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Test Order Does Not Affect Vestibular/Ocular Motor Screening Item Scores in High School Athletes. Clin J Sport Med 2021; 31:e240-e244. [PMID: 31842048 DOI: 10.1097/jsm.0000000000000776] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 06/19/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare VOMS item scores between a fixed and randomized administration order in a sample of nonconcussed high school athletes. DESIGN Post-test only, quasi-experimental design. SETTING Local high schools in a mid-west region of the United States. PATIENTS Fifty nonconcussed high school athletes (M = 15.64; SD = 1.12 years) completed the VOMS in a randomized testing order (RANDOM), and 49 (M = 15.64; SD = 1.12 years) completed the VOMS in the fixed testing order (FIXED). The groups were matched on age, sex, learning disorder, attention-deficit/hyperactivity disorder, concussion history, and baseline concussion symptoms. INTERVENTIONS The Vestibular/Ocular Motor Screening (VOMS) tool comprises pretest symptoms, smooth pursuit (SP), horizontal/vertical saccade (HSAC/VSAC), average near-point of convergence (NPC) distance, convergence symptoms, horizontal/vertical vestibular ocular reflex (HVOR/VVOR), and visual motion sensitivity (VMS). MAIN OUTCOME MEASURES Mann-Whitney U tests were performed to examine differences between FIXED and RANDOM groups on VOMS items. RANDOM scores were rearranged in order of administration and combined with the FIXED group scores, and a Freidman test was performed for repeated measures. RESULTS There were no significant differences between FIXED and RANDOM groups on VOMS pretest symptoms (U = 1171, P = 0.57), SP (U = 1122.5, P = 0.35), HSAC (U = 1128.5, P = 0.44), VSAC (U = 1055.5, P = 0.16), convergence symptoms (U = 1129.0, P = 0.41), average NPC distance (U = 979.0, P = 0.06), HVOR (U = 1085.0, P = 0.25), VVOR (U = 1126.0, P = 0.41), and VMS scores (U = 1101.0, P = 0.32). When VOMS items were rearranged and the sample was combined, there were no differences for repeated measures [χ2 (6) = 9.92, P = 0.13]. CONCLUSIONS There were no significant differences on VOMS items between FIXED and RANDOM groups for repeated measures. The testing order of VOMS items does not affect VOMS scores in nonconcussed high school athletes.
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Symons GF, Clough M, Fielding J, O'Brien WT, Shepherd CE, Wright DK, Shultz SR. The Neurological Consequences of Engaging in Australian Collision Sports. J Neurotrauma 2021; 37:792-809. [PMID: 32056505 DOI: 10.1089/neu.2019.6884] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Collision sports are an integral part of Australian culture. The most common collision sports in Australia are Australian rules football, rugby union, and rugby league. Each of these sports often results in participants sustaining mild brain traumas, such as concussive and subconcussive injuries. However, the majority of previous studies and reviews pertaining to the neurological implications of sustaining mild brain traumas, while engaging in collision sports, have focused on those popular in North America and Europe. As part of this 2020 International Neurotrauma Symposium special issue, which highlights Australian neurotrauma research, this article will therefore review the burden of mild brain traumas in Australian collision sports athletes. Specifically, this review will first provide an overview of the consequences of mild brain trauma in Australian collision sports, followed by a summary of the previous studies that have investigated neurocognition, ocular motor function, neuroimaging, and fluid biomarkers, as well as neuropathological outcomes in Australian collision sports athletes. A review of the literature indicates that although Australians have contributed to the field, several knowledge gaps and limitations currently exist. These include important questions related to sex differences, the identification and implementation of blood and imaging biomarkers, the need for consistent study designs and common data elements, as well as more multi-modal studies. We conclude that although Australia has had an active history of investigating the neurological impact of collision sports participation, further research is clearly needed to better understand these consequences in Australian athletes and how they can be mitigated.
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Affiliation(s)
- Georgia F Symons
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Meaghan Clough
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Joanne Fielding
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - William T O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Claire E Shepherd
- Neuroscience Research Australia, The University of New South Wales, Sydney, New South Wales, Australia
| | - David K Wright
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Sandy R Shultz
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
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Rodriguez AI, Chiao J, Spencer G. Vestibular-Evoked Myogenic Potential Outcomes Associated with Pediatric Sports-Related Concussion. Laryngoscope 2021; 132:436-442. [PMID: 34363397 DOI: 10.1002/lary.29803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/13/2021] [Accepted: 07/27/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVES/HYPOTHESIS To 1) characterize vestibular-evoked myogenic potential responses in children and young adults with sports-related concussion (SRC) histories as compared with a normal healthy control group, and 2) correlate VEMP characteristics to SRC/sport history outcomes. STUDY DESIGN Prospective cohort study. METHODS Seventy-six children and young adults with and without a history of SRC received cervical and ocular VEMP testing using a 500 Hz tone burst air conduction stimuli. VEMP response parameters (response rates, peak latencies, and peak-to-peak amplitudes) were assessed. Other clinical vestibular measures were performed. In the SRC group, sport history outcomes including number of SRC sustained over a lifetime, years of playing contact sports, and length of time playing contact sports were collected via in-person questionnaire. RESULTS Children and young adults with SRC had significantly reduced oVEMP responses and peak-to-peak amplitudes and greater amplitude response asymmetries between left and right ear. There was no effect of group on cVEMP findings. A greater frequency of SRCs sustained throughout a lifetime, a greater number of contact sports played, and a longer duration of playing a contact sport correlated with significantly poorer VEMP response characteristics. CONCLUSIONS Our results suggest that SRC and repeated subclinical head impact events have an effect on oVEMP outcomes. SRC may affect the utricle, superior vestibular nerve, and/or brainstem-mediated vestibular-ocular-reflex pathway. The prevalence of post-concussion-related dizziness is becoming increasingly common in a pediatric-otology clinic, thus performing VEMP testing in youth post-SRC provides an objective, noninvasive, and cost-effective method for monitoring the effects of sports-related impact on the vestibular system and related neural pathways. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Amanda I Rodriguez
- Department of Special Education and Communication Disorders, University of Nebraska-Lincoln, Lincoln, Nebraska, U.S.A
| | - Jonathan Chiao
- Department of Otolaryngology - Head and Neck Surgery, University of Nebraska Medical Center, Omaha, Nebraska, U.S.A.,Bobby R. Alford Department of Otolaryngology - Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A.,Division of Pediatric Otolaryngology, Texas Children's Hospital, Houston, Texas, U.S.A
| | - Gretchen Spencer
- Department of Special Education and Communication Disorders, University of Nebraska-Lincoln, Lincoln, Nebraska, U.S.A
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Cochrane GD, Christy JB, Almutairi A, Busettini C, van Heyningen HKK, Weise KK, Swanson MW, Gould SJ. Vestibular, Oculomotor, and Balance Functions in Children With and Without Concussion. J Head Trauma Rehabil 2021; 36:264-273. [PMID: 33656474 PMCID: PMC8249322 DOI: 10.1097/htr.0000000000000651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The main objective of this study was to assess whether objective vestibular, oculomotor, and balance functions were impaired in children with a current diagnosis of concussion with vestibular and/or ocular symptoms. SETTING Data were collected in a vestibular/ocular clinical laboratory. Patient participants were recruited from a concussion clinic in a children's hospital. PARTICIPANTS Thirty-three children aged 8 to 17 years with a current diagnosis of concussion and vestibular and/or ocular symptoms and 30 children without concussion. DESIGN Cross-sectional single-visit study. MAIN OUTCOME MEASURES Eye-tracking rotary chair oculomotor and vestibular measures, vestibular evoked potentials, and static posturography. RESULTS There were no statistically significant differences on any clinical measure between children with concussion and children without concussion. Younger children without concussion performed significantly worse on several rotary chair and balance measures compared with older children without concussion. CONCLUSIONS No vestibular, oculomotor, or balance measures were significantly different between children with concussion and children without concussion, suggesting these measures may not be useful in the evaluation of a child with concussion and vestibular and/or oculomotor symptoms. Future research should investigate age effects and other vestibular and oculomotor tests to identify objective findings that better relate to vestibular and/or ocular symptoms in children with concussion.
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Affiliation(s)
- Graham D. Cochrane
- Medical Scientist Training Program, School of Medicine, University of Alabama at Birmingham
- Department of Physical Therapy, School of Health Professions, University of Alabama at Birmingham
| | - Jennifer B. Christy
- Department of Physical Therapy, School of Health Professions, University of Alabama at Birmingham
| | - Anwar Almutairi
- Department of Physical Therapy, Allied Health Sciences Center, Kuwait University
| | | | | | | | | | - Sara J. Gould
- Concussion Clinic, Children’s of Alabama
- Division of Orthopedics, Department of Surgery, University of Alabama at Birmingham
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55
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Kontos AP, Eagle SR, Marchetti G, Sinnott A, Mucha A, Port N, Ferris LM, Elbin RJ, Clugston JR, Ortega J, Broglio SP, McAllister T, McCrea M, Pasquina P, Brooks A, Buckley T, Mihalik J, Miles C, Collins MW. Discriminative Validity of Vestibular Ocular Motor Screening in Identifying Concussion Among Collegiate Athletes: A National Collegiate Athletic Association-Department of Defense Concussion Assessment, Research, and Education Consortium Study. Am J Sports Med 2021; 49:2211-2217. [PMID: 33979240 DOI: 10.1177/03635465211012359] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Vestibular and ocular motor screening tools, such as the Vestibular/Ocular Motor Screening (VOMS), are recognized as important components of a multifaceted evaluation of sport-related concussion. Previous research has supported the predictive utility of the VOMS in identifying concussion, but researchers have yet to examine the predictive utility of the VOMS among collegiate athletes in the first few days after injury. PURPOSE To determine the discriminative validity of individual VOMS item scores and an overall VOMS score for identifying collegiate athletes with an acute sport-related concussion (≤72 hours) from healthy controls matched by age, sex, and concussion history. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Participants (N = 570) aged 17 to 25 years were included from 8 institutions of the National Collegiate Athletic Association-Department of Defense CARE Consortium (Concussion Assessment, Research, and Education): 285 athletes who were concussed (per current consensus guidelines) and 285 healthy controls matched by age, sex, and concussion history. Participants completed the VOMS within 3 days of injury (concussion) or during preseason (ie, baseline; control). Symptoms are totaled for each VOMS item for an item score (maximum, 40) and totaled across items for an overall score (maximum, 280), and distance (centimeters) for near point of convergence (NPC) is averaged across 3 trials. Receiver operating characteristic analysis of the area under the curve (AUC) was performed on cutoff scores using Youden index (J) for each VOMS item, overall VOMS score, and NPC distance average. A logistic regression was conducted to identify which VOMS scores identified concussed status. RESULTS A symptom score ≥1 on each VOMS item and horizontal vestibular/ocular reflex ≥2 significantly discriminated concussion from control (AUC, 0.89-0.90). NPC distance did not significantly identify concussion from control (AUC, 0.51). The VOMS overall score had the highest accuracy (AUC, 0.91) for identifying sport-related concussion from control. Among the individual items, vertical saccades ≥1 and horizontal vestibular/ocular reflex ≥2 best discriminated concussion from control. CONCLUSION The findings indicate that individual VOMS items and overall VOMS scores are useful in identifying concussion in collegiate athletes within 3 days of injury. Clinicians can use the cutoffs from this study to help identify concussion in collegiate athletes.
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Affiliation(s)
- Anthony P Kontos
- Department of Orthopedic Surgery, UPMC Sports Medicine Concussion Program, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shawn R Eagle
- Department of Orthopedic Surgery, UPMC Sports Medicine Concussion Program, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gregory Marchetti
- Duquesne University, Pittsburgh, Pennsylvania, USA.,Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Aaron Sinnott
- Department of Orthopedic Surgery, UPMC Sports Medicine Concussion Program, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anne Mucha
- Department of Orthopedic Surgery, UPMC Sports Medicine Concussion Program, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nicholas Port
- Indiana University, Bloomington, Indiana, USA.,Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lyndsey M Ferris
- Indiana University, Bloomington, Indiana, USA.,Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - R J Elbin
- University of Arkansas, Fayetteville, Arkansas, USA.,Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James R Clugston
- University of Florida, Gainesville, Florida, USA.,Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Justus Ortega
- Humboldt State University, Arcata, California, USA.,Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Steven P Broglio
- University of Michigan, Ann Arbor, Michigan, USA.,Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Thomas McAllister
- Indiana University, Indianapolis, Indiana, USA.,Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael McCrea
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Paul Pasquina
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.,Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | -
- Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alison Brooks
- University of Wisconsin, Madison, Wisconsin, USA.,Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Thomas Buckley
- University of Delaware, Newark, Delaware, USA.,Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jason Mihalik
- University of North Carolina, Chapel Hill, North Carolina, USA.,Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christopher Miles
- Wake Forest University, Winston-Salem, North Carolina, USA.,Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael W Collins
- Department of Orthopedic Surgery, UPMC Sports Medicine Concussion Program, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Investigation performed at University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Corwin DJ, Grady MF, Master CL, Joffe MD, Zonfrillo MR. Evaluation and Management of Pediatric Concussion in the Acute Setting. Pediatr Emerg Care 2021; 37:371-379. [PMID: 34180858 DOI: 10.1097/pec.0000000000002498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Concussion, a type of mild traumatic brain injury, is a common injury encountered by providers caring for pediatric patients in the emergency department (ED) setting. Our understanding of the pathophysiologic basis for symptom and recovery trajectories for pediatric concussion continues to rapidly evolve. As this understanding changes, so do recommendations for optimal management of concussed youth. As more and more children present to EDs across the country for concussion, it is imperative that providers caring for children in these settings remain up-to-date with diagnostic recommendations and management techniques. This article will review the definition, epidemiology, pathophysiology, diagnosis, and management of pediatric concussion in the ED setting.
