The diagnostic and prognostic utility of the dual-task tandem gait test for pediatric concussion

The Diagnostic Utility of Cervical Spine Proprioception for Adolescent Concussion

OBJECTIVE

Cervical spine proprioception may be impaired after concussion. Our objective was to determine the diagnostic utility of cervical spine proprioception for adolescent concussion.

DESIGN

Cross-sectional.

SETTING

Research laboratory.

PARTICIPANTS

Adolescents ≤18 days of concussion and uninjured controls.

INTERVENTIONS

N/A.

MAIN OUTCOMES

Head repositioning accuracy (HRA) testing, a measure of cervical spine proprioception. The HRA test involved patients relocating their head back to a neutral starting position with eyes closed after maximal cervical spine flexion, extension, and right and left rotations. The overall HRA error score was the mean error (distance from the starting point to self-reported return to neutral) across 12 trials: 3 trials in each direction. We used t-tests to compare group means and logistic regression (outcome = group, predictor = HRA, covariates) to calculate odds ratios. We used a receiver operator characteristic curve to evaluate area under the curve (AUC) and calculate the optimal HRA cutpoint to distinguish concussion from controls.

RESULTS

We enrolled and tested 46 participants with concussion (age = 15.8 ± 1.3 years, 59% female, mean = 11.3 ± 3.3 days postconcussion) and 83 uninjured controls (age = 16.1 ± 1.4 years, 88% female). The concussion group had significantly worse HRA than controls (4.3 ± 1.6 vs 2.9 ± 0.7 degrees, P < 0.001, Cohen d = 1.19). The univariable HRA model AUC was 0.81 (95% CI = 0.73, 0.90). After adjusting for age, sex, and concussion history, the multivariable model AUC improved to 0.85 (95% CI = 0.77, 0.92). The model correctly classified 80% of participants as concussion/control at a 3.5-degree cutpoint.

CONCLUSIONS

Adolescents with concussion demonstrated worse cervical spine proprioception than uninjured controls. Head repositioning accuracy may offer diagnostic utility for subacute concussion.

Cognition Uniquely Influences Dual-Task Tandem Gait Performance Among Athletes With a Concussion History

BACKGROUND

After a concussion, there are unique associations between static balance and landing with cognition. Previous research has explored these unique correlations, but the factor of time, dual-task, and different motor tasks leave gaps within the literature. The purpose of this study was to determine the associations between cognition and tandem gait performance.

HYPOTHESIS

We hypothesized that athletes with a concussion history would display stronger associations compared with athletes without a concussion history between cognition and tandem gait.

STUDY DESIGN

Cross-sectional.

LEVEL OF EVIDENCE

Level 3.

METHODS

A total of 126 athletes without (56.3% female; age, 18.8 ± 1.3 years; height, 176.7 ± 12.3 cm; mass, 74.8 ± 19.0 kg) and 42 athletes with (40.5% female; age, 18.8 ± 1.3 years; height, 179.3 ± 11.9 cm; mass, 81.0 ± 25.1 kg) concussion history participated. Cognitive performance was assessed with CNS Vital Signs. Tandem gait was performed on a 3-meter walkway. Dual-task tandem gait included a concurrent cognitive task of serial subtraction, reciting months backward, or spelling words backward.

RESULTS

Athletes with a concussion history exhibited a larger number of significant correlations compared with athletes without a concussion history for cognition and dual-task gait time (4 significant correlations: rho-range, -0.377 to 0.358 vs 2 significant correlations: rho, -0.233 to 0.179) and dual-task cost gait time (4 correlations: rho range, -0.344 to 0.392 vs 1 correlation: rho, -0.315). The time between concussion and testing did significantly moderate any associations (P = 0.11-0.63). Athletes with a concussion history displayed better dual-task cost response rate (P = 0.01). There were no other group differences for any cognitive (P = 0.13-0.97) or tandem gait (P = 0.20-0.92) outcomes.

CONCLUSION

Athletes with a concussion history display unique correlations between tandem gait and cognition. These correlations are unaffected by the time since concussion.

CLINICAL RELEVANCE

These unique correlations may represent shared neural resources between cognition and movement that are only present for athletes with a concussion history. Time does not influence these outcomes, indicating the moderating effect of concussion on the correlations persists long-term after the initial injury.

