Archive for May, 2014

Young Athletes More Likely to Suffer Serious Overuse Injuries If Their Parents Have High Incomes

The higher your annual income, the higher the chances that your young athlete will suffer an overuse injury.

That’s the eyebrow raising result of a new study that shows, for the first time, a link between overuse injury rates in young athletes and their socioeconomic status.

The rate of serious overuse injuries in athletes who come from families that can afford private insurance is 68% higher than the rate in lower-income athletes who are on public insurance (Medicaid), according to the study.Class AA-A Girls Soccer

Privately insured young athletes are also twice as likely as publicly insured athletes to be highly specialized in one sport, state Loyola University researchers who previously reported that young athletes who specialize in one sport are more likely to suffer serious overuse injuries.

Neeru Jayanthi, MD, medical director of Primary Care Sports Medicine and an associate professor in the departments of Family Medicine and Orthopaedic Surgery and Rehabilitation of Loyola University Chicago Stritch School of Medicine, recently reported the results at the International Olympic Committee World Conference on Prevention of Injury & Illness in Sport in Monaco.

The findings also were presented at the American Medical Society for Sports Medicine Annual Meeting in New Orleans, LA.

Intense specialization in one sport can cost thousands of dollars a year in equipment, fees, transportation, and private lessons,” Jayanthi said.

“Having the financial resources to afford such costs may provide increased opportunities for young athletes to participate in a single sport.”

RESULTS FROM ONGOING STUDY

Jayanthi and colleagues are conducting an ongoing collaborative study of athletes ages 7-18 who were seen at primary care and sports medicine clinics at Loyola University Health System and the Ann & Robert H. Lurie Children’s Hospital of Chicago.

So far, nearly 1,200 athletes have been enrolled in the study.

Both institutions care for a socioeconomically diverse population.

The median income of the families of the young athletes was approximately $70,000.

About 11% came from low-income neighborhoods, while 19% are on public aid.

Athletes completed surveys reporting training volumes, age of engagement in competitive sports, and degree of specialization.

The researchers found that 30% of privately insured athletes were highly specialized in one sport, compared with 18% of athletes who were publically insured.

SERIOUS OVERUSE INJURIES

Among the privately insured athletes, 13% suffered serious overuse injuries, compared with 8% of publicly insured athletes.

Serious overuse injuries can force young athletes to the sidelines for 1 to 6 months or longer.

These injuries include stress fractures in the back or limbs, elbow ligament injuries, and osteochondral injuries (injuries to cartilage and underlying bone).

Evidence on Testosterone Therapy Does Not Support Cardiac Risk

Does testosterone therapy to treat testosterone deficiency, or “low T,” increase a man’s risk of cardiovascular disease?

No, says a provocative editorial that asserts there are flaws in the cardiovascular risks quoted in recent articles in the scientific literature and mass media.

The public judgment of the overselling of testosterone therapy demands a response, stated the lead author, Martin Miner, MD, Clinical Associate Professor of Family Medicine and Urology, Warren Alpert Medical School of Brown University.

The editorial appeared in the April 8, 2014 issue of Journal of Men’s Health.

NO CREDIBLE EVIDENCE

“As researchers and clinicians with extensive experience with testosterone deficiency and its treatment, we do not find any credible evidence that testosterone prescriptions increase health risks.

We find the assertion that testosterone is prescribed to men ‘who are simply reluctant to accept the fact that they are getting older’ is without foundation, and we object to comments that question the reality of testosterone deficiency, regardless of whether it is called hypogonadism or, as in advertisements, ‘low T,’” Dr. Miner stated.

“In addition, in our opinion, the idea that physicians prescribe testosterone due to pressure from drug companies is irresponsible and not supported by scientific evidence.”

OVER-THE-TOP COMMENTS

Over-the-top comments tend to scare both patients and physicians.

“The FDA announcement that it is investigating the reports of increased cardiovascular risks has only added to the impression that a major study has determined serious problems with testosterone therapy,” he stated.

A case in point is a recent report published in PLoS ONE that investigated the risk of acute nonfatal myocardial infarction (MI), or heart attack, in a retrospective cohort study of a health-claims database.

The authors compared the rates of heart attack within the first 90 days of an initial prescription for testosterone with the rates of heart attack for the 12 prior months in nearly 56,000 men.