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Affiliation(s)
- Daniel J Corwin
- From the Attending Physician, Division of Emergency Medicine, Children's Hospital of Philadelphia
| | - Matthew F Grady
- Attending Physician, Sports Medicine and Performance Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christina L Master
- Attending Physician, Sports Medicine and Performance Center, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mark D Joffe
- From the Attending Physician, Division of Emergency Medicine, Children's Hospital of Philadelphia
| | - Mark R Zonfrillo
- Attending Physician, Departments of Emergency Medicine and Pediatrics, Alpert Medical School of Brown University and Hasbro Children's Hospital, Providence, RI
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57
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Iverson GL, Cook NE, Howell DR, Collings LJ, Kusch C, Sun J, Virji-Babul N, Panenka WJ. Preseason Vestibular Ocular Motor Screening in Children and Adolescents. Clin J Sport Med 2021; 31:e188-e192. [PMID: 31233433 DOI: 10.1097/jsm.0000000000000767] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 05/07/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The primary purpose of this study was to examine vestibular/ocular motor screening (VOMS) test performance in a sample of healthy youth ice hockey players. A particular focus was to investigate the potential effects of age and pre-existing health conditions, including concussion history, attention-deficit/hyperactivity disorder (ADHD), learning disability (LD), headaches/migraines, and depression/anxiety on preseason baseline VOMS performance, including the near point of convergence (NPC) distance. DESIGN Cross-sectional cohort. SETTING Outpatient physiotherapy clinic. PARTICIPANTS Three hundred eighty-seven male youth hockey players, with an average age of 11.9 years (SD = 2.2, range = 8-17), completed the VOMS and responded to self- or parent-reported demographic and medical history questionnaires during preseason baseline assessments. INDEPENDENT VARIABLES ASSESSED Age, sex, and mental and physical health history including ADHD, headaches, depression, anxiety, migraine, and LD. OUTCOME MEASURE Vestibular/ocular motor screening. RESULTS The large majority of boys scored within normal limits on the VOMS, ie, they reported no symptom provocation of more than 2 points on any VOMS subset (89%) and had a normal NPC distance, ie, <5 cm (78%). The individual VOMS subtests had low abnormality rates, and demographic and pre-existing health conditions, such as age, headache or migraine history, previous neurodevelopmental conditions, or mental health problems, were not associated with clinically meaningful symptom provocation during the VOMS. CONCLUSIONS There was a low rate of abnormal findings for the individual VOMS subtests, with the exception of NPC distance, among male youth hockey players during preseason assessment.
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Affiliation(s)
- Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
- Spaulding Rehabilitation Hospital and Spaulding Rehabilitation Institute, Charlestown, Massachusetts
- MassGeneral Hospital for Children Sport Concussion Program, Boston, Massachusetts
- Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Charlestown, Massachusetts
| | - Nathan E Cook
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
- Spaulding Rehabilitation Hospital and Spaulding Rehabilitation Institute, Charlestown, Massachusetts
- MassGeneral Hospital for Children Sport Concussion Program, Boston, Massachusetts
| | - David R Howell
- Department of Orthopedics, University of Colorado School of Medicine, Sports Medicine Center, Children's Hospital Colorado, Aurora, Colorado
| | - Laurel J Collings
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
- British Columbia Mental Health and Addictions Research Institute, Vancouver, BC, Canada
| | - Cody Kusch
- Seafair Minor Hockey Association, Richmond, BC, Canada
| | | | - Naznin Virji-Babul
- British Columbia Mental Health and Addictions Research Institute, Vancouver, BC, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, Vancouver, BC, Canada ; and
| | - William J Panenka
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
- British Columbia Mental Health and Addictions Research Institute, Vancouver, BC, Canada
- British Columbia Provincial Neuropsychiatry Program, Vancouver Coastal Health, University of British Columbia, Vancouver, BC, Canada
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Archbold P, Rankin AT, Webb M, Davies R, Nicholas R, Eames NWA, Wilson RK, Vincent J, McKeever D, Duddy K, Matthews M, Bleakley C. Injury patterns in U15 rugby players in Ulster schools: A Rugby Injury Surveillance (RISUS) Study. TRANSLATIONAL SPORTS MEDICINE 2021. [DOI: 10.1002/tsm2.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Sherry NS, Fazio-Sumrok V, Sufrinko A, Collins MW, Kontos AP. Multimodal Assessment of Sport-Related Concussion. Clin J Sport Med 2021; 31:244-249. [PMID: 30908330 PMCID: PMC6751034 DOI: 10.1097/jsm.0000000000000740] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 02/09/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The purpose of this study was to determine which assessments best identify athletes with sport-related concussion (SRC) from healthy controls in the acute/early subacute phase (within 10 days of SRC) of injury. DESIGN Prospective, cohort study. SETTING Specialty concussion clinic. PARTICIPANTS Sixty-four athletes with SRC (52% male) and 59 matched (age and sex), healthy controls (56% male) aged 12 to 20 years (Mean [M] = 15.07, Standard Deviation [SD] = 2.23). ASSESSMENT Participants completed symptom, cognitive, vestibular/oculomotor, near point of convergence (NPC), and balance assessments. MAIN OUTCOME MEASURES Univariate analyses were conducted to compare athletes with SRC to healthy controls across all assessments. Assessments that significantly differed between the SRC group and healthy controls were used as predictors in an enter method logistic regression (LR) model and subsequent forward stepwise LR. RESULTS Results of LR analyses indicated that symptom inventory and symptom provocation on vestibular/oculomotor assessments significantly predicted athletes with SRC versus controls. The forward stepwise LR accurately classified 84.6% of the overall sample (78.3% of athletes with SRC and 91.2% of controls were accurately predicted) and accounted for 60.5% of the variance in predicting athletes with SRC versus controls. Total symptom inventory score (P = 0.003) and vestibular/oculomotor symptom provocation (P < 0.01) were the most sensitive and specific measures in a comprehensive, multimodal assessment for distinguishing athletes with SRC from healthy controls within 10 days of injury. CONCLUSIONS Elements within a multimodal evaluation that are the most robust at discriminating athletes with SRC from healthy controls in the acute/early subacute phase of injury include symptom report and provocation of symptoms on vestibular/oculomotor assessment. These assessments should be considered in conjunction with other objective assessments (ie, NPC measurement and cognitive testing) as part of a comprehensive evaluation of SRC.
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Affiliation(s)
- Natalie Sandel Sherry
- UPMC Sports Medicine Concussion Program, Pittsburgh, PA
- University of Pittsburgh – Department of Orthopaedic Surgery, Pittsburgh, PA
| | - Vanessa Fazio-Sumrok
- UPMC Sports Medicine Concussion Program, Pittsburgh, PA
- University of Pittsburgh – Department of Orthopaedic Surgery, Pittsburgh, PA
| | - Alicia Sufrinko
- UPMC Sports Medicine Concussion Program, Pittsburgh, PA
- University of Pittsburgh – Department of Orthopaedic Surgery, Pittsburgh, PA
| | - Michael W. Collins
- UPMC Sports Medicine Concussion Program, Pittsburgh, PA
- University of Pittsburgh – Department of Orthopaedic Surgery, Pittsburgh, PA
| | - Anthony P. Kontos
- UPMC Sports Medicine Concussion Program, Pittsburgh, PA
- University of Pittsburgh – Department of Orthopaedic Surgery, Pittsburgh, PA
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Allen JW, Trofimova A, Ahluwalia V, Smith JL, Abidi SA, Peters MAK, Rajananda S, Hurtado JE, Gore RK. Altered Processing of Complex Visual Stimuli in Patients with Postconcussive Visual Motion Sensitivity. AJNR Am J Neuroradiol 2021; 42:930-937. [PMID: 33574098 DOI: 10.3174/ajnr.a7007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/16/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Vestibular symptoms are common after concussion. Vestibular Ocular Motor Screening identifies vestibular impairment, including postconcussive visual motion sensitivity, though the underlying functional brain alterations are not defined. We hypothesized that alterations in multisensory processing are responsible for postconcussive visual motion sensitivity, are detectable on fMRI, and correlate with symptom severity. MATERIALS AND METHODS Twelve patients with subacute postconcussive visual motion sensitivity and 10 healthy control subjects underwent vestibular testing and a novel fMRI visual-vestibular paradigm including 30-second "neutral" or "provocative" videos. The presence of symptoms/intensity was rated immediately after each video. fMRI group-level analysis was performed for a "provocative-neutral" condition. Z-statistic images were nonparametrically thresholded using clusters determined by Z > 2.3 and a corrected cluster significance threshold of P = .05. Symptoms assessed on Vestibular Ocular Motor Screening were correlated with fMRI mean parameter estimates using Pearson correlation coefficients. RESULTS Subjects with postconcussive visual motion sensitivity had significantly more Vestibular Ocular Motor Screening abnormalities and increased symptoms while viewing provocative videos. While robust mean activation in the primary and secondary visual areas, the parietal lobe, parietoinsular vestibular cortex, and cingulate gyrus was seen in both groups, selective increased activation was seen in subjects with postconcussive visual motion sensitivity in the primary vestibular/adjacent cortex and inferior frontal gyrus, which are putative multisensory visual-vestibular processing centers. Moderate-to-strong correlations were found between Vestibular Ocular Motor Screening scores and fMRI activation in the left frontal eye field, left middle temporal visual area, and right posterior hippocampus. CONCLUSIONS Increased fMRI brain activation in visual-vestibular multisensory processing regions is selectively seen in patients with postconcussive visual motion sensitivity and is correlated with Vestibular Ocular Motor Screening symptom severity, suggesting that increased visual input weighting into the vestibular network may underlie postconcussive visual motion sensitivity.
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Affiliation(s)
- J W Allen
- From the Department of Radiology and Imaging Sciences (J.W.A., A.T., J.L.S.), Emory University, Atlanta, Georgia
- Department of Neurology (J.W.A.), Emory University, Atlanta, Georgia
- Wallace H. Coulter Department of Biomedical Engineering (J.W.A., R.K.G.), Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - A Trofimova
- From the Department of Radiology and Imaging Sciences (J.W.A., A.T., J.L.S.), Emory University, Atlanta, Georgia
| | - V Ahluwalia
- Georgia State University/Georgia Tech Center for Advanced Brain Imaging (V.A.), Atlanta, Georgia
| | - J L Smith
- From the Department of Radiology and Imaging Sciences (J.W.A., A.T., J.L.S.), Emory University, Atlanta, Georgia
| | - S A Abidi
- School of Medicine (S.A.A.), Emory University, Atlanta, Georgia
| | - M A K Peters
- Department of Bioengineering (M.A.K.P., S.R.), University of California, Riverside, Riverside, California
| | - S Rajananda
- Department of Bioengineering (M.A.K.P., S.R.), University of California, Riverside, Riverside, California
| | | | - R K Gore
- Wallace H. Coulter Department of Biomedical Engineering (J.W.A., R.K.G.), Georgia Institute of Technology and Emory University, Atlanta, Georgia
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Glendon K, Blenkinsop G, Belli A, Pain M. Does Vestibular-Ocular-Motor (VOM) Impairment Affect Time to Return to Play, Symptom Severity, Neurocognition and Academic Ability in Student-Athletes following acute Concussion? Brain Inj 2021; 35:788-797. [PMID: 33896286 DOI: 10.1080/02699052.2021.1911001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Research indicates Sports-Related Concussion (SRC) impairs Vestibular-Ocular-Motor (VOM) function. The aim was to explore if VOM impairment correlates with longer Return To Play (RTP), symptom burden, neurocognitive performance and academic capability.Participants: 40 (61.4% male) Loughborough University, UK, rugby union student-athletes who sustained 42 SRCs.Methods: Student-athletes completed an assessment battery during pre-season (baseline), 2, 4, 8 and 14 days post-SRC and prior to RTP and were managed according to the rugby Football Union' community pathway.Outcome measures: Vestibular Ocular-Motor Screening (VOMS), Immediate Post-Concussion Assessment and Cognitive Test, Post-Concussion Symptom Scale, Perceived Academic Impairment Tool questionnaire and percentage of academic activities specifically missed due to SRC.Results: VOMS scores were significantly (p < 0.005) greater than baseline at all time points except RTP. Presence of VOM dysfunction at 14 days post-SRC significantly correlated with a longer RTP, greater symptom burden and increased odds ratio at 2, 4 and 8 days and academic time loss at 2, 4 and 8 days post-SRC.Conclusion: VOM impairment is associated with an increased symptom burden and impaired academic capability, and a longer time to RTP when present at 14 days post-SRC.
