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Development of a Concussion Assessment Instrument DEVELOPMENT OF A CONCUSSION ASSESSMENT INSTRUMENT FOR THE SOUTH KOREAN SOLDIERS by Junbae Mun A Dissertation Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy in Human Performance Middle Tennessee State University December 2017 Dissertation Committee: Dr. Minsoo Kang, Chair Dr. Norman L. Weatherby Dr. Ying Jin I dedicate this dissertation to my wife, Wonwoo Choi, for her endless love, sacrifice, and support. ii ACKNOWLEDGEMENTS Thank you to God for your endless love and guidance, thank you to my lovely wife (Wonwoo Choi) and my children (Samuel Mun and Hyungyeom Mun) for being my family, thank you to Dr. Minsoo Kang and Dr. Brian Ragan for their never ending support, patience, and consideration during last four years, thank you to Dr. Norman L. Weatherby, and Dr. Ying Jin for being on my committee and their support, and thank you to members of Kinesmetrics laboratory (Youngdeok Kim, James Farnsworth, Heontae Kim, and Seungho Ryu) for their great help. iii ABSTRACT The purpose of this study was to develop and validate a practical concussion evaluation tool for the South Korean soldiers (SKS). This study was conducted in two phases. For phase 1, the English version of the current standardized assessment of concussion (SAC) was adapted for SKS by modifying and adding some items for resolving psychometric issues and considering cultural and linguistic equivalences, which led to develop the Korean version of the adapted SAC (K-SAC). The psychometric properties of the K-SAC were evaluated using an advanced measurement theory of Rasch model in a sample of healthy young adults without concussive injury. For phase 2, K-SAC was administered three times (i.e., baseline, time of injury, and after 48 hours) for the concussion and non-concussion groups, and the data collected was analyzed using a two-way repeated measured ANOVA to evaluate the validity of K-SAC in concussion assessment. The results of phase 1 indicated that the developed K- SAC has sound psychometric properties at baseline evaluation of cognitive function in the target population. All items of K-SAC were properly contributed to measure cognitive function level of the sample. There was no ceiling effect on the K-SAC scores. The item difficulties of K-SAC covered all range of participants’ cognitive function levels, ranging from very easy to very difficult. The results of phase 2 demonstrated that the K-SAC also has a good validity for concussion assessment. There were significant mean differences in K-SAC scores between concussion and non-concussion groups at time of injury and no iv differences at baseline and after 48 hours. In concussion group, K-SAC score at time of concussion was significantly different when compared to the scores at baseline and after 48 hours. The findings of this study supports that the K-SAC can be a potential field concussion evaluation instrument for SKS. Further research will be required to validate K-SAC and improve generalizability of K- SAC in various settings and populations. v TABLE OF CONTENTS LIST OF TABLES ........................................................................................... viii LIST OF FIGURES ...........................................................................................ix LIST OF APPENDICES .................................................................................... x CHAPTER 1: INTRODUCTION ........................................................................ 1 Background ................................................................................................. 1 Purpose of This Study ................................................................................. 7 Research Hypotheses ................................................................................. 8 Significance of This Study ........................................................................... 8 Limitations ................................................................................................... 9 CHAPTER 2: LITERATURE REVIEW ............................................................ 10 Concussion ............................................................................................... 10 Concussion Assessment Tools ................................................................. 21 Measurement Issues in Concussion Evaluation ........................................ 39 Methods to Evaluate Psychometric Properties .......................................... 48 Translation ................................................................................................ 59 vi CHAPTER 3: METHODS ................................................................................ 65 Phase 1 ..................................................................................................... 65 Phase 2 ..................................................................................................... 71 CHAPTER 4: RESULTS ................................................................................. 75 Psychometric Properties of the K-SAC (Phase 1) ..................................... 75 Validity of K-SAC in Concussion Assessment (Phase 2) .......................... 87 CHAPTER 5: DISCUSSION ........................................................................... 94 Psychometric Properties of the K-SAC (Phase 1) ..................................... 94 Validity of K-SAC in Concussion Assessment (Phase 2) ........................ 100 Limitations ............................................................................................... 104 Directions for Future Research ............................................................... 105 CHAPTER 6: CONCLUSIONS ..................................................................... 108 REFERENCES .............................................................................................. 110 APPENDICES ............................................................................................... 124 vii LIST OF TABLES Table 1. Definitions of Concussion .................................................................. 12 Table 2. Acute Symptoms and Signs of Concussion ....................................... 16 Table 3. Sideline/field Assessment Tools of Concussion ................................ 38 Table 4. Participants Characteristics in Phase 1 ............................................. 77 Table 5. Summary of K-SAC Items in Phase 1 ............................................... 82 Table 6. Participants Characteristics in Phase 2 ............................................. 88 Table 7. Symptoms & Sign of Concussion in Concussed Groupa ................... 88 Table 8. Descriptive Statistics for K-SAC Total Scores at Each Assessment .. 91 Table 9. Sidak Pairwise Comparisons for SAC Total Scores among Assessments in Concussed and Non-concussed Groups ............................... 92 viii LIST OF FIGURES Figure 1. A Case of Meeting Assumptions for Use of Individual-centered Standard.......................................................................................................... 43 Figure 2. A Case of Violating Assumptions for Use of Individual-centered Standard.......................................................................................................... 45 Figure 3. Item Characteristic Curve ................................................................. 57 Figure 4. Item Difficulty ................................................................................... 58 Figure 5. Histogram of K-SAC Total Scores .................................................... 79 Figure 6. Normal Q-Q Plot of the K-SAC Total Scores .................................... 80 Figure 7. Item - Person Distribution Map ......................................................... 86 Figure 8. K-SAC Total Scores at Baseline, Time of Concussion, and After 48 Hours for Concussed and Non-concussed Groups ......................................... 93 ix LIST OF APPENDICES APPENDIX A: IRB Approval for Phase 1 ...................................................... 125 APPENDIX B: IRB Approval for Phase 2 ...................................................... 127 APPENDIX C: Recruitment Script for Phase 1 (English & Korean) ............... 129 APPENDIX D: Recruitment Script for Phase 2 (English & Korean) ............... 131 APPENDIX E: Informed Consent for Phase 1 (English & Korean) ................ 133 APPENDIX F: Informed Consent for Phase 2 (English & Korean) ................ 137 APPENDIX G: Injury History Form (English & Korean) ................................. 141 APPENDIX H: Korean Version of the Adapted SAC (English & Korean) ...... 143 APPENDIX I: Official Approval Electronic Document from Korea Military Academy (English & Korean) ........................................................................ 147 APPENDIX J: Original Version of Standardized Assessment of Concussion 149 x 1 CHAPTER 1 INTRODUCTION Background Concussion has been prevalent in the military setting. Concussion is a transient alteration in brain function induced by direct or indirect traumatic and biomechanical forces to the head.4, 5, 6, 7, 8 Concussion represents the less severe end of the continuum of traumatic brain injury (TBI).2, 8, 22 The concussion rate within the US military has been increased and increase in this rate of concussion accounts for most of the increase in overall TBI rate. According to Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), Department of Defense (DOD),
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