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Article 4 An exploratory study of the potential effects of vision training on concussion incidence in football

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Background: Vision training has become a component of sports enhancement training; however, quantifiable and validated improvement in visual performance has not been clearly demonstrated. In addition, there is minimal literature related to the effects of vision training on sports performance and injury risk reduction. The purpose of the current investigation was to determine the effects of vision training on peripheral vision and concussion incidence. Methods: Vision training was initiated among the University of Cincinnati football team at the beginning of the 2010 season and continued for four years (2010 to 2013). The sports vision enhancement was conducted during the two weeks of preseason camp. Typical vision training consisted of Dynavision D2 light board training, Nike strobe glasses, and tracking drills. Nike Strobe glasses and tracking drills were done with pairs of pitch-and-catch drills using footballs and tennis balls, with instructions to vary arc, speed, and trajectory. For skilled players, “high ball” drills were the focus, whereas for linemen, bounce passes and low pitch drills were stressed. Reaction time data was recorded for each athlete during every Dynavision D2 training session. We monitored the incidence of concussion during the four consecutive seasons of vision training, as well as the previous four consecutive seasons, and compared incidence of concussions (2006 to 2009 referent seasons v. 2010 to 2013 vision training seasons). Results: During the 2006-2013 pre- and regular football seasons, there were 41 sustained concussion events reported. The overall concussion incidence rate for the entire cohort was 5.1 cases per 100 player seasons. When the data were evaluated relative to vision trained versus referent untrained player seasons, a statistically significant lower rate of concussion was noted in player season in the vision training cohort (1.4 concussions per 100 player seasons) compared to players who did not receive the vision training (9.2 concussions per 100 player seasons; p
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Volume 3 | Issue 1 | 2015, February Optometry & Visual Performance 7
Article 4
An exploratory study of the potential eects of vision training
on concussion incidence in football
Joseph F. Clark, Departments of Neurology & Rehabilitation Medicine, University of Cincinnati, Cincinnati,
Ohio
Pat Graman, Department of Education, University of Cincinnati, Cincinnati, Ohio
James K. Ellis, Departments of Sports Medicine, University of Cincinnati, Cincinnati, Ohio
Robert E. Mangine, Departments of Orthopedic Surgery, Athletics, & Neurosurgery, University of Cincinnati,
Cincinnati, Ohio
Joseph T. Rauch, Departments of Orthopedic Surgery, Athletics, & Neurosurgery, University of Cincinnati,
Cincinnati, Ohio
Ben Bixenmann, Division of Sports Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
Kimberly A. Hasselfeld, Department of Athletics, University of Cincinnati, Cincinnati, Ohio
Jon G. Divine, Department of Athletics, University of Cincinnati, Cincinnati, Ohio
Angelo J. Colosimo, Department of Athletics, University of Cincinnati, Cincinnati, Ohio
Gregory D. Myer, Division of Sports Medicine, Cincinnati Children’s Hospital Medical Center, Department
of Pediatrics and Orthopaedic Surgery, University of Cincinnati, & Sports Medicine Sports Health & Performance Institute, e
Ohio State University, Columbus, Ohio, & e Micheli Center for Sports Injury Prevention, Boston, Massachusetts
ABSTRACT
Background: Vision training has become a component of sports enhancement training, however quantiable and
validated improvement in visual performance has not been clearly demonstrated. In addition, there is minimal literature
related to the eects of vision training on sports performance and injury risk reduction. e purpose of the current
investigation was to determine the eects of vision training on peripheral vision and concussion incidence.
Methods: Vision training was initiated among the University of Cincinnati football team at the beginning of the 2010
season and continued for four years (2010 to 2013). e sports vision enhancement was conducted during the two
weeks of preseason camp. Typical vision training consisted of Dynavision D2 light board training, Nike strobe glasses,
and tracking drills. Nike Strobe glasses and tracking drills were done with pairs of pitch and catch drills using footballs,
and tennis balls with instructions to vary arc, speed and trajectory. For skilled players “high ball” drills were the focused,
whereas for linemen, bounce passes and low pitch drills were stressed. Reaction time data was recorded for each athlete
during every Dynavision D2 training session. We monitored the incidence of concussion during the four consecutive
seasons of vision training, as well as the previous four consecutive seasons and compared incidence of concussions; (2006
to 2009-referent seasons vs. 2010 to 2013 vision training seasons).
Results: During the 2006 -2013 pre- and regular football seasons, there were 41 sustained concussion events reported.
e overall concussion incidence rate for the entire cohort 5.1 cases per 100 player seasons. When the data were evaluated
relative to vision trained versus referent untrained player seasons, a statistically signicant lower rate of concussion was
noted in players season in the vision training cohort (1.4 concussions per 100 player seasons) compared to players who
did not receive the vision training (9.2 concussions per 100 game exposures; P <0.001). e decrease in injury frequency
in competitive seasons with vision training was also associated with a concomitant decrease in missed play time.
Discussion: e current data indicates an association of a decreased incidence of concussion among football players
during the competitive seasons where vision training was performed as part of the preseason training. We suggest that
better eld awareness gained from vision training may assist in preparatory awareness to avoid concussion causing injuries.
Future large scale clinical trials are warranted to conrm the eects noted in this preliminary report.