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Affiliation(s)
- K Glendon
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - G Blenkinsop
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - A Belli
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - M Pain
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
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Elbin RJ, Eagle SR, Marchetti GF, Anderson M, Schatz P, Womble MN, Stephenson K, Covassin T, Collins MW, Mucha A, Kontos AP. Using change scores on the vestibular ocular motor screening (VOMS) tool to identify concussion in adolescents. APPLIED NEUROPSYCHOLOGY-CHILD 2021; 11:591-597. [PMID: 33896282 DOI: 10.1080/21622965.2021.1911806] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To develop clinical cutoffs using change scores for the VOMS individual items and an overall VOMS change score that identified concussion in adolescent athletes. METHODS Change score clinical cutoffs were calculated from a sample of adolescents (13-18 years) with SRC (n = 147) and a sample of uninjured adolescents CONTROL (n = 147). Receiver operating characteristic (ROC) curves, with area under the curve (AUC), based on Youden's J statistic were used to identify optimal cutoffs for identifying SRC from CONTROLS using VOMS individual item change scores, an overall VOMS change scores, and NPC distance (cm). RESULTS AUC values for VOMS item change scores ranged from .55 to .71. Optimal change score cutoffs were ≥1 for VOMS items and ≥3 for overall VOMS change score. The optimal cutoff for NPC distance was ≥3 cm. A ROC analysis revealed a three-factor model (AUC = .76) for identifying SRC that included vertical vesibular ocular reflex (VVOR), visual motion sensitivity (VMS), and NPC distance items. The AUC (.73) for the overall VOMS change score was higher than any individual VOMS AUC values. CONCLUSIONS This study supports an alternate scoring approach and clinical interpretation of VOMS items involving change scores that account for pretest symptoms.
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Affiliation(s)
- R J Elbin
- Department of Health, Human Performance and Recreation/Office for Sport Concussion Research, University of Arkansas, Fayetteville, Arkansas, USA
| | - Shawn R Eagle
- Department of Orthopaedic Surgery, UPMC Sports Medicine Concussion Program, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gregory F Marchetti
- Rangos School of Health Sciences, Duquesne University, Pittsburgh, Pennsylvania, USA
| | - Morgan Anderson
- Department of Kinesiology, Michigan State University, East Lansing, Michigan, USA
| | - Philip Schatz
- Department of Psychology, Saint Joseph's University, Philadelphia, Pennsylvania, USA
| | | | - Katie Stephenson
- Department of Health, Human Performance and Recreation/Office for Sport Concussion Research, University of Arkansas, Fayetteville, Arkansas, USA
| | - Tracey Covassin
- Department of Kinesiology, Michigan State University, East Lansing, Michigan, USA
| | - Michael W Collins
- Department of Orthopaedic Surgery, UPMC Sports Medicine Concussion Program, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anne Mucha
- Department of Orthopaedic Surgery, UPMC Sports Medicine Concussion Program, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anthony P Kontos
- Department of Orthopaedic Surgery, UPMC Sports Medicine Concussion Program, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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63
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McGeown JP, Kara S, Fulcher M, Crosswell H, Borotkanics R, Hume PA, Quarrie KL, Theadom A. Predicting Sport-related mTBI Symptom Resolution Trajectory Using Initial Clinical Assessment Findings: A Retrospective Cohort Study. Sports Med 2021; 50:1191-1202. [PMID: 31845203 DOI: 10.1007/s40279-019-01240-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To identify which aspects of initial clinical assessment for sport-related mild traumatic brain injury (SR-mTBI) predict whether an athlete achieves symptom resolution within 14 days of the injury. RESEARCH DESIGN Retrospective cohort study using prospectively collected data. METHODS Clinical assessment data were collected from 568 patients diagnosed with SR-mTBI at a single medical clinic between February 2017 and December 2018. Demographic data, medical history, SCAT-5 testing, and physician notes were included in the data set. Data were processed and analysed to identify a shortlist of predictor variables to develop a logistic regression model to discriminate between SR-mTBI symptom resolution that occurred in ≤ 14-days or > 14-days. The data were randomly divided into model development and validation subsamples. The top 15 models were analysed to determine the predictor variables to be included in the final logistic regression model. The final model was then applied to the validation subsample. RESULTS Half of the athlete participants in this study experienced > 14-day symptom resolution. The final logistic regression model included sex, symptom reporting at initial assessment and presentation with a physiological predominant symptom cluster. The model accounted for 0.90 and 0.85 of the area under the curve and predicted recovery trajectory with 81% and 76% accuracy for the training and validation subsamples, respectively. CONCLUSIONS Being female, reporting a higher Positive Symptom Total at initial assessment, and being less likely to have a physiological predominant symptom cluster at initial assessment predicted > 14 versus ≤ 14-day SR-mTBI symptom resolution with a high level of accuracy.
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Affiliation(s)
- Joshua P McGeown
- Faculty of Health and Environmental Science, Sports Performance Research Institute New Zealand (SPRINZ), Auckland University of Technology, Private Bag 92006, Auckland, 1142, New Zealand.
| | - Stephen Kara
- Axis Sports Medicine Clinic, Auckland, New Zealand
| | - Mark Fulcher
- Axis Sports Medicine Clinic, Auckland, New Zealand
| | | | - Robert Borotkanics
- Faculty of Health and Environmental Science, Sports Performance Research Institute New Zealand (SPRINZ), Auckland University of Technology, Private Bag 92006, Auckland, 1142, New Zealand
| | - Patria A Hume
- Faculty of Health and Environmental Science, Sports Performance Research Institute New Zealand (SPRINZ), Auckland University of Technology, Private Bag 92006, Auckland, 1142, New Zealand.,Faculty of Health and Environmental Science, National Institute of Stroke and Applied Neuroscience (NISAN), Auckland University of Technology, Auckland, New Zealand
| | - Kenneth L Quarrie
- Faculty of Health and Environmental Science, Sports Performance Research Institute New Zealand (SPRINZ), Auckland University of Technology, Private Bag 92006, Auckland, 1142, New Zealand.,New Zealand Rugby, 100 Molesworth Street, Wellington, New Zealand
| | - Alice Theadom
- Faculty of Health and Environmental Science, National Institute of Stroke and Applied Neuroscience (NISAN), Auckland University of Technology, Auckland, New Zealand
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Knell G, Caze T, Burkhart SO. Evaluation of the vestibular and ocular motor screening (VOMS) as a prognostic tool for protracted recovery following paediatric sports-related concussion. BMJ Open Sport Exerc Med 2021; 7:e000970. [PMID: 33868706 PMCID: PMC7996664 DOI: 10.1136/bmjsem-2020-000970] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2021] [Indexed: 12/02/2022] Open
Abstract
Objective To understand the relationship between initial vestibular and ocular motor screening (VOMS) and recovery time, and the utility of VOMS to screen for protracted recovery in youth/adolescent patients with sport-related concussion (SRC). Methods Participants (8–18 years) who were diagnosed with an SRC within 7 days of the injury were administered the VOMS test by certified medical personnel. Recovery time (days) and protracted recovery (>30 days) were the primary outcomes. Multivariable regression models were used to evaluate the association between VOMS symptom provocation and (1) recovery time (days) and (2) protracted recovery. Measures of VOMS validity, predictive ability and receiver operator curves were used to assess VOMS as a prognostic tool to accurately classify a normal/protracted recovery. Results After adjustment, any symptom provocation across all VOMS domains was associated (p<0.05) with greater recovery time, except the convergence test (p=0.08) in females. All VOMS test thresholds (≥1 to ≥10) in males and (≥1 to ≥5) in females were associated (p<0.05) with recovery time. However, the VOMS test performed poorly among males (receiver operating characteristic (ROC) area=0.66) and failed among females (ROC area=0.56) as a prognostic tool to identify those that will have a normal/protracted recovery. Conclusion In this sample, overall, the VOMS test was associated with recovery time (days); however, the VOMS was not a valid stand-alone prognostic tool to identify a delayed recovery, but may be useful in combination with other concussion symptomology assessments. Future studies should confirm these findings in larger samples while taking into consideration other comorbid factors that may influence recovery time.
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Affiliation(s)
- Gregory Knell
- Center for Pedatric Population Health, Children's Health System of Texas and University of Texas Health Science Center at Houston, Dallas, TX, USA.,Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health Science Center at Houston, Dallas, TX, USA.,Andrews Institute for Orthopaedics and Sports Medicine, Children's Health System of Texas, Plano, TX, USA
| | - Todd Caze
- Andrews Institute for Orthopaedics and Sports Medicine, Children's Health System of Texas, Plano, TX, USA.,Department of Psychiatry, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Scott O Burkhart
- Andrews Institute for Orthopaedics and Sports Medicine, Children's Health System of Texas, Plano, TX, USA
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Longitudinal Vestibular and Oculomotor Impairments Among Amateur Athletes 1 Year Following Sport-Related Concussion: A Prospective Follow-Up. J Head Trauma Rehabil 2021; 37:E55-E64. [PMID: 33741825 DOI: 10.1097/htr.0000000000000667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To investigate (i) the presence of vestibular and oculomotor impairments and (ii) the self-perceived effects of concussion-associated dizziness on health-related quality of life among amateur athletes 6 months and 1 year following sport-related concussion compared with nonconcussed, control athletes. DESIGN Prospective, matched-cohort study. SETTING Clinical assessment laboratory. PARTICIPANTS Amateur athletes who were diagnosed with sport-related concussion within 1 week of injury, and sex-, age-, and activity-matched nonconcussed, control athletes. MAIN MEASURES Participants were evaluated 6 months and 1 year following sport-related concussion and enrollment in the longitudinal study using the Vestibular and Oculo-Motor Screening and the Dizziness Handicap Inventory. We performed multivariate analyses of variance and chi-square analyses to compare concussion and control group scores at each study assessment. RESULTS Forty-seven participants with concussion and 47 control participants completed the study. The concussion group reported similar mean symptom provocation scores on the Vestibular and Oculo-Motor Screening and exhibited a similar near-point convergence distance compared with the control group at the 6-month and 1-year study assessments. The concussion and control groups had similar perceptions of the effects of dizziness on their health-related quality of life at both study assessments. CONCLUSION Meaningful differences in vestibular and oculomotor symptom provocation and self-perceived effects of dizziness on everyday life were not observed between concussed and nonconcussed, control athletes 6 months and 1 year following sport-related concussion.
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Trofimova A, Smith JL, Ahluwalia V, Hurtado J, Gore RK, Allen JW. Alterations in Resting-State Functional Brain Connectivity and Correlations with Vestibular/Ocular-Motor Screening Measures in Postconcussion Vestibular Dysfunction. J Neuroimaging 2021; 31:277-286. [PMID: 33476477 DOI: 10.1111/jon.12834] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/31/2020] [Accepted: 12/31/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE Vestibular symptoms after concussion are common and associated with protracted recovery. The purpose of this study is to define resting-state functional MRI (rs-fMRI) brain connectivity alterations in patients with postconcussion vestibular dysfunction (PCVD) and correlations between rs-fMRI connectivity and symptoms provoked during Vestibular/Ocular-Motor Screening (VOMS) assessment. METHODS Prospective IRB approved study. STUDY GROUP 12 subjects with subacute PCVD (2-10 weeks); control group: 10 age-matched subjects without history of concussion or vestibular impairment. Both groups underwent clinical vestibular assessment. rs-fMRI was acquired on 3.0T Siemens Trio with a 12-channel head coil. rs-fMRI data analysis included independent component analysis-based functional connectivity group differences, graph theory analysis, and ROI-to-ROI connectivity correlation analysis with VOMS clinical derivatives. Group difference maps between resting-state networks were calculated using dual regression method and corrected for multiple comparisons. Correlation analysis between ROI-to-ROI rs-fMRI brain activation and VOMS assessment ratings was performed using Pearson correlation coefficient, with a significance threshold of P ≤ .05. RESULTS Compared to controls, PCVD group demonstrated significantly increased rs-fMRI connectivity between the default-mode network and right middle frontal gyrus and right postcentral gyrus; and between a vestibular-sensorimotor network and right prefrontal cortex. Significant positive correlations were found between clinical derivative VOMS scores and components of the vestibular, visual networks, and multisensory processing cortical representations. CONCLUSION Altered rs-fMRI brain connectivity with increased connectivity of visual input, multisensory processing, and spatial memory in PCVD is correlative with clinical derivative VOMS scores, suggesting maladaptive brain plasticity underlying vestibular symptomatology.
