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Beauchamp MH, Dégeilh F, Rose SC. Improving outcome after paediatric concussion: challenges and possibilities. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:728-740. [PMID: 37734775 DOI: 10.1016/s2352-4642(23)00193-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/12/2023] [Accepted: 07/17/2023] [Indexed: 09/23/2023]
Abstract
The term concussion has permeated mainstream media and household vocabulary mainly due to awareness regarding the risks of concussion in professional contact sports, yet it occurs across a variety of settings and ages. Concussion is prevalent in infants, preschoolers, children, and adolescents, and is a common presentation or reason for referral to primary care providers, emergency departments, and specialised trauma clinics. Its broad range of symptoms and sequelae vary according to multiple individual, environmental, and clinical factors and can lead to health and economic burden. More than 20 years of research into risk factors and consequences of paediatric concussion has revealed as many questions as answers, and scientific work and clinical cases continue to expose its complexity and heterogeneity. In this Review, we present empirical evidence for improving outcome after paediatric concussion. We consider work pertaining to both sports and other injury mechanisms to provide a perspective that should be viewed as complementary to publications focused specifically on sports concussion. Contemporary challenges in prevention, diagnosis, prognosis, and intervention are discussed alongside pathways and future directions for improving outcome.
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Affiliation(s)
- Miriam H Beauchamp
- Sainte-Justine Research Center, University of Montreal, Montréal, QC, Canada; Department of Psychology, University of Montreal, Montréal, QC, Canada.
| | - Fanny Dégeilh
- Univ Rennes, CNRS, Inria, Inserm, IRISA UMR 6074, EMPENN ERL U-1228, Rennes, France
| | - Sean C Rose
- Pediatric Neurology, Nationwide Children's Hospital, Columbus, OH, USA; Ohio State University College of Medicine, Columbus, OH, USA
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Yeates KO, Räisänen AM, Premji Z, Debert CT, Frémont P, Hinds S, Smirl JD, Barlow K, Davis GA, Echemendia RJ, Feddermann-Demont N, Fuller C, Gagnon I, Giza CC, Iverson GL, Makdissi M, Schneider KJ. What tests and measures accurately diagnose persisting post-concussive symptoms in children, adolescents and adults following sport-related concussion? A systematic review. Br J Sports Med 2023; 57:780-788. [PMID: 37316186 DOI: 10.1136/bjsports-2022-106657] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To determine what tests and measures accurately diagnose persisting post-concussive symptoms (PPCS) in children, adolescents and adults following sport-related concussion (SRC). DESIGN A systematic literature review. DATA SOURCES MEDLINE, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, CINAHL and SPORTDiscus through March 2022. ELIGIBILITY CRITERIA Original, empirical, peer-reviewed findings (cohort studies, case-control studies, cross-sectional studies and case series) published in English and focused on SRC. Studies needed to compare individuals with PPCS to a comparison group or their own baseline prior to concussion, on tests or measures potentially affected by concussion or associated with PPCS. RESULTS Of 3298 records screened, 26 articles were included in the qualitative synthesis, including 1016 participants with concussion and 531 in comparison groups; 7 studies involved adults, 8 involved children and adolescents and 11 spanned both age groups. No studies focused on diagnostic accuracy. Studies were heterogeneous in participant characteristics, definitions of concussion and PPCS, timing of assessment and the tests and measures examined. Some studies found differences between individuals with PPCS and comparison groups or their own pre-injury assessments, but definitive conclusions were not possible because most studies had small convenience samples, cross-sectional designs and were rated high risk of bias. CONCLUSION The diagnosis of PPCS continues to rely on symptom report, preferably using standardised symptom rating scales. The existing research does not indicate that any other specific tool or measure has satisfactory accuracy for clinical diagnosis. Future research drawing on prospective, longitudinal cohort studies could help inform clinical practice.
