By Steve Yanda
Washington Post Staff Writer
Thursday, August 19, 2010; A01
Across the spectrum of athletics from youth soccer to the National Football League, concussions are one of the most worrisome of injuries: hard to diagnose and even harder to know when an athlete has recovered. Now, in an unusual combination of real sports and their digital imitators, a handful of colleges, including the University of Maryland, are turning to a video game for help.
Athletic trainers in College Park and on other campuses are using the Wii Fit video game as an objective and practical -- if unproven -- method of assessing athletes' balance, an important yardstick for determining recovery from concussion.
For the past year, Maryland and Ohio State have partnered to conduct research into the reliability of Wii Fit -- an exercise video game played on Nintendo's Wii console, which allows for physical interaction between player and game -- as an effective concussion management instrument. Darryl Conway, Maryland's head athletic trainer, said this will be the third year the school has used components of the game to conduct baseline testing of its athletes' balance.
Proponents of using Wii Fit as a tool to examine concussions praise its simplicity and affordability -- not to mention its popularity with student-athletes.
"The athletes love it because what we've done is we've incorporated this fun game that they're playing at home into their rehab system," said Tamerah Hunt, director of research at the Ohio State Sports Concussion Program. "But they're also enjoying it at a time when they're injured or at a time when their spirits are down, and they have to come into the athletic training room every day and they have to get all this treatment . . . and it's kind of a reaction of, 'Oh, this is fun.' "
Others, however, are cautious to accept it as a valid means of treating the injury.
"Obviously, the spotlight on this injury is iridescent right now, and there's a lot of people that are concerned about it," said Micky Collins, assistant director of the Sports Medicine Concussion Program at the University of Pittsburgh Medical Center.
"What I'm afraid of is that that's leading to sort of this potentially dangerous, really limited scope in terms of how you evaluate this and trying to come up with easy tools and sort of one-size-fits-all recommendations that can end up being very dangerous."Increasing concern
The issue of concussions in athletics has emerged as a major health concern in recent years -- from professional sports organizations such as the NFL all the way down to high school and youth teams. Increasing efforts have been made to attempt to limit the number of head injuries.
Prior to the start of training camps last month, the NFL announced it would dispense posters to its 32 teams detailing the dangers of concussions in blunt terms. The posters must be displayed in each team's locker room all season. Additionally, the NFL recently tested 16 helmet models in an effort to improve the technology of its headgear to better prevent concussions; the results of the tests were distributed to league players.
NFL retirees have reported rates of Alzheimer's and other memory-related diseases at five times or more the national rate, according to a league-funded study. Boston University scientists, whose research was funded in part by the NFL, have discovered a link between head injuries suffered by athletes and a condition that mimics Lou Gehrig's disease, or ALS.
Also, the NFL and its players' union have worked to reduce the amount of hitting during team practices in an attempt to decrease the number of player-incurred concussions.
At the amateur level, the National Federation of State High School Associations has established a new rule, effective this fall, that prohibits football players who merely show symptoms of a concussion from returning to the field of play until cleared by a medical professional. Previously, an athlete had to be "unconscious or apparently unconscious" to be removed from the field.'An evolving area'
At Maryland, athletes stand barefoot on a small rectangular platform in front of a television screen and mimic the three different yoga poses performed by their digital Wii Fit instructor. They stand in each pose twice -- once with their eyes open and again with their eyes closed. The final component is a test during which athletes shift their weight on the platform as they attempt to get a varying number of virtual marbles to fall through a table of holes on the screen.
After each portion of the test, a numerical score shows up on the screen indicating how well the athlete maintained his or her center of balance during the exercise. Trainers catalogue each score into the athlete's medical file.
The purpose of such baseline testing is to provide doctors with an idea of how an athlete normally functions. If the athlete later suffers a concussion, doctors possess a frame of reference to measure how far an athlete's ability to function is from its starting point. When the athlete returns to his or her baseline measurements, they are deemed safe to return to competition.
Judging the effectiveness of Wii Fit and other balance-testing mechanisms is a question of reliability. Hunt said the studies done by Maryland and Ohio State have shown that Wii Fit's reliability -- when compared with other, more studied balance tests -- is "pretty decent," but acknowledged that, ideally, it would be much higher.
Collins, who was consulted during the treatment of Tim Tebow after the former Heisman-winning Florida quarterback suffered a midseason concussion last year, said part of the issue with Wii Fit and other balance tests stems from the rawness of their data. While neurocognitive testing -- which measures a person's capacity to react, pay attention and remember -- has been researched "extensively," Collins noted that "the balance stuff is just really an evolving area."
The Balance Error Scoring System (BESS), developed by clinicians at the University of North Carolina, is the most thoroughly studied and most commonly used balance test, though it also has shortcomings.
Subjects stand either on the ground or on a foam pad and perform a number of stances with their hands on their hips during a given time. The subjects are scored by a spotter based on how many errors they make. Proponents like that the BESS test is reproducible on the sideline. Critics point to the subjectivity of its scoring system; an error judged by one spotter could be missed or not judged an error by another.
Some schools, such as Virginia Tech, use force plates, which are a more intricate -- and much more expensive -- form of balance testing. Subjects stand on a plate in different areas and a computer generates an algorithm that reveals their level of equilibrium.
Force plates cost between $40,000 and $50,000, which makes them a less-affordable option for most schools, and generate in-depth data that only those very familiar with the mechanism can discern. Conway said he purchased Maryland's first Wii Fit unit for $300. Now, all three athletic training rooms at Maryland are equipped with a Wii Fit. Goforth said the training staff at Virginia Tech has discussed trying the Wii Fit system as a balance test for its athletes, and he believes athletes would be more willing to comply with rehab if Wii Fit was an option.Question of consistency
In an April 29 memo to all NCAA head athletic trainers, Debra Runkle, chair of the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports, wrote that baseline assessments of an athlete who has suffered a concussion should minimally consist of a symptoms checklist, as well as standardized cognitive and balance tests. Wii Fit was one of the three balance-testing mechanisms Runkle suggested for use.
Collins, though, said he "certainly would not recommend the use of" Wii Fit until more normative studies are published because "it's just anecdotal in nature. There's no evidence to suggest it works. What the results suggest are that it's convenient and affordable, but it doesn't provide consistent results when you look at it in a controlled study."
In fact, a study published last year by three researchers at the Sage Colleges in Troy, N.Y., found that Wii Fit "does not provide consistent, accurate results" when compared with a force plate mechanism.
Hunt said the joint research done by Ohio State and Maryland does not include data on anyone who has suffered a concussion following baseline Wii Fit testing. She said she hopes in the project's second year to be able to grow the sample size and incorporate more schools in the study. She and Conway have reached out to the University of Delaware and the University of Georgia, among other schools, to gauge their interest.
"The most important thing is that you can have some steady norms established, and I'm not aware of any normative data that's been done" on Wii Fit, said Jason Freeman, associate professor of neuropsychology at the University of Virginia. "I think in theory it's a great idea. But without normative studies to really establish steady, consistent, reliable data collection, I think that's really the key."