A Narrative Review Of Risk Factors And Predictors For Poor Outcome And Prolonged Recovery After A Mild Traumatic Brain Injury

MATERIAL AND METHODS

A comprehensive search of the main scientific databases (PubMed, Web of Science, Embase, and Cochrane Library) was performed using keywords, such as: "prolonged post-concussion syndrome", combined with "risk factors", "predictors", and "outcomes".

RESULTS

Multiple studies reported more than one risk factor for PPCS development following mTBIs that were generally the results of sports-related concussions and car accidents. The most prevalent risk factor associated with PPCS was the female sex. Social factors/personality traits, anxiety, mental health disorders, or other health conditions from their past medical history, the occurrence of headache/migraines during TBI recovery, somatization, physical activity, and litigation were also reported to contribute to PPCS risk.

CONCLUSIONS

An exhaustive approach is required to mitigate the risk of PPCS and to ensure optimal recovery after concussive events. However, larger prospective cohort studies evaluating patients that were examined and treated with standardized protocols could be needed to further validate these associations and mandate the highest risk factors for delayed recovery.

Pediatric Sport-Related Concussion: Recommendations From the Amsterdam Consensus Statement 2023

The 6th International Consensus Conference on Concussion in Sport, Amsterdam 2022, addressed sport-related concussion (SRC) in adults, adolescents, and children. We highlight the updated evidence-base and recommendations regarding SRC in children (5-12 years) and adolescents (13-18 years). Prevention strategies demonstrate lower SRC rates with mouthguard use, policy disallowing bodychecking in ice hockey, and neuromuscular training in adolescent rugby. The Sport Concussion Assessment Tools (SCAT) demonstrate robustness with the parent and child symptom scales, with the best diagnostic discrimination within the first 72 hours postinjury. Subacute evaluation (>72 hours) requires a multimodal tool incorporating symptom scales, balance measures, cognitive, oculomotor and vestibular, mental health, and sleep assessment, to which end the Sport Concussion Office Assessment Tools (SCOAT6 [13+] and Child SCOAT6 [8-12]) were developed. Rather than strict rest, early return to light physical activity and reduced screen time facilitate recovery. Cervicovestibular rehabilitation is recommended for adolescents with dizziness, neck pain, and/or headaches for greater than 10 days. Active rehabilitation and collaborative care for adolescents with persisting symptoms for more than 30 days may decrease symptoms. No tests and measures other than standardized and validated symptom rating scales are valid for diagnosing persisting symptoms after concussion. Fluid and imaging biomarkers currently have limited clinical utility in diagnosing or assessing recovery from SRC. Improved paradigms for return to school were developed. The variable nature of disability and differences in evaluating para athletes and those of diverse ethnicity, sex, and gender are discussed, as are ethical considerations and future directions in pediatric SRC research.

Dual Task Performance in Adolescents With Idiopathic Scoliosis

Daily life activities commonly include many combinations of dual tasks. Although dual task ability has been studied in healthy young adults, dual task performance in adolescents with idiopathic scoliosis (IS) has not been explored. Our objective in this study was to investigate dual task performance in adolescents with IS. We paired 33 adolescents diagnosed with IS and 33 healthy control participants (age range: 11-17 years) and administered to both groups the Stroop Color and Word test as a measure of cognitive ability, and both the Expanded Timed Up and Go (ETUG) test and the Tandem Gait test as measures of motor tasks. During the motor tasks, we had participants spell five-letter words in reverse and count down by seven from a randomly presented number between 50 and 100 to assess their dual task (cognitive-motor) performance. All cognitive, motor, and dual cognitive-motor test scores differed significantly between the IS and healthy control groups. The time taken to complete all these tasks was longer for participants with IS compared with controls (p < .05). These results revealed diminished performances on dual cognitive-motor tasks among adolescents with IS when compared to peers without IS. Dual task performance is a new research paradigm in the scoliosis rehabilitation field, and it should be further investigated in future studies.

Improving outcome after paediatric concussion: challenges and possibilities

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.