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Affiliation(s)
- Keith Owen Yeates
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Anu M Räisänen
- Department of Physical Therapy Education - Oregon, Western University of Health Sciences, College of Health Sciences - Northwest, Lebanon, Oregon, USA
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Zahra Premji
- Libraries, University of Victoria, Victoria, British Columbia, Canada
| | - Chantel T Debert
- Department of Clinical Neuroscience, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pierre Frémont
- Department of Rehabilitation, Laval University, Quebec, Quebec, Canada
| | - Sidney Hinds
- Uniformed Services University, Bethesda, Maryland, USA
| | - Jonathan D Smirl
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
- Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Karen Barlow
- Child Health Research Centre, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Gavin A Davis
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Cabrini Health, Malvern, Victoria, Australia
| | - Ruben J Echemendia
- Department of Psychology, University of Missouri, Kansas City, Missouri, USA
- Psychological and Neurobehavioral Associates, Inc, State College, Pennsylvania, USA
| | - Nina Feddermann-Demont
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
- Sports Neuroscience, University of Zurich, Zurich, Switzerland
| | - Colm Fuller
- College of Medicine and Health, University College Cork, Cork, Ireland
- Sports Medicine Department, Sports Surgery Clinic, Dublin, Ireland
| | - Isabelle Gagnon
- School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Trauma Center, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Christopher C Giza
- Department of Neurosurgery, UCLA Steve Tisch BrainSPORT Program, Los Angeles, California, USA
- Department of Pediatrics/Pediatric Neurology, Mattel Children's Hospital UCLA, Los Angeles, California, USA
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
- Sports Concussion Program, MassGeneral Hospital for Children, Boston, Massachusetts, USA
| | - Michael Makdissi
- Melbourne Brain Centre, Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Victoria, Australia
- Australian Football League, Melbourne, Victoria, Australia
| | - Kathryn J Schneider
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
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Thirty-Second Single-Leg Stance Identifies Impaired Postural Control in Children After Concussion: A Preliminary Report. J Sport Rehabil 2021; 31:511-516. [PMID: 34808596 DOI: 10.1123/jsr.2021-0178] [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: 05/12/2021] [Revised: 08/09/2021] [Accepted: 09/19/2021] [Indexed: 11/18/2022]
Abstract
CONTEXT Objective and expedient assessments of standing postural control incorporating static and dynamic tasks are necessary for identifying subtle motor deficits and clearing children to return to high-risk activities after concussion. The Revised Physical and Neurological Examination for Subtle Signs (PANESS) gaits and stations tasks evaluate both static and dynamic aspects of postural control. While the PANESS gaits and stations subscale is sensitive to concussion in youth, the benefit of each specific task for this purpose is unknown. PURPOSE This study evaluated whether specific PANESS tasks identify postural impairments after youth concussion. DESIGN Cross-sectional study. SETTING Academicallyaffiliated research laboratory. PARTICIPANTS Sixty youth, ages 10-17 years, comprised 3 groups: (1) youth symptomatic from concussion (4-14 d postinjury [n = 18]), (2) clinically-recovered youth (27-122 d postinjury [n = 15]), and (3) age- and gender-matched never-concussed controls (n = 27). MAIN OUTCOME MEASURE PANESS gaits and stations tasks (6 dynamic and 3 static) at the time of the initial research visit. RESULTS Kruskal-Wallis statistic identified a significant main effect of group on standing on one foot (a 30-s task). Both symptomatic and clinically-recovered youth showed deficits on standing on one foot relative to controls. CONCLUSIONS Single-leg tasks of longer duration may maximize the ability to detect residual postural deficits after concussion and can be readily incorporated in targeted sport rehabilitation protocols.