Keywords: athletic training, concussion, Dynavision, football, injury, injury prevention, peripheral vision, vision, vision
training
Volume 3 | Issue 1 | 2015, February Optometry & Visual Performance 9 8 Optometry & Visual Performance Volume 3 | Issue 1 | 2015, February
Introduction
Football is a complex skilled sport with the need to
integrate sensory input to be successful; vision plays a key
component.1 ere are 22 players on the eld of play, and
players need to see, track, and identify multiple targets for
successful performance, as well as avoid injuries. Success in
football requires robust vision tracking, the substantial intake
of visual information, and analysis this information rapidly.2,3
is requires processing of information in the central and
peripheral visual elds. Since rule changes in the 1970’s, the
concept of see what you hit has reduced the risk of catastrophic
injury, yet the number of concussions remains high.4
In recent years the management of traumatic brain injury
(TBI) in sports has come under scrutiny from academia
and media, both noting the short and long term outcomes
associated with concussions. Athletic concussions have been in
the forefront of the public’s focus due to the high prole injuries,
deaths, and lawsuits concerning long term consequences from
concussion.5,6 Recently the reported incidence rate for TBI,
which includes concussions, went from 1.75 million annually
to 3.6 million annually.7 is likely reects, in part, increased
awareness by both the athletes and support personnel, as well
as an increase in the reporting of TBI’s. is apparent doubling
of reported concussions is supported by recent media reports
concerning the burden and seriousness of concussions in sports
such as football with some teams reporting 20 concussions per
year, up from 10 per year.7
Over the last 10 years, the volume of literature that denes
or describes the process of injury, assessment processes, and
rehab strategies has expanded. e primary emphasis has been
on neuro-psychological tools, balance systems, and posture.
Although multiple organizations associated with sports
have published recommendations, a gold standard still does
not exist in terms of post traumatic management, and pre-
participation assessment.1,8,9 In 2004 the National Athletic
Trainers Association (NATA) published a position statement
based on the available research and clinical practice trends at
that time. e position statement included recommendations
to its association membership for concussions, however
research is evolving at a pace that often overshadows many
recommendations. NATA outlines multiple sections in its
2004 position statement,9 from dening, to pre-participation
to evaluation, to assessment, to post concussion management
and to return to play. e primary emphasis is on the
management of post-TBI and recommended pre-participation
assessment tools.
e National Collegiate Athletic Association (NCAA)
guidelines also in 201310 focused on the assessment process
and recommended that member institutions formulate a
concussion management plan with recommendations for
baseline testing, neuropsychological evaluation and a return to
play pathway. Minimal to no information contained in either
policy reects vision assessment or the role of vision in return
to play. On an annual basis the NCAA publishes a guideline
on sports related concussions, which the membership holds as
the standard set by the organization.
Overall, little to no emphasis is placed on prevention or
training to reduce the risk of traumatic brain injury. Primary
work occurs in the area of equipment alteration, by way of
either adding a layer for load absorption or in the direction
of monitoring impact size and location. However, eorts to
use performance training as a tool to reduce injury risk, has
received minimal attention in the literature. ere remains the
question, “Is there a viable option to provide the athlete the
opportunity to train neuro-cognitive function to avoid and/or
assist the brain in the recovery process?”
e prevention of TBI in football up to this point has
received minimal attention,11 and primary emphasis has been
on rule changes and interpretation, equipment evolution, and
base line neurological assessment testing. Studies designed to
reduce the risk by way of performance training the athlete
directly has received negligible attention. Since the equation
for injury involves both intrinsic and extrinsic factors, at
some point intrinsic factors must be addressed. With that as a
direction, our group assessed available techniques and training
modalities to address this issue.
Unfortunately, helmets and concussion mitigation
strategies reported to date have been ineective.11 What is
needed is a strategy that can decrease the risk of injury from
collisions and concussive injuries that is easily adoptable by
coaches and medical practitioners. e purpose of this study
was to evaluate the potential for vision training to decrease
the incidence of concussive injury in elite football players. We
hypothesized that preseason vision training would signicantly
reduce both practice and competition concussion incidence in
football.
Methods
Human Subjects
Vision training was incorporated into the preseason
football camp training schedule of all University of Cincinnati
football team members from the 2010 to the 2013 seasons.
e testing and training was a team wide activity. No informed
consents were signed as this was implemented as part of the
standard evaluation for concussions and training was integrated
into the performance enhancement segment of the athletes’
program. e University of Cincinnati Institutional Review
Board (IRB) reviewed the project and determined that it did
not meet the criteria for research involving human subjects and
therefore IRB oversight was not required.
Dynavision
e Dynavision is a device designed to evaluate and
train eye-hand coordination to improve visual motor skills.
7,8 Training typically consists of two one-minute sessions
with the athletes. e reason for doing multiple sessions is to
demonstrate consistency and improvement with the tasks. e
staged and progressive nature of the tasks also helps keep the
athletes engaged.
e o-the-shelf, “*A training session” is an established
Dynavision protocol.12-15 “*A” is the program name that comes
as part of the package for the Dynavision and is a one minute
task of hitting lights on the board as quickly as possible. It
uses traditional eye-hand reaction training to challenge an
individual’s eye hand coordination in multiple visual elds. e
resultant output provides that athlete with feedback relative
to the number of hits in one minute, as well as the average
reaction time for each hit. Targeted programs were written
to improve the perception of the regions of interest and eye
hand performance and precision. For example, quarterbacks
focused on their blind side while linemen focused on central
visual elds.
e other o-the-shelf training program that is also
completed on the Dynavision was the reaction test. e
reaction test is a task where the subjects use one hand at a time
to hold down one button and when a light illuminates, hits
that light. e subject is required to scan an area or region
of interest in preparation for the light to be hit. A computer
records how long it takes for the subject to initiate a response
to the light; moving their hand from the button they were
holding. en the subject hits the newly lit light and the task
is completed. So, two tasks in one are performed; seeing the
light and responding and hitting the light.15 e Dynavision
assesses visual and motor reaction times for the left and right
hands. e lights are arranged horizontally, vertically (with
an arc), and a single light. e subjects are told to scan the
area where the lights could illuminate and respond when lit.
