(upbeat music) Welcome to At Issue, I'm H Wayne Wilson.

Thank you so much for joining us for this conversation.

The Children's Innovation Lab at the Jump Simulation Center at OSF Healthcare may have created a process that will better identify and detect head injuries, specifically concussions.

We've talked about concussions before on this program.

It's a serious issue that has one problem.

We don't know how to detect early enough whether there's a concussion or not and we may be on the threshold of a new way to do that.

And we're going to have that conversation with Dr. Adam Cross.

Dr. Cross, thank you for joining us on At Issue.

- Happy to be here.

- Dr. Cross holds multiple titles.

He's with the University of Illinois College of Medicine Peoria as an assistant professor.

He's also OSF Healthcare Children's Hospital Pediatric Hospitalist.

So before we start, we probably should define what a concussion is.

- Sure, so a concussion is defined as a temporary change in someone's cognitive performance, cognitive perceptual, or behavioral.

Any sort of change from the norm that occurs after an injury sustained to the head.

- Are concussions more common today or are we just more aware of them?

- That's a great question.

I don't think anyone really knows.

Certainly we're finding more and more of them every year and we're getting better at doing so.

- So what causes a concussion?

I mean, everyone's aware that you bump your head, you're possibly subject to a concussion but what really is happening?

- Yeah, that's another great question.

So on the cellular level, we think there's injury to the brain, but the injury is so subtle that we can't see anything on MRI or CT. And actually if, if you can, then it's defined as a more severe traumatic brain injury or TBI.

But to be a concussion, you actually can't find anything on head imaging.

So it's difficult to know what's really happening at the cellular level unless you take a biopsy of that brain, which we don't usually do after a concussion.

But if you look at the brains of individuals like pro-athletes who've had concussions numerous times sustained over their lives, we do see some significant changes in their brains.

Basically what might be akin to scarring of the brain in some sense where we just see some repetitive injury sustained at the cellular level.

- And that can lead to CTE?

- Yes, all kinds of long permanent or semi-permanent sequelae of that injury.

- And if I understand it, the brain sits, it's kind of cushioned inside the skull.

And so when you hit your head really hard, the brain bounces back and forth?

- It can, yeah.

You do have a nice soft layer of fluid that's between your brain and the skull.

But if you get hit hard enough, yeah.

That brain can head up against your skull, either in the front or the back or both if it's really hard.

- Head injuries are one of the leading causes of death to young, well, I suppose to all people but in young people only surpassed by gun violence.

- That's right.

- So, I mean this is something that really needs to be addressed.

- Yeah we need to solve this issue and detect these concussions more reliably and more quickly.

- And I think everybody, I shouldn't say everybody, we talked about long-term effects but concussions are not necessarily temporary.

- Right, usually they are, but sometimes, some individuals can have a longer recovery time and rarely you can have permanent issues from a concussion.

- So what led you to decide this is something I need to address, we need to find a better way of detecting concussions?

- Well, as you said, it's such a big problem and such a big issue, and for long standing injury to some of our children, it needed to be solved.

And I also felt like it might be a very solvable solution.

So the typical method that we have of detecting impairments from concussion involves a series of questionnaires, some symptom reporting, and then some physical exam findings.

And those exam findings really haven't changed much in the last hundred years or so.

In my opinion, we're pretty far behind the times in terms of the way in which we identify things like imbalance or impaired coordination.

And I got to thinking that, well, a lot of the the games that people play, the things we do on our phones and tablets require a fair bit of coordination, balance, reaction time.

Why not really customize and fine tune an application that allows you to quantify those parameters and get a better measurement of these injury, of the impact these injuries have on a player?

- Right now, there may or may not be a physician at a youth event, football, basketball, what have you.

So a coach or somebody like that may be making a determination as to, I need to put this player back in or I need to withhold this player from activity.

The player quite often will want to go back in and is that called sandbagging?

- That is sandbagging.

So some of the valuation tests that we have nowadays for concussion are very susceptible to sandbagging because they rely heavily on a player's symptom reporting.

But if a player wants to keep playing, they may say, no, I don't have a headache, I don't have double vision.

I'm fine, put me in coach.

And if they deny those things, it can be more challenging for us to detect concussion with the currently available tests.

- So you've come up with a more definitive way to detect, is he sandbagging or is he okay?