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Smulligan KL, Wingerson MJ, Seehusen CN, Magliato SN, Wilson JC, Howell DR. Patient perception of dizziness and imbalance does not correlate with gait measures in adolescent athletes post-concussion. Gait Posture 2021; 90:289-294. [PMID: 34564000 DOI: 10.1016/j.gaitpost.2021.09.184] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/13/2021] [Accepted: 09/16/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Dizziness and gait impairments are commonly observed following a concussion, and both are associated with prolonged concussion recovery. RESEARCH QUESTION Is there a correlation between combined self-reported dizziness and balance impairment severity with objective gait impairments after concussion? METHODS Participants (n = 51; 15.4 ± 1.6 years; 51 % female; 7.3 ± 3.2 days post-injury) age 12-18 years self-reported ratings of dizziness and balance impairment using the Post-Concussion Symptom Inventory (PCSI) within 14 days of injury. Individual ratings of dizziness, balance impairment, and moving clumsily on the PCSI were combined to create a comprehensive dizziness and imbalance score. Participants also completed a smartphone-based gait evaluation under single-task and dual-task conditions. Correlation coefficients (Pearson r for normally distributed and Spearman rho for non-normally distributed variables) were calculated between self-reported symptoms and single and dual-task spatiotemporal gait parameters, specifically step velocity, step time, and step length. RESULTS Correlation coefficients indicated that there was low to no correlation between self-reported dizziness and imbalance impairment severity and smartphone-obtained gait parameters under single- or dual-task conditions, including step velocity (single-task: r=-0.22, p = 0.13; dual-task: r=-0.05, p = 0.72), step time (single-task: rho = 0.16, p = 0.27; dual-task: rho = 0.14, p = 0.33), and step length (single-task: r=-0.15, p = 0.30; dual-task: r = 0.03, p = 0.84). SIGNIFICANCE Self-reported dizziness and balance impairment severity within the first two weeks of concussion may not reflect objectively measured gait performance, given the lack of association between subjective symptom ratings and functional measures. Further, smartphone collected gait parameters may not provide the necessary sensitivity to detect an association with dizziness. The lack of significant correlation between self-reported symptoms and objective gait performance highlights the importance of using both objective and subjective measures to obtain a more complete picture of concussion deficits.
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Affiliation(s)
- Katherine L Smulligan
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Mathew J Wingerson
- Sports Medicine Center, Children's Hospital of Colorado, Aurora, CO, USA
| | - Corrine N Seehusen
- Sports Medicine Center, Children's Hospital of Colorado, Aurora, CO, USA
| | - Samantha N Magliato
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Julie C Wilson
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA; Sports Medicine Center, Children's Hospital of Colorado, Aurora, CO, USA; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - David R Howell
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA; Sports Medicine Center, Children's Hospital of Colorado, Aurora, CO, USA.
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Static and Dynamic Cognitive Performance in Youth and Collegiate Athletes With Concussion. Clin J Sport Med 2021; 31:442-447. [PMID: 31860545 DOI: 10.1097/jsm.0000000000000779] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 06/19/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine if individuals with a concussion demonstrate altered cognitive performance while standing still or while walking relative to uninjured controls. DESIGN Cross-sectional. SETTING Sports-medicine clinic. PARTICIPANTS Youth and collegiate athletes diagnosed with a concussion, assessed within 10 days of injury, and a group of uninjured control subjects. INDEPENDENT VARIABLES Concussion and control groups. MAIN OUTCOME MEASURES Participants stood still for 30 seconds while completing a cognitive task (spelling words backward, serial subtraction, or reverse month recitation) and completed a similar set of cognitive tasks while walking. Our primary outcome variables were (1) overall cognitive task performance (accuracy) and (2) the total number of task items completed during testing (completion rate) during standing and walking conditions. RESULTS One hundred ninety-one participants completed the study: 94 with concussion (tested mean = 5.1 ± 2.9 days postconcussion; 51% female; mean age = 17.1 ± 3.3 years) and 97 control subjects (40% female; mean age = 17.5 ± 2.1 years). The concussion group completed significantly fewer responses than the control group while standing still (37.3 ± 14.5 vs 45.1 ± 17.6 responses; P = 0.03) and while walking (22.7 ± 7.5 vs 33.6 ± 13.4 responses; P < 0.001). They were also significantly less accurate at spelling words backward (81.2 ± 28.6% correct vs 89.8 ± 15.0% correct; P = 0.049) and reciting months in reverse order (95.8 ± 10.4% correct vs 98.2 ± 4.2% correct; P = 0.034) while walking. CONCLUSIONS Athletes displayed lower cognitive task accuracy rates after concussion compared with control subjects during backward spelling and reverse month recitation tasks while walking but similar levels of accuracy while standing. Assessment of cognitive performance during dynamic tasks may be a clinically viable method to evaluate post-concussion deficits.
