It’s a long way from Boston to Denver — 5 Questions with David Howell

David Howell, alongside one of many of the research posters he has produced

When I now think of my friend, David Howell, I have this beautiful John Denver song in my head:

It’s a long way from LA to Denver
It’s a long time to hang in the sky
It’s a long way home to Starwood in Aspen
A sweet Rocky Mountain paradise
Oh, my sweet Rocky Mountain paradise

Granted, David just moved to Denver from Boston, not LA, but I can’t separate the melody from his journey, and the visions I have of him hanging out in the Rockies…..

David Howell PhD, ATC–and the team of researchers with whom he most recently worked at Children’s Hospital, Boston–has been one of the more prolific authors for CJSM in the last several years.  This summer, he moved to Children’s Hospital, Colorado, where he continues the pioneering research into kids’ sports safety that has been the hallmark of his career.

As lead author of two recently published CJSM studies, he was a natural interview for this, our most recent blog post and contribution to the recurring “5 Questions with CJSM” column.

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1) CJSM just published your new study, “Near Point of Convergence and Gait Deficits in Adolescents after Sport-Related Concussion.”  What would you state are the most important, new contributions to the literature your team made with this study?  And are there specific take-home points that the practicing clinician can use in their assessment of concussed teenagers?

DH: The idea of combining visual and gait-based measures in patients with a concussion was a result of an interdisciplinary collaboration. I was fortunate to work alongside colleagues from optometry/ophthalmology (Aparna Raghuram PhD, OD, and Ankoor Shah, MD, PhD) and sports medicine (William Meehan, MD and Michael O’Brien, MD) on this study. Based on our discussions, we were interested in the value and association of instrumented gait measures and vergence measures, since both have documented value for use within concussion evaluations. Additionally, both tests were relatively easy to administer within the sport concussion clinic at Boston Children’s Hospital.

Dual-task gait assessments, in particular, have been an interesting concept to me over the past several years. When pairing a motor and cognitive task simultaneously, we have observed that athletes demonstrate post-concussion deficits occur that (a) are undetectable if only using isolated motor or cognitive measures, (b) take longer to resolve than symptoms, and (c) reflect the demands of sport, since athletes must rely on both systems to move, think, perform, and avoid further injury. Since walking patterns are influenced by visual input, we hypothesized that there would be an association between visual and gait measurements.

The new contribution to the literature is that the patients with receded near point of convergence also demonstrated altered gait patterns, relative to a control group, while those without receded near point of convergence did not. This furthers our understanding that concussion affects multiple systems of the brain, but not uniformly among all individuals. The clinical takeaway for me is that objective and multimodal test protocols may help clinicians better identify deficits, leading to effective treatment pathways and individualized care. Specifically, we found value in gait and vergence measures due to their objectivity and ease of administration (the full evaluation takes about 5 minutes to conduct).

2) CJSM: You have been involved in some of the more interesting research we’ve seen on the subject of the diagnosis and management of concussion in youngsters.  What are some of the other recent projects you have worked on/published?

DH: Thanks for the compliment, Jim. I am fortunate to work with many talented and bright physicians and scientists across the country on this topic. Building on the concept of dual-task gait testing, we have been interested in translating our methods into clinically feasible, yet objective and useful protocols. Using the same assessment technology (an instrumented portable sensor system to measure gait patterns), we recently reported that measures of gait can have prognostic value. When tested within the first 10 days of a concussion, we found that those who had to slow down more to accommodate for a cognitive task while walking were more likely to go onto experience persistent symptoms (lasting more than 28 days).¹

David Howell, bringing home the PRISM blue ribbon

Our most recent work in CJSM focuses on translating objective gait measures into low-technology assessments (right now in e-pub ahead of print format),² where I was fortunate to work alongside researchers from Harvard (Bill Meehan) and the University of Delaware (Tom Buckley, Jessie Oldham, and Melissa DiFabio). We wanted to identify if an instrumented measure, such as gait speed, relates to a test that has ubiquitous application potential across a variety of sports medicine settings. We used the tandem gait test since it is a part of the SCAT5³ and all it takes to administer is a stopwatch or smartphone and a strip of 3-meter tape. We have also seen that dual-task tandem gait times take longer to recover than single-task tandem gait times after a concussion, suggesting the sensitivity of dual-task testing in monitoring post-concussion deficits (2017 PRISM Best Scientific Poster award winner).⁴ If instrumented gait and tandem gait measures were significantly associated, we hypothesized that the tandem gait test could serve as a proxy measure for an instrumented gait evaluation.