- Right, we've tried to create an objective measurement of their ability to perform a complex task and look at the different ways that a concussion can manifest in that performance.

- And the name of this program is... - Flight Path.

- Flight Path.

And the reason it's called Flight Path is... - It's because we use a hummingbird that flies around in a mixed reality space.

So basically you can see your room through your camera and then the hummingbird is flying around in that room and your job is to catch it.

- So just to be clear, mixed reality as opposed to virtual reality.

- Yeah, there's virtual, augmented, extended, mixed, there are a lot, but mixed and augmented reality are very similar.

Mixed reality is a little bit different in that not only is there an object that's superimposed or inserted into your space that you see through like your camera app for example, but that this object also interacts with your environment.

It knows that there's a mug here.

It knows where the walls and boundaries of your room are and it interacts with them.

- We have a video, a short video.

It's a prototype, it's not the current method but I want everybody to understand, you can describe this as we show this video as to what it requires of the individual who's taking this test.

- Sure, yeah, this is an early prototype about a year ago.

This was when we first started our testing.

And in this video you'll see that we've got someone who's trying to catch a ping pong ball that's slowly moving around this football field.

And the ping pong ball is not only moving up and down but actually around the field.

And so the person needs to walk around in order to find it.

- Now you're not using a ping pong ball anymore.

It's a bird and this bird, the equipment recognizes the environment in which the person is taking the test?

- Yes, that's right.

It will detect any obstacles, chairs, tables, walls, and it will fly around them and avoid them so that you don't accidentally bump into things.

- And this requires the person who's taking the test to move in what ways?

- So the bird will move in a semi randomized way.

I say semi randomized because we actually adapt the way that the bird moves to how well a user performs during that testing.

And it will oftentimes make really rapid adjustments in its angle, its trajectory.

It will speed up and will slow down.

It'll hover like a hummingbird does and try to move both in a way that's natural for a hummingbird but also challenging for you to capture.

- Does it get more difficult as you go further into the test?

- Yes, it does.

So we adapt because we really want to test you at the limits of your performance.

If you're always doing exceptionally well, then, who's to say that you have a concussion or not?

But if you're always doing really poorly and the bird is just too hard to track, then it's difficult for us to assess as well.

So we need to find the right balance to see really the limits of your performance to get the best measurement.

- How do you know that?

Because I might be worse than you are at following the hummingbird without any concussion.

I'm just not as quick to move.

It may be a heavy lineman who doesn't, because you have to walk and turn.

A heavy lineman may not be as agile as the quarterback.

So how do you know that the person, is there a baseline or how does it determine that he's okay, he's just slower than the quarterback?

- That's a great question.

So there's a couple of things that we do.

One is establishing the baseline, both for the individual but also for certain age groups or athletes versus non-athletes.

As we test more individuals, we'll get better sense of what should be the typical performance of someone based on their age and athletic capabilities.

But we also have methods in place for how we can tell someone who's just slow from someone who's truly concussed.

And as an example of that, consider two people, one who just is a bit slower at following the bird and one who has a concussion.

Now, when the bird moves, let's say that it suddenly changes trajectory and the individual that is just slow to move, they'll be behind that bird.

But they'll notice immediately when that bird changes direction and they'll start to follow that bird even though it's slower, they'll make that change in their trajectory pretty quickly.

The individual with a concussion, sometimes concussion manifests with delayed reaction time.

And in that case it will take that person perceptively longer to notice a bird has changed before they change trajectory.

And our application samples, it tests how someone's moving at a frequency of 60 times per second so we can really get a good sense of exactly when somebody starts to adapt to the new path of that bird.

- Flight Path can be used on location?

- That's right.

All it takes is right now an iPad or an iPhone, one of the newer generation devices.

- So I'm the coach of the high school football team or the basketball team or soccer team or any other sport because concussions can occur in I suppose, in cross country if you fall.

Does the coach, I mean, do you have to have any medical background in order to administer this test?

- No, you don't and that's the goal.

We want it to be able to be used by really anybody.

You just pull out the tablet, you put in basic information, just what's their age and then give the tablet to the player and they just take the test themselves.

- How long does this take?

- It only takes actually two minutes.

We get a lot of data at that frequency rate of 60 times a second over two minutes.