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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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Sweeny M, Habib Perez O, Inness EL, Danells C, Chandra T, Foster E, Comper P, Bayley M, Mochizuki G. The Toronto concussion study: a cross-sectional analysis of balance deficits following acute concussion in community-dwelling adults. Brain Inj 2021; 35:587-595. [PMID: 33734923 DOI: 10.1080/02699052.2021.1891288] [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] [Indexed: 10/21/2022]
Abstract
Objective: To characterize balance deficits in community-dwelling adults following acute concussion.Design: Cross-sectional observational study.Methods: Individuals with acute concussion (n=100) and healthy controls (n=20) completed the BESS (Balance Error Scoring System) and quiet standing trials on forceplates with the eyes open, closed, or during a cognitive dual task. BESS score and centre-of-pressure root mean square and high-frequency power (0.4-3Hz) were used to characterize group differences. In a secondary analysis, participants were subdivided based on self-reported symptoms of balance problems and dizziness using the SCAT-3 (Sport Concussion Assessment Tool - Third Edition) Symptom Checklist.Results: In comparing individuals with concussion and controls, BESS score (16.0 ± 6.0 vs 12.6 ± 3.8; F(1,116) = 5.814, p = .017) and anteroposterior [F(1.78, 204.2) = 11.93, p < .001] and mediolateral [F(1, 114) = 10.05, p = .002] high-frequency power revealed significant group differences. Dividing individuals based on self-reported symptoms revealed significant differences in mediolateral high frequency power, such that participants reporting balance and dizziness problems as well as those participants not reporting balance or dizziness symptoms following concussion were less stable than controls.Conclusions: Deficits in clinical and posturographic measures of balance occur in community-dwelling adults with concussion. These measures do not align with self-reported balance symptoms. Future research and clinical practice aimed at careful selection of optimized balance assessment is recommended.
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Affiliation(s)
- Michelle Sweeny
- Toronto Rehabilitation Institute -University Centre, University Health Network, Toronto, Canada.,Rehabilitation Sciences Institute,Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Olinda Habib Perez
- Toronto Rehabilitation Institute -University Centre, University Health Network, Toronto, Canada
| | - Elizabeth L Inness
- Toronto Rehabilitation Institute -University Centre, University Health Network, Toronto, Canada.,Rehabilitation Sciences Institute,Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Cynthia Danells
- Toronto Rehabilitation Institute -University Centre, University Health Network, Toronto, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Tharshini Chandra
- Toronto Rehabilitation Institute -University Centre, University Health Network, Toronto, Canada
| | - Evan Foster
- Toronto Rehabilitation Institute -University Centre, University Health Network, Toronto, Canada
| | - Paul Comper
- Toronto Rehabilitation Institute -University Centre, University Health Network, Toronto, Canada.,Rehabilitation Sciences Institute,Faculty of Medicine, University of Toronto, Toronto, Canada.,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Canada
| | - Mark Bayley
- Toronto Rehabilitation Institute -University Centre, University Health Network, Toronto, Canada.,Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - George Mochizuki
- Toronto Rehabilitation Institute -University Centre, University Health Network, Toronto, Canada.,Rehabilitation Sciences Institute,Faculty of Medicine, University of Toronto, Toronto, Canada.,School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Canada
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Sensitivity and Specificity of a Multimodal Approach for Concussion Assessment in Youth Athletes. J Sport Rehabil 2021; 30:850-859. [PMID: 33547256 DOI: 10.1123/jsr.2020-0279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 10/21/2020] [Accepted: 11/06/2020] [Indexed: 12/16/2022]
Abstract