Alternately, the subjects are told to keep their eyes on one point
and uses peripheral vision to see and respond to the lights.
us, the training enhances scanning practices and peripheral
vision response times.
Peripheral vision reaction time ratio is a calculation to
determine an athlete’s speed of reaction to what they see in
their peripheral vision. We used the data collected during the
Dynavision program; “*A” session during the 2013 preseason
football camp for each athlete and calculated the average
reaction time for the buttons hit in the outer two rings of the
vision board compared to the inner three rings. We compared
every athlete’s peripheral vision reaction time ratio from the
rst training session of football camp to their last training
session of football camp. e ratio was calculated by taking
the mean reaction times for the outer two rings divided by the
mean of the reaction times for the inner two rings. A higher
ratio means it takes longer to see and hit the buttons in the
periphery compared to the center of the visual eld.
Strobe Glasses
Strobe glasses (Nike SPARQ Vapor Strobe) are LED lenses
that ash and block the light signal to the eyes.14 ey are set to
Figure 1: in this Figure we see th e scheme For v ision tra ining oF unive rsity oF cincin nati Football player s
pre-seaso n where th ere is very re gular and i ntense tr aining. during these t wo plus weeks t he complexi ty and
demands oF t he vision t rainin g are escal ated as the trai ning proce eds. during the seas on, no new drills are
added and a ma intenance p hase is init iated where sub jects per Form exclusi vely the dynavisio n once week ly in
approximately ten min ute session s.
Volume 3 | Issue 1 | 2015, February Optometry & Visual Performance 11 10 Optometry & Visual Performance Volume 3 | Issue 1 | 2015, February
ash more rapidly in the initial training stages and are gradually
slowed as the athlete adapts to the training. e slower the
interval, the more dicult the task becomes because of the
reduced visual input.
e Vision Training Procedure
Vision training was divided by position with targeted drills
for each position. is included Dynavision, strobe glasses,
pitch and catch and tachistoscope. Typically, this training
occurred during pre-season once-per-day during training
camp. Vision training was considered part of conditioning and
groups of players rotated through the vision training stations.
We typically ran three main vision training stations during the
football camp and subjects did the training daily as part of
their pre-season conditioning (Figure 1).
Dynavision Methods.
During football camp, typically 2.5 weeks immediately
prior to the start of camp, players had approximately 40 minutes
of structured vision training per day, 6 or 7 days per week. e
vision training typically included 20 minutes of Dynavision.
e Dynavision training programs performed on the light
board were purpose built programs that were structured to be
appropriate to the players’ positions. For example, receivers
and defensive backs would do training requiring the subjects to
see and hit lights over their head. Linemen would have specic
tasks but with less reaching over their heads as their positions
do not require many overhead actions like catching high balls.
All players were required to do dual task drills with their
vision. is required tasks that had the subjects call numbers,
words, or characters ashed on the tachistoscope while
hitting buttons. e instructions for these drills were to use
eye discipline and keep their eyes on the scope, while using
peripheral vision to see the buttons and hit the buttons. is,
we believe helps train functional peripheral vision. Peripheral
vision reaction training was also done with the Dynavision
where subjects had to react to ashing lights in their peripheral
visual elds while focusing on the tachistoscope or another
light.
Tachistoscope.
Typically, several players could work on the projected
tachistoscope training simultaneously. Using football photos
from the University of Cincinnati games a timed power point
program was developed where ashed pictures (still photos)
of the games were projected. e subjects were to watch the
timed power point and make note of one or two specic
bits of information based on questions posed after the ash.
e ashed pictures had numbers and or letters randomly
distributed throughout the pictures and the players had to note
the numbers/letters. Additional questions were asked of the
players such as player numbers from the photos, teams being
played etc. is tachistoscope training was made progressively
more complicated during the training camp by making the
• Abighitofconcernorathletegoingdowntriggersan
athletic trainer to assess the athlete.
• Iftheathletehasasuspectedconcussiontheathletic
trainer pulls the athlete from play for a further
evaluation by other members of the concussion
management team.
• Typical side lineconcussionassessmenttest(SCAT)
II, SCAT III, and question and answer are performed.
• Iftheinitialconcussionsuspicionisnotfoundedthe
player may return to play.
• If the suspicion of concussion remains, the athlete
is pulled from all play that day and referred to be
evaluated by a physician or physician designate such
as a sports neuro specialist.
• enaldiagnosisofconcussionismadebytheteam
physician based in part on the report of the neuro
specialist, the trainers and his/her observations.
• etreatment,rehab,andreturnto playpathwayis
initiated for the athlete.
