Objective Balance and Cognitive Testing - 190

Hey, this is Sandy. And Randy? And we're here on AT Corner. Being an Athi trainer comes with ups and downs, and we're here to showcase it all. Join us as we share our world in sports medicine. Welcome back to another episode of AT Corner. For this week's episode, we have a very exciting interview on the expanding role of balance and cognitive testing. You know. When you think balance and cognitive testing was the first thing you think?

I would say concussion. Exactly, that's what I was thinking too, but as we figure out in this episode, there is so much more to balance testing and cognitive testing beyond concussion, which I think is what makes this so exciting. Yeah, for sure. Literally after you said, I kind of was thinking as like you could apply that to a lot of different things in some way, shape or form.

Right. So we have two very special guests today, which is also pretty cool because we don't usually have two guests at once, but that's true. We do have kind of best of both worlds. We have APT and an AT. You want to introduce them. Yes. So our first guest is Kim Wyan. She received her DPT degree from Springfield College, now working in outpatient orthopaedic setting with sports teams. She specialized in concussion management and vestibular

rehabilitation. She works with Sway as the Director of Customer Experience. And fun fact, she is married to an athletic trainer. I know someone married to an athletic trainer. Hey, me too.

We also have Casey Paulk. He received his bachelor's in AT from Southwestern Oklahoma State University and then his master's in career and Technical education as well from Oklahoma State University. Though he's practiced in several settings for the past 18 years, I'm sure you know his name because he serves half of the US as the Sway Sales executive. Or you might know him because he's also the Oklahoma Athletic Trainers Association president. OK.

Yeah. So some people might know him, but also just a little serving half the US, that's a big, that's a big range for a sale for sales. Right. So whether you use Sway now or if you don't yet, why don't we get to know Kim and Casey? Maybe you want to start us off. Yes. So as with any starting interview guys, go with the cryo Breakers. So what is your athletic training muse? This could be any modality, rehab tool, tape, braces, etcetera. Any tool of the trade that represents you.

Or physical therapy? Muse. Yeah, yeah. You can go first, Casey, any little time. Oh, I could say Sway. I think like for an athletic trainer, it's like your hands, right? Like I think you can do so many different things with your hands, manual therapies, things like that. And then you could be sentimental and say, you know, your heart and soul. Remember, ATC stands for all things Covered, so we can do everything. There it is. There it is. Got it in there. Oh, that's it. That was good.

And you know that I used to say that too. Like, I don't know when I would play, you know, volleyball or whatever sports like, you know, after college. And I like be afraid of getting injured myself. Like these hands are my livelihood, you know, I need these. So yeah, that was that's a good one, Casey. All right. I'll be a little just more boring, I guess, like on like,

you know, in the rehab world. And one of the things I grew to, you know, use a lot across so many different, you know, patient populations is blaze pods talked about them, you know, plenty before. But I found so much utility and just fun, whether it's like an older adult, like literally just trying to make sure they don't fall in their bathroom and or you know, the sports concussion vestibular patients, I found

like so many fun uses for them. And it's just really your creativity is, you know, your mind's the limit of how you want to use those type of tools. So I guess that would be like my rehab muse. Yeah, really versatile. You can go really anyway with it. I'm very surprised blaze pods haven't haven't come up before. You're right, Blaze pods is a new one for us. That one's pretty cool. Oh yeah, yeah, they're fun. Why don't we kick it off with a story or experience or case

study? Some life hack or something about cognitive testing? Sure. Well, I'll start and this one relates a little bit more to balance. You know, I was thinking about this and really one of my favorite cases from when I was treating in an outpatient orthopedic practice in the Philly area. I had a, you know, young girl come in. She was a gymnast and she was just coming in for an ankle sprain.

I had seen her like a year prior also for an ankle, you know, just one of those kind of repetitive ankle sprains. And this time she came in and I said, did you keep up with your exercises, the hip strengthening, the core, all the stuff we talked about, you know, last time I saw you. And it turns out after digging into this particular mechanism of injury she had, she sustained a concussion And, you know, she wasn't coming to me for that. I happened to be the concussion

specialist at my clinic. So it worked out that I was able to, you know, just dive into that. But if this particular case just was fit the bill of, you know, increased risk of lower extremity injury after a concussion. And then at the time, this is when I was using Sway in the clinic as well as with our, you know, high school and middle school contracts, it was the perfect time to use Sway. I didn't have force plates or any way to like, objectively measure balance.

And as a gymnast, like her balance was above the norm, like, you know, her baseline balance. And I didn't have a baseline honor that would have been too, you know, picture perfect. But I was at least able to get a starting balance of where she was injured and then over her course of therapy, keep watching her improve. And by the end, she was in the, you know, 99th percentile for

her age and sex. But like, she still had some, you know, lingering issues with her performance because the, you know, the flips and the tricks and her vestibular system wasn't, you know, her ankle was theoretically OK, but there were other components, you know, lingering from this concussion that essentially went undiagnosed. I shouldn't say undiagnosed. She was cleared early. Everyone was like, oh, you're fine from the concussion.

But the level that she had to perform at, and I mean, she was just a high school, you know, freshman gymnast. She's not like elite level here, but the demands of that sport are just so different than, you know, volleyball, lacrosse or or whatnot. So I don't know, that's one of my favorite cases from from my past that I think about often. You know, it's funny how she found her way to you. Yeah. Yeah, well, she was a repeat

patient. I had seen her, you know, years prior, but never for a head injury, just for lower extremity. You know that that after school rush and in PT clinics, it's like busiest from, you know, 3:30 to, you know, 7:00 PM and get all the athletes in at one time. And it's just it's just like the AT room. It's a great time. For that, for that concussion, how how long was she like returned to play before you, before you saw her, if you remember? So she was, yeah, she was

cleared. So she, I think at the time of the head injury, she went to the Ed and then was told like, oh, go see your pediatrician. And she was reporting no symptoms. That's all they were really doing. And they're like, OK, like, you're fine. And then a few weeks later, she sprained her ankle really bad. So she never saw like a

concussion specialist. Or. You know, anyone further than Ed pediatrician and, you know, that's the tough, you know, part of pediatricians like they're yeah, have to be aware of so many things. And that might just not be something that you picked up on. And this is pre consensus statement. So the Amsterdam consensus statement just came out, the Scout 6, you know, the new scat 6.