CONTEXT Current international consensus endorses a multimodal approach to concussion assessment. However, the psychometric evaluation of clinical measures used to identify postconcussion performance deficits once an athlete is asymptomatic remains limited, particularly in the pediatric population. OBJECTIVE To describe and compare the sensitivity and specificity of a multimodal assessment battery (balance, cognition, and upper and lower body strength) versus individual clinical measures at discriminating between concussed youth athletes and noninjured controls when asymptomatic. DESIGN Prospective cohort study. SETTING Hospital laboratory setting. PARTICIPANTS A total of 32 youth athletes with a concussion and 32 matched (age and sex) noninjured control participants aged 10-18 years. INTERVENTION(S) Participants were administered preinjury (baseline) assessments of cognition (Immediate Post-Concussion Assessment and Cognitive Testing [ImPACT]), balance (BioSway), and upper and lower body strength (grip strength and standing long jump). Assessments were readministered when concussed participants reported symptom resolution (asymptomatic time point). Noninjured control participants were reassessed using the same time interval as their concussion matched pair. Sensitivity and specificity were calculated using standardized regression-based methods and receiver operating characteristic curves. MAIN OUTCOME MEASURES Outcome measures included baseline and postinjury ImPACT, BioSway, grip strength, and standing long jump scores. RESULTS When asymptomatic, declines in performance on each individual clinical measure were seen in 3% to 22% of the concussion group (sensitivity = 3%-22%) compared with 3% to 13% of the noninjured control group (specificity = 87%-97%) (90% confidence interval). The multimodal battery of all combined clinical measures yielded a sensitivity of 41% and a specificity of 77% (90% confidence interval). Based on discriminative analyses, the multimodal approach was statistically superior compared with an individual measures approach for balance and upper and lower body strength, but not for cognition. CONCLUSIONS Results provide a foundation for understanding which domains of assessment (cognition, balance, and strength) may be sensitive and specific to deficits once symptoms resolve in youth athletes. More work is needed prior to clinical implementation of a preinjury (baseline) to postinjury multimodal approach to assessment following concussion in youth athletes.
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Sweeny M, Inness EL, Singer J, Habib Perez O, Danells C, Chandra T, Foster E, Comper P, Bayley M, Mochizuki G. The Toronto Concussion Study: a longitudinal analysis of balance deficits following concussion in community-dwelling adults. Brain Inj 2020; 34:1384-1394. [DOI: 10.1080/02699052.2020.1802665] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Michelle Sweeny
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth L. Inness
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan Singer
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, MB, Canada
| | - Olinda Habib Perez
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Cynthia Danells
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tharshini Chandra
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Evan Foster
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Paul Comper
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Mark Bayley
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - George Mochizuki
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Ontario, Canada
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Miyashita TL, Cote C, Terrone D, Diakogeorgiou E. Detecting changes in postural sway. J Biomech 2020; 107:109868. [DOI: 10.1016/j.jbiomech.2020.109868] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 05/12/2020] [Accepted: 05/24/2020] [Indexed: 01/14/2023]
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Büttner F, Howell DR, Ardern CL, Doherty C, Blake C, Ryan J, Catena R, Chou LS, Fino P, Rochefort C, Sveistrup H, Parker T, Delahunt E. Concussed athletes walk slower than non-concussed athletes during cognitive-motor dual-task assessments but not during single-task assessments 2 months after sports concussion: a systematic review and meta-analysis using individual participant data. Br J Sports Med 2019; 54:94-101. [DOI: 10.1136/bjsports-2018-100164] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2019] [Indexed: 01/01/2023]
Abstract
ObjectivesTo determine whether individuals who sustained a sports concussion would exhibit persistent impairments in gait and quiet standing compared to non-injured controls during a dual-task assessment .DesignSystematic review and meta-analysis using individual participant data (IPD).Data sourcesThe search strategy was applied across seven electronic bibliographic and grey literature databases: MEDLINE, EMBASE, CINAHL, SportDISCUS, PsycINFO, PsycARTICLES and Web of Science, from database inception until June 2017.Eligibility criteria for study selectionStudies were included if; individuals with a sports concussion and non-injured controls were included as participants; a steady-state walking or static postural