For this study the past concussions were conrmed
based upon retrospective review of injury logs generated by
the athletic trainer, concussion management team member’s
report, and the team physician’s nal diagnosis based on the
two reports and in combination with his/her assessment.
Currently the diagnosis is unchanged, but the records were
being kept as part of an IRB approved concussion protocol
so a historical analysis was not needed as they were directly
entered into the system.
Helmets
All team members for each season used the same helmet
models from the same two manufactures (Ridell and Schutte).
All helmets were properly tted by individuals well-trained in
proper helmet tting and maintenance. Helmets were checked
weekly for damage and repaired or replaced as needed. e
ratio of helmet type on the team was recorded annually.
Athlete Season Exposures
e relative rates reect the reported concussions from the
beginning of the fall training season (usually August) through
the end of the season, including bowl games (except for the
2013-2014 season which did not include the bowl).
ash time shorter and the information to be obtained more
complicated. Subjects were tasked to do the tachistoscope
training for approximately 7-10 minutes per session.
Pinhole glasses, strobe glasses, and pitch and catch.
Groups of players, typically 2 to 6 players, were given balls,
pinhole glasses, and strobe glasses and advised to throw the
ball(s) around. is was done for approximately 7-10 minutes
per session. Subjects rotated strobes and pinhole glasses every
minute or two. e pitch and catch tasks were progressed
throughout camp by varying the speed of the ash with the
strobes, narrowing the visual eld of the pinhole glasses etc.
Also, pitch and catch routines were made progressively more
complicated by having subjects turn away from their partner
and having to turn and catch.
In Season Training – Maintenance Phase.
During football season a maintenance phase of vision
training was initiated exclusively using the Dynavision.
Subjects could use the Dynavision at any time on their own,
but there was also one weekly structured training, typically 10
minutes at a time, where subjects were run through the series
of Dynavision routines that they had done at camp. No new
routines were initiated during the season. In-season training
sessions were expanded and contracted based on practice and
game schedules.
Denition of a Concussion
e concussion management team for the University
of Cincinnati sports medicine division uses the American
Association of Neurological Surgeons (AANS) denition
of concussion at its core; a trauma induced alteration in
brain function that is documentable.16 e documentable
component to the denition can come from a change in brain
function from a baseline or an abnormal parameter in the
absence of baseline.
For the University of Cincinnati the process for identifying
a concussion starts on the eld.
Statistics
e initial statistical approach was to compare the pre
vision training years’ incidence rates to the post vision training
years’ rates using an unpaired Student’s t-Test. e secondary
approach for data analysis was an examination of rate of
concussion for total player year exposure at the categorized
grouping of vision training versus control year sample.
Concussion rates were compared between vision training and
referent untrained condition using a chi-square test with a
Yates correction. Statistical signicance was established a priori
at P < 0.05.
RESULTS
Number of injuries
During the 2006 -2013 pre- and regular football seasons,
there were 41 sustained concussion events reported. e
concussion incidence rate for the entire cohort 5.1 cases per 100
player seasons. When the data were evaluated relative to vision
trained versus referent untrained player seasons, a statistically
signicant lower rate of concussion was noted in players in the
vision training cohort (1.4 concussions per 100 player seasons)
compared to players who did not receive the vision training
(9.2 concussions per 100 game exposures; P <0.001).
e average number of diagnosed concussions per season
for the four years prior to vision training was 8.75 ± 1.7. is
compares to 1.5 ± 1.0 concussion per season over the four years
after initiation of vision training (P < 0.001). e years of 2006
to 2009 and 2010 to 2013 each covered two dierent coaching
stas (Table 1).
Peripheral Vision
e average peripheral vision reaction time ratio calculated
during the Dynavision *A training session from the rst vision
training session of football camp in 2013 was 1.50 ± 0.23.
is improved to a ratio of 1.42 ± 0.15 following two weeks of
vision training (P < 0.01; N=105).
In Table 2 we see the reaction times taken to hit the
Dynavision D2 buttons reported by year and broken down
by ring to give a clearer indication of the functional peripheral
vision changes seen. What we see is the year to year improvement
for the intake of upperclassmen who have had vision training.
Table 1: Shows Results from the Individual Years.
Number of CoN-
CussioNs
Number of Players CoaCh t hat year
2006 9 103 m. DaNtoNio
2007 8 102 b. Kelly
2008 7 103 b. Kelly
2009 11 109 b. Kelly
2010* 1 113 b. JoNes
2011 3 110 b. JoNes
2012 1 109 b. JoNes
2013 1 105 t. tuberville
*Vision train ing was initiated aug 1 2010.
aVerage Hit time + sd
(time in seconds)
ring 1 ring 2 ring 3 ring 4 ring 5 Functional PeriPHer al Vision ratio
Pre season
2010 0.56 ± 0.08 0.56 ± 0.06 0.69 ± 0.11 0.77 ± 0.12 0.98 ± 0.18 1.52
2011 0.62 ± 0.21 0.64 ± 0.19 0.72 ± 0.20 0.85 ± 0.26 1.02 ± 0.25 1.48
2012 0.55 ± 0.12 0.56 ± 0.12 0.64 ± 0.15 0.77 ± 0.20 0.91 ± 0.33 1.51
2013 0.52 ± 0.08 0.53 V 0.09 0.57 ± 0.07 0.67 ± 0.10 0.80 ± 0.19 1.40
diameter oF rings (incHes) 8.125 17.25 21.25 34.75 43.5
Table 1: The Average Time it Takes for Subjects to Hit the Dierent Rings When they Start the Vision
Training Pre-season.