There's so many new tools for providers that maybe aren't as well versed in concussion as a, you know, specialist would be. So, you know, I would love if I don't want this case to happen again. But if this was the scenario, maybe that pediatrician could have been exposed to the Scout 6 had some, you know, ideas about, you know, how to just surface level manage a concussion or no, you know, at least to pick out the signs. For sure. All right, you want me to talk about a cool cognitive test

story or whatever? Let's do it. It's it's one of a customer that we have a friend of mine and it's in rodeo specifically like bull riding. And so I ran into my buddy who who works for the does professional rodeo and he would say, Hey, I got a story for you. All right. He said it was kind of this correlation. He said, we had this bull rider that got a concussion and going through return to play, you

know, their process. He was, they were looking at the sway data and, and everything else in their clinical evaluations and everything they were doing and their protocols and everything was looking really, really good. Like coming up to within normal limits, the balance and, and, but his reaction time test specifically was still like below norms, like still decreased in performance. So they were like, you know, you're just not, he was same thing. I don't have any symptoms.

I'm feeling really good. Everything else is backed up with the normal limits, but this reaction time is still low. And the rodeo cowboy, the bull rider, said, well, he finally opened up and was honest. And he said, where I live is like a rural part of New Mexico, and I live in a trailer house, and there's lots of flies around, you know, the barn or the house or whatever. So I used to always train myself to catch flies. Like, that's how he would train

reaction time for himself. Like Mr. Miyagi kind of stuff with chopsticks. He would reach and grab flies. And I'm now I'm like, hooked into this story and I'm like, all right, so he said, yeah, I could catch 10 out of 10 flies. Like, you know, see it, catch it, he said. But now since I've had my injury, I'm down to like 2 out of 10. So I was like, so you're telling me the correlation between the sway reaction time scores and his ability to catch flies is correlated?

I was like, this is a cool research study we need to start doing. It's fine. So he's like, so once he started getting better, he could see himself catching more flies. And I'm like, that's such a great story number. There's so many pieces to that story that are hilarious and fun, but like, great at the same time. We're like, yeah, OK, that tracks with bull riders and catching flies and he. Literally did a real life reaction real life reaction test

on itself. It does not get more functional than that. Not get more functional than that because if, and it makes sense if you're a bull rider, it's a completely reactionary sport because if, if you don't have good reaction time as a bull rider, you're not holding on for 8 seconds, you know, you're not a professional bull

or anymore. So I thought that was pretty awesome that, you know, they do all kinds of different types of trainings and different things that, but I never would have thought catching flies would have been one of those things. But that was that's one of my favorite stories that I've heard from friends of mine that are athletic trainers that use that use Sway. You know, bull riding and gymnastics, those are both highly, highly vestibular

activities. And you, you just, if you look at, you know, obviously sports are very vestibular and there's like a lot going on. But you it's really cool to see when when we're talking about like deficits and what role kind of a concussion plays, you can really highly see it in these activities that are more towards that extreme. Yeah. Yeah, for sure. You know what that should have been? My muse is the vestibular organ. I mean, I got a picture of it

back here. It's like, I think it's like the unsung hero of the body. Casey's heard me go off on, you know, feels on this. But it's the size of a dime and you got one on each side and it's like the most amazing organ in my opinion. And and if it gets thrown out of whack, you're all out of whack. Yes, yes, you're so yeah, you're screwed. I mean, it's, it's so important and no one realizes it until something's wrong.

Yeah. So actually Speaking of that, can we talk about the role that balance plays within concussion?

Yeah, Oh yeah, I love it. And so balance is what was always is one of my favorite things to talk about with patients and just educating this can go from educating parents to athletes to patients to older adults, doesn't matter. We all use balance and you know, the three components of balance are your eyes, your inner ear, your vestibular system, and then your proprioception or you know, I'll say to patients like your joints or you know, just the the way your body can talk to your

brain. And the most important thing is your brain has to take input from all three of those systems, eyes, inner ear, you know, body and joints. And, you know, normally your brain can just process it and Bing, bang, boom, do what you want, turn around real quick, no

problem. But when there's an injury to the brain, to the the thing that has to take input from all those systems as well as do a million other things that you know, your brain does, you know, that's why there's so many not even just balance, but that kind of fogginess or I'm on a boat or that visual, you know, perception issues.

There's so many things that you know, your brain's doing and when there's an injury to the brain and that energy demand, your brain can't do its normal functions because it's just, it costs more energy to do that. You know, that's, that's the link. It's trying to manage that demand of what it normally could do when it was healthy, but then there's an injury and it and it can't do all those functions, take in all that input and and do the right outputs.

For sure. So now going away from the brain and kind of like expanding that view, what about for other pathologies maybe outside of concussion?

How do we how does balance play a role into that? Yeah. I mean, if you think about, you know, just when it comes to, I mean, I guess there's so many things that balance can play a role in. If you're thinking like, you know, stroke or more, you know, serious injuries or just in general aging. Like balance for people becomes obviously a serious, you know, risk as you get older or even just recovering from any type of

injury. Like I would always say to my athletes going through, you know, an ACL or older folks with a knee replacement, like something was altered in your body, especially any type of surgery, right, Something was altered in your body. Now that joint, whether it's, you know, the sprained ankle or the knee, the replaced knee, like that part of the body needs to get reacquainted with the brain. Like your brain and that joint

need to talk to each other. They get they have to get to know each other again and how to work properly. Here I am still relating it to the brain, but you know, I mean, I don't know, that's kind of what it comes down to. And balance obviously plays a role in that. You have to relearn how to integrate that part of your body to all your, you know, balance activities.