Empowering Lower Limb Disorder Identification through PoseNet and Artificial Intelligence

A novel approach is presented in this study for the classification of lower limb disorders, with a specific emphasis on the knee, hip, and ankle. The research employs gait analysis and the extraction of PoseNet features from video data in order to effectively identify and categorize these disorders. The PoseNet algorithm facilitates the extraction of key body joint movements and positions from videos in a non-invasive and user-friendly manner, thereby offering a comprehensive representation of lower limb movements. The features that are extracted are subsequently standardized and employed as inputs for a range of machine learning algorithms, such as Random Forest, Extra Tree Classifier, Multilayer Perceptron, Artificial Neural Networks, and Convolutional Neural Networks. The models undergo training and testing processes using a dataset consisting of 174 real patients and normal individuals collected at the Tehsil Headquarter Hospital Sadiq Abad. The evaluation of their performance is conducted through the utilization of K-fold cross-validation. The findings exhibit a notable level of accuracy and precision in the classification of various lower limb disorders. Notably, the Artificial Neural Networks model achieves the highest accuracy rate of 98.84%. The proposed methodology exhibits potential in enhancing the diagnosis and treatment planning of lower limb disorders. It presents a non-invasive and efficient method of analyzing gait patterns and identifying particular conditions.

Tandem gait test-retest reliability among healthy physically active young adults

BACKGROUND

A tandem gait assessment is recommended after concussion. There is limited research examining psychometric properties of tandem gait assessments.

OBJECTIVE

To determine tandem gait test intertrial and 1-week test-retest reliability. It was hypothesized that the tandem gait test would yield moderate to good reliability, times would improve across trials/sessions, and average scores would have higher reliability.

DESIGN

Reliability study.

SETTING

Research laboratory.

INTERVENTIONS

Sixty participants (36 females, age: 20.4 ± 1.8 years) completed 10 tandem gait test trials on two occasions.

MAIN OUTCOME MEASURES

Dependent variables included number of normal trials (participants stayed on the line, heel and toe touched on every step, and they avoided touching an examiner/object) and times for each trial. We analyzed intertrial reliability using a one-way analysis of covariance and intraclass correlation coefficients (ICC), and test-retest reliability using dependent samples t-tests and ICCs.

RESULTS

At the first testing session, there were significant differences in times across seven trials (F2.44,80.42  = 21.55, p < .001). All trials were faster than the first trial. The second, third, and fifth trial were faster than the previous trial. There was moderately high overall reliability across the first seven trials (ICC2,1  = 0.77, 95% confidence interval = 0.63, 0.87). All times were faster at the second testing session (compared to the first). Most outcomes for the 1-week test-retest reliability demonstrated at least moderate reliability, including the best times for the first three, four, and five trials; average times for the first four and five trials; and best and average times for all of the participants' normal trials during five and 10 attempted trials.

CONCLUSIONS

There are practice effects when administering multiple tandem gait test trials, but scores stabilize after the fifth trial. There are practice effects associated with multiple administrations of the tandem gait test, but outcomes using times for four or five trials have adequate 1-week test-retest reliability in healthy physically active young adults.

Validity and Reliability of Methods to Assess Movement Deficiencies Following Concussion: A COSMIN Systematic Review

BACKGROUND

There is an increased risk of subsequent concussion and musculoskeletal injury upon return to play following a sports-related concussion. Whilst there are numerous assessments available for clinicians for diagnosis and during return to play following concussion, many may lack the ability to detect these subclinical changes in function. Currently, there is no consensus or collated sources on the reliability, validity and feasibility of these assessments, which makes it difficult for clinicians and practitioners to select the most appropriate assessment for their needs.

OBJECTIVES

This systematic review aims to (1) consolidate the reliability and validity of motor function assessments across the time course of concussion management and (2) summarise their feasibility for clinicians and other end-users.

METHODS

A systematic search of five databases was conducted. Eligible studies were: (1) original research; (2) full-text English language; (3) peer-reviewed with level III evidence or higher; (4) assessed the validity of lower-limb motor assessments used to diagnose or determine readiness for athletes or military personnel who had sustained a concussion or; (5) assessed the test-retest reliability of lower-limb motor assessments used for concussion management amongst healthy athletes. Acceptable lower-limb motor assessments were dichotomised into instrumented and non-instrumented and then classified into static (stable around a fixed point), dynamic (movement around a fixed point), gait, and other categories. Each study was assessed using the COSMIN checklist to establish methodological and measurement quality.