They also examined pre- and post-prescription incidence rates for nonfatal heart attack in another large cohort of more than 167,000 men for whom only phosphodiesterase-5 inhibitor (PDE5i) medications (such as Viagra) were prescribed, and after adjusting for potential confounders, compared these results to those of men who received testosterone prescriptions.

The authors concluded that the risk of heart attack following testosterone prescription was “substantially” increased (at least twofold) in older men and younger men with preexisting, diagnosed heart disease.

STUDY IS “TOO FLAWED”

“A close examination reveals that this study is too flawed to provide meaningful information on the cardiovascular risk of testosterone therapy,” stated Dr. Miner.

“First, the overall rate of nonfatal MI in the testosterone-treated group increased in all ages from 3.48 to 4.75 per 1,000 person-years.

This amounts to just greater than 1 additional MI in 1,000 years of exposure to testosterone.

It is misleading to characterize this increase as ‘substantial’ based on relative risk when the absolute risk is so small and clinically meaningless.”

Also, the study duration (90 days) was short, and a true control group would have consisted of men with untreated testosterone deficiency, not those who received PDE5i medications.

The overall risk was low, and the number of events in subgroups was remarkably few, he noted.

More data from larger, longer term studies are needed to assess the potential effects of testosterone therapy on cardiovascular events in men.

Based on the current evidence, he stated, “we can find no foundation for suggesting new restrictions on testosterone therapy in men with cardiac disease.”

Irregular Heart Rhythm in Men Associated With Exercise Intensity Over Time

Young men who undertake endurance exercise for more than 5 hours a week may increase their risk of developing an irregular heart rhythm later in life, according to the results of a new study.

“Physical activity contributes to prevention of several diseases, and in general is good for the well-being of your body and mind.

However, frequent high-intensity exercise during many years could increase the risk for atrial fibrillation (AF),” lead author Dr Nikola Drca, Department of Cardiology, Karolinska Institute, Karolinska Hospital, Stockholm, Sweden, said in an interview.

The increase in risk is real, but quite small, he added.

The researchers presented their results online in the May 14, 2014, issue of the journal Heart.

RISK FACTOR FOR STROKE

In the Swedish study, the researchers quizzed more than 44,000 men aged 45 to 79 years about their leisure-time physical activity patterns at the ages of 15, 30, 50, and during the past year, when their average age was 60.

They tracked the participants’ heart health for an average of 12 years from 1997 onward to gauge how many developed AF, which is a known risk factor for stroke.

The men who had exercised intensively for more than 5 hours a week were 19% more likely to have developed AF later in their lives than those exercising for less than 1 hour a week.

The level of risk rose to 49% among those who did more than 5 hours of exercise a week at the age of 30, but who subsequently did less than an hour by the time they were age 60.

But those who cycled or walked briskly for an hour a day or more at age 60 were about 13% less likely to develop AF than those who did virtually no exercise at all.

MODERATION, MODERATION, MODERATION

“It seems that moderate doses of physical activity are enough to get the positive effects without acquiring the negative effects, while these benefits are lost with very high intensity and prolonged efforts,” Dr. Drca noted.

There are several possible mechanisms by which frequent endurance exercise could increase the risk for AF, he said.

These include enlargement of the left atrium, enlargement of and left ventricular hypertrophy, inflammatory changes in the left atrium, and an increase in the activity of the parasympathetic nervous system.

“In our study, the men who had the highest risk of developing atrial fibrillation were those who were very physically active when they were young, but stopped being physical active.

I think that moderate intensity regular physical activity that you continue throughout your life is the best way to maximize the benefits obtained by regular exercise while preventing undesirable effects.”

He added: “Physical inactivity and a sedentary lifestyle is a far bigger problem in the general population than excessive physical activity.

However, frequent high-intensity exercise during many years is associated with an increased risk of AF.”

Moderate Exercise Lowers Risk of Death for Older Hypertensive Men

Older men who have high blood pressure can lower their risk of death with even moderate amounts of exercise, according to a new study.

“To substantially reduce his risk of death, an elderly man needs to walk briskly for 20 to 40 minutes a day, 4 to 6 times per week,” lead author Charles Faselis, MD, Chief and Associate Professor of Medicine at George Washington University School of Medicine and Health Sciences (SMHS) in Washington, DC, said in an interview.