We tested a group of collegiate athletes at two sites: Harvard University and the University of Delaware. Our data indicated that dual-task tandem gait times were significantly associated with dual-task average walking speed, while controlling for potentially confounding variables, such as age, gender, height, sport type, or prior concussion history. We believe this finding suggests that dual-task tandem gait testing can be a method to evaluate dynamic postural control with a high level of impairment detection, but without the necessary technical and financial aspects required by other sophisticated testing techniques.

3) CJSM: Your study team has historically been composed of clinicians and researchers from the Boston area.  Rumor has it that you just moved to Colorado Children’s Hospital.  Tell us about your years working at Boston Children’s, and please tell us about what hopes and dreams you have for your years in Denver.

DH: Yes, it is true. As of September 1, I began work as the Lead Researcher for the Sports Medicine Center at Children’s Hospital Colorado and as Assistant Professor in the Department of Orthopedics at the University of Colorado School of Medicine, in Aurora, CO. I spent 3 wonderful years working as a post-doctoral fellow at Boston Children’s Hospital and the value of those years for my development as scientist cannot be measured. I worked (and still continue to work) under the mentorship of Bill Meehan, a name many of your readers are likely familiar with. In addition, I had the pleasure of working with many talented clinicians and scientists who have published studies in CJSM: Dai Sugimoto, Andrea Stracciolini, Pierre D’Hemecourt, Michael O’Brien, Rebekah Mannix, and Lyle Micheli to name a few. During my time there, I gained invaluable insights into clinical research, and how to design and implement studies that address a key need for clinicians while maintaining a high level of scientific rigor. Through my experiences there, I also developed wonderful collaborative relationships with many others throughout the country and around the world. I am hopeful that the work started in Boston will continue and help to advance our collective knowledge on ways we can improve concussion assessment, management and treatment.

My new job at Children’s Hospital Colorado is fantastic- in many ways this is the type of work I hope to be doing for the rest of my career. Among our Sports Medicine Center personnel, we have several talented physicians and researchers working to address gaps in the literature on a multitude of different sports medicine topics. While I have high hopes and expansive dreams of what we will continue to build here, I’ll save your readers some time. Simply put, we hope to establish a line of sports medicine research that consistently helps to advance the clinical care of youth athletes. We certainly hope that our work continues to show up on the pages of CJSM for years to come!

4) CJSM: We know you are on Twitter (@HowellDR) – can you compose a Tweet telling us about your initial impressions of your new home in Colorado?

Indeed, Twitter has become a fun place to share ideas, learn about work from collaborators, or discover new ideas and people. Although I am not, and will likely never be, as active as you are, I enjoy it. In 140 characters or less (as you can tell, I’m a bit long-winded so this is tough):

“My new home at Children’s Hospital Colorado combines the best of everything: great people, top-notch research, and easy mountain access!” (CJSM: 4 characters to spare — you are a Twitter pro, David!)

5) CJSM: We last saw you at PRISM, which takes place this year in Ft. Lauderdale FLA in Jan 2018.  We’ll be there – will you?  If so, can you give us a brief ‘spoiler alert’ about what you may be presenting?

DH: Yes, I will definitely be there. This is one conference I always look forward to attending. Given the multi-disciplinary focus, I always walk away with a new perspective on a variety of topics.  Plus, in my (biased) opinion, there is a high volume of quality people there, which always makes for a good time.

During the conference, I will be presenting some collaborative work between Boston Children’s Hospital and Cincinnati Children’s Hospital Medical Center. My presentation will focus on how integrated assessments of neurophysiological and functional performance can help quantify injury severity and prognosis following concussion diagnosis in youth athletes. This will build on some of the work I’ve explained here, so I’m looking forward to discussing with conference attendees while there.

Looking forward to seeing you in Fort Lauderdale!

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Enjoy your ‘sweet, Rocky Mountain paradise,’ David — we’re looking forward to catching up with you in Ft. Lauderdale in January.

References

1          Howell DR, Brilliant A, Berkstresser B, et al. The association between dual-task gait after concussion and prolonged symptom duration. J Neurotrauma. 2017.

2          Howell DR, Oldham JR, Meehan WP, et al. Dual-Task Tandem Gait and Average Walking Speed in Healthy Collegiate Athletes. Clin J Sport Med Off J Can Acad Sport Med. 2017. Doi: 10.1097/JSM.0000000000000509.

3          Echemendia RJ, Meeuwisse W, McCrory P, et al. The Sport Concussion Assessment Tool 5th Edition (SCAT5). Br J Sports Med. 2017. Doi: 10.1136/bjsports-2017-097506.

4          Howell DR, Osternig LR, Chou L-S. Single-task and dual-task tandem gait test performance after concussion. J Sci Med Sport. 2017;20:622–626. Doi: http://dx.doi.org/10.1016/j.jsams.2016.11.020.