Volume 3 | Issue 1 | 2015, February Optometry & Visual Performance 13 12 Optometry & Visual Performance Volume 3 | Issue 1 | 2015, February
A comparison of pre and post training functional
peripheral ratios was made to assess the impact of the training
program using data from the 2013 camp. Preseason athletes
had an average ratio of 1.50 ± 0.23. After vision training these
athletes had a ratio of 1.42 ± 0.15 (P ≤ 0.01).
DISCUSSION
e concept of vision training to improve the athlete’s on
eld performance has evolved into a common practice for the
University of Cincinnati sports teams.14 Multiple authors have
suggested that training the visual eld may improve several
elements of competition.13,14,17 ere is a growing body of
evidence that vision training may have an added benet of
injury prevention.18,19 e objective of training would be to
improve specic visual parameters allowing athletes in sports
such as football and baseball may impart an improved ability
to focus on the eld of play and prepare for or avoid injuries,
including mild traumatic brain injury.
In this paper we report that a comprehensive pre-season
vision training program is associated with a reduction in
concussion incidence in elite football players. It would be easy
to criticize the association of vision training to a decrease in
injury rate if this were a one-year study. But, this trend was
seen over multiple years and coaching regimes (four dierent
coaches). Further, it might be suggested that the decrease in
reported injuries was not a causal relationship to vision training
as vision training might have had no other demonstrable
eects. However, we found that functional peripheral vision
(dened by the peripheral vision reaction time ratio) was
improved in the team following vision training (Table 2). e
research team had previously used vision training methods to
improve batting performance in baseball players, so there is
familiarity with the initiation and implementation of vision
training.14 A main dierence between the training regimen
performed for baseball and football is that football was limited
to the summer camp about two and a half weeks whereas
baseball was six weeks. Finally, the decrease in concussions was
seen at a time when most other universities were reporting a
rise in concussions.7 us, we believe that there is a strong
association between vision training and injury prevention.
e question remains as to how might vision training
prevent injuries. We believe that the vision training we
performed is broadening the athlete’s eld of awareness or
functional peripheral vision. It may be that with training, the
eyes and brain are able to use information obtained within
the eld of functional peripheral vision to react faster to their
changing environment and avoid injury causing collisions. In a
post hoc analysis we attempted to assess if the peripheral vision
might have improved. To do this we analyzed the Dynavision
data from the University of Cincinnati Football team at the
beginning and end of the 2013 camp. e improvement from
1.50 ± 0.23 before training to 1.42 ± 0.15 (P ≤ 0.01) after
vision training suggests that the ability of the athletes to see
and respond to the lights in their peripheral vision improves
with training, and by extension we posit that they may become
better able to respond to situations and avoid injuries. It should
be recalled that the higher ratio means it takes longer to see and
hit the buttons in the periphery compared to the center of the
visual eld.
Rationale for Vision Training
e vision training was initiated in 2010 for baseline
concussion testing and performance enhancement. Also,
we published our results on the performance enhancement
associated with vision training of baseball players where batting
performance was enhanced.14 For football, the Dynavision
and strobe glasses were the main vision training methods used
as this was being done as part of concussion management and
position specic performance enhancement.
Empirical evidence indicates that the vision training,
which included ocular motor and visual conditioning, led to
an improvement in the control and delity of the extra ocular
and intra ocular muscles of the eyes.12-14,17,20-24 is likely
included an improvement in muscle memory for the arms to
hit the buttons eectively. e eyes were able to more precisely
“focus” on a point, remain there and give the brain better input
concerning information from peripheral visual elds. is, to
an extent, may be what the athletes use during competition to
increase awareness of where that point is in physical space.14,15,24
Limitations
A limitation of this study is that it is a retrospective
analysis of reported concussions after the initiation of vision
training. ere was no control group. e vision training
was performed during the summer camp on all players and
continued to a limited extent during the football season. is
isin compliance with contact hour rules. is restricted vision
training to once a week to less than 15 minutes per session.
e vision training was always directed by the same person
for all four years and the focus on the vision training was for
concussion management and presented to the students as
performance enhancement. us, there was a dual purpose for
the vision training. We estimate that the average player had 20
minutes of vision training on the Dynavision during camp,
which is two weeks. is includes all players and all positions.
Plus, there was an additional 20 minutes doing other vision
training related activities. is training duration is similar to
what we reported for the University of Cincinnati baseball
players of about twelve minutes of vision training per week.14
While the results of this study provide important preliminary
data on the potential benets of vision training to reduce sport
related concussion in football, the small sample size indicates
that interpretation of these results should be taken with
caution. Before applying these results to clinical applications, a
prospective controlled study designed is needed to conrm the
nding of the current study
CONCLUSION
Future prospective studies are needed to determine a
causal relationship of vision training and injury prevention.
Further, from this retrospective analysis, it is not clear what
vision training method or methods are most benecial to
support concussion injury risk reduction. Future prospective
randomized clinical trials are warranted to better assess the
cause and eect of vision training and its potential to reduce
concussion incidence in football players.
Acknowledgements
e authors wish to acknowledge the coaching stas of
Coaches Butch Jones and Tommy Tuberville. Without their
support this work would not have been possible. anks to
Jen Umberg for assistance at 2012 football camp. anks to
Geraldine Warner for supporting this work.