You know, we're talking about like gymnasts and bull riders and athletic trainers, like needing to really know what that athlete has to do and like what's unique to that athlete. And it's everybody is different #1 every athlete is different. Everybody is different and you know, sometimes that's the challenge is that depending on what setting you're in as an athletic trainer and the bandwidth that you have, you know, the support that you've got as far as other staff, are

you by yourself? You might not be able to do very in depth stuff. That's where like having a great relationship with a physical therapist like let's say Kim, I can refer over, you need to go do this, this and this. Like Kim, teach me what I need to do, like a quick snapshot evaluation test to identify if that's really bad, then that means that he just come to you. It's not really bad. I might be able to handle it myself, but we work together on

that. And so, you know, I think as athletic trainers there, there was always this, we knew how to make balanced testing or not really balanced testing, but like rehabs harder for athletes. You know, we knew that like if you start out with the basic flat ground, eyes open, you know, barefooted and count to 10 or the longer they can go without moving all over the place, the better their balance was. All right, Well, now let's we learn to take away things like have them stand on an unstable

surface. It's just with that and then have them close their eyes like that's going to be the next level harder, right? But we never really, at least me thinking back to when I was in college or an undergrad was like, we were never really taught the inner ear and the vestibular system and this is what was happening. We just knew like just do these things, right, But we were never taught like why or like this is going on. Maybe we were and I just wasn't paying attention.

Who knows? That could have been the case. But and then you got really then you see the fun, cool stuff, right? Like, OK, now we're going to stand on a Bosu ball and you're going to kick a soccer ball because you're a soccer player or you're going to catch a football. Like how can we make it harder and challenging? So they're ready to go back on the field. It's going to decrease the injury, you know, and all those things.

But I, you know, just thinking about balance and the better strength you've got, should we do a functional movement screen on these athletes? You know, do do I know how to do a functional movement screen? Is it really going to decrease?

Now we're doing research like there's but that all depends on like the support you've got to go with it and time and the setting that you're in. Again, it's like, I'd love to be able to do all these things and do all these ACL prevention things and FIFA11, but like if the coaches aren't going to buy into it, then it's going to be a waste of my time. If the athletes aren't going to buy into it, it's going to be a

waste of my time. Already already got so many things that are taking time away from us as a setting and as an athletic trainer. So yeah, that's just one thing. And you kind of think back to Kim's story about the girl, the gymnast. It's like you feel bad that she got hurt. You said she hurt her ankle really bad, like she sprained it really bad after she was cleared from the concussion and thinking what if that would have been

handled better? Then maybe she would have avoided the really bad ankle sprain. Yeah. You know and. Mind you too, she this is club, this is club gymnastics. They don't have an ATC at her club. I mean, it was just the coach saying, oh, you're out. My daughters do gymnastics so I am the club AT. Yeah. That's why it turns up. That's what it turns into. Yeah, yeah, all the other parents start having questions for you, huh? Yeah. Yeah, yeah.

And I'm watching the coaches tape ankles and stuff and I'm thinking didn't say anything. Should I say something like, do I want to? I don't know. Yeah. So, Casey, you kind of went into it a little bit, but how can an athletic trainer assess those

deficits and balance? So with sway, the best way to assess is to use our Ms. assessment, right? So any kind of mobile device, hold it to the chest, have the athlete go through all the different stances. If if you don't have sway, maybe you've got a force plate or a Biodex bio sway machine, but that depends on the setting that you're in a lot. I never had AI, never had either one of those years ago. I only see that like in the college settings, you know, or if you're at a college setting

that has. A lab that is doing some research on this kind of thing, right. I've got friends that are doing these in different settings, like different colleges throughout the country which is really cool. But what are they really evaluating? Maybe the functional movement screening like the FMS but. Or just the pen and paper? Best I mean. Still. On the SAT like. Yep. And that's a thing. But like, are you really measuring that at baseline or you're doing that post?

And we all know like, well, I don't know what was normal for you before I did this. So maybe next year I'll do this before and then I'll have to, you know, go back and look at it. So I don't know, man, that's a great question. I would want to pose that to different settings of athletic trainers, like if you're in the secondary school setting and are you even evaluating balance? Yeah. Do you have the time? Do you have the time if you're in a collegiate setting?

Oh yeah. You know, we work with our this neuropsychologist that we have on staff and we have a like. Or strength and conditioning, like they could take that over. I mean, there's for sure so dependent. 'Cause it's an injury prevention, right? Like if I'm working on injury prevention, I've got to have a good relationship with my strength and conditioning coach or team. I don't have a strength conditioning coach. I'm in a small high school, right? We don't even have a school

nurse. So everything's a little different. You are strength conditioning, you are athletic trainer, you are science teacher and counselor and bus driver. You know, but all. Things covered. All things covered, right? Everything you got to do it all. There's a university in the SEC that has a multi $1,000,000 grant with the NFL. So they do a very in depth evaluation baseline of of let's say concussion. But they can use the data for

all different kinds of things. So it's, you know, cognitive testing, it's driving. They use simulated baseline driving tests that balance so they can use a flash plate and they have all these resources and they have a team of people who are running that. So that athletic trainer on staff probably doesn't even have to worry about it.

It's like if anything is a concussion, you go see these people and they handle it. That just kind of reminds me of the athletic trainers who work with NASCAR or like just race car drivers in general because they have any alterations in reaction time or if they have any post concussion deficits. They it just like the gymnastics in the rodeo, like like it is a very highly vestibular and very highly cognitive activity.

I agree for sure. I would say the military too, depending on the setting that those guys are in. Yeah, I was like, there's videos of the they're doing the G force training to see like how they can handle G forces. The resources too, I, I feel like we keep going to Kim's story, but like the resources, like that does make a big difference because again, maybe if the pediatrician had that resource or knew about the resource, right, the initial management would have been different.

