Recovery of postural control after cerebral concussion: new insights using approximate entropy

Abstract

Context: The return-to-play decision after sport-related cerebral concussion depends in part on knowing when an athlete has fully recovered postural control after injury.

Objective: To describe the postconcussion recovery of postural control using approximate entropy (ApEn), a regularity statistic from nonlinear dynamics.

Design: Retrospective case series analysis.

Setting: Sports medicine research laboratory.

Patients or other participants: Collegiate athletes from whom center-of-pressure and symptom data were collected at preseason, less than 48 hours after injury, and 48 to 96 hours after injury.

Main outcome measure(s): Approximate entropy values reflecting the amount of randomness contained in center-of-pressure oscillations were calculated for anterior-posterior (AP) and medial-lateral (ML) time series. Equilibrium scores reflecting the amplitude of center-of-pressure AP oscillations were used to indicate postural stability. The number and severity of symptoms were described.

Results: Compared with the healthy preseason state, ApEn values for the AP and ML time series generally declined immediately after injury in both steady and unsteady injured athletes. At 48 to 96 hours after injury, ApEn values for the ML time series remained significantly depressed (mean difference compared with preseason = -0.268, standard error = 0.072), even among athletes whose initial postural instability had resolved. We found few significant relationships between changes in ApEn values and changes in symptoms before and after injury.

Conclusions: The effects of cerebral concussion on postural control appear to persist for longer than 3 to 4 days, even among athletes with no signs of unsteadiness. Our results may reflect changes in neurophysiologic or mechanical constraints on postural control. Approximate entropy provides a theoretically distinct, valuable measurement alternative that may prove useful for reducing uncertainty in the return-to-play decision.

Figure 1. Sensory Organization Test 6 conditions. Vision is absent in conditions 2 and 5. In conditions 3 and 6, the sway-referenced anterior-posterior angular motion of the surrounding wall reduces optic flow stimulation useful for the perception of self-motion relative to the visual field. In conditions 4 through 6, sway-referenced angular motion of the forceplates reduces somatosensory stimulation useful for the perception of anterior-posterior self-motion relative to the support surface. (Used by permission from NeuroCom International, Inc)

Figure 2. Mean approximate entropy values for center-of-pressure anterior-posterior time series in athletes (A) with (n = 13) and (B) without (n = 16) postural instability after concussion. Approximate entropy values are displayed for the 6 Sensory Organization Test conditions. Athletes were tested at preseason, within 48 hours after injury, and between 48 and 96 hours after injury. Lower scores reflect greater regularity of center-of-pressure oscillations

Figure 3. Mean approximate entropy values for center-of-pressure medial-lateral time series in athletes (A) with (n = 13) and (B) without (n = 16) postural instability after concussion. Approximate entropy values are displayed for the 6 Sensory Organization Test conditions. Athletes were tested at preseason, within 48 hours after injury, and between 48 and 96 hours after injury. Lower scores reflect greater regularity of center-of-pressure oscillations

Figure 4. Mean equilibrium scores in athletes (A) with (n = 13) and (B) without (n = 16) postural instability after concussion. Equilibrium scores are displayed for the 6 Sensory Organization Test conditions. Athletes were tested at preseason, within 48 hours after injury, and between 48 and 96 hours after injury. Lower scores reflect greater postural instability