At the moment, only about 25% to 30% of older men engage in a brisk walk of 20 to 40 minutes most days of the week, Dr. Faselis noted.

BENEFITS OF A BRISK WALK

For the study, researchers assessed the fitness status of more than 2150 men with hypertension, aged 70 years and older, using a standard treadmill exercise test.

The researchers published their results online in the May 12, 2014 issue of Hypertension.

They used metabolic equivalents (METs)—equal to the amount of oxygen the body uses per kilogram of body weight per minute—to determine the men’s peak fitness levels.

One MET is the amount of energy expended at rest; anything above that represents work.

The researchers categorized the men as very low fitness, low fitness, moderate fitness, and high fitness.

“To put this in perspective, the peak MET level of a sedentary 50-year-old is about 5 to 6 METs,” said Dr. Faselis.

“For a moderately fit individual, it’s about 7 to 9 METS, and for a highly fit person, it’s 10 to 12 METs.”

After an average follow-up of 9 years, the researchers found that the risk of death was 11% lower for every 1-MET increase in exercise capacity.

Compared with least-fit men (up to 4 peak METs), the risk of death was 18% lower in those in the low-fit category (4.1 to 6 peak METs), 36% lower in the moderately fit men (6.1 to 8 peak METs), and 48% lower in the high-fit men (peak METs of more than 8).

“A regular brisk walk most days of the week is a safe, effective form of exercise.

Most health benefits are realized at this exercise level.

More vigorous exercise is not required,” said senior author Peter Kokkinos, PhD, Professor at Veterans Affairs Medical Center, Georgetown University School of Medicine and George Washington University SMHS.

He added that an exercise stress test is highly recommended for patients before they engage in any exercise program.

Also, doctors should check with the patient periodically and encourage him to maintain exercise, he said.

“PHYSICAL ACTIVITY AWARENESS” CAMPAIGN

“The evidence supporting exercise-related health benefits for all ages is overwhelming,” Dr Kokkinos said.

“Physical activity is an inexpensive way to improve health.

It can easily be implemented for most populations at any age.

Yet, we are in the midst of a physical inactivity epidemic.

Health-care providers can help change all this by simply taking a few minutes to discuss physical activity with their patients.”

Dr. Faselis added: “The responsibility of promoting physical activity should not stop with the health care provider.

In this digital age, where inactivity is fostered, the time has come for a ‘Physical Activity Awareness’ campaign nationwide.”

Carotid Narrowing Tied to Cognitive Decline as Well as Stroke

Patients who have blockages in the carotid arteries are at risk not only for stroke but possibly for cognitive impairment as well, according to the results of a new study.

“We have fairly compelling evidence that there is a decline in cognitive function associated with blockages in the carotid arteries in asymptomatic patients (those with no symptoms),” principal investigator Brajesh Lal, MD, Professor of Vascular Surgery at the University of Maryland School of Medicine in Baltimore, said in an interview.

“No one has asked about what happens to the way the brain functions—thinks, processes information, remembers, recollects new information—when blood flow is restricted from stenosis (narrowing).”

A neuropsychologist at the University of Maryland, Moira C. Dux, PhD, presented the details of the study at the American Academy of Neurology annual meeting in Philadelphia.

NARROW CAROTIDS, WORSE MEMORY

The study involved 67 persons with asymptomatic carotid stenosis who had a 50% reduction in the diameter of the artery, and 60 persons with vascular risk factors, including diabetes mellitus, hypertension, hypercholesterolemia, and coronary artery disease, with no stenosis.

The patients underwent extensive testing for overall thinking abilities and for specific aspects of thinking, such as processing speed, learning, memory, decision making, and language.

The stenosis group performed significantly worse on the overall memory and thinking tests, as well as on tests for motor and processing speed, and learning and memory.

Language scores did not differ between the 2 groups.

“We have demonstrated, for the first time, that carotid stenosis without a neurologic deficit is not necessarily ‘asymptomatic’ and is associated with greater cognitive impairment compared to patients with similar risk factors but no stenosis,” said Dr. Lal.

TWO POTENTIAL MECHANISMS

Two potential mechanisms are restriction of blood flow caused by the stenosis and microinfarction from the release of microparticles, Dr. Lal stated.

“Microparticles could lodge in non-expressive areas of the brain, which become infarcted, and then be expressed as cognitive impairment,” he said.