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Correspondence regarding this article should be emailed to Joseph F. Clark at
joseph.clark@uc.edu. All statements are the authors’ personal opinions and
may not reect the opinions of the the representative organizations, ACBO or
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www.oepf.org, and www.ovpjournal.org.
Clark JF, Graman P, Ellis JK, Mangine RE et al. An exploratory study of
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e online version of this article
contains digital enhancements.
... Interventions or Regulations Participants A total of 726 collegiate football players participated and completed studies included in this review, however this number is not fully representative of all players because two studies did not mention the total number of participants in the study. Clark et al. 10 specified the number of players by year, however it is unclear whether players participated in multiple years. Wiebe et al. 60 mentioned each team had approximately 100 players but was not specific to be able to include in the total. ...
... Five studies analyzed the effectiveness of intervention or regulations on head impacts or head injuries in collegiate football. 10,50,51,54,60 The types of study designs varied across interventions and regulations. As shown in Table 3, study designs included one RCT, three cohort studies, and one retrospective analysis. ...
... As shown in Table 3, study designs included one RCT, three cohort studies, and one retrospective analysis. 10,50,51,54,60 Only one study design randomized participants. Swartz et al. 54 (2015) stratified participants by position and then randomized players to the intervention or control group. ...
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The purpose of this study was to assess the effectiveness of regulations and behavioral interventions on head impacts and concussions in youth, high-school, and collegiate football, using a systematic search strategy to identify relevant literature. Six databases were searched using key search terms related to three categories: football, head-injuries, and interventions. Studies that met inclusion criteria were included in the study and underwent data extraction. Twenty articles met inclusion criteria and were included in the final systematized review. Of the 20 included studies, 8 studies evaluated interventions in high-school football, 5 studies evaluated interventions in collegiate football, 6 studies evaluated interventions in youth football, and 1 study evaluated interventions in both, high-school and collegiate football. The four categories of interventions and regulations included rule changes, training, education/instruction/coaching tactical changes, and tackle football alternatives. Studies evaluating the effectiveness of interventions and regulations on reducing head impact exposures or head injuries have shown mixed results. Some regulations may be more effective than others, but methodological design and risk of bias pose limitations to generalize effects.
... Cor responding results report a number of hits, accuracy, and speed in each ring and quadrant, according to spe cific mode settings. Clark and colleagues (2015) [9] found that ocular motor and visual conditioning with use of the DynavisionTM D2 and additional vision training methods positively impacted hand-eye coordination, improving the accuracy and control of the intraocular and extraocular muscles of the eye and the muscle memory of the arms and hands. These improvements indicated an ability to maintain central focus while successfully receiving and reacting to information from the peripheral visual fields. ...
... Athlete stance may have also contributed to the ability to visualize more of the board, especially for outer rings, using peripheral vi sion instead of head turns. Rings furthest from the cen tral field (3, 4, and 5) require more peripheral aware ness and were found to have improved reaction time within Groups A and B. These findings are similar to findings from Clark and colleagues (2015) [9], noting that reaction time in ring 5 (that furthest from the cen tral field) was indicative of the slowest reaction time. ...
... While much of these regulations have been put in place due to safety concerns for assessing head and neck injuries [17], virtually no research has been completed to elucidate whether these types of equipment impair visual reactive performance. Since previous evidence has suggested that improvements in visuomotor ability may possibly decrease concussion incidence [18], understanding how facemasks and visors influence reactive ability has important implications for player performance and safety. The purpose of this study was to investigate how varying facemask reinforcements and visor tints influence peripheral reaction time and target detection in Division I NCAA football players. ...
... Supporting possible poorer performance at night with tinted visors, tinted vehicle windows have been shown to diminish visual performance and target detection under night-simulated conditions [41]. The formation of appropriate reactive responses has been suggested to mitigate injury and possibly concussion in football [18]. While general safety considerations on tinted visors for the assessment of head and neck injury remain, current data suggest that reactive and visuomotor ability during gameplay may also be altered by tinted visors, which could pose additional safety concerns. ...
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... For example, effects of vision training could be incorporated to preventive and rehabilitation exercise as a part of SRC management strategy. 49,50 The current investigation has a few limitations. Firstly, athletic background and age of participants were not strictly matched. ...
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IntroductionSensorimotor characteristics such as visual-motor reaction time (VMRT), peak force, and rate of force development (RFD) of the neck muscles play an important role in sports-related concussions (SRC). The purpose of this study was to establish reliability and sex differences of neck-specific VMRT and force characteristics of neck muscles using a novel test. Methods This is a two-part study. A total of 15 subjects and 49 subjects participated to examine test–retest reliability and sex differences in multidirectional choice VMRT and peak force and RFD values, respectively. ResultsReliability was moderate for VMRT (Intraclass Correlation Coefficient, ICC = 0.406–0.624) and moderate to excellent for peak force and RFD (ICC = 0.443–0.948). Females had significantly slower VMRT (P < 0.001–0.012), while no sex differences were found in peak force and RFD (P = 0.079–0.763). DiscussionFuture investigations should incorporate these characteristics during baseline testing and examine if they can be identified as prospective risk factors of SRC.