RESULTS

A total of 1270 records were identified, with 637 duplicates removed. Titles and abstracts of 633 records were analysed, with 158 being retained for full-text review. A total of 67 records were included in this review; 37 records assessed reliability, and 35 records assessed the validity of lower-limb motor assessments. There were 42 different assessments included in the review, with 43% being non-instrumented, subjective assessments. Consistent evidence supported the use of instrumented assessments over non-instrumented, with gait-based assessments demonstrating sufficient reliability and validity compared to static or dynamic assessments.

CONCLUSION

These findings suggest that instrumented, gait-based assessments should be prioritised over static or dynamic balance assessments. The use of laboratory equipment (i.e. 3D motion capture, pressure sensitive walkways) on average exhibited sufficient reliability and validity, yet demonstrate poor feasibility. Further high-quality studies evaluating the reliability and validity of more readily available devices (i.e. inertial measurement units) are needed to fill the gap in current concussion management protocols. Practitioners can use this resource to understand the accuracy and precision of the assessments they have at their disposal to make informed decisions regarding the management of concussion.

TRAIL REGISTRATION

This systematic review was registered on PROSPERO (reg no. CRD42021256298).

Acute evaluation of sport-related concussion and implications for the Sport Concussion Assessment Tool (SCAT6) for adults, adolescents and children: a systematic review

OBJECTIVES

To systematically review the scientific literature regarding the acute assessment of sport-related concussion (SRC) and provide recommendations for improving the Sport Concussion Assessment Tool (SCAT6).

DATA SOURCES

Systematic searches of seven databases from 2001 to 2022 using key words and controlled vocabulary relevant to concussion, sports, SCAT, and acute evaluation.

ELIGIBILITY CRITERIA

(1) Original research articles, cohort studies, case-control studies, and case series with a sample of >10; (2) ≥80% SRC; and (3) studies using a screening tool/technology to assess SRC acutely (<7 days), and/or studies containing psychometric/normative data for common tools used to assess SRC.

DATA EXTRACTION

Separate reviews were conducted involving six subdomains: Cognition, Balance/Postural Stability, Oculomotor/Cervical/Vestibular, Emerging Technologies, and Neurological Examination/Autonomic Dysfunction. Paediatric/Child studies were included in each subdomain. Risk of Bias and study quality were rated by coauthors using a modified SIGN (Scottish Intercollegiate Guidelines Network) tool.

RESULTS

Out of 12 192 articles screened, 612 were included (189 normative data and 423 SRC assessment studies). Of these, 183 focused on cognition, 126 balance/postural stability, 76 oculomotor/cervical/vestibular, 142 emerging technologies, 13 neurological examination/autonomic dysfunction, and 23 paediatric/child SCAT. The SCAT discriminates between concussed and non-concussed athletes within 72 hours of injury with diminishing utility up to 7 days post injury. Ceiling effects were apparent on the 5-word list learning and concentration subtests. More challenging tests, including the 10-word list, were recommended. Test-retest data revealed limitations in temporal stability. Studies primarily originated in North America with scant data on children.

CONCLUSION

Support exists for using the SCAT within the acute phase of injury. Maximal utility occurs within the first 72 hours and then diminishes up to 7 days after injury. The SCAT has limited utility as a return to play tool beyond 7 days. Empirical data are limited in pre-adolescents, women, sport type, geographical and culturally diverse populations and para athletes.

PROSPERO REGISTRATION NUMBER

CRD42020154787.

Beyond acute concussion assessment to office management: a systematic review informing the development of a Sport Concussion Office Assessment Tool (SCOAT6) for adults and children

OBJECTIVES

To systematically review the scientific literature regarding the assessment of sport-related concussion (SRC) in the subacute phase (3-30 days) and provide recommendations for developing a Sport Concussion Office Assessment Tool (SCOAT6).

DATA SOURCES

MEDLINE, Embase, PsycINFO, Cochrane CENTRAL, CINAHL, SPORTDiscus and Web of Science searched from 2001 to 2022. Data extracted included study design, population, definition of SRC diagnosis, outcome measure(s) and results.