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Affiliation(s)
- Anna Trofimova
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA
| | - Jeremy L Smith
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA
| | - Vishwadeep Ahluwalia
- Georgia Statue University/Georgia Tech Center for Advanced Brain Imaging, Atlanta, GA
| | | | - Russell K Gore
- Shepherd Center, Atlanta, GA.,Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA
| | - Jason W Allen
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA.,Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA.,Department of Neurology, Emory University, Atlanta, GA
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67
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Ernst N, Schatz P, Trbovich AM, Emami K, Eagle SR, Mucha A, Collins MW, Kontos AP. Utility of 1 Measurement Versus Multiple Measurements of Near Point of Convergence After Concussion. J Athl Train 2021; 55:850-855. [PMID: 32577736 DOI: 10.4085/1062-6050-431-19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Increased near point of convergence (NPC) distance is a common finding after concussion and is associated with physical symptoms and worsened neurocognitive performance. Vestibular/Ocular Motor Screening measures NPC distance across 3 trials and uses the average measurement to inform clinical care. However, whether 3 trials are necessary, are consistent, or add clinical utility is unknown. OBJECTIVE To investigate the consistency across 3 trials of NPC and establish the classification accuracy (ie, clinical utility) of 1 or 2 trials compared with the standardized average of 3 trials. DESIGN Retrospective cohort study. SETTING Sports medicine clinic and research laboratory. PATIENTS OR OTHER PARTICIPANTS Consecutively enrolled patients aged 10 to 22 years with diagnosed concussions (74% sport related; n = 380). MAIN OUTCOME MEASURE(S) The previously reported clinical cutoff value of ≥5 cm across 3 trials was used. Pearson correlation and intraclass correlation coefficients were used to evaluate agreement between trials and average scores. Reliable change indices (RCIs) using 95% confidence intervals were also calculated. RESULTS The Pearson correlation (r = .98) and intraclass correlation (0.98) coefficients revealed excellent agreement between the first measurement and average NPC distance across 3 measurements. The RCI across all trials was 2 cm. When the first NPC measurement was ≤3 cm or ≥7 cm, agreement existed within the RCI between the first measurement and the average of 3 measurements in 99.6% of cases. When we averaged the first and second measurements, 379/380 (99.7%) participants had the same classification (ie, <5 cm = normal, ≥5 cm = abnormal) as the average NPC distance across 3 measurements. CONCLUSIONS Our findings suggest limited utility of multiple or average NPC distance measurements when the initial NPC distance is outside of RCI clinical cutoffs (ie, ≤3 cm or ≥7 cm). Given the high consistency between the first measurement and average NPC distance across 3 trials, only 1 measurement of NPC distance is warranted unless the first measurement is between 3 and 7 cm.
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Affiliation(s)
- Nathan Ernst
- Department of Orthopaedic Surgery, University of Pittsburgh, PA.,UPMC Sports Medicine Concussion Program, University of Pittsburgh, PA
| | | | - Alicia M Trbovich
- Department of Orthopaedic Surgery, University of Pittsburgh, PA.,UPMC Sports Medicine Concussion Program, University of Pittsburgh, PA
| | - Kouros Emami
- Department of Orthopaedic Surgery, University of Pittsburgh, PA.,UPMC Sports Medicine Concussion Program, University of Pittsburgh, PA
| | - Shawn R Eagle
- Department of Orthopaedic Surgery, University of Pittsburgh, PA
| | - Anne Mucha
- UPMC Center for Rehab Services, University of Pittsburgh, PA
| | - Michael W Collins
- Department of Orthopaedic Surgery, University of Pittsburgh, PA.,UPMC Sports Medicine Concussion Program, University of Pittsburgh, PA
| | - Anthony P Kontos
- Department of Orthopaedic Surgery, University of Pittsburgh, PA.,UPMC Sports Medicine Concussion Program, University of Pittsburgh, PA
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68
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Haider MN, Patel KS, Willer BS, Videira V, Wilber CG, Mayer AR, Master CL, Mariotti BL, Wertz C, Storey EP, Arbogast KB, Park G, Oglesbee SJ, Bezherano I, Aguirre K, Fodero JG, Johnson BD, Mannix R, Miecznikowski JC, Leddy JJ. Symptoms upon postural change and orthostatic hypotension in adolescents with concussion. Brain Inj 2021; 35:226-232. [PMID: 33459038 DOI: 10.1080/02699052.2021.1871951] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objective: Concussion is associated with dysautonomia, altered blood pressure (BP) control, and may cause Orthostatic Hypotension (OH). We measured prevalence of OH using the 1-minute supine-to-standing OH Test in adolescents with concussion and controls.Participants: Adolescents within 10 days of injury (Concussion Group, n = 297, 15.0 ± 1.7 years, 59% male) were compared with controls (Control Group, n = 214, 15.0 ± 1.5 years, 58% male).Methods: BP, heart rate (HR), and complaints of lightheadedness/dizziness were measured after 2-minute supine and 1-minute standing. Control Group was assessed once. Concussion Group was assessed twice; (1) initial visit (mean 6.0 ± 3 days-since-injury) and (2) after clinical recovery (mean 46.3 ± 42 days-since-injury).Results: Initial visit; Concussion Group reported feeling lightheaded/dizzy on postural change more often than the Control Group (37% vs 4%, p < .001) but did not differ in meeting standard OH criteria (3% vs 5%, p = .32). Experiencing symptoms did not correlate with meeting OH criteria, but correlated with abnormal vestibulo-ocular reflex. After clinical recovery; Concussion Group did not differ in experiencing lightheaded/dizziness on postural change than controls (4%, p = .65).Conclusion: Adolescents commonly experience orthostatic intolerance after concussion without meeting the standard criteria for OH.
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Affiliation(s)
- M Nadir Haider
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA.,Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Kush S Patel
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Barry S Willer
- Department of Psychiatry, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | | | - Charles G Wilber
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Andrew R Mayer
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, New Mexico, Unites States.,Departments of Neurology and Psychiatry, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Christina L Master
- Sports Medicine and Performance Center, Division of Orthopedic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Brandon L Mariotti
- Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Christopher Wertz
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, New Mexico, Unites States
| | - Eileen P Storey
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kristy B Arbogast
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Grace Park
- Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque, New Mexico
| | - Scott J Oglesbee
- Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque, New Mexico
| | - Itai Bezherano
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Kenneth Aguirre
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Jesse G Fodero
- Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
| | - Blair D Johnson
- Department of Exercise and Nutrition Sciences, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, New York, USA
| | - Rebekah Mannix
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey C Miecznikowski
- Department of Biostatistics, School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, New York, USA
| | - John J Leddy
- UBMD Department of Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York, USA
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Sherry N, Trbovich A, Holland C, Eagle S, Bitzer H, Kontos AP. Predictors of poor reading performance in student-athletes following sport-related concussion. APPLIED NEUROPSYCHOLOGY-CHILD 2021; 11:364-372. [PMID: 33428451 DOI: 10.1080/21622965.2020.1850449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The goal of the current study was to determine which sport/recreation-related concussion (SRC) assessments predict academic reading performance following SRC. The study included 70 concussed students aged 14-22 years (M = 16.21, SD = 1.90) evaluated 2-30 days (M = 8.41, SD = 5.88) post-injury. SRC assessments included: Post-Concussion Symptom Scale, Immediate Post-Concussion Assessment and Cognitive Testing, Vestibular/Ocular Motor Screening, and King-Devick test. The Nelson-Denny Reading Test (NDRT) comprehension subtest measured academic reading accuracy and rate. Pearson correlations examined relationships among SRC assessments and reading accuracy/rate; those assessments that significantly correlated with the NDRT were included in multiple regressions (MRs) predicting reading accuracy and reading rate. Results supported positive correlations between visual motor speed and reading accuracy (r = .31, p = .01), and near point of convergence (NPC) and reading rate (r = .30, p = .01). The MRs for reading accuracy (F = 4.61, p = .01) and reading rate (F = 4.61, p = .01) were significant, and predicted approximately 40% of the variance, with visual motor speed and NPC as the only significant predictors in both models. Symptoms were not predictive of reading accuracy or rate. The present study indicates that visual motor speed and NPC are predictive of academic reading performance after SRC, suggesting clinicians should consider these clinical outcomes to better inform academic accommodations.
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Affiliation(s)
- Natalie Sherry
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alicia Trbovich
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Cyndi Holland
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shawn Eagle
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hannah Bitzer
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Quintana CP, McLeod TCV, Olson AD, Heebner NR, Hoch MC. Vestibular and Ocular/Oculomotor Assessment Strategies and Outcomes Following Sports-Related Concussion: A Scoping Review. Sports Med 2021; 51:737-757. [DOI: 10.1007/s40279-020-01409-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2020] [Indexed: 10/22/2022]
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Leddy J, Lesh K, Haider MN, Czuczman N, Baker JG, Miecznikowski J, Willer B. Derivation of a Focused, Brief Concussion Physical Examination for Adolescents With Sport-Related Concussion. Clin J Sport Med 2021; 31:7-14. [PMID: 30418219 PMCID: PMC6488454 DOI: 10.1097/jsm.0000000000000686] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe the derivation of a brief but pertinent physical examination (PE) for adolescents who have sustained sport-related concussion (SRC). DESIGN Prospective cohort. SETTING University concussion management clinic. PARTICIPANTS Acutely concussed (AC, n = 52, 15.5 ± 1.4 years, 4.4 ± 2 days since injury, 26.2 ± 38 days to recovery, 71% males) and healthy control (HC) adolescents (n = 30, 15.8 ± 1.4 years, 73% males). INTERVENTION Acutely concussed had a PE on visit 1 and were retested at visit 2 (13.6 ± 1 day after visit 1). Acutely concussed were further characterized as normal recovery (NR, n = 41, 15.5 ± 1.5 years, recovery time 13.0 ± 7 days) and delayed recovery (DR, n = 11, 15.5 ± 1.2 years, recovery time 75.4 ± 63 days). MAIN OUTCOME MEASURE Physical examination findings, including cervical, vestibular, and oculomotor systems. RESULTS Visit 1 abnormal PE signs were significantly greater in AC versus HC (2.79 ± 2.13 vs 0.07 ± 0.37, P < 0.0001) but not in NR versus DR (2.61 ± 2.2 vs 3.45 ± 1.8, P = 0.246). Visit 2 abnormal PE signs differentiated NR versus DR (0.17 ± 0.7 vs 2.45 ± 2.1, P < 0.0001). CONCLUSIONS A brief focused PE can help to diagnose SRC, establish recovery, and may have prognostic value.