... The eyes cannot be trained in isolation, the body must be taught to work as a unit. 27 Training was integrated into the performance enhancement segment of the athletes' program includes the instruments like dynavision, strobe glasses, Tachistoscope, eye port, pin hole glasses etc. 28 The eyes can be trained just like any other muscle in the body to improve reaction to what is seen. Just as exercise and practice increase strength and speed, so can the visual performance be improved to achieve maximum results (Smythies, 1996). ...
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... For the subset of single-task studies, because dual-task studies implicitly have their participants fixate on the central LCD, only 4 (27%) of 15 studies mentioned to have instructed their participants to use peripheral vision. There is some variability in wording compared with the standard instructions proposed by Klavora et al. 63 Similar to the standard instructions, for example, Clark et al. 74 asked participants to "use eye discipline and to keep their eyes on the scope while using peripheral vision to see the buttons and to hit the buttons." Hoffman et al. 81 instructed participants "to fixate their gaze on the LCD screen in the middle of the board and to keep their focus there for the entirety of the experiment." ...
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... Similar training methods were used for a preseason conditioning programme with ongoing maintenance training during the baseball season, which improved batting performance among collegiate baseball players [43]. Preliminary results have also demonstrated that vision training involving the Dynavision light board and strobe glasses have the potential to improve functional peripheral vision and reduce the concussion rate among collegiate American Football players [66]. These drills were suggested to help improve the athlete's awareness of the visual field and ability to see and respond to peripheral visual cues. ...
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Chapter
Training to optimize visual performance abilities is a logical supplement to other training programs that athletes perform in order to improve sports performance in competition. An overview of how to develop and successfully implement sports vision training is presented. A detailed description of common sports vision training approaches is provided with research evidence to support efficacy, when available. Updates on commercially available instrumentation to train various visual performance abilities is presented.
Chapter
Participation in sports exposes athletes to the potential for eye injuries. This chapter presents the epidemiology and risks for sport-related eye injuries with discussion of sport-related ocular trauma management. For each type of injury, both sideline and clinical management considerations are presented. An overview of sport-related concussion is also presented with an emphasis on the management of visual symptoms.
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Data
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Unlabelled: PURPOSE OF THE STATEMENT: ▸ To provide an evidence-based, best practises summary to assist physicians with the evaluation and management of sports concussion. ▸ To establish the level of evidence, knowledge gaps and areas requiring additional research. Importance of an amssm statement: ▸ Sports medicine physicians are frequently involved in the care of patients with sports concussion. ▸ Sports medicine physicians are specifically trained to provide care along the continuum of sports concussion from the acute injury to return-to-play (RTP) decisions. ▸ The care of athletes with sports concussion is ideally performed by healthcare professionals with specific training and experience in the assessment and management of concussion. Competence should be determined by training and experience, not dictated by specialty. ▸ While this statement is directed towards sports medicine physicians, it may also assist other physicians and healthcare professionals in the care of patients with sports concussion. Definition: ▸ Concussion is defined as a traumatically induced transient disturbance of brain function and involves a complex pathophysiological process. Concussion is a subset of mild traumatic brain injury (MTBI) which is generally self-limited and at the less-severe end of the brain injury spectrum. Pathophysiology: ▸ Animal and human studies support the concept of postconcussive vulnerability, showing that a second blow before the brain has recovered results in worsening metabolic changes within the cell. ▸ Experimental evidence suggests the concussed brain is less responsive to usual neural activation and when premature cognitive or physical activity occurs before complete recovery the brain may be vulnerable to prolonged dysfunction. Incidence: ▸ It is estimated that as many as 3.8 million concussions occur in the USA per year during competitive sports and recreational activities; however, as many as 50% of the concussions may go unreported. ▸ Concussions occur in all sports with the highest incidence in football, hockey, rugby, soccer and basketball. RISK FACTORS FOR SPORT-RELATED CONCUSSION: ▸ A history of concussion is associated with a higher risk of sustaining another concussion. ▸ A greater number, severity and duration of symptoms after a concussion are predictors of a prolonged recovery. ▸ In sports with similar playing rules, the reported incidence of concussion is higher in female athletes than in male athletes. ▸ Certain sports, positions and individual playing styles have a greater risk of concussion. ▸ Youth athletes may have a more prolonged recovery and are more susceptible to a concussion accompanied by a catastrophic injury. ▸ Preinjury mood disorders, learning disorders, attention-deficit disorders (ADD/ADHD) and migraine headaches complicate diagnosis and management of a concussion. Diagnosis of concussion: ▸ Concussion remains a clinical diagnosis ideally made by a healthcare provider familiar with the athlete and knowledgeable in the recognition and evaluation of concussion. ▸ Graded symptom checklists provide an objective tool for assessing a variety of symptoms related to concussions, while also tracking the severity of those symptoms over serial evaluations. ▸ Standardised assessment tools provide a helpful structure for the evaluation of concussion, although limited validation of these assessment tools is available. Sideline evaluation and management: ▸ Any athlete suspected of having a concussion should be stopped from playing and assessed by a licenced healthcare provider trained in the evaluation and management of concussions. ▸ Recognition and initial assessment of a concussion should be guided by a symptoms checklist, cognitive evaluation (including orientation, past and immediate memory, new learning and concentration), balance tests and further neurological physical examination. ▸ While standardised sideline tests are a useful framework for examination, the sensitivity, specificity, validity