“We are now looking at transcranial flow within the brain, microembolization from plaque, and microinfarction and brain injury in these patients.”

The researchers also plan to monitor these patients, average age 60 years, for at least another 2 years to assess their risk of stroke.

Every patient with carotid stenosis has significant atherosclerosis and should be receiving aspirin and statin therapy, Dr. Lal said.

“HOW HAS YOUR MEMORY BEEN?”

“With these data, I will start asking my carotid stenosis patients, how has your memory been? Do you have trouble thinking? If they have any suggestion of cognitive impairment, I will refer them to a neuropsychologist,” he said, adding “I don’t think I can recommend carotid endarterectomy yet.”

Carotid endarterectomy is a surgical procedure used to reduce the risk of stroke by correcting narrowing in the carotid arteries.

Dr. Lal has preliminary data from a previous study that show using both surgery and stenting for carotid artery stenosis leads to a net improvement in cognitive function.

“From 8 to 15 million US patients have asymptomatic carotid artery stenosis.

I anticipate a large number of follow-up studies searching for causes and the best treatment options for this newly identified morbidity associated with carotid narrowing,” Dr. Lal said.

“Once we identify the mechanism, we potentially can mount a clinical trial comparing cognitive rehabilitation versus revascularization.”

Home-based Training Program Improves Memory Function in Epilepsy

Everyone has moments of memory lapses — you forget someone’s name or telephone number, or to take your medication.

These types of memory problems can be part of the normal aging process.

But about half of those with seizures report more than average memory difficulties.

Now a simple self-management intervention may improve the cognitive performance of patients who have epilepsy, according to the results of a new study.

“About half of the 2 million people in the US living with epilepsy have cognitive problems.

Despite the significant impact cognitive functioning has on quality of life, there are limited treatment modalities with which to intervene.

This program teaches epilepsy patients self-efficacy and strategies on how to manage memory problems.

It also helps ease anxiety about memory problems and enhances the ability to cope with memory deficits,” Tracie Caller, MD, Neurophysiology Fellow at Dartmouth Hitchcock Medical Center in Hanover, New Hampshire, said in an interview before her presentation at the American Academy of Neurology annual meeting in Philadelphia.hobscotch_logo

Epileptic seizures typically interrupt cognitive functioning.

“Small epileptic discharges impair cognition.

Eventually, this interrupts the encoding process for new memories.

Also, many epileptic patients have overlying anxiety and depression, which can affect concentration, which in turn affects memory,” said Dr. Caller.

In addition, certain epilepsy medications, such as topiramate, can cause fatigue and affect memory and concentration.

The underlying brain abnormality that causes seizures, for example, scarring in the temporal lobe, also may affect memory, she said.

Dr. Caller and colleagues conducted a pilot study of a self-management intervention for cognitive impairment in epilepsy.

TEACHING PROBLEM-SOLVING STRATEGIES

HOBSCOTCH (HOme Based Self-management and COgnitive Training CHanges lives) is an 8-week, telephone-based intervention developed to teach problem-solving strategies and compensatory memory strategies.

Dr. Caller reported on the results of 16 adult patients with epilepsy and subjective cognitive complaints who were randomized to receive HOBSCOTCH, HOBSCOTCH+ (which adds working memory training), or usual care.

“We found that the 9 HOBSCOTCH participants had significantly improved quality of life scores as compared to 7 controls, and significant changes in depression, as well as improvement in executive function,” said Dr. Caller.

“As a pleasant surprise, we also found improvement in objective memory function.”

The program is “designed to teach memory strategies, to work around deficits, and improve memory confidence,” Dr. Caller said.

“People with epilepsy often lose confidence in their memory, and this becomes a vicious cycle.”

The structure of the program is similar to problem-solving therapy now used by primary care doctors and applied to depression and chronic diseases, such as heart disease and diabetes.

“We teach patients how to solve their own problems, for example, how to remember to take their medication by setting a reminder alarm on a cell phone or putting the medication next to their tooth brush or coffee machine,” Dr. Caller stated.

She said the program would be easy to implement in a doctor’s office.

“We have nurse practitioners deliver HOBSCOTCH.

A variety of practitioners, including psychologists and social workers, can deliver the intervention,” she said.