So yeah, resources do play a pretty big role in a lot of things. I think in terms of that, it's really it falls a lot on the AT or the PT shoulders of, you know, sometimes educating the, you know, pediatrician down the street, the school nurse, the, you know, parents on the sideline of this is the way we do things. This is the way research is moving. This is, you know, and it's, we're always, I feel like the

connectors of everyone. You know, you're calling the doctor, you're calling the parent, you're calling the guidance counselor. It's it's just everyone. And athletic trainers in a secondary school setting always complain. I feel like, or it's always like that pain that a kid gets hurt in club sports and then they come see the athletic trainer at, you know, afternoon and they're like, hey, can you check me out? I sprained my ankle. Oh, how'd you strain your ankle?

Oh, gymnastics. You're like, I, I mean, I can't take care of all of your club sports injuries on top of like, I've paid to be here to take care of athletic injuries that happened at school. Like you need to go see Kim, you know, like I, I have. So yeah, like educating everybody. It's like super hard. And that's like a big secondary schools are not secondary, but the, the, the youth sports athletes. That's like the biggest population of, of kids and your

highest injury rates. And they're kind of just left unattended and unlucky. Unless you've got, unless you're playing at a high level of club and you have access, somebody's taking care of you. But you're paying a lot of money to do all that stuff for sure. I would say resources. Yeah, again, back to it. Back to it. But regardless of of resources, when would an injury cue you to

actually jump in and assess that balance because you know, you you think concussion and you're going to assess that balance. It just kind of goes hand in hand. But Kim, like, for example, for your gymnast, what made you think like ankle sprain? Let me assess his balance and see if. You were concussed. Exactly. I'm trying to remember with her case, I mean, with an ankle sprain, I'm assessing balance anyways, right? Like no matter what.

And I really think the concussion piece came up from the subjective history for me just diving into like how she injured her ankle. What was it on the beam or the bars or it was she said it was on a floor routine and she was, you know, practicing for a competition. And it was one of her like normal stunts. And the way she like injured it, she was like, yeah, I just like on my final flip. And I have no gymnastics

background. So for anyone listening, like, sorry, I'm butchering these terms. But, you know, from on the on the final, you know, flip dismount trick, she, you know, misjudged where the corner of the mat was and she went flying off of it and, you know, landed on her leg like, you know, leg crumbled underneath her basically. Thank God she didn't have a knee injury. It was really just her ankle.

But she also, you know, and I probably hit her head a second time, but she said before that like these, her floor routine is what was giving her the issues. And so hearing the floor like repetitive, you know, flips, tumbles that made me think, you know, inner ear got to talk about this. And and then obviously just the back out my training from the concussion standpoint, I'm always just in tune to ask those

questions. Right. Yeah, I was telling Kim earlier before we got started as athletic trainers, I think the older we get and the more experience in the year in this point for PTS as well. Same, right, and Kims husband who's an athletic trainer. I always like to throw that in there for Dan. But when we were young in our profession, I know myself, it was like somebody came in with a shoulder injury. It was just starting doing all the special tests that we ever

learned, right? It was like we're doing every special test. And then you start to figure out like if you'll just ask a really good history and specific questions, you can probably narrow it down to one or two of the things, do one test and then be like, that's exactly what it is because there's so many different patterns. But on the same, I had a case the other day for a high school football athlete at a rural town in Oklahoma. No athletic trainer, really small school and everybody's

connected. So my buddy is friends with them and they reached out to him and said that his kid had a potential concussion. So he called me because of what I do. So I reached out and talked to him. They did a remote sway test for me and we went over the results like in real time. And I'm looking at his balance tests 1st and I'll look at each individual stance that that they did. And I look at the data and I'm, you know, and I noticed that

everything looked really good. Like the scores were pretty high, meaning he had really good stability and balance except for like one side, like the left side, it wasn't equal bilateral right. It was decreased on the left side. So I was everything else was looking really good. Like even the cognitive tests were looking really good. And I said, so just a question. Have you ever had an injury to, like, your left leg, like a left foot, a left ankle, a knee, maybe a hip?

And he was like, well, yeah, like a year and a half ago, I broke my left ankle. You know, I didn't get into the details. So it was maybe a distal fib fracture or something like that, who knows what, because that's kind of common. But anyway, I was like, OK, great to know. I wouldn't have asked that question if I didn't see this data that pointed me to ask that question. So this decrease in balance I don't think is related to your inner ear vestibular concussion.

I think it's related to a decrease because of that injury that you had. You're at a small high school. You probably don't have very many resources. I know you don't have an athletic trainer. Where's the closest PT you know? What do I know about your family, your dad, your mom? Are they blue collar people who are kind of like, you know, just get tough, you'll be fine. Do these exercises, I'm sure. Just start walking, get out there. They don't know how to do

balance, you know, whatever. So it was really cool to be able to like identify that and say that might be something you should work on, right? Like how can you improve your balance without anybody there? Here's some ideas while you're getting dressed in the morning and you're putting your socks on and your shoes on, staying on one foot.

On. One foot, close your eyes and, you know, so it was pretty cool to like identify that, yeah, like staying on one foot and while you're getting dressed or when you're standing in line to check out at Target or Walmart, like staying on one foot, you know, so. I always say you're putting stuff in the in the microwave. It's an automatic timer. You can stay on the one foot. Oh. That's a good one. Yeah, right. That's pretty good.

Get this, I used to tell my older patients to use oh I don't have a timer at home, use the microwave. And then 11 old lady came back to me. She goes, I broke my microwave. Just so you know. Oh my gosh. Yeah, 'cause she was. Like, does she want you to pay for her microwave? No. No, but yeah, that one, the microwave came back to bite me one time. Bill insurance, So going along with Casey's story, so once you

kind of identified those deficits in balance, and I think we've kind of mentioned it like 80s, I feel like I have a pretty good idea of like, OK, here's how we're going to attack balance. But what are some tips that you would have to say work on those balance deficits? Like apparently the microwave could be one. I think one thing I used to tell people was obviously if they didn't have an Air X pad at home, it was like find an unstable surface to stand on. And I learned the pillows

weren't that great. Sounded great. But as soon as you step on a pillow, it like just flattens out and you're standing on the surface. Pretty much. It was like fold up a towel like, but obviously you stand in a corner to be safe. I was like, fold up a towel, you know, and then if that's really easy, close your eyes, you know, like simple stuff. You know, I would, I would yeah. Oh, see, no, I never did that because I never knew that was a thing.

