Does Concussion Affect Perception-Action Coupling Behavior? Action Boundary Perception as a Biomarker for Concussion

Eagle SR, Nindl BC, Johnson CD, Kontos AP, Connaboy C. Clin J Sport Med. 2019 [Epub ahead of print]

Take Home Message: Athletes that reported a history of concussion demonstrated vestibular and oculomotor dysfunction as well as had an impaired ability to perceive/visualize a stimulus and respond it compared to athletes with no concussion history.

After a concussion, an athlete is at greater risk for a musculoskeletal injury (articles listed below). The increased risk of injury may be caused by an array of reasons (e.g., deficiencies in complex tasks, increased emotional problems) that cause an athlete to overestimate their abilities, misinterpret visual cues, and place themselves in riskier situations. However, there are no clinical tests sensitive enough to detect these issues. Therefore, the authors evaluated differences in perception-action coupling behaviors, which involves correctly perceiving an event and acting accordingly, between 22 participants with a previous concussion and 24 people without a history of concussion. All participants with a history of concussion were cleared for play and reported about 3 prior concussions (~264 days since last concussion). All participants completed the Sport-Related Concussion and Medical History Questionnaire (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Perception-Action Coupling Task, Immediate Postconcussion Assessment and Cognitive Testing (ImPACT), Post-Concussion Symptoms Scale (PCSS), and Vestibular-Ocular Motor Screening (VOMS). The Perception-Action Coupling Task required a participant to use an electronic tablet to pair virtual balls into virtual holes quickly and accurately over 15 minutes. The test measured the visual perception and movement required to achieve an action (e.g., reaction time, movement time). Not surprisingly, athletes with a history of concussion reported more signs and symptoms following 3 parts of the VOMS: saccadic eye movements, gaze stabilization head movements, and visual motion sensitivity. Additionally, the concussion history group’s Perception-Action Coupling Task reaction time, movement time, and response time were slower compared to the athletes without a history of concussion. There were no differences between groups in ImPACT scores.

The authors of this study found that even after an athlete is fully returned to play they likely experience deficits in how they perceive things and respond to those stimuli. Athletes that reported a previous concussion performed slower on the Perception-Action Coupling Task than peers. This delay could be exacerbated during on-field situations when there are other distractions. The delayed perception and action could increase the risk of injury. Additionally, athletes reported increased symptoms following VOMS. It is difficult to determine without a baseline assessment if these scores were present before the sport-related concussion, or as a result of the concussion. Further prospective studies are necessary to validate these findings. Currently, medical professionals should incorporate multiple concussion assessments such as VOMS and a functional return-to-play protocol to ensure athletes have the aerobic capacity, coordination, and sport-specific skill level to safely to return to play. It may also be helpful for clinicians to include a measure or task to assess how an athlete perceives visual stimuli and reacts to those stimuli.

Questions for Discussion: Have you noticed a relationship between previous concussion and musculoskeletal injury risk? Do you perform the VOMS? If so, do you feel like this has helped your diagnosis and return to play protocol?

Written by: Jane McDevitt

Reviewed by: Jeffrey Driban

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