ELIGIBILITY CRITERIA

(1) Original research, cohort studies, case-control studies, diagnostic accuracy and case series with samples >10; (2) SRC; (3) screening/technology that assessed SRC in the subacute period and (4) low risk of bias (ROB). ROB was performed using adapted Scottish Intercollegiate Guidelines Network criteria. Quality of evidence was evaluated using the Strength of Recommendation Taxonomy classification.

RESULTS

Of 9913 studies screened, 127 met inclusion, assessing 12 overlapping domains. Results were summarised narratively. Studies of acceptable (81) or high (2) quality were used to inform the SCOAT6, finding sufficient evidence for including the assessment of autonomic function, dual gait, vestibular ocular motor screening (VOMS) and mental health screening.

CONCLUSION

Current SRC tools have limited utility beyond 72 hours. Incorporation of a multimodal clinical assessment in the subacute phase of SRC may include symptom evaluation, orthostatic hypotension screen, verbal neurocognitive tests, cervical spine evaluation, neurological screen, Modified Balance Error Scoring System, single/dual task tandem gait, modified VOMS and provocative exercise tests. Screens for sleep disturbance, anxiety and depression are recommended. Studies to evaluate the psychometric properties, clinical feasibility in different environments and time frames are needed.

PROSPERO REGISTRATION NUMBER

CRD42020154787.

Early physical activity after concussion is associated with sleep quality but not dizziness among adolescent athletes

OBJECTIVES

To assess the association between early physical activity and post-concussion sleep quality, dizziness, and postural stability among adolescents with concussion compared to uninjured controls.

DESIGN

Cross-sectional.

METHODS

Adolescents ages 13-18 years assessed within 14 days post-concussion and uninjured controls. Those with concussion reported if they participated in physical activity between the concussion and assessment. Participants completed the Dizziness Handicap Inventory, Pittsburgh Sleep Quality Index, and single/dual-task tandem gait.

RESULTS

We enrolled 34 participants with concussion (early physical activity: n = 10, age = 15.8 ± 1.6 years, 70% female; no physical activity: n = 24, age = 16.0 ± 1.3 years, 50% female) and 21 uninjured controls (age = 16.0 ± 1.8 years, 48% female). Compared to controls, the no physical activity group reported worse sleep quality (Pittsburgh Sleep Quality Index: 3.8 ± 2.7 vs 8.0 ± 4.9 points, p = 0.002) and single-task tandem gait time (13.7 ± 3.4 vs 21.2 ± 8.1 s, p = 0.0006), while the early physical activity group did not (Pittsburgh Sleep Quality Index: 3.8 ± 2.7 vs 5.8 ± 3.2 points, p = 0.38; single-task tandem gait: 13.7 ± 3.4 vs 19.0 ± 5.7 s, p = 0.08). Compared to controls, early/no physical activity groups reported worse dizziness (Dizziness Handicap Inventory: 2.0 ± 3.4 vs 22.9 ± 23.8 vs 27.4 ± 19.2 points, p < 0.0001). There were no significant between-group differences for dual-task tandem gait (24.1 ± 8.0 vs 24.8 ± 6.2 vs 26.6 ± 7.3 s, p = 0.57).

CONCLUSIONS

The no physical activity group reported worse sleep quality and slower single-task tandem gait than controls, while both groups reported similar sleep quality and tandem gait. Early physical activity may promote sleep quality and postural stability, or early physical activity may be a function of improved sleep and postural stability after concussion.

Lower Extremity Musculoskeletal Injuries After Concussion in Collegiate Student-Athletes

BACKGROUND

An association has been identified between concussion and lower extremity musculoskeletal injury (LEMSKI) after return to sports participation. However, the collegiate student-athlete studies have relied on relatively small single-institution studies, which limits generalizability.

PURPOSE

To assess odds of, and time to, LEMSKI after concussion in US collegiate athletes, using the National Collegiate Athletic Association (NCAA) Injury Surveillance Program (ISP).