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Affiliation(s)
- John Leddy
- Department of Orthopedics and Sports Medicine, UBMD Orthopedics and Sports Medicine, SUNY at Buffalo, Buffalo, New York
| | - Kevin Lesh
- Department of Orthopedics and Sports Medicine, UBMD Orthopedics and Sports Medicine, SUNY at Buffalo, Buffalo, New York
| | - Mohammad N Haider
- Department of Orthopedics and Sports Medicine, UBMD Orthopedics and Sports Medicine, SUNY at Buffalo, Buffalo, New York
- Department of Neuroscience, SUNY at Buffalo, Buffalo, New York
| | - Natalie Czuczman
- SUNY at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| | - John G Baker
- Department of Orthopedics and Sports Medicine, UBMD Orthopedics and Sports Medicine, SUNY at Buffalo, Buffalo, New York
- Departments of Nuclear Medicine
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Orr R, Bogg T, Fyffe A, Lam LT, Browne GJ. Graded Exercise Testing Predicts Recovery Trajectory of Concussion in Children and Adolescents. Clin J Sport Med 2021; 31:23-30. [PMID: 30439726 DOI: 10.1097/jsm.0000000000000683] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine whether graded exercise testing can predict recovery trajectory of concussion in children and adolescents. DESIGN Prospective study. SETTING Children's Hospital, Westmead, Australia. PARTICIPANTS One hundred thirty-nine children aged 12 to 16 years at 5 to 7 days after an acute concussive injury. INTERVENTION Graded exercise testing on a treadmill at the subacute phase to assess symptom provocation and determine clinical recovery indicating readiness to commence a return to activity (RTA) protocol. Exercise time to symptom exacerbation and clinical recovery were measured. MAIN OUTCOME MEASURES Standard concussion assessment and clinical testing (neurocognitive, vestibular/ocular, and balance) were conducted to determine major clinical drivers/indicators. RESULTS Participants (mean age 12.4 ± 2.8 years, 73% male) had a confirmed sport-related concussion. The main clinical drivers identified on exercise testing were headache, balance, and vestibular dysfunction. Participants fell into 1 of 2 groups, exercise-tolerant (54%) and exercise-intolerant (46%). Exercise-tolerant patients showed mild clinical indicators, no symptom exacerbation during 10.3 ± 3.3 minutes of exercise, were safely transitioned to a RTA protocol, and recovered within 10 days. Exercise-intolerant patients had high clinical indicators, significant symptom exacerbation at 4.2 ± 1.6 minutes of exercise, and prolonged recovery of 45.6 days. No adverse effects from exercise were reported in either group. Combined use of provocative exercise and clinical testing was 93% predictive of outcome. CONCLUSIONS Exercise testing during the subacute phase after a concussion can predict longer recovery. Exercise testing can identify a unique window where patients can be safely transitioned to activity, enabling clinicians to better inform patients and families, allocate resources and streamline care.
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Affiliation(s)
- Rhonda Orr
- Discipline of Exercise and Sport Science, Faculty of Health Sciences, and Discipline of Emergency Medicine, The Children's Hospital at Westmead Clinical School, The University of Sydney, Sydney, Australia
| | - Tina Bogg
- Sydney Children's Hospital Network, Children's Hospital Institute of Sports Medicine, The Royal Alexandra Hospital for Children, Children's Hospital Westmead, Sydney, Australia
| | - Andrew Fyffe
- Sydney Children's Hospital Network, Children's Hospital Institute of Sports Medicine, The Royal Alexandra Hospital for Children, Children's Hospital Westmead, Sydney, Australia
| | - Lawrence T Lam
- Graduate School of Health, Faculty of Health, University of Technology Sydney, Sydney, Australia ; and
| | - Gary J Browne
- Sydney Children's Hospital Network, Children's Hospital Institute of Sports Medicine, The Royal Alexandra Hospital for Children, Children's Hospital Westmead, Sydney, Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, The University of Sydney, Sydney, Australia
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73
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Wallace J, Schatz P, Covassin T, Iverson GL. Brief iPad-Based Assessment of Cognitive Functioning with ImPACT® Quick Test: Prevalence of Low Scores Using Multivariate Base Rates. Arch Clin Neuropsychol 2020; 35:1276-1282. [PMID: 33000122 DOI: 10.1093/arclin/acaa078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 07/24/2020] [Accepted: 09/04/2020] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE The ImPACT® Quick Test is a brief iPad-based battery of neurocognitive tests that has been standardized on a sample of children, adolescents, and adults (ages 12-70). This study provides information on the prevalence of ImPACT® Quick Test scores falling below specific percentiles in the normative sample to aid in clinical interpretation and reduce the risk of over-interpreting, or misinterpreting, a single low score. METHOD Participants were 683 individuals ranging in age from 12 to 70, who were assessed individually. The ImPACT® Quick Test includes five subtests, contributing to three factor scores: motor speed, memory, and attention tracker. The prevalence of low factor scores, stratified by age and sex, were calculated using multivariate base rates. RESULTS In the total sample, obtaining 1 or more scores below the 25th percentile was common (base rate, BR = 47.2%), but obtaining 2 or more scores in this range was uncommon (BR = 15.3%). Similarly, obtaining 1 or more scores below the 16th percentile was common (BR = 31.4%), but obtaining two or more scores in this range was uncommon (BR = 6.9%). There were small differences in BRs between sexes and the number of low scores was fairly similar across the age groups. CONCLUSION Results from this study parallel previous work illustrating that a substantial percentage of healthy individuals will obtain one or more low test scores when administered a brief battery of cognitive tests. Given that some healthy individuals will obtain a single score below expected cut-offs, clinicians should caution against overinterpreting a single low test score.
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Affiliation(s)
- Jessica Wallace
- Department of Health Science, University of Alabama; Harvard T.H. Chan School of Public Health, Tuscaloosa, AL, USA
| | - Philip Schatz
- Department of Psychology, Saint Joseph's University, Philadelphia, PA, USA
| | - Tracey Covassin
- Department of Kinesiology, Michigan State University, East Lansing, MI, USA
| | - Grant L Iverson
- Harvard Medical School; Spaulding Rehabilitation Hospital and Spaulding Research Institute; MassGeneral Hospital for Children Sports Concussion Program; & Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Charlestown, MA, USA
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Abstract
This article provides a summary of clinical assessment methods and nonpharmacologic rehabilitation techniques used for concussed patients. It describes concussion-relevant physical examination methods to identify underlying symptom generators. This approach allows practitioners to prescribe targeted rehabilitation therapies to treat postconcussion symptoms. Evidence-based rehabilitation approaches include cervical rehabilitation, vestibulo-ocular rehabilitation, and sub-symptom threshold aerobic exercise.
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75
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Zasler N, Haider MN, Grzibowski NR, Leddy JJ. Physician Medical Assessment in a Multidisciplinary Concussion Clinic. J Head Trauma Rehabil 2020; 34:409-418. [PMID: 31479079 PMCID: PMC7096076 DOI: 10.1097/htr.0000000000000524] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Concussive brain injury (CBI) is encountered by clinicians in sports medicine, pediatrics, neurosurgery, neurology, physiatry, and primary care. There is no gold standard diagnostic test for CBI, nor is there consensus on what neuromusculoskeletal physical examination tests should be performed on patients who have sustained CBI. This article presents an approach to the history and physical examination of the patient who has sustained a CBI that is based on a review of the literature evidence and the authors' extensive experience with this patient population. Suggested components include an elemental neurological examination that emphasizes the oculomotor/ophthalmologic and vestibular systems, as well as appropriate musculoskeletal assessment of the craniocervical and upper shoulder girdle complex. The use of supplementary tests for CBI, including assessment of exercise tolerance using the Buffalo Concussion Treadmill Test and tests of neurocognitive function, can aid in the differential diagnosis of CBI. The proposed protocol is envisioned for initial and follow-up assessments in the clinic after CBI, as well as for those with more protracted signs or symptoms. If symptoms persist beyond 2 weeks in adults or 4 weeks in adolescents, then referral to a multidisciplinary center that focuses on CBI is recommended.
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Affiliation(s)
- Nathan Zasler
- Concussion Care Centre of Virginia, Ltd, Richmond (Dr Zasler); Tree of Life Services, Inc, Richmond, Virginia (Dr Zasler); Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond (Dr Zasler); UBMD Orthopaedics and Sports Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo (Drs Haider and Leddy); and Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo (Dr Haider and Mr Grzibowski)
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van Ierssel J, Osmond M, Hamid J, Sampson M, Zemek R. What is the risk of recurrent concussion in children and adolescents aged 5-18 years? A systematic review and meta-analysis. Br J Sports Med 2020; 55:663-669. [PMID: 33077482 DOI: 10.1136/bjsports-2020-102967] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE We aimed to examine the risk of concussion in children with a previous history of concussion. DESIGN Systematic review and meta-analysis. The primary outcome was number of children with and without a previous lifetime history of concussion who sustained a diagnosed concussion within each study period. Risk of bias was assessed using the Newcastle-Ottawa Scale. A random effects model was used to estimate a pooled risk ratio (RR) with corresponding 95% CIs; results were summarised in forest plots. DATA SOURCES Four electronic databases (MEDLINE, Embase, CINAHL, SPORTDiscus) and selected reference lists were searched (PROSPERO registration No CRD42019135462). ELIGIBILITY CRITERIA Original English language peer-reviewed publications that compared concussion risk in children aged 5-18 years with and without a previous concussion history in which risk estimates were reported or able to be calculated. RESULTS Of 732 identified studies, 7 studies representing 23 411 children (risk of bias range, 7-9; maximum possible score=9) were included for meta-analysis. Pooled risk of sustaining a concussion was more than three times greater in children with a previous concussion compared with those with no previous concussion (RR=3.64; 95% CI: 2.68 to 4.96; p<0.0001; I 2=90.55%). Unreported sex-stratified data precluded direct comparison of concussion risk in male versus female athletes. CONCLUSION Previously concussed children have four times the risk of sustaining a concussion compared with those with no previous concussion history. This should be a consideration for clinicians in return to sport decision-making. Future studies examining subsequent recurrent concussion in youth sports must consider sex differences.
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Affiliation(s)
| | - Martin Osmond
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,Emergency Department, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Jemila Hamid
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,Department of Mathematics and Statistics, University of Ottawa, Ottawa, Ontario, Canada
| | - Margaret Sampson
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Roger Zemek
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,Emergency Department, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
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77
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Changes in Vestibular/Ocular-Motor Screen Scores in Adolescents Treated With Vestibular Therapy After Concussion. Pediatr Phys Ther 2020; 32:331-337. [PMID: 32773522 DOI: 10.1097/pep.0000000000000729] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To examine interrelationships among Vestibular/Ocular-Motor Screen (VOMS) items and to characterize the recovery of VOMS performance in a sample of adolescents treated with vestibular physical therapy (VPT) after concussion. METHODS Seventy-seven patients with concussion and 77 participants without concussion completed the study. Adolescents with concussion received an individualized VPT intervention consisting of targeted exercises for gaze stability, postural stability, ocular-motor control, habituation, and aerobic activities. The exercises were performed during a weekly clinic visit and via a home exercise program. RESULTS Except for near-point convergence distance, all VOMS items were significantly interrelated. Over the course of VPT, significant improvements in VOMS performance were observed, and discharge scores were similar to scores observed in adolescents without concussion. CONCLUSIONS The VOMS measured moderately related functions and captured changes over the course of VPT. Clinicians should consider the contextual risk of "false positive" in their interpretation of VOMS.
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78
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Hurtado JE, Heusel-Gillig L, Risk BB, Trofimova A, Abidi SA, Allen JW, Gore RK. Technology-enhanced visual desensitization home exercise program for post-concussive visually induced dizziness: a case series. Physiother Theory Pract 2020; 38:985-994. [PMID: 32955968 DOI: 10.1080/09593985.2020.1815259] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Purpose: Post-concussive visually induced dizziness (VID), in which symptoms are provoked by exposure to complex visual motion, is associated with protracted recovery. Although vestibular rehabilitation therapy (VRT) is recommended to treat post-concussive dizziness, there is sparse literature reporting on specific VRT interventions treating VID. Methods: A consecutive series of 26 individuals referred for VRT post-concussion were retrospectively assessed for inclusion in this case series. Each participant underwent a combination of conventional VRT and a technology-enhanced visual desensitization home exercise program (HEP). Self-report and objective measures were recorded from initial and discharge therapy evaluations. Twenty-three individuals (mean age 23.1 ± 12.4) with post-concussive dizziness (mean 109 ± 56 days post-injury) and no evidence for peripheral vestibular dysfunction were included. Treatment duration averaged 6.9 ± 2.5 weeks. Results: There were significant improvements in post-intervention on subjective and objective measures of dizziness and gait (p < .05). The response to intervention was independent of pre-injury migraine history but pre-injury depression/anxiety increased self-report of post-treatment anxiety. Concurrent treatment with medications did not influence response to treatment. Conclusions: The combination therapy intervention improved outcome measures consistent with VRT treatment outcomes in both concussion and non-traumatic vestibular conditions. Individuals referred for VRT post-concussion warrant assessment for VID and may benefit from the addition of technology-enhanced visual desensitization.