I've learned a ton of stuff from Kim in the short time she's been working for sway about like she says these words and I'm like, I don't know what that means, you know, VMSVOR visual emotion sensitivity. And I'm like, damn, I don't, I'm I'm just an athletic trainer. I don't know what that. Means for anyone like it just comes down to like going back to anatomy and Physiology, it doesn't matter if you're talking balance or if you're talking, you know, an exercise for your

knee. You got to know how the quad work, how the quad and hamstring work together, how the knee joint, you know, it's just a hinge joint, but there is a little bit of rotation. Like if you, you know, and for me too, you know, Anat kinesiology, anatomy, those were a long time ago. I don't remember the origin insertion of anything, but like if you just can remember, you know, and sometimes you got to brush up on it, you know, the hot, the principles behind things.

And for balance, it's those 3 components, eyes, inner ear, proprioception or somatosensory system. You know, like if you know those three things, you can make up any balance intervention. You can challenge your athletes and your patients to do anything by no, by manipulating those three things. In case, even though he doesn't know the big words, he says it all the time. Oh, I have my, I have my athletes stand on one foot or I make them close their eyes like you're, you're halfway there.

You're already doing it. Well, you know, I was thinking about stories and I was at a theme park and I don't ride roller coasters anymore. I'm just thinking. I'm just old. I don't like to roller. They make me nauseous now. They used to. Challenge your vestibular system. OK. And I really just kind of just gave up on it and like, I'm just not going to ride rides. I'll be that dad that just pushes his stroller around, sits on the bench, watches the kids, you know, enjoys the weather and

some food. And I'm like, I can't ride rides because I get like not, I don't get motion sick driving in a car right on boats, none of that stuff flying in planes, nothing but riding roller coasters just like, and about a year and a half ago, I was up in Missouri at Silver Dollar City in Branson. And I was, I got, I rode a ride. For some reason, I thought I rode something that was not going to mess me up, but it kind of did.

And I texted Becky Bliss, right, who's a who's APT friend of mine that's a vestibular PT, neuro neuro PT. And I was like, why does it bother me to ride roller coasters? And she gave me this. She texted me back with this very long big word scientific

explanation. And I said, all right, you have to dumb that down for me. She said, basically what you do every day is you're sitting down, you're looking at a computer screen, and you're not challenging your vestibular system as much as you used to, right? Like, I don't play sports anymore. Like, I don't do all these activities, you know, I don't know. So I need to start doing more of what Kim said. Like, I think athletic trainers were our worst. We're the worst patients, right?

We all know this. We will tell you everything you need to do. We will not do it ourselves. Right. No. Your ergonomics are terrible, yeah, but that's OK. Just do as I say and not as I do. It's one of my favorite things I used to say before, so yeah. Anyway. But learn it. Learn something to do every day. For sure. So we've talked a lot about balance, but I'd like to switch gears a little bit and talk more about cognition. How can like, what does that cognition role play in like, for

example, a concussion? Yeah, I mean, I think cognition, especially to, you know, a TS and P TS and really any perfect any health professions outside of like neuropsychologist who like that's all they studied, you know, and maybe O TS there's I've worked with some great occupational therapists that have, you know, done further studies in or just, you know, courses and whatnot in cognitive therapy.

But I personally feel, you know, for the PTAT and you know, you know, other folks out there that don't get that specialized training in it. It almost feels like the great unknown of like, oh, like, you know, it's not something I could put my hands on. Like, I can't, I can't test your, you know, physically, I guess with, you know, what your reaction time is or, or things of that nature.

And that's what as a clinician drew me to sway initially was OK, this gives me a way, a simple way to get a glimpse of someone's cognition, you know, in the clinic. I wasn't doing cognitive therapy myself. I would, you know, incorporate cognitive tasks into my intervention. So like one of my favorite ones, I would have a kid on a Bosu ball.

We would be throwing tennis balls back and forth and then when they were ready, I would have them, you know, count backwards, you know, if they were taking Spanish in school, like count backwards in Spanish or count the amount of times of reps we got in a row. So incorporating, you know, dual like cognitive tasks into, you know, different interventions was something I was doing, but I never really had a way to measure is that having an effect on on their cognition?

So, you know, the ability to at least for me to use swag to get, you know, benchmarks of where they're at. I loved it because it felt like, you know, a mystery to me before that. And obviously you think reaction time and sports, like it's pretty self-explanatory to explain to a an athlete or a parent how important reaction time is. And you know, if I'm working with like the catcher or, you know, literally any athlete, like your reaction time should be better than this.

If if you're going to go back and sit in the goal and wait for a lacrosse ball to come flying at you at 100 miles an hour, what you know for sure. So I would say, like back when I was practicing our cognitive test, it made me basically think, do you know where you're at? Like are they cognitively aware that they know where they're at? So it's like, you know what day it is? This is basic stuff. What day is it? What month is it? What time is it within 30 minutes? What you know?

And then I remember one of my sports medicine fellows or sports medicine docs was doing 11 time and he said, is Mickey Mouse a cat or a dog? And in my head I was like cat. But then the kid was like neither. And I was like, oh, crap, I even got that wrong. Like I wasn't paying attention, you know, and and then, you know, then it kind of comes to like, OK, scats. Like I think we could all do a scat in our head.

At least, you know, you get the months of the year in reverse order and you start doing the numbers in reverse order and you know, like elbow, apple carpet, saddle, bubble, like that's one kind of fun thing is like, you know, what are your 5 words? You know, everybody has a list of five words, every athletic trainer I think, and now it's 10 words. But I think Kim, spot on when it comes to sports in like reaction

time. I never really gave it too much thought until learning more like working for Sway and getting really into the in depth and all these different things and talking to some other clinicians that I know, like you said, neurologist, neuropsychologist, sports neuropsychologist. And like your eyes, like your eyes or the how you intake data, your brain can't absorb information from outside. It's all got to come through the eyes.