and reliability of these tests among different age groups, cultural groups and settings is largely undefined. Their practical usefulness with or without an individual baseline test is also largely unknown. ▸ Balance disturbance is a specific indicator of a concussion, but not very sensitive. Balance testing on the sideline may be substantially different than baseline tests because of differences in shoe/cleat-type or surface, use of ankle tape or braces, or the presence of other lower extremity injury. ▸ Imaging is reserved for athletes where intracerebral bleeding is suspected. ▸ There is no same day RTP for an athlete diagnosed with a concussion. ▸ Athletes suspected or diagnosed with a concussion should be monitored for deteriorating physical or mental status. Neuropsychological testing: ▸ Neuropsychological (NP) tests are an objective measure of brain-behaviour relationships and are more sensitive for subtle cognitive impairment than clinical exam. ▸ Most concussions can be managed appropriately without the use of NP testing. ▸ Computerised neuropsychological (CNP) testing should be interpreted by healthcare professionals trained and familiar with the type of test and the individual test limitations, including a knowledgeable assessment of the reliable change index, baseline variability and false-positive and false-negative rates. ▸ Paper and pencil NP tests can be more comprehensive, test different domains and assess for other conditions which may masquerade as or complicate assessment of concussion. ▸ NP testing should be used only as part of a comprehensive concussion management strategy and should not be used in isolation. ▸ The ideal timing, frequency and type of NP testing have not been determined. ▸ In some cases, properly administered and interpreted NP testing provides an added value to assess cognitive function and recovery in the management of sports concussions. ▸ It is unknown if use of NP testing in the management of sports concussion helps prevent recurrent concussion, catastrophic injury or long-term complications. ▸ Comprehensive NP evaluation is helpful in the post-concussion management of athletes with persistent symptoms or complicated courses. Return to class: ▸ Students will require cognitive rest and may require academic accommodations such as reduced workload and extended time for tests while recovering from a concussion. Return to play: ▸ Concussion symptoms should be resolved before returning to exercise. ▸ A RTP progression involves a gradual, step-wise increase in physical demands, sports-specific activities and the risk for contact. ▸ If symptoms occur with activity, the progression should be halted and restarted at the preceding symptom-free step. ▸ RTP after concussion should occur only with medical clearance from a licenced healthcare provider trained in the evaluation and management of concussions. SHORT-TERM RISKS OF PREMATURE RTP: ▸ The primary concern with early RTP is decreased reaction time leading to an increased risk of a repeat concussion or other injury and prolongation of symptoms. LONG-TERM EFFECTS: ▸ There is an increasing concern that head impact exposure and recurrent concussions contribute to long-term neurological sequelae. ▸ Some studies have suggested an association between prior concussions and chronic cognitive dysfunction. Large-scale epidemiological studies are needed to more clearly define risk factors and causation of any long-term neurological impairment. Disqualification from sport: ▸ There are no evidence-based guidelines for disqualifying/retiring an athlete from a sport after a concussion. Each case should be carefully deliberated and an individualised approach to determining disqualification taken. Education: ▸ Greater efforts are needed to educate involved parties, including athletes, parents, coaches, officials, school administrators and healthcare providers to improve concussion recognition, management and prevention. ▸ Physicians should be prepared to provide counselling regarding potential long-term consequences of a concussion and recurrent concussions. Prevention: ▸ Primary prevention of some injuries may be possible with modification and enforcement of the rules and fair play. ▸ Helmets, both hard (football, lacrosse and hockey) and soft (soccer, rugby) are best suited to prevent impact injuries (fracture, bleeding, laceration, etc.) but have not been shown to reduce the incidence and severity of concussions. ▸ There is no current evidence that mouth guards can reduce the severity of or prevent concussions. ▸ Secondary prevention may be possible by appropriate RTP management. Legislation: ▸ Legislative efforts provide a uniform standard for scholastic and non-scholastic sports organisations regarding concussion safety and management. Future directions: ▸ Additional research is needed to validate current assessment tools, delineate the role of NP testing and improve identification of those at risk of prolonged post-concussive symptoms or other long-term complications. ▸ Evolving technologies for the diagnosis of concussion, such as newer neuroimaging techniques or biological markers, may provide new insights into the evaluation and management of sports concussion.
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Baseball requires an incredible amount of visual acuity and eye-hand coordination, especially for the batters. The learning objective of this work is to observe that traditional vision training as part of injury prevention or conditioning can be added to a team's training schedule to improve some performance parameters such as batting and hitting. All players for the 2010 to 2011 season underwent normal preseason physicals and baseline testing that is standard for the University of Cincinnati Athletics Department. Standard vision training exercises were implemented 6 weeks before the start of the season. Results are reported as compared to the 2009 to 2010 season. Pre season conditioning was followed by a maintenance program during the season of vision training. The University of Cincinnati team batting average increased from 0.251 in 2010 to 0.285 in 2011 and the slugging percentage increased by 0.033. The rest of the Big East's slugging percentage fell over that same time frame 0.082. This produces a difference of 0.115 with 95% confidence interval (0.024, 0.206). As with the batting average, the change for University of Cincinnati is significantly different from the rest of the Big East (p = 0.02). Essentially all batting parameters improved by 10% or more. Similar differences were seen when restricting the analysis to games within the Big East conference. Vision training can combine traditional and technological methodologies to train the athletes' eyes and improve batting. Vision training as part of conditioning or injury prevention can be applied and may improve batting performance in college baseball players. High performance vision training can be instituted in the pre-season and maintained throughout the season to improve batting parameters.
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