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Affiliation(s)
- Julia E Hurtado
- Shepherd Center, Complex Concussion Clinic , Atlanta, GA, USA
| | - Lisa Heusel-Gillig
- Department of Rehabilitation Medicine, Emory Dizziness and Balance Center , Atlanta, GA, USA
| | - Benjamin B Risk
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University , Atlanta, GA, USA
| | - Anna Trofimova
- Diagnostic Radiology, Department of Radiology and Imaging Sciences, Neuroradiology Division, Emory University School of Medicine , Atlanta, GA, USA
| | - Syed A Abidi
- School of Medicine, Emory University , Atlanta, GA, USA
| | - Jason W Allen
- Diagnostic Radiology, Department of Radiology and Imaging Sciences, Neuroradiology Division, Emory University School of Medicine , Atlanta, GA, USA.,Department of Neurology, Emory University School of Medicine, Emory University School of Medicine , Atlanta, GA, USA
| | - Russell K Gore
- Shepherd Center, Complex Concussion Clinic , Atlanta, GA, USA.,Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University , Atlanta, GA, USA
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79
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Clinical Detection and Recovery of Vestibular and Oculomotor Impairments Among Amateur Athletes Following Sport-Related Concussion: A Prospective, Matched-Cohort Study. J Head Trauma Rehabil 2020; 36:87-95. [PMID: 32898028 DOI: 10.1097/htr.0000000000000608] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To (1) quantify the diagnostic accuracy of the vestibular/oculomotor screening (VOMS), and (2) determine the recovery of vestibular and oculomotor impairments exhibited by concussed athletes compared with nonconcussed athletes using the VOMS. SETTING Clinical assessment laboratory. PARTICIPANTS Amateur athletes who were diagnosed with sport-related concussion by emergency department physicians, and non-concussed, control athletes. DESIGN Prospective, longitudinal study. MAIN MEASURES Participants were assessed 1 week following sport-related concussion, upon clearance to return-to-sporting activity, and 2 weeks following return-to-sporting activity by a study investigator who administered the VOMS. We calculated test sensitivity, specificity, and positive and negative predictive values to estimate the diagnostic accuracy of the VOMS. We performed a mixed-design analysis of variance to assess differences in VOMS symptom scores reported by concussed athletes compared with control athletes. RESULTS Fifty concussion participants and 50 control participants completed the study. The VOMS demonstrated sensitivity and specificity of 96% and 46%, respectively, and produced positive and negative predictive values of 64% and 92%, respectively. The concussion group exhibited a significantly greater symptom provocation change score from baseline than the control group for all test domains of the VOMS only in the first week following concussion. CONCLUSION The VOMS may be most useful as a clinical screening tool to rule out, rather than confirm, the presence of sport-related concussion. The VOMS may be appropriate to inform the recovery of vestibular and oculomotor impairments exhibited by concussed individuals over time.
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80
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Abstract
This article presents a brief, focused physical examination [PE, the Buffalo Concussion Physical Examination (BCPE)] for sport-related concussion (SRC) to be considered for use in the outpatient setting by sports medicine physicians, pediatricians, and primary-care physicians. This companion paper describes how to perform the PE, which was derived in a separate study presented in this journal. It is envisioned for use at the initial and follow-up outpatient visits both for acute concussions and in patients with prolonged symptoms. A pertinent PE, combined with other assessments, can help identify specific treatment targets in those with persistent symptoms after SRC. The BCPE includes orthostatic vital signs and examinations of the cranial nerves, oculomotor/ophthalmologic, cervical, and vestibular systems. Supplementary tests, including testing for exercise tolerance and neurocognitive function, may be performed if indicated. It is recommended that a PE be performed at the initial visit and every 1 to 2 weeks after SRC. On return of symptoms, cognition, and the PE to baseline, as well as normalization of any supplementary tests, patients can begin a return to play program.
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81
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Katz M, Lenoski S, Ali H, Craton N. Concussion Office Based Rehabilitation Assessment: A Novel Clinical Tool for Concussion Assessment and Management. Brain Sci 2020; 10:brainsci10090593. [PMID: 32867319 PMCID: PMC7563760 DOI: 10.3390/brainsci10090593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/13/2020] [Accepted: 08/21/2020] [Indexed: 11/16/2022] Open
Abstract
The Concussion Office Based Rehabilitation Assessment (COBRA) is a novel tool constructed to ensure a comprehensive assessment of patients who may have sustained a concussion. The SCAT-5 (Sport Concussion Assessment Tool) has long been the gold standard for concussion assessment, however, it was designed as a sideline tool and its utility can be seen to decrease after a few days post-concussion. It also does not prompt evaluation of all the phenotypes of concussion. As such, the COBRA was created to assess the majority of potential manifestations of concussion in the office setting a day or two after an injury has been sustained. The COBRA utilizes the eight phenotypes of concussion as a guide to assess each of the potential biopsychosocial features that can be associated with these injuries and can be used to guide evidence-based treatments. Through early identification of concussion phenotypes, the clinician may start optimal treatment and hopefully prevent prolonged recovery and persisting symptoms.
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82
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Northam WT, Cools MJ, Chandran A, Alexander A, Mihalik JP, Guskiewicz KM, Carneiro KA. Sports Medicine Fellowship Training Improves Sport-related Concussion Evaluation. Curr Sports Med Rep 2020; 19:272-276. [PMID: 32692063 DOI: 10.1249/jsr.0000000000000730] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Evaluating acute sport-related concussion (SRC) differs among providers, who apply international consensus and national guidelines variably. Retrospective medical record review was completed for 889 outpatients aged 7 to 18 years, diagnosed with SRC from 2014 to 2017. Associations between board-certified sports medicine fellowship (SMF) training status and assessment of concussion-specific history and physical examination items were tested using nonparametric χ tests. Differential odds (by fellowship training status) of using history and physical examination items were assessed using multivariable logistic regression modeling. Each SRC history and physical examination items were assessed in higher proportions by SMFs, as compared with non-SMFs, statistically significant for all tested items with the exception of headache history. SMFs demonstrated higher odds of detailed neurologic examinations and clinical cognitive testing compared with non-SMFs, after adjusting for patient and physician characteristics. Physicians caring for concussed patients should seek continuing education opportunities aligning them with training provided to sports medicine fellows.
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Affiliation(s)
| | | | | | | | | | - Kevin M Guskiewicz
- Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, Department of Exercise and Sport Science, University of North Carolina, Chapel Hill, NC
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Abstract
BACKGROUND AND PURPOSE According to the most recent consensus statement on management of sport-related concussion (SRC), athletes with suspected SRC should receive a comprehensive neurological examination. However, which measures to include in such an examination are not defined. Our objectives were to (1) evaluate test-retest reliability and normative data on vestibular and balance tests in athletes without SRC; (2) compare athletes with and without SRC on the subtests; and (3) identify subtests for concussion testing protocols. METHODS Healthy athletes (n = 87, mean age 20.6 years; standard deviation = 1.8 years; 39 female and 48 male) and athletes with SRC (n = 28, mean age 20.7 years; standard deviation = 1.9 years; 11 female and 17 male) were tested using rotary chair, cervical vestibular-evoked myogenic potential (c-VEMP), and the Sensory Organization Test (SOT). A subset (n = 43) were tested twice. We analyzed reliability of the tests, and compared results between athletes with and without SRC. RESULTS Reliability ranged from poor to strong. There was no significant difference between athletes with and without SRC for tests of peripheral vestibular function (ie, rotary chair and c-VEMP). Athletes with SRC had significantly worse scores (P < 0.05) on vestibular-ocular reflex (VOR) cancellation gain, subjective visual vertical and horizontal variance, and all conditions of the SOT. DISCUSSION AND CONCLUSION SRC did not affect medium frequency VOR or saccular function. SRC did affect the ability to use vestibular inputs for perception of vertical and postural control, as well as ability to cancel the VOR.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A274).
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84
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Eye Movements, Dizziness, and Mild Traumatic Brain Injury (mTBI): A Topical Review of Emerging Evidence and Screening Measures. J Neurol Phys Ther 2020; 43 Suppl 2:S31-S36. [PMID: 30883491 DOI: 10.1097/npt.0000000000000272] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Eye movements may be adversely affected after mild traumatic brain injury (mTBI) and should be examined. The purpose of this topical review is to provide the clinician with the most up-to-date knowledge related to eye movement abnormalities, screening measures, and evidence related to exercise interventions that are designed to enhance outcomes in persons after mTBI. SUMMARY OF KEY POINTS Presence of eye misalignment such as tropias or phoria or symptoms with head/eye movements such as vestibulo-ocular reflex (VOR) × 1, saccades, or smooth pursuits may slow the person's recovery. Tools such as the Convergence Insufficiency Symptom Survey, the Vestibular/Ocular Motor Screening, the Pediatric Vestibular Symptom Questionnaire, and the Pediatric Visually Induced Dizziness questionnaire may aid in identifying visual concerns to target in the physical therapy intervention program. There is emerging evidence that vestibular rehabilitation enhances recovery in persons after mTBI. RECOMMENDATIONS FOR CLINICAL PRACTICE A thorough eye examination is highly recommended after mTBI to identify targeted areas for intervention.
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85
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Horan B, Heckenberg R, Maruff P, Wright B. Development of a new virtual reality test of cognition: assessing the test-retest reliability, convergent and ecological validity of CONVIRT. BMC Psychol 2020; 8:61. [PMID: 32532362 PMCID: PMC7291630 DOI: 10.1186/s40359-020-00429-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/05/2020] [Indexed: 01/26/2023] Open
Abstract
Background Technological advances provide an opportunity to refine tools that assess central nervous system performance. This study aimed to assess the test-retest reliability and convergent and ecological validity of a newly developed, virtual-reality, concussion assessment tool, ‘CONVIRT’, which uses eye-tracking technology to assess visual processing speed, and manual reaction time (pushing a button on a riding crop) to assess attention and decision-making. CONVIRT was developed for horse jockeys, as of all sportspersons, they are most at risk of concussion. Methods Participants (N = 165), were assessed with CONVIRT, which uses virtual reality to give the user the experience of riding a horse during a horserace. Participants were also assessed with standard Cogstate computer-based concussion measures in-between two completions of the CONVIRT battery. The physiological arousal induced by the test batteries were assessed via measures of heart rate and heart rate variability (LF/HF ratio). Results Satisfactory test-retest reliability and convergent validity with Cogstate attention and decision-making subtests and divergent validity in visual processing speed measures were observed. CONVIRT also increased heart rate and LF/HF ratio, which may better approximate participant arousal levels in their workplace. Conclusions CONVIRT may be a reliable and valid tool to assess elements of cognition and CNS disruption. The increased ecological validity may also mean better informed ‘return-to-play’ decisions and stronger industry acceptance due to the real-world meaningfulness of the assessment. However, before this can be achieved, the sensitivity of the CONVIRT battery needs to be demonstrated.
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Affiliation(s)
- Ben Horan
- School of Engineering, Deakin University, Geelong, VIC, 3216, Australia
| | - Rachael Heckenberg
- School of Psychology and Public Health, La Trobe University, Wodonga, Victoria, 3690, Australia
| | - Paul Maruff
- The Florey Institute, The University of Melbourne, Parkville, VIC, 3052, Australia
| | - Bradley Wright
- School of Psychology and Public Health, La Trobe University, Bundoora, Victoria, 3086, Australia.
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86
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Vestibular Lab Testing: Interpreting the Results in the Headache Patient with Dizziness. Curr Neurol Neurosci Rep 2020; 20:16. [PMID: 32430768 DOI: 10.1007/s11910-020-01036-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW To provide an overview of vestibular lab testing and to familiarize the reader with common results observed in headache patients with dizziness. RECENT FINDINGS The latest research indicates variable levels of both peripheral and central vestibular dysfunction in headache populations with dizziness. Mechanisms may include vestibulocerebellar loss of inhibition, central vestibular network misfiring, and peripheral pathology aggravating central hypersensitization. Headache patients are commonly affected by dizziness stemming from various etiologies. Although history is still the gold standard in diagnosis, vestibular lab testing can identify the integrity of vestibular function. Research is emerging and future directions are encouraging.
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87
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Eagle SR, Puligilla A, Fazio-Sumrok V, Kegel N, Collins MW, Kontos AP. Association of time to initial clinic visit with prolonged recovery in pediatric patients with concussion. J Neurosurg Pediatr 2020; 26:165-170. [PMID: 32330895 DOI: 10.3171/2020.2.peds2025] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 02/24/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE No studies to date have investigated the role of early clinical care in time to recovery from concussion in a pediatric population. The purpose of this study was to investigate the role of clinic presentation timing (≤ 7 days [early] compared to 8-20 days [late] from injury) in concussion assessment performance and risk for prolonged recovery (> 30 days) in pediatric concussion. METHODS This study is a retrospective cross-sectional study from a concussion clinic between April 2016 and January 2019, including 218 children and adolescents with diagnosed concussion, separated based on clinic presentation timing following injury: early (≤ 7 days) and late (8-20 days). Outcomes were recovery time, Postconcussion Symptom Scale (PCSS), Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), Vestibular/Ocular Motor Screen (VOMS), and demographics, medical history, and injury information. A general linear model and chi-square analyses were used to assess differences between early and late presentation, along with logistic regression, to predict prolonged recovery (> 30 days). RESULTS Those with early presentation reported higher symptoms on VOMS subtests (79%-85%) compared to those with late presentation (61%-78%), with the exception of near-point of convergence distance and visual motion sensitivity (VMS). The strongest predictor of prolonged recovery was number of days to first clinic visit (OR 9.8). Positive VMS (OR 5.18), history of headache/migraine (OR 4.02), and PCSS score (OR 1.04) were also predictive of prolonged recovery. CONCLUSIONS Despite patients in the early presentation group presenting with more positive VOMS scores, the early presentation group recovered sooner than patients in the late presentation group. Even after controlling for vestibular dysfunction, history of headache or migraine, and total symptom severity, days to first visit remained the most robust predictor of recovery > 30 days. These findings suggest that early, specialized medical care and intervention for children and adolescents with recent concussion is associated with normal recovery time. Clinicians should educate children and parents on the potential importance of early treatment to improve the odds of positive outcomes following concussion.