And if you, you don't have good visual processing speed, then the if you can't absorb that data, anything that's coming in, then the next domino is, is not going to be, it's going to fall too, right? So there's going to be a decrease there. So your neuromotor response, so the brain telling the muscles to move, all right, and then the brain telling the muscles to not move or when to move, which is like say in sports. So Kim always gives me a hard time. I'm like the master of

analogies. I try to be to try and get people to understand like this complex thing. Like I try and take everything that Kim teaches me and I try and put it in athletic trainer words when I'm talking athletic trainer. So another, I'll get to another story here in a second, but is like it, it helps that athletic trainer be able to explain to that athlete and to that coach and to that parent. Like it can't just it's it can't just stop with me. It's got to go.

That education's got to continue to go on. So like I want to understand and be able to be a knowledgeable person to be able to explain this information. So then like, what challenges do they run into and getting accurate information, like and like consistent data and accurate data, usable data in the event of the injury that

might occur. And in, I used to tell athletic trainers like, OK, you're, you know, if you've been using a computerized cognitive test and now you're switching to our program, which is, you know, app based and the kids get to use their phones. That's like, yes, now I'm not in the computer lab anymore. And now I can, you know, do this testing way more flexible around my time, right around the coach's time. And. These are the challenges without blah, blah, blah.

And then it was like, OK, cool. So how do you get the kids to buy into it? And you tell them like, well, hey, the better you do, the faster you'll get done. And I used to think that would work. And it it kind of did. It helped. But then I was looking at the data and I'm learning all these things about reaction time and how it relates to sports and like what's important to a high school athlete playing the sport, Like being on the field is important to the high school

athlete. So then we started looking at the normative data and how are data things? And I'm, and I said, I'm going to experiment the next time I do baseline testing. So I said, listen, athletes, I'm going to be able to look at this data with your coaches and we're going to be able to compare you to everyone else on the team.

And we're going to be able to work on the depth chart and figure out like who actually should probably be on the field playing like who's first string, who's second string based on this cognitive data. Because like in the combine, when they go to the NFL combine, they do bench press and broad jump and all these different physical tests. And like the quarterbacks do like the Wunderlich test, like they do that cognitive, how smart are you test?

I guess. So I'm like, why can't we do that at the high school level, club level, high school level, college level and help. So then what I noticed is when those, when I said those words to these athletes, they were like, I got their attention. They're like, oh, so oh, I'm like, yeah, like I can look at this and say like this guy on paper on the data, he looks like he's probably going to be making

better decisions on the field. And you can evaluate his physically and like his all the other things that only a coach can evaluate. But I can help you evaluate this data and what that means from a cognitive and neuromotor like brain and body and movement and all that stuff like this. Kids got a higher ceiling or he's probably going to be able to do this, this and this. So did I do that maybe a little bit, you know, or evaluating them.

And but it's, you know, trying to get a kid, a high school kid to do what you asked him to do. Go to sleep before midnight, turn their phone off and use it a little less, eat better, drink more water. There's just so many challenges that go into that for sure. Kind of alluding to that again,

man, the Segways here have been just on point what about going outside of the concussion, right? Like how what other pathologies could kind of influence that that reaction time or the other cognitive factors I'm. Going to start. I'm going to start. My parents got older and they'd go to the doctor and they have to get the fall risk assessment, basically that, you know, they're over 65 and they'd go get these Medicare Wellness visits and, and I was learning what, what is that like?

You know, And they were like, well, they ask you, you know, if you've ever fallen in the last year. And if you say no, then the doctors move on to the next question, right? And we started, so sway came out with a functional like 30 seconds set to stand test, which is PT driven. Like that's not something athletic trainers were doing because we weren't, I wasn't, I was like, why am I doing this? And it's an assessment of this.

And then we had a, so then we created the CDC four stage balance test, which is for older patient populations there. And then we were then we had our reaction time to that. And those three tests were like our fall risk assessment. So then I'm starting to Kim loves fall risk. She and I will get into like, well, we love it. And we're talking about and people have in our company have to like pull us back. But I'm like, well, everybody

always wants Guinea pigs, right? Like I can test my daughter's on the cognitive concussion side with sway. And I was like, well, my parents like I know a ton of older people who are over 65. It's like parents Guinea pigs. Perfect. So the next time I go home, hey guys, FYI, you're going to do this test. And I'll never forget I had my mom do the Ms. which is eyes closed. And I was there with her watching her do this. And after the first tandem stance, it was I was like, this is unsafe.

Like she does not need to be doing this. Like she could fall right now while she's doing the test. So we stopped it. And then we did the CDC four stage with her eyes open. And I was just like, man, this is really cool. And then you start to learn that older adults act very similar to an athlete who might be concussed as far as being honest with clinicians, right? Kim? Like, they won't tell. I'll say this, and I'm just, this is what I've learned.

And I assume is that they don't want to tell somebody that they have maybe fallen or that they've had things that have made them almost fall. They've almost fallen because they don't want to lose their independence and they don't want to have like their life change and, and whatever, whatever. Just so it's almost like athletes, if they really want to play, they're probably going to lie about their symptoms.

If they don't really want to play, they're still probably going to lie about their symptoms. And an older patient person might actually do the same because they don't lose their independence. And I'm not a 65 year old guy yet, but like, maybe that is the thing. So anyway, that was that was one really cool thing is like fall risk. And then you start looking in the data of fall risk.

It's like, you know, if you're, what is it if you're 80, if you're at least 80 and you fall and break your hip, your chances? Of Oh yeah, the mortality. You know. Rates associated with falls. It's like, unbelievable. Yeah. So it's like. And even gate speed, you know, gate speed is another indicator of mortality. So here Kim, now you go talk about that.

Know you love it. No, I mean, you know, obviously that's definitely a huge piece, you know, of the PT realm and you know, I always he would talk to my students when I was ACI of, you know, I got into PT because I really like the sports aspect. I was an athlete, you know, in high school I got injured and was in APT clinic and thought, oh, that's cool, I could do this.