balance task was used as the primary motor task; dual-task performance was assessed with the addition of a secondary cognitive task; spatiotemporal, kinematic or kinetic outcome variables were reported, and; included studies comprised an observational study design with case–control matching.Data extraction and synthesisOur review is reported in line with the Preferred Reporting Items for Systematic review and Meta-Analyses-IPD Statement. We implemented the Risk of Bias Assessment tool for Non-randomised Studies to undertake an outcome-level risk of bias assessment using a domain-based tool. Study-level data were synthesised in one of three tiers depending on the availability and quality of data: (1) homogeneous IPD; (2) heterogeneous IPD and (3) aggregate data for inclusion in a descriptive synthesis. IPD were aggregated using a ‘one-stage’, random-effects model.Results26 studies were included. IPD were available for 20 included studies. Consistently high and unclear risk of bias was identified for selection, detection, attrition, and reporting biases across studies. Individuals with a recent sports concussion walked with slower average walking speed (χ2=51.7; df=4; p<0.001; mean difference=0.06 m/s; 95% CI: 0.004 to 0.11) and greater frontal plane centre of mass displacement (χ2=10.3; df=4; p=0.036; mean difference −0.0039 m; 95% CI: −0.0075 to −0.0004) than controls when evaluated using a dual-task assessment up to 2 months following concussion.Summary/conclusionsOur IPD evidence synthesis identifies that, when evaluated using a dual-task assessment, individuals who had incurred a sports concussion exhibited impairments in gait that persisted beyond reported standard clinical recovery timelines of 7–10 days. Dual-task assessment (with motion capture) may be a useful clinical assessment to evaluate recovery after sports concussion.Protocol pre-registrationThis systematic review was prospectively registered in PROSPERO CRD42017064861.
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Self-reported Balance Disturbance and Performance-Based Balance Impairment After Concussion in the General Population. J Head Trauma Rehabil 2019; 34:E37-E46. [DOI: 10.1097/htr.0000000000000431] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Howell DR, Myer GD, Grooms D, Diekfuss J, Yuan W, Meehan WP. Examining Motor Tasks of Differing Complexity After Concussion in Adolescents. Arch Phys Med Rehabil 2018; 100:613-619. [PMID: 30193950 DOI: 10.1016/j.apmr.2018.07.441] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 07/18/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVES (1) To determine the effects of concussion-related motor impairments at different task complexities in isolation and with a cognitive dual-task and (2) to determine if self-reported balance deficits after concussion are associated with gait, quiet stance, or cognitive dual-task impairments. DESIGN Cross-sectional study. SETTING Sports medicine clinic. PARTICIPANTS Adolescent athletes clinically diagnosed with a sport-related concussion and those without concussion. Forty-nine patients with concussion (mean age=14.9±1.9y; 51% female; tested 7.0±3.0d postinjury) and 65 control participants (mean age=14.9±1.6y; 52% female) completed the study (N=114). INTERVENTIONS Athletes with concussion completed a single-task and dual-task standing and walking protocol within 14 days of injury and were compared to those without concussion. MAIN OUTCOME MEASURES Outcome measures included gait speed, quiet stance (root mean square [RMS] coronal/sagittal plane sway), and cognitive performance (accuracy). Dual-task costs were calculated as the percentage change between single-task and dual-task conditions. Participants with concussion were then stratified by those who did and did not report subjective balance problems at the time of testing and compared using objective balance and gait metrics. RESULTS The concussion group walked slower during dual-task gait than controls (0.83±0.17 m/s vs 0.92±0.15 m/s; Cohen's d=0.53). Dual-task quiet stance RMS sway values were similar for concussion and control groups in coronal (1.20±0.52 m/s-2 vs 1.26±0.65 m/s-2; d=0.09) and sagittal (0.56±0.24 m/s-2 vs 0.73±0.44 m/s-2; d=0.20) movement planes. The concussion participants with subjectively-reported balance problems had significantly greater walking speed dual-task costs than concussion participants without self-reported balance problems (-25±10% vs -19±9%; P=.02). CONCLUSIONS Following concussion, adolescents demonstrate slower gait speeds, but similar quiet stance values relative to those without concussion. The study results indicate that tasks requiring greater motor coordination may elicit greater alterations following a concussion.