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Whitney SL, Eagle SR, Marchetti G, Mucha A, Collins MW, Kontos AP. Association of acute vestibular/ocular motor screening scores to prolonged recovery in collegiate athletes following sport-related concussion. Brain Inj 2020; 34:840-845. [DOI: 10.1080/02699052.2020.1755055] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Susan L. Whitney
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shawn R. Eagle
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gregory Marchetti
- Department of Physical Therapy, Duquesne University, Pittsburgh, Pennsylvania, USA
| | - Anne Mucha
- Centers for Rehabilitation Service, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael W. Collins
- Centers for Rehabilitation Service, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Anthony P. Kontos
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Abstract
Over the last decade, numerous concussion evidence-based clinical practice guidelines (CPGs), consensus statements, and clinical guidance documents have been published. These documents have typically focused on the diagnosis of concussion and medical management of individuals post concussion, but provide little specific guidance for physical therapy management of concussion and its associated impairments. Further, many of these guidance documents have targeted specific populations in specific care contexts. The primary purpose of this CPG is to provide a set of evidence-based recommendations for physical therapist management of the wide spectrum of patients who have experienced a concussive event. J Orthop Sports Phys Ther 2020;50(4):CPG1-CPG73. doi:10.2519/jospt.2020.0301.
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90
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Zalesky CC, Moran TP, Koval RR, Usher J, Ratcliff JJ, Wu D, Wright DW. A prospective cross-sectional study examining the documented evaluation of patients at high risk for mild traumatic brain injury. Am J Emerg Med 2020; 42:150-160. [PMID: 32165070 DOI: 10.1016/j.ajem.2020.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 02/04/2020] [Accepted: 02/12/2020] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVES Annually, the CDC reports that 2.5 million Emergency Department (ED) visits occur due to Traumatic Brain Injuries (TBI) with nearly 75% classified as mild TBI (mTBI). Generally, these injuries are thought to be under recognized. This study was done to determine the proportion of patients, who were considered high risk for an mTBI, that had documentation of an mTBI evaluation. METHODS A prospective cross-section of patients was identified using a 3-question screen at the time of triage: did an injury occur; was the mechanism consistent with mTBI; and was there a period of altered mental status. Chart review was completed for these patients who were thought to meet a minimum threshold warranting an evaluation for mTBI. RESULTS 38,621 patients were screened over 16 weeks, of whom 441 (1.14%) were identified as being high risk for having an mTBI and met inclusion criteria. Recommended portions of an mTBI evaluation occurred in fewer than 50% of patients. In total, 98 subjects were diagnosed with an mTBI, and 49 received mTBI discharge instructions. The odds ratio for the subgroup of patients who had documented criteria sufficient for diagnosis revealed that an isolated head injury increased a patient's odds of a documented diagnosis by 2.1 times (95%, 1.3-3.4). CONCLUSIONS Many patients with a possible mTBI did not have significant portions of an mTBI evaluation documented, and roughly half of the patients with a documented mTBI diagnosis did not receive discharge education. Changes in clinicians' approach to mTBI must occur to ensure patients receive appropriate evaluations, management, and education.
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Affiliation(s)
- C Christopher Zalesky
- University of Cincinnati College of Medicine, Department of Emergency Medicine, Cincinnati, OH, United States of America.
| | - Tim P Moran
- Emory University School of Medicine, Department of Emergency Medicine Atlanta, GA, United States of America
| | - Rachel R Koval
- Emory University School of Medicine, Department of Emergency Medicine Atlanta, GA, United States of America
| | - Jasmine Usher
- Grady Memorial Hospital, Atlanta, GA, United States of America
| | - Jonathan J Ratcliff
- Emory University School of Medicine, Department of Emergency Medicine Atlanta, GA, United States of America
| | - Daniel Wu
- Emory University School of Medicine, Department of Emergency Medicine Atlanta, GA, United States of America; Grady Memorial Hospital, Atlanta, GA, United States of America
| | - David W Wright
- Emory University School of Medicine, Department of Emergency Medicine Atlanta, GA, United States of America
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91
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Sarmiento K, Gioia GA, Kirkwood MW, Wade SL, Yeates KO. A commentary for neuropsychologists on CDC's guideline on the diagnosis and management of mild traumatic brain injury among children. Clin Neuropsychol 2020; 34:259-277. [PMID: 31530221 PMCID: PMC7039321 DOI: 10.1080/13854046.2019.1660806] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 07/28/2019] [Accepted: 08/18/2019] [Indexed: 12/27/2022]
Abstract
Objective: In 2018, the Centers for Disease Control Prevention (CDC) published an evidence-based guideline on the diagnosis and management of mild traumatic brain injury (mTBI) among children. This commentary summarizes the key recommendations in the CDC Pediatric mTBI Guideline most relevant for neuropsychologists and discusses research gaps and topics that should receive attention in future iterations of the Guideline.Method: We described the methods used to develop the Guideline, which included a comprehensive Systematic Review. We also distilled and presented key practice strategies reflected in Guideline.Results: To optimize care of pediatric patients with mTBI, neuropsychologists should: use validated, age-appropriate symptom scales, assess evidence-based risk factors for prolonged recovery, provide patients with instructions on return to activity customized to their symptoms, and counsel patients to return gradually to nonsports activities after a short period of rest. Future iterations of the Guideline should encompass a review and guidance on care of patients with psychiatric and psychological difficulties, as well as the potential use of imaging to assess patients with persistent symptoms. Expanded research on mTBI among girls, children age 8 and under, and effective treatments for pediatric mTBI will be beneficial to inform care practices.Conclusions: Recommendations in the CDC Pediatric mTBI Guideline highlight multiple opportunities for neuropsychologists to take action to improve the care of young patients with mTBI and to advance research in the field. Multiple resources and tools are available to support implementation of these recommendations into clinical practice.
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Affiliation(s)
- Kelly Sarmiento
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Gerard A. Gioia
- Division of Pediatric Neuropsychology, Children’s National Health System, George Washington University School of Medicine, Washington, DC, USA
| | - Michael W. Kirkwood
- Department of Physical Medicine and Rehabilitation, Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | - Shari L. Wade
- Division of Physical Medicine and Rehabilitation, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Keith O. Yeates
- Departments of Psychology and Pediatrics and Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
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92
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Schilling S, Mansour A, Sullivan L, Ding K, Pommering T, Yang J. Symptom Burden and Profiles in Concussed Children with and without Prolonged Recovery. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17010351. [PMID: 31947942 PMCID: PMC6981707 DOI: 10.3390/ijerph17010351] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 12/30/2019] [Accepted: 01/03/2020] [Indexed: 12/27/2022]
Abstract
Although symptom burden and symptom profile severity are independent predictors of post-concussion symptom duration, few studies have examined their effects on prolonged recovery simultaneously. This study examined differences in symptom burden and symptom profile scores between concussed children with prolonged recovery and those with typical recovery. We conducted a retrospective case-control study of concussed children aged 10–18 years. Prolonged recovery was defined as symptom duration beyond 28 days post-injury. Symptom burden was measured as total symptom score (TSS) at injury. Symptom profiles included: (1) vestibular, (2) ocular, (3) cognitive/fatigue, (4) migraine, and (5) anxiety. A total of 4380 unique concussions sustained by 3777 patients were included; 80.3% white, 60.0% male, and 44.0% aged 13–15 years. The prolonged recovery group had a significantly higher TSS and greater number of symptoms than the typical recovery group (p < 0.001 and p < 0.001, respectively). The prolonged recovery group had significantly higher scores on all five symptom profiles, including vestibular (p < 0.001), ocular (p < 0.001), cognitive/fatigue (p < 0.001), migraine (p < 0.001) and anxiety (p < 0.001), than the typical recovery group, even after adjusting for number of symptoms and other covariates. Further studies using prospective cohort designs are needed to better understand the influence of symptom burden and profiles on pediatric concussion recovery.
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Affiliation(s)
- Samantha Schilling
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH 43205, USA; (S.S.); (A.M.); (J.Y.)
| | - Adam Mansour
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH 43205, USA; (S.S.); (A.M.); (J.Y.)
| | - Lindsay Sullivan
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH 43205, USA; (S.S.); (A.M.); (J.Y.)
- Correspondence: ; Tel.: +614-355-5852
| | - Kele Ding
- Department of Health Sciences, Kent State University, Kent, OH 44240, USA;
| | - Thomas Pommering
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH 43210, USA;
- Division of Sports Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA
| | - Jingzhen Yang
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH 43205, USA; (S.S.); (A.M.); (J.Y.)
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH 43210, USA;
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93
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Abstract
Concussion is an ongoing concern for health care providers. The incidence rates continue to be high and the rate of recovery is variable due to potential risk factors. With no valid biomarkers, diagnosis and assessment of concussion remain a clinical challenge. The heterogeneity in presentation following injury provides an additional level of complexity, requiring the screening and evaluation of diverse body systems, including oculomotor, vestibular, autonomic, psychiatric, cervical, and cognitive symptoms. While a few tools, such as the Vestibular/Ocular Motor Screening and Balance Error Scoring System, have been developed specifically for concussion, the vast majority of tests are adapted from other conditions. Further complicating the process is the overlapping and interactive nature of the multiple domains of postconcussion presentation. This commentary illustrates how clinicians can conceptualize the multiple profiles that present following concussion and describes tools that are available to assist with screening and evaluation of each area. The multifaceted nature of concussion warrants broad clinical screening skills and an interdisciplinary approach to management. J Orthop Sports Phys Ther 2019;49(11):787-798. doi:10.2519/jospt.2019.8855.
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94
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Moran RN, Wallace J, Murray NG, Covassin T. Effects of attention deficit hyperactivity disorder and learning disability on vestibular and ocular baseline concussion assessment in pediatric athletes. APPLIED NEUROPSYCHOLOGY-CHILD 2019; 10:276-282. [PMID: 31650856 DOI: 10.1080/21622965.2019.1683453] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Vestibular and ocular motor assessment has gained popularity as a tool for sport-related concussion among healthcare professionals. With awareness of premorbid risk factors, such as attentional problems, it is imperative to understand their effects at baseline. The purpose of this study was to examine the effects of attention deficit/hyperactivity disorder (ADHD) and diagnosed learning disability (LD) on vestibular and oculomotor baseline concussion assessment in pediatrics. Pediatric athletes between the ages of 8 and 14 years with ADHD/LD (n = 30) and match controls without ADHD/LD (n = 30) completed baseline concussion testing, consisting of symptom provocation on the Vestibular/Ocular Motor Screening (VOMS) and oculomotor performance on near point of convergence (NPC) and King-Devick (K-D) tools. Those diagnosed with ADHD/LD performed worse on baseline saccades (p range = .02-.10), convergence (p = .04), vestibular ocular reflex (VOR) (p = .03) and visual motion sensitivity (VMS) (p = .04) of the VOMS. Base rate analyses revealed that 26% of athletes in the ADHD/LD group had ≥1 and 13.3% had ≥2 VOMS domains over clinical cutoff levels, compared to 3.3% (≥1 domain) and 0 (≥2 domains) of controls. Individuals with ADHD/LD also performed worse on K-D assessment (p = .005). However, no differences were reported on NPC distance (p = .19). These findings suggest worse baseline concussion assessment scores on vestibular/ocular motor assessment domains in pediatric athletes diagnosed with ADHD/LD. Additional research is needed on assessment outcomes to determine if special consideration to those diagnosed with ADHD/LD is warranted.