So far, the researchers have enrolled 50 of a planned 60 patients with epilepsy in a clinical trial to test the effectiveness of HOBSCOTCH.

The patients in the pilot study “are satisfied with the program.

We have a low drop-out rate compared to similar interventions,” said Dr. Caller.

She thinks the program also would be helpful in other neurological disorders, such as multiple sclerosis, in which patients often have memory difficulties and depression, as well as for chemotherapy patients who suffer so-called “chemobrain” post-therapy.

Exercise May Boost Recovery of Motor Function in Stroke Patients

Aerobic exercise improves cardiorespiratory fitness in patients with stroke, and also may have a beneficial effect on their brain function as well as help them improve recovery of motor function, according to the results of a new study.

Aerobic exercise elicits a variety of positive effects in people of all ages.

Recently, researchers have found significant improvements in aerobic exercise capacity among stroke patients who underwent a structured cycling exercise program.

“The effects of aerobic exercise may serve to prime the central nervous system in individuals with stroke to create an environment optimal for neuroplasticity (the brain’s ability to reorganize itself),” Susan Linder, a research physical therapist at the Cleveland Clinic in Cleveland, told a packed poster session at the American Academy of Neurology annual meeting in Philadelphia.

“Our work in individuals with Parkinson’s disease indicates that forced exercise administered via a motor-assisted stationary bicycle results in increased cortical activation and improved motor and non-motor function when compared to voluntary exercise,” Linder said.

The precise mechanism responsible for improvements in patients with Parkinson disease is unknown, but Cleveland Clinic researchers hypothesize that aerobic exercise increases concentrations of brain-derived neurotrophic factor (BDNF), a protein released in the CNS that facilitates long-term enhancement of signals within the brain and promotes growth of dendrites, which are branched filaments in nerve cells.

“Pairing aerobic exercise with upper extremity repetitive task practice in individuals with stroke may exploit the neuroplasticity properties associated with BDNF and optimize motor learning,” said Linder.

IMPROVED MOTOR OUTCOMES

She reported the results of a study of 14 patients who had a stroke within the previous 6 to 12 months.

They were randomized into 3 groups.

One group performed a 45-minute session of aerobic exercise at a forced rate within their heart rate range on an exercise cycle, followed by 45 minutes of repetitive task practice with hands or arms.

The second group performed the same exercises but exercised at their own rate.

The third group did no aerobic exercise and performed two 45-minute sessions of upper extremity exercises.

All participants exercised 3 times a week for 8 weeks, and they were able to complete the cycling protocol with modifications for fatigue.

All were able to achieve hundreds of repetitions with repetitive task practice.

“Motor outcomes are trending in a positive direction for all groups, but the group who performed forced rate exercise displayed the most consistent improvements,” Linder said, noting that the control group had twice the amount of time doing upper extremity exercises.

“We also saw improvement in depression and quality of life in the aerobic exercise group trending toward favorable.”

Linder added, “We know that aerobic exercise can help stroke patients’ physical fitness.

Is there a neuroplasticity effect?

We hope that the byproduct of aerobic exercise is reduced amounts of rehabilitation time as well as doses that lead to better motor outcomes for stroke patients.”

The Cleveland Clinic researchers are expanding their research to include 75 patients and will add in neurological examinations.

Said Linder, “We plan to look at changes in structure of connectivity within the brain using imaging and resting MRI to see whether areas of brain regrow and improve neural connections with aerobic exercise.”

A Medical Device to Relieve Constipation

An oral capsule that vibrates as it moves through the digestive tract may become a unique nonpharmacological treatment for chronic constipation, according to a new study.

“This is the first time we have a medical device, not a chemical, to relieve the long-term concerns of patients with chronic constipation,” Yishai Ron, MD, lead researcher for the study and Director of Neurogastroenterology and Motility at Tel-Aviv Sourasky Medical Center’s Department of Gastroenterology and Hepatology, said in an interview.

“If it proves itself with similar results in more studies, it could be a potential revolutionary treatment to relieve constipation,” Dr. Ron noted.

Chronic constipation is a highly prevalent disorder that affects about 15% of the US population.

Eating a high-fiber diet is not only good for your heart but also can reduce the symptoms of irritable bowel syndrome.

A fiber supplement may also add bulk to your bowel movement or make it softer.

A laxative may help relax and loosen your intestines to help you have a bowel movement.