But you know, when the rest of PT there's sports is just a small sliver right there is, you know, geriatrics, Pediatrics, you know, inpatient hospital stuff, which you know, I've done a ton. I've done a lot of that too, because it's just such an interesting, so different than outpatient orthopedics. But you know, yeah, when it comes to, I guess, balance and cognition and, you know, on the sway side, it's really the options are endless of how you

want to, you know, use the tool. And, you know, right now we obviously talk a ton about concussion, but we have, you know, certainly all different types of folks using our platform for research and just for different uses in different patient populations. Looking at folks with Parkinson's and how can obviously, you know, cognition and balance play a huge role in that folks with Parkinson's deal

a lot with tremors. So can our reaction time test that is, you know, dependent on holding the device, does a tremor mess that up or, you know, is, are these things that are, can we use technology to help other patient populations, you know, still in the head injury realm? But you can look at motor vehicle accidents. You can look at, we had a study at one point looking at folks that were involved in domestic violence. And how can you know, you again, use technology to serve, you

know, those type of populations. And then, you know, you get the cool ones, Of course, you know, the bull riders and the, you know, different, you know, realms in the in the sports world. But I think there's so much opportunity for, you know, all different pathologies really, because cognition and balance can fall into almost every, I don't know, pathology. Every person. I feel, yeah, yeah. It's just such a, you know, huge part of human function, those two things.

We've got like military is one too, with like blast exposure. You know, they use the word concussion differently than we do. They use MTBI. Concussion for them is like the reverb of the explosion. So there's, yeah, I think the possibilities are pretty much endless. So I know I use, I personally use Sway and I've seen, I've taken it myself and I, I use it with my athletes. But can you explain a little bit of what that cognition test looks like, 'cause I know like

the balance is a little bit easier to imagine for someone who does like a best like pen and paper, but for like a cognitive test, what does that look like when you're testing cognition? Yeah. So on the sway side, you know, we have kind of our Core 4 cognitive test that, you know, in the sports concussion world, folks will take the M best and then four different cognitive,

you know, modules. So reaction time, which you've, you know, it's pretty self-explanatory in terms of that, you know, just quick neuromotor response. And then what comes after is called impulse control. And I love the relationship between those two and I really Love Actually reaction time and impulse control, even for the older adult, because the impulse control test for anyone that's taken it is, you know, a green check or a red X.

Do I have to make a decision? Do I move the phone or hold it still with the older adult if they're driving, is it a green light or a red light? Am I crossing the street? Am I stopping? You know, there's so many different factors and now there's no direct correlations. There's no research to say if you've, if you're an older adult and you fail a sway test, you cannot drive. There's absolutely nothing like that.

Maybe one day someone will do a study, but you know, if you think about these different measures of cognition and relating them back to function, and even you could do the same in sports. You know, you you have the play call in your head and you know, you have to remember the play call. You have to think, are you going left, you going right or whatever the scenario. And then, you know, we have inspection time, which is, you know, just more visual processing.

So that quick, you know what you see and then can you make a response after that. And then you know, a memory test and memory is going to be important in older adults and sports. And obviously it's part of the SCAT 6. So, you know, it covers kind of all those, all those aspects of cognition. Once you've kind of identified those kind of deficits, are

there some interventions that can be done to kind of improve like say reaction time or impulse control?

Yeah, that's a great question. And again, it's really, you know, a matter it always comes back to like your understanding of like the anatomy, the Physiology and kind of the cause behind it. So we were talking about, you know, just reaction time and like, are you in the sports specific realm where you can, you know, it's a lacrosse player and you can throw different colored balls and they have to catch it and you're giving different commands of, you know,

well, I don't know, like when when I throw the red ball, you're going to name, you know, 3 red foods. When I throw the yellow ball, you have to do, you know, yellow or whatever, or use your left hand and your right hand. I would use that a lot as with red and yellow, whether it's post it or blaze pods, you can, you know, get it. You could choose the colors you want. So you know, red is right, yellow is left.

And you know, you would have to use different hands that really challenge it. Again, it brings in so many different aspects of cognition. It's sometimes kind of hard in the intervention side to isolate. I'm only going to work on reaction time, you know, or I'm only going to work on, you know, you know, I this eye movement or something like when it comes to intervention, there's so many pieces that you're going to factor into what you're choosing

for the intervention. And you know, it doesn't matter ATPT, like I would always tell folks, as long as you have a rationale for why you're doing an intervention and you can relate it back to, you know, whether it's something with the Physiology, the anatomy of it, that's what matters. Like, you know, there's so many fancy exercises and all these fancy things you see on Instagram like in the rehab

world. But you know, I'm going to sound like just an old granny PT here, but like the basics work too. Like you got to start simple. You don't have to get all these fancy, you know, throwing tennis balls, blaze pods, blah, blah, blah. Like you don't have to be super fancy with that. If you start with the basics and get the brain and the body, you know, talking, working together, that's how you building and get to the, you know, the fancier

cooler interventions. I will say that we do have ACEU coming up that kind of is going to talk about this. Stacey Ritter is going to be talking about like neuroplasticity and concussion recovery. And Becky Bliss did a talk at NATA that I actually got to help moderate. And I learned a lot of like those interventions that she has.

And like Kim was saying, you know, the Reds and the greens and catching things with one hand or the other and listing out like, here's this tool and I bought it on Amazon for $5. Like, not super expensive. And it was just like, you know how like trainers are. Macgyver's right? You give us very little, few things because we don't have a lot of money and we'll make it work, right? Like we can't afford the cool stuff.

We'll figure out a way to get, you know, whatever we need or want to. I mean, I've seen it where you take a roll of tape and you can write numbers on it and you throw the tape, the roll of tape to the athlete and say call out what number you see. I mean, there's so many ways to get creative of, you know, if you see something that's cool or you know, a piece of equipment that you really want, but it's

not in the budget this year. Like think about the rationale behind the use of whatever it is. I mean, I didn't have blaze pods forever. I got them at one point I was using post it notes and I was putting post it notes all over the place and giving the verbal commands of where to go and drawing different letters on different colored post it notes. I mean my clinic was a hot mess with post. It notes.