So it's really reliable.

- Where's this data go and how does the coach get the feedback?

- It's a great question.

So that data is then sent to a deep learning, a machine learning algorithm that we call Neuro DNA.

And the algorithm does a few different things.

The model actually will detect not only concussion overall, but it will look at different levels of performance and different areas, things like balance, reaction time, coordination, perception, visual.

There are a lot of different pieces of this that it looks at and then at the end of that analysis, it gives the coach basically a report card and says here's how well the player performed in each of these different common areas of impairment for concussion.

And then it also gives them an overall determination of what the app suggests might be happening, concussion or not, for the player.

- Who makes the determination that the player can or cannot go back in?

- So while the app provides you the information and makes a preliminary determination, it's not meant to supersede decisions by any human whether it be coach or athletic trainer or on onsite physician.

We want to give people better information to make better decisions, but not make the decision for them unless they truly have no idea what to do.

- So a coach with this additional information may say, I have a concern for the health of my young player, I'm going to, even if it's marginal, I'm gonna err on the side of caution and say son or daughter, you need to stay out of the game and we need to have someone take a closer look at you and then if you're okay, next game.

- That's right, that's right.

- Although it probably depends on whether it's a second string player or the star quarterback.

- That's up to the coach.

- So you're not trying to undermine the coach's decision making?

- No, we just want to provide better information to make better decisions.

- Where are you right now?

You've designed this and tested it.

Where are we right now?

Have we gone into trials?

- We have a few internal trials that have been done.

We have a couple publications surrounding healthy players.

We've gone through the IRB process and everything's been fully approved.

- IRB Process?

- IRB, so, it's basically the review board that helps us to make sure that our research strategy is logical, it's sound, and that it's ethical as well.

So basically we have a green light from the research group to tell us that we can go ahead with our strategy for how to do a clinical trial in the OSF healthcare system.

- In this particular case, what will the clinical trial involve?

I assume there's gonna be some players, some people taking the test, but what really happens in this clinical trial?

- So we are going to be asking for volunteers who are both healthy and concussed.

And those concussed individuals can be players.

They can be people who were just in car accidents.

Any cause of of concussion will be eligible for participation.

And those individuals will get assessed just like they normally do when they present to the concussion clinic or the emergency department.

And if the physician or primary care provider determines that they're safe to do the app and that they don't have more severe or more urgent matters, then we ask them if they're interested in participating and then they'll do all the normal things they usually do.

And then we'll do the app for like two minutes and see how they perform.

- Volunteers would be able to make the offer, how?

How would they reach out and say, I've had a concussion in the past, or I want to just do it because I'm an athlete.

I haven't been concussed, but I'm an athlete.

- So for the concussion arm of the study, right now we wanna focus on people who've just been concussed so that we know that we can really find these symptoms, these signs of concussion when they're readily apparent.

As we get better with this, we'll start to look more at people who have maybe long-term or more subtle findings from their concussions.

- Is there a timetable as to, and I assume the idea is to put this app into the, I mean, it's just a tablet, that you have to have.

So you put this app into the hands of coaches of any number of people.

What's the timetable to do that?

- Well, the first phase is to put the app on the app store and that first phase is just meant to get a lot of healthy people to just play the game, try out the app, and get us data, no identifiable information.

We don't know who you are, all we know is how you move when you play the game.

And we're trying to get a sense of how people usually perform and that is nearly ready.

The app is complete, we have permission.

So that will happen early next year at some point.

The actual use of the app for concussion detection, will take a little bit more time as it should, because we want the FDA and any other relevant governing bodies to make sure that we've dotted our I's and crossed our T's and that this is ready for the big time.

And to be frank, I don't know that anyone really understands exactly what sort of regulations need to surround an app like this.

It's such a new idea.

So there'll be some new ground for us to cover.

- So the mixed reality throws a new wrinkle into the certification process?

- At least to me it does.

I don't think there are a whole lot of apps that do what ours does out there.

So I think it'll be a new process.

- So the Food and Drug Administration has to give a final okay though?

- I would think so, that's our plan is to submit to them, yes.

- I've been talking about the coach of a high school football team or what have you, younger people, but this could be used by anybody?

- Anyone, we could use it when we arrive at a scene of a vehicle collision, we could potentially even deploy it with soldiers on a battlefield, anywhere where there's an immediate need to understand a person's manifestations of a head injury.