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Data from the NCAA ISP during the 2010-2011 through 2019-2020 athletic seasons were considered for analysis. Frequency distributions were examined for details related to the initial and subsequent injuries (injuries to bone, bursa, joint, ligament, muscle, or tendon). Multivariable logistic regression models and random-effects Poisson regression models examined odds of time loss (TL) and non-time loss (NTL) LEMSKI after concussion, as well as the time interval between initial concussion and subsequent LEMSKI in a single athletic season, or initial musculoskeletal injury (MSKI) and subsequent LEMSKI in a single athletic season. Analyses were performed separately for football and other sports.

RESULTS

A total of 31,556 initial injuries were recorded (football: 11,900; other sports: 19,656), which were followed by 0 or 1 injury in the same season. Overall, first injury type was not a significant predictor of subsequent LEMSKI, although certain contrasts yielded significant estimates. In football, the odds of NTL LEMSKI were higher after concussion than after upper extremity MSKI (UEMSKI; adjusted odds ratio [OR_Adj], 1.56; 95% CI, 1.06-2.31). In football, the odds of TL LEMSKI were lower after concussion than after UEMSKI (OR_Adj, 0.71; 95% CI, 0.51-0.99). No other significant effect estimates were observed for football or other sports.

CONCLUSION

First injury type, either concussion or upper extremity, was not associated with an elevated risk of LEMSKI. Specifically, the results of this study did not identify an elevated odds of LEMSKI after a concussion. However, the authors observed greater odds of NTL LEMSKI and lower odds of TL LEMSKI in football.

Multi-domain assessment of sports-related and military concussion recovery: A scoping review

OBJECTIVE

This review explores the literature on multi-domain assessments used in concussion recovery, to inform evidence-based and ecologically valid return-to-play. It asks: What simultaneous, dynamic multi-domain paradigms are used to assess recovery of youth and adults following concussion?

METHODS

Five databases were searched (CINAHL, EMBASE, MEDLINE, PsycInfo, SPORTDiscus) until September 30, 2021. Records were limited to those published in peer-reviewed journals, in English, between 2002 and 2021. Included studies were required to describe the assessment of concussion recovery using dynamic paradigms (i.e., requiring sport-like coordination) spanning multiple domains (i.e., physical, cognitive, socio-emotional functioning) simultaneously.

RESULTS

7098 unique articles were identified. 64 were included for analysis, describing 36 unique assessments of 1938 concussed participants. These assessments were deconstructed into their constituent tasks: 13 physical, 17 cognitive, and one socio-emotional. Combinations of these "building blocks" formed the multi-domain assessments. Forty-six studies implemented level walking with a concurrent cognitive task. The most frequently implemented cognitive tasks were 'Q&A' paradigms requiring participants to answer questions aloud during a physical task.

CONCLUSIONS

A preference emerged for dual-task assessments, specifically combinations of level walking and Q&A tasks. Future research should balance ecological validity and clinical feasibility in multi-domain assessments, and work to validate these assessments for practice.

Clinical gait characteristics in the early post-concussion phase: A systematic review

BACKGROUND

Understanding gait alterations immediately post-concussion can improve identification, management and prognosis of concussion.

OBJECTIVE

To identify and define gait characteristics immediately post-concussion.

METHOD

A review of electronic databases was conducted using terms gait alteration AND mTBI OR concussion. 172 reports were identified. After restricting to English and human studies, 158 remained. Reports were screened to include studies assessing quantifiable gait change post-concussion. 12 studies were included.

DISCUSSION

Multiple gait features are altered post-impact: stability, step length, walking speed and postural control. There is evidence that postural measures in gait initiation and termination may identify more subtle deficits. There is paucity of data evaluating the impact of concussion on gait function acutely and the authors identified no studies examining immediate changes.

CONCLUSION

Acutely post-concussion, various gait alterations are seen and correlate with degree of deficit and prognosis. Slowed gait, instability and postural control are several features. Dynamic gait and postural assessments identify more subtle gait alterations. Given the absence in literature, high quality prospective studies examining immediate gait alterations post-concussion would contribute to improved assessment, management and prognostication. Given difficulty in participant recruitment, technological and standardised gait assessments should be used to assess force of impact and immediate gait alteration.