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Affiliation(s)
- David R Howell
- Sports Medicine Center, Children's Hospital Colorado, Aurora, CO; Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO; The Micheli Center for Sports Injury Prevention, Waltham, MA.
| | - Gregory D Myer
- The SPORT Center, Division of Sports Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Dustin Grooms
- Ohio Musculoskeletal & Neurological Institute and Division of Athletic Training, School of Applied Health Sciences and Wellness, College of Health Sciences and Professions, Ohio University, Athens, OH
| | - Jed Diekfuss
- The SPORT Center, Division of Sports Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Weihong Yuan
- Pediatric Neuroimaging Research Consortium, Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; University of Cincinnati College of Medicine, Cincinnati, OH
| | - William P Meehan
- The Micheli Center for Sports Injury Prevention, Waltham, MA; Division of Sports Medicine, Boston Children's Hospital, Boston, MA; Departments of Orthopaedic Surgery and Pediatrics, Harvard Medical School, Boston, MA
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Vavilala MS, Farr CK, Watanitanon A, Clark-Bell BC, Chandee T, Moore A, Armstead W. Early changes in cerebral autoregulation among youth hospitalized after sports-related traumatic brain injury. Brain Inj 2017; 32:269-275. [PMID: 29182378 DOI: 10.1080/02699052.2017.1408145] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To examine early cerebral haemodynamic changes among youth hospitalized with sports-related traumatic brain injury (TBI). STUDY DESIGN Youth 0-18 years admitted to a level one trauma centre with sports-related TBI were enrolled. Daily measures included clinical symptoms and Glasgow Coma Scale (GCS) score. Using Transcranial Doppler (TCD) ultrasonography and tilt testing, we measured middle cerebral artery flow velocity (Vmca) and cerebral autoregulation index (ARI). RESULTS Six previously healthy males age 14 (IQR 12-16) years with headache and abnormal head CT were admitted with median admission GCS 15. Six patients underwent 12 TCD examinations between hospital days 0-9. Low Vmca occurred in 3/6 patients and on the side of TBI, whereas high Vmca occurred in 2/6 patients. Five patients had at least one measurement of impaired and five patients had absent cerebral autoregulation of at least one hemisphere; all these five patients had GCS 15 and headache during TCD examinations. Three patients were discharged with absent cerebral autoregulation. Five (83%) patients were discharged to home and one patient was discharged to a rehabilitation facility. CONCLUSION Headache, abnormal Vmca and impaired cerebral autoregulation occur after sports-related TBI, despite normal GCS. Headache may signal underlying neurovascular abnormality in sports-related TBI.
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Affiliation(s)
- Monica S Vavilala
- a Department of Anesthesiology and Pain Medicine , University of Washington , Seattle , WA, USA.,b Harborview Injury Prevention and Research Center , University of Washington , Seattle , WA, USA
| | - Carly K Farr
- a Department of Anesthesiology and Pain Medicine , University of Washington , Seattle , WA, USA.,b Harborview Injury Prevention and Research Center , University of Washington , Seattle , WA, USA
| | - Arraya Watanitanon
- a Department of Anesthesiology and Pain Medicine , University of Washington , Seattle , WA, USA.,b Harborview Injury Prevention and Research Center , University of Washington , Seattle , WA, USA
| | - Bs Crystalyn Clark-Bell
- a Department of Anesthesiology and Pain Medicine , University of Washington , Seattle , WA, USA.,b Harborview Injury Prevention and Research Center , University of Washington , Seattle , WA, USA
| | - Theerada Chandee
- a Department of Anesthesiology and Pain Medicine , University of Washington , Seattle , WA, USA.,b Harborview Injury Prevention and Research Center , University of Washington , Seattle , WA, USA
| | - Anne Moore
- c Department of Neurological Surgery, Harborview Medical Center , University of Washington , Seattle , WA, USA
| | - William Armstead
- d Department of Anesthesiology , University of Pennsylvania , Philadelphia , PA, USA
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