- You're working in conjunction with the Illinois Neurological Institute.

Why is, I can guess why, but I mean what role do they play?

- So they house our concussion clinic.

So it's really important for us to be able to partner with the people who take care of our patients long-term through the recovery process.

- You mentioned recovery.

This app will help determine whether or not, well it'll determine the possibility of detecting a possible concussion but will it help with developing a recovery protocol?

- That's also our goal.

Right now, there isn't really a standardized method of evaluating someone's recovery performance over time.

And we hope that this tool can be an objective way to measure all of these impairments.

So we can use that not only to see how impaired they are at the beginning, but how those impairments improve over time.

So it's used as a prognostication tool as well.

- I suppose we ought to address the issue of the quickness in identifying or detecting a concussion because my assumption is the earlier you detect, the better, for complete recovery, the better prospects for complete recovery.

- Absolutely, yeah, the single greatest risk factor for prolonged time to recovery is delayed diagnosis and management.

- I'm going to suggest to you that coaches are going to get this app if it's FDA approved and schools will, maybe a physician's office will, but what about the person who falls and you know, you're out with your family and you slip on some ice and you just conk your head.

Is there the possibility that it might be available in cases like that or what's the scenario?

- We do hope to use this app as what we call an interoperability standard.

So basically any cause of concussion or mild brain injury can use this application to create a standardized method of evaluation.

Now that being said, we will need to fine tune, I think, aspects of the application for fall injuries because if someone is unsteady on their feet or physically at more of a risk from falling, you don't necessarily want them to try to walk around the room, make sharp turns, and follow a hummingbird.

So the way in which and who uses the application needs to be under the discretion of the person and the people around them.

- So a nursing home or a assisted living facility might have this in their toolbox but they also have to consider the condition of the patient.

- Right, right.

And we are considering making a stationary version of the application too so that someone can do some of this while seated to better accommodate that population.

- I know that you've just been testing this but have you had people who you've been able to detect a concussion in using this?

- So we haven't used it for detection of concussion yet because we wanted to make sure that we went through the whole review process first.

So we have not done that but we are all prepared to do that.

- So that's what the clinical trial is for?

- Right, we have been able to show that healthy people, we can really tell, we can tell any sort of deviation from their normal behavior.

We've done certain things to temporarily affect their ability to follow things like vision goggles where we kind of blur their vision and that sort of thing.

And we've seen that we can see those differences pretty well that way.

- Might a player be able to memorize the flight path of the hummingbird?

I mean does it repeat its, okay, I've got a down, coach, I know what this is doing.

- No, they can't.

And that's one thing we were really sure to employ.

So the path is always random.

There are certain parameters that govern the way it moves, certain speed limitations and trajectory limitations.

And it won't fly higher and you can reach that sort of thing.

But other than that, the places that it goes are only really defined by your user space, but it's really random.

- So it could be on the field, it could be in a room.

- Yeah, and it's never the same path twice.

- So this incorporates just about every movement a person, I mean they have to walk?

What all do they have to do in doing this test?

- They have to hold it, the tablet or the phone, they have to walk, pivot, raise arms up and down, they need to be able to move with the bird in all different kinds of angles.

Occasionally they'll need to bend over a little bit.

So quite a wide range of motion.

- And that's intentional because it will help determine whether there's a concussion or not?

- Right, right, we want to make the player do as many different types of movements to really simulate all of the kinds of tasks that the brain needs to perform to be able to see how well it does.

- How hopeful are you that this will be widely distributed?

Are you at that point yet where you say, this is going to work, this is going to get FDA approval?

- Well, the FDA approval process, as I said, it's gonna be I think new ground for a lot of us.

But I do think the more we work on this, the more excited I become.

I'm very confident that regardless of the algorithm, the machine learning model, we have created a measurement system.

And if a ruler is useful, then this is useful.

- Dr. Adam Cross, thank you so much for joining us on At Issue.

- Thank you.

- And we'll see in the future if there's progress made, it sounds like there might be some progress made with regard to Flight Path.

Next time on At Issue, we're to have a final visit with the retiring congresswoman Cheri Bustos.

After 10 years in Congress, she will be joining us on the next At Issue.

Join us for that.

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