Sports-related concussion: assessing the comprehension, collaboration, and contribution of chiropractors

Over the last 2 decades, sports-related concussion (SRC) awareness and management have evolved from an emphasis on complete cognitive and physical rest to evidence-based protocols and interventions. Chiropractors are primary care providers with exposure to athletes and teams in collision sports and, in addition, manage patients with concussion-like symptoms including neck pain, dizziness, and headache. With SRC frequently occurring in the absence of a medical practitioner, the role of allied health practitioners like chiropractors should be emphasised when it comes to the recognition, assessment, and management of SRC. This commentary discusses the potential contribution of chiropractors in SRC and the specific role their expertise in the cervical spine may play in symptom evaluation and management. A PubMed and Google scholar review of the chiropractic SRC literature suggests that the chiropractic profession appears under-represented in concussion research in athletic populations compared to other medical and allied health fields. This includes an absence of chiropractic clinicians with a focus on SRC participating in the Concussion in Sport Group (CISG) and the International Consensus Conferences on Concussion. Furthermore, with evolving evidence suggesting the importance of cervicogenic manifestations in SRC, there is an opportunity for chiropractors to participate in SRC diagnosis and management more fully and contribute scientifically to an area of specialised knowledge and training. With a dearth of chiropractic orientated SRC science, clinical SRC expertise, and clinical chiropractic representation in the CISG; it is incumbent on chiropractic clinicians and scientists to take up this opportunity through meaningful contribution and involvement in the SRC field.

Dizziness Is Associated With Neck/Shoulder Pain Following Pediatric Concussion

OBJECTIVE

To examine the association between dizziness and neck/shoulder pain after concussion and if differences in postural stability and oculomotor function exist among patients reporting dizziness with or without concurrent neck/shoulder pain.

DESIGN

Cross sectional.

SETTING

Sports medicine clinic.

PATIENTS

Pediatric patients ≤14 days post concussion.

INTERVENTIONS

N/A.

OUTCOME MEASURES

Patients completed the Health and Behavior Inventory (HBI) symptom rating and separately rated neck/shoulder pain (scale 0-3; 0 = no pain). We grouped patients by HBI dizziness rating (0 = not-dizzy; 1-3 = dizzy) and compared neck/shoulder pain ratings between the groups. We then compared oculomotor and postural stability outcomes between dizzy patients with and without neck/shoulder pain.

RESULTS

We included 153 patients: dizzy (n = 100; age = 14.6 ± 2.2 years; 48% female) and not-dizzy (n = 53, age = 14.4 ± 3.1 years; 38% female). The dizzy group reported significantly higher neck/shoulder pain (1.4 ± 1.1 vs 0.5 ± 0.9 points, P < 0.001) and total symptom score (25.7 ± 11.2 vs 11.7 ± 9.3 points, P < 0.001) than the not-dizzy group. After adjusting for total symptom score and preinjury anxiety, depression, and migraines, dizziness was associated with higher odds of neck/shoulder pain (odds ratio = 1.9, 95% CI, 1.2-3.0; P = 0.004). No differences were observed between dizzy patients with and without neck/shoulder pain for near point of convergence (10.0 ± 7.5 vs 8.5 ± 6.7 cm, P = 0.43), modified Balance Error Scoring System (8.9 ± 5.5 vs 6.8 ± 4.7 errors, P = 0.09), or tandem gait (single-task: 26.0 ± 12.3 vs 24.2 ± 11.9 seconds, P = 0.56; dual-task: 35.1 ± 14.3 vs 35.6 ± 18.6 seconds, P = 0.90).

CONCLUSIONS

In concussion patients experiencing dizziness, evaluating neck/shoulder pain may help identify individuals who would benefit from cervical spine rehabilitation. However, other potential causes of dizziness should also be evaluated to facilitate timely recovery.

Postconcussion Exercise Volume Associations With Depression, Anxiety, and Dizziness Symptoms, and Postural Stability: Preliminary Findings

OBJECTIVE

To examine the association between postconcussion exercise volume and changes in depression, anxiety, dizziness, and postural stability.

DESIGN

Secondary analysis of a single-site prospective clinical trial.

SETTING

Cerebrovascular research laboratory.

PARTICIPANTS

Participants completed questionnaires and underwent tests of gait and balance within 2 weeks of a concussion (mean = 11 ± 3 days postconcussion) and approximately 1 month later (mean = 41 ± 7 days postconcussion). Exercise volume was tracked by weekly exercise logs.