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Affiliation(s)
- Ryan N Moran
- Athletic Training Research Laboratory, Department of Health Science, The University of Alabama, Tuscaloosa, AL, USA
| | - Jessica Wallace
- Athletic Training Research Laboratory, Department of Health Science, The University of Alabama, Tuscaloosa, AL, USA
| | - Nicholas G Murray
- School of Community Health Sciences, University of Nevada, Reno, NV, USA
| | - Tracey Covassin
- Sport Injury Research Laboratory, Department of Kinesiology, Michigan State University, East Lansing, MI, USA
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95
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Ratka J, Cheever K, Mansell JL, Tierney RT. The effect of an interval fatigue protocol on Vestibular/Ocular Motor Screening (VOMS) performance. Brain Inj 2019; 34:110-114. [DOI: 10.1080/02699052.2019.1682194] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Jenna Ratka
- Department of Kinesiology, Temple University, Philadelphia, PA, USA
| | - Kelly Cheever
- Department of Kinesiology, Health, and Nutrition, University of Texas at San Antonio, TX, USA
| | - Jamie L. Mansell
- Department of Kinesiology, Temple University, Philadelphia, PA, USA
| | - Ryan T. Tierney
- Department of Kinesiology, Temple University, Philadelphia, PA, USA
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96
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McGinnis I, Tierney R, Mansell J, Phillips J. The Effect of Target Speed and Verbal Instruction on NPC Measures in a Young, Healthy, and Active Population. J Eye Mov Res 2019; 12. [PMID: 33828741 PMCID: PMC7880140 DOI: 10.16910/jemr.12.4.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Purpose: Evaluate the effect of target speed and verbal instruction on near point of convergence (NPC) measurements in a young, healthy, and active population. Methods: NPC was measured in 20 individuals with three target speeds and two sets of verbal instruction. The target speeds used were 1 cm/s, 3 cm/s, 5 cm/s, and participant self-paced. The verbal instruction given was either to indicate when the target became “double” or “blurry”. Results: Paired-samples t-tests revealed significant differences between 5 cm/s (5.44 ± 2.01) and 1 cm/s (6.72 ± 2.39, p = .003), 3 cm/s (6.10 ± 2.36, p = .030) and self-paced (6.63 ± 2.26, p = .005). A significant difference (p < .001) was also found between the “double” (6.72 ± 2.39) and “blurry” (10.82 ± 3.08) conditions. Conclusion: For young, healthy and active individuals, target speed and verbal instruction matter when measuring NPC.
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97
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Raghuram A, Cotter SA, Gowrisankaran S, Kanji J, Howell DR, Meehan WP, Shah AS. Postconcussion: Receded Near Point of Convergence is not Diagnostic of Convergence Insufficiency. Am J Ophthalmol 2019; 206:235-244. [PMID: 31004592 DOI: 10.1016/j.ajo.2019.04.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE To determine the frequency of occurrence of receded near point of convergence (NPC) in patients with chronic concussion-related symptoms and in those with receded NPC to enumerate the frequency of convergence insufficiency and other oculomotor disorders. DESIGN Retrospective cross-sectional study. METHODS Clinic charts were retrospectively reviewed for the prior 3.5 years to identify all patients < 21 years old who were > 28 days postconcussion, had chronic concussion-related symptoms, had normal visual acuity, and had received a comprehensive sensorimotor examination. The frequency of receded NPC and oculomotor diagnoses were determined. RESULTS Of the 83 eligible patients, 74 (89%) had receded NPC. Of these, 70 (95%) had oculomotor disorders; 30 (41%) had disorders of accommodation only; 21 (28%) had convergence insufficiency and accommodation deficits; and 6 (8%) had convergence insufficiency only. Six (8%) had a convergence deficit other than convergence insufficiency (all with concurrent accommodative disorders); 4 (5%) had both a nonspecific vergence dysfunction and accommodation deficits; 2 (3%) had convergence excess only; and 1 (1%) had both convergence excess and accommodative deficits. CONCLUSION A receded NPC was present in the majority of young patients with chronic postconcussion symptoms. Associated with numerous underlying oculomotor dysfunctions, the clinical finding of a receded NPC is not synonymous with the diagnosis of convergence insufficiency. Because treatment options for the various oculomotor dysfunctions differ, it is prudent that these patients undergo a thorough examination of their vergence and accommodative systems so that an accurate diagnosis can be made and appropriate treatment prescribed.
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Affiliation(s)
- Aparna Raghuram
- Department of Ophthalmology, Boston Children's Hospital, Boston, MA, USA; Department of Ophthalmology, Harvard Medical School, Boston, MA, USA.
| | - Susan A Cotter
- Southern California College of Optometry, Marshall B. Ketchum University, Fullerton, CA, USA
| | | | - Jameel Kanji
- New England College of Optometry, Boston, MA, USA
| | - David R Howell
- The Micheli Center for Sports Injury Prevention, Waltham, MA, USA; Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA; Brain Injury Center, Boston Children's Hospital, Boston, MA, USA
| | - William P Meehan
- The Micheli Center for Sports Injury Prevention, Waltham, MA, USA; Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA; Brain Injury Center, Boston Children's Hospital, Boston, MA, USA; Department of Orthopedic Surgery, Harvard Medical School, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Ankoor S Shah
- Department of Ophthalmology, Boston Children's Hospital, Boston, MA, USA; Department of Ophthalmology, Harvard Medical School, Boston, MA, USA; Department of Ophthalmology, Massachusetts Eye and Ear, Boston, MA, USA
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98
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Abstract
BACKGROUND AND PURPOSE The utility of prospective changes on the Vestibular/Ocular Motor Screening (VOMS) assessment are unknown, and 2 methods of scoring are published in the literature. Total scores are the total symptom scores for each VOMS component, and change scores are the difference between the pretest total symptom score and component total symptom scores. This study documented prospective changes in vestibular and ocular motor impairments and symptoms in high school athletes with concussion using the total and change scoring methods and compared the percentage of scores over clinical cutoffs using the total and change scoring methods for the VOMS. METHODS Sixty-three athletes (15.53 ± 1.06 years) completed the VOMS at baseline (ie, preinjury), 1 to 7 days, and 8 to 14 days after concussion. A series of repeated-measures multivariate analyses of variance were conducted on total and change scores. A 2-way repeated-measures analysis of variance was performed on the near-point convergence distance. A series of χ analyses compared scores exceeding clinical cutoffs between the total and change scoring methods. RESULTS Total scoring revealed impairments (Wilks λ = 0.39, F16,47 = 4.54, P < 0.001, η = 0.61) on all VOMS components at 1 to 7 and 8 to 14 days compared to baseline. Change scoring revealed postinjury impairments compared with baseline (Wilks λ = 0.58, F14,49 = 2.52, P = 0.009, η = 0.42) on all components at 1 to 7 days; however, impairments at 8 to 14 days were revealed only for the vertical vestibular oculomotor reflex and vestibular motor sensitivity components. Total scoring identified significantly more scores over cutoffs at 1 to 7 days (χ1,63 = 5.97, P = 0.02) compared with change scores. DISCUSSION AND CONCLUSIONS Both total and change scoring methods on the VOMS are useful for identifying impairments following concussion.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A230).
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99
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Elbin RJ, Kontos AP, Sufrinko A, McElroy M, Stephenson-Brown K, Mohler S, D'Amico NR, Collins MW. Motion Sickness Susceptibility and Baseline Vestibular and Ocular-Motor Performance in Adolescent Athletes. J Athl Train 2019; 54:939-944. [PMID: 31454287 DOI: 10.4085/1062-6050-347-18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT High school athletes with a history of motion sickness susceptibility exhibit higher baseline vestibular and ocular-motor scores than those without a history of motion sickness susceptibility. OBJECTIVE To examine the effects of motion sickness susceptibility on baseline vestibular and ocular-motor functioning, neurocognitive performance, and symptom scores. DESIGN Cross-sectional study. SETTING Preseason concussion testing. PATIENTS OR OTHER PARTICIPANTS A convenience sample of high school athletes (N = 308, age = 15.13 ± 1.21 years) involved in a variety of sports. MAIN OUTCOME MEASURE(S) Vestibular/Ocular Motor Screening, computerized neurocognitive assessment, symptom scale, and Motion Sickness Susceptibility Questionnaire-Short Form (MSSQ-S). RESULTS Participants were categorized into 3 groups based on a median split of the scores (eg, NONE, LOW, and HIGH). The LOW (n = 95) and HIGH (n = 92) groups (ie, MSSQ-S score > 0) were 2.64 times more likely (χ21,257 = 7.94, P = .01, 95% confidence interval = 1.32, 5.26) to have baseline Vestibular/Ocular Motor Screening scores larger than the clinical cutoffs for the NONE group (n = 70). No between-groups main effects were present for the NONE (n = 52), LOW (n = 89), and HIGH (n = 90) MSSQ-S groups for verbal (F2,230 = .09, P = .91, η2 = .001) and visual (F2,230 = .15, P = .86, η2 = .001) memory, processing speed (F2,230 = .78, P = .46, η2 = .007), or reaction time (F2,230 = 2.21, P = .11, η2 = .002). The HIGH group exhibited higher total baseline symptom scores than the LOW (U = 3325.50, z = -1.99, P = .05, r = .15) and NONE (U = 1647.50, z = -2.83, P = .005, r = .24) groups. CONCLUSIONS Motion sickness should be considered a preexisting risk factor that might influence specific domains of the baseline concussion assessment and postinjury management.
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Affiliation(s)
- R J Elbin
- Office for Sport Concussion Research, Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville
| | - Anthony P Kontos
- UPMC Sports Medicine Concussion Program-Department of Orthopaedic Surgery, University of Pittsburgh, PA
| | - Alicia Sufrinko
- UPMC Sports Medicine Concussion Program-Department of Orthopaedic Surgery, University of Pittsburgh, PA
| | - Mallory McElroy
- Office for Sport Concussion Research, Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville
| | - Katie Stephenson-Brown
- Office for Sport Concussion Research, Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville
| | - Samantha Mohler
- Office for Sport Concussion Research, Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville
| | - Nathan R D'Amico
- Office for Sport Concussion Research, Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville
| | - Michael W Collins
- UPMC Sports Medicine Concussion Program-Department of Orthopaedic Surgery, University of Pittsburgh, PA
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100
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Sinnott AM, Elbin RJ, Collins MW, Reeves VL, Holland CL, Kontos AP. Persistent vestibular-ocular impairment following concussion in adolescents. J Sci Med Sport 2019; 22:1292-1297. [PMID: 31521485 DOI: 10.1016/j.jsams.2019.08.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 06/04/2019] [Accepted: 08/04/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The current study investigated the role of persistent vestibular-ocular symptoms and impairment following sport-related concussion on recovery time and clinical outcomes among adolescents. DESIGN Prospective cohort. METHODS 50 (F-22/M-28) adolescents aged 12-20 years completed a vestibular-ocular motor screening, neurocognitive assessment, and the Post-Concussion Symptom Scale (PCSS) at clinical assessments conducted at 0-10 and 11-21 days after concussion. Participants were assigned to: 1) persistent vestibular-ocular (PERSIST), 2) vestibular-ocular improvement (IMPROVE), or 3) no vestibular-ocular impairment (NONE) groups based on vestibular-ocular motor screening conducted during each assessment. A 3 (GROUP) X 2 (TIME) ANOVA was performed on neurocognitive and symptom scores, and a between-subjects ANOVA was performed for recovery time. RESULTS 49 subjects were identified among the PERSIST (n=17), IMPROVE (n=12) and NONE (n=20) groups. There were no neurocognitive performance differences between groups at 0-10 days post-concussion, but groups differed on PCSS at 11-21 days (p=.001), with the PERSIST (29.0±24.9) group reporting higher symptoms than the NONE (5.45±10.0; p=.005) group. The PERSIST group took significantly longer to recover (34.9±11.6 days) than the NONE (22.9±14.9 days) group (p=.03). All groups improved on verbal (p<.001) and visual memory (p=.028), visual motor speed (p=.005), and reaction time (p=.004) from 0-10 to 11-20 days following SRC and no significant group by time interactions for cognitive scores identified. CONCLUSIONS Persistent post-concussion vestibular-ocular symptoms and impairment may influence neurocognitive performance and clinical recovery following sport-related concussion.
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Affiliation(s)
- Aaron M Sinnott
- Neuromuscular Research Laboratory and Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, School of Health and Rehabilitation Sciences, University of Pittsburgh, USA
| | - R J Elbin
- Department of Health, Human Performance, and Recreation, Office for Sport Concussion Research, University of Arkansas, USA
| | - Michael W Collins
- Department of Orthopedic Surgery, UPMC Sports Medicine Concussion Program, University of Pittsburgh Medical Center, USA
| | - Valerie L Reeves
- Department of Orthopedic Surgery, UPMC Sports Medicine Concussion Program, University of Pittsburgh Medical Center, USA
| | - Cyndi L Holland
- Department of Orthopedic Surgery, UPMC Sports Medicine Concussion Program, University of Pittsburgh Medical Center, USA
| | - Anthony P Kontos
- Department of Orthopedic Surgery, UPMC Sports Medicine Concussion Program, University of Pittsburgh Medical Center, USA.
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