best wasn’t as sensitive post-concussion. The difference that it comes down to is really the head movement.”

Amy Alexander, PT: “It is, and the both feet on the ground.”

Bridgett Wallace, PT, DPT: “It’s both feet on the ground, head movement, eyes closed and doing the motion sensitivity. I think the best really opened up our eyes about the modified CTSIB not being enough. A difficult but doable test, but by the COBALT adding the head shake, a higher demand vestibular, and the motion sensitivity, I think… I would love to see at a minimum people doing the VOMS and the modified COBALT together. And for those of you who may not know, the modified COBALT is the non instrumented version. Not everyone can afford force plate technology or computerized testing, so you can set up the modified COBALT, and just like Amy has continued to say, at least pick up on error rate. The other thing I want people to know, Amy, is you have all have also collected quite a bit of data on older adults too, correct?”

Amy Alexander, PT: “Yes.”

Bridgett Wallace, PT, DPT: “And what were the ages, and what did you find there?”

Amy Alexander, PT: “That they can still do it. There’s a group of men that I did get to test every year. I don’t get to talk about their data very… but just know that up through the mid-sixties, they can all still do the test. There’s one that is consistently two errors every time, but because I’m baseline preseason testing him, I know that he’s going to commit that many errors. So if he were to get a concussion and come in and see me, and he says he’s fine but he has that many errors and he looks the same, that’s how I know he’s okay. But if he had a lot more… So I haven’t collected… I don’t have an end size in older athletes enough to say this is what older athletes do in terms of SWAY and error. I can tell you anecdotally, because of the size, that’s what I usually say is because of the end size, it’s not very… But it’s doable.”

Bridgett Wallace, PT, DPT: “In our patient population, 62% are over the age of 65, and we use the COBALT regardless. If modified CTSIB isn’t sensitive enough, we use the COBALT in all of our patients, regardless if it’s concussion or not, which eludes to what you’re saying, is think of it not just as a concussion test, but as a high level balance test.”

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RESOURCES & LINKS:

• This Q&A is an excerpt from the Vestibular Health Summit Sessions
• The Vestibular Health Summit Sessions are included with 360NeuroGO Enterprise

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FACULTY:

Amy Alexander, PT

Amy is the primary vestibular physical therapist for Banner Sports Medicine and Concussion Specialists Clinic, a physician led multiple discipline clinic in Phoenix, AZ. Amy has been practicing physical therapy since 1988. She chose to specialize in vestibular physical therapy in 2003, completing the APTA competency course in 2006. She started working at the Banner Health concussion specialty clinic in August 2014, managing vestibular and balance disorders in the post injury population. In vestibular physical therapy, Amy’s interest is in assessing athletes in ways that more closely approximate sport related activity. Through her work with MMA fighters, Amy was part of a multiple discipline team that developed a sport specific return to play protocol for combat sports. She was also a part of the clinical research project assessing normative gaze stability in elite baseball players.  Sport specific exertion and gaze stability is a current project that has evolved from working with athletes experiencing post-concussion syndrome.

Bridgett Wallace, PT, DPT

Bridgett Wallace, PT, DPT, has a doctorate of physical therapy and holds competency-based certifications in vestibular rehabilitation and concussion management. Dr. Wallace has been treating patients with dizziness and balance disorders for more than 20 years and is the founder and President of 360 Balance & Dizziness – a specialty clinic for the evaluation and treatment of dizziness and balance disorders that includes both audiology and therapy services. She is also the co-founder and Director of Clinical Education for 360 Neuro Health Institute, which provides online, mobile and live educational offerings for health care providers.