Prescription drugs are also available for long-term use in chronic constipation.

“Sometimes, drug therapies bring more issues than relief for these patients,” said Dr. Ron.

“The results of this study point to the potential for an alternative treatment that avoids the typical drug side effects, such as bloating and electrolyte imbalance, by imitating the body’s natural physiology.”

CAPSULE STIMULATES MOVEMENT

Dr. Ron presented the results of a pilot study (abstract Sa2023 “Vibrating Capsule for the Treatment of Chronic Idiopathic Constipation (CIC) and Constipation Predominant Irritable Bowel Syndrome (C-IBS) – Safety and Efficacy”) at Digestive Disease Week 2014 in Chicago.

The study included 26 patients who took the capsule twice per week and responded to a daily bowel movement and laxative use questionnaire.

All patients initially underwent a 2-week preliminary period without the use of laxatives.

In the study, the vibrating capsule was found to nearly double the weekly bowel movements of patients who had chronic idiopathic constipation and constipation-predominant irritable bowel syndrome.

Patients reported an increase in spontaneous bowel movements from 2 to 4 times per week, as well as a decrease in constipation symptoms, including reduced difficulty in passing stools and incomplete evacuation.

The study found minimal adverse effects from the capsule use, primarily abdominal pain, which was minor and self-limiting.

“We don’t know if this has to do with constipation or the capsule. We assume it is unrelated to the capsule,” Dr. Ron said.

The capsule, which houses a small engine inside, is programmed to begin vibrating 6 to 8 hours after swallowing.

The mechanical stimulations cause contractions in the intestine, which help move stool through the digestive tract, he said.

“Despite the widespread use of medication to treat constipation, nearly half of patients are unsatisfied with the treatment either because of side effects, safety concerns about long-term use, or the fact that it simply doesn’t work,” Dr. Ron said.

UNMET NEED TO MANAGE CONSTIPATION

Colleen Schmitt, MD, gastroenterologist in the Galen Medical Group in Chattanooga, Tennessee, and President-Elect of the American Society For Gastrointestinal Endoscopy, told me:

“There are clearly unmet needs in our management of constipation from irritable bowel syndrome.

Research of this capsule among diverse patient populations and assessment of associated costs will help evaluate effectiveness.

Theoretically, local, rather than systemic, therapies are an appealing idea.”

Dr. Ron said he and his team are now recruiting 80 patients for a double-blind, multicenter, multinational trial.

The patients will take the capsule over 2 months and will be monitored for 1 year or more.

Simple Sideline Vision Test Helps Identify Concussions

A simple vision test performed on the sidelines can help identify athletes who have suffered a concussion, according to a new study.

“Adding a vision-based test to evaluate athletes on the sidelines may allow us to better detect more athletes with concussion more quickly.

This is particularly important since not all athletes reliably report their symptoms of concussion, including any vision problems,” said senior author Laura Balcer, MD, New York University School of Medicine.

She presented the results of the study at the American Academy of Neurology annual meeting in Philadelphia on April 30.college football concussions

Sports medicine experts have been using standard tests based on balance and cognitive tasks to detect concussion on the sidelines.

But these tests cannot pick up subtle signs of concussion.

They started using vision tests because visual pathways are commonly affected in concussion, said Balcer.

DETECTION RATE 100%

The 1-minute vision test involves reading a series of numbers from index cards or an iPad screen.

The results on the sideline can be compared to a baseline assessment.

Any slowing in time taken to complete the test can be deemed a sign of concussion.

In the study, a total of 217 athletes aged 18 to 22 years playing on the University of Florida men’s football, women’s soccer, and women’s lacrosse teams were tested at the start of the season and again if a concussion was suspected during play.

Among 30 athletes with a first concussion, 79% had a worsen performance on the vision test compared with 52% using a standard concussion evaluation.

Combining information from both tests, the researchers found that 89% of athletes with a concussion were correctly identified.

When results from a third test evaluating errors in balance was added, 100% were identified.

What’s more, a worse score on the vision test correlated with more severe concussion symptoms.

The researchers don’t think the vision test alone is enough to diagnose a concussion.

They believe it’s best used in combination with standard balance and cognition tests.

The bottom-line: All athletes in sports with high concussion rates should undergo pre-season and postseason vision testing, with additional evaluations in real-time to check for suspected concussions.