There's so many cool things like I've seen bull riders that they're in a kneeling position on an air on a, on a exercise ball, on a physio ball, and they have to balance that way where they'll jump people that jump up on it onto their feet, you know, and they can hold it and they stand on it. Like one of my former students from when I was in, when I was in in a high school setting, he was one of my high school

student athletic training aids. He is now one of the athletic trainers for the one of the professional bull riding teams. And he does, they use Blaze pods and they do all these really cool things that are very, very specific to like that athlete, right? And I had a guy who had a ballerina who was recovering from concussion or ankle sprain, and he was using blade spots on the ground.

And she would be on point and she would have to, like, move over and, like, touch the blade spot with a foot. And then she'd move over. And, like, I was like, athletic trainers and PTS were pretty, you know, smart when it comes to, like, those different things. But yeah, the resources, like what?

And there was one thing you were I wanted to bring up was like Kim said, if you can make sure that it matches the reason why you're doing it. And there Becky had talked about the, is it the concussion profile screen where if you can identify the different subtype of concussion, it might be, then that might help you like go this direction with some of these

therapeutic interventions. So just try and learn as much as you can and ask people questions and utilize the resources that you do have, not just monetary resources, but like Kim, your PT resources and your neuropsychologists and neurologists, all those different. Things oh, your educational podcast resource Your. Educational podcasts? Exactly. Good plug there. Thank you. I think it's time for an action item.

I think so go for it. What would you guys want the AT community to know about a system like Sway or some sort of cognitive testing, balance testing Zeus outside of a

concussion? I think, you know, my favorite one, and we kind of alluded to this earlier, is, you know, obviously if you have the time and resources and you're using Sway or you're, you know, considering it as, you know, implementing it in your setting, you know, yes, it has the concussion utility for it, but you can, you know, really think about prevention and performance with it.

You know, looking at the individual balance stances and, you know, looking at those left, right asymmetries, looking at the reaction time and realizing, wow, you're in a lower percentile than I expected you to be at for our starting wide receiver. You know, things of that nature, like, you know, using what you know of the team and your players and then being able to, you know, use the data to, you know, help them perform better. So, performance prevention.

I would say on the visual processing speed, like the inspection time tests, if you start seeing those normative day, those points being kind of low compared to norms, a simple question like have you ever, do you have a do you wear contacts or glasses or have you ever been to the eye doctor? Like maybe you never have. And and maybe that I know I never went and I found out at college I had astigmatisms in both eyes. Maybe that's why I couldn't hit the baseball. So there's that.

Yeah. But I agree 100% with what Kim said. So after going through this interview, now I have like all these ideas and now I'm like super excited to like use like what we use for like concussion testing for maybe muscoskeletal stuff. Yeah, I feel like it's something that you have accessible and you have profiles. I mean if you are doing like a mobile based app like you would have access to it.

Yeah. And I was going to say, I feel like now because of there are, you know, more mobile, like mobile kind of apps coming out for this, like it's so accessible now. Like I feel like it's a lot easier to try and like work with it on a day-to-day than just like some of the older systems where it was really like tied down and it's so specific for like only for concussion. Right, right. I mean, just an example, like we

do use Sway at my school. And one of the things that I really like about it is like Kim was talking about there's like the different modules of tests. So it always starts with the balance. And like if you do the whole like profile, it starts with the balance and has the four core like memory inspection time, reaction time, like stuff like

that. And then there's what I really like about it is like as soon as they take the test, it tells you it gives you like a chart, but it also gives you like a percentage of increase or decrease compared to their baseline. So someone like I had a an athlete who post concussion was down 129 percent on reaction time. And so then a little bit like once he became a little bit more asymptomatic, we had him take it again and he was down by 22% on reaction time.

So then I was like, OK, now like he's a little bit less symptomatic, we can start incorporating some reaction time into his rehab. So even though, like, we were still making it through the protocol, like I was be able to use Blaze pods like Kim was talking about, and we were just doing like some, you know, just colors, like I only want you to hit if it's blue or like, let's see how fast you can hit the

pink one. And then like, like, even if I just set the blaze pods up, like right in front of them or like turn around and then you have to turn around and hit one. Yeah. And so like there's a lot of things that we were able to do to work on his reaction time so that he was able to get back to. Full like baseline. Yeah, I know. I, I like that too. And kind of what we brought it up is like using that to kind of guide your treatments in rehab. I thought that's, that's a

really cool idea. Like you can actually have an objective number on deficits again, whether it's concussion or not, or you can see where a deficit may be and OK, how can we adjust that? I also like the aspect of hey, you may not, you know, you may be starting it for a like muscoskeletal thing, but you might find an underlying like

just unhealed concussion, right? I thought that was a nice story at the beginning of it. That kind of just shows the importance of hey, even if someone may walk in, you don't know. Right, right. And even beyond this, like even if you're able to notice that someone's like working on reaction time or something, you don't have to have all these fancy tools. You could just do like post it notes or you could just like call out numbers or have them like dual tasking sort of

things. So there's so much that you could do with it and it's just this is just the beginning. Weird. It's it's funny, it's almost like we talked about resources a lot. That sounds familiar, but anyway, we do have every episode of our podcast kind of differing between story episodes or Education episodes or interview episodes like this one. So make sure you check those different types of episodes out. Our education episodes are also worth CE us.

Thank you to clinically pressed and athletic training chat. So make sure you check those out. If you guys are interested in getting some CE us, some of them are free. So make sure you check those out. And then we also have story episodes where we bring stories from athletic trainers all over the world and we synthesize them into one topic and kind of talk about one various aspect of our crazy jobs.

Yes, so if you want to submit stories for that, make sure you go to our Instagram at AT Corner podcast. Thank you so much again to Sway for being on our podcast and we have so much more for you in the show. That's below, including a promo code for Med bridge. You have anything else to add, Randy? Nope, that's perfect. Thank you for helping us showcase Athi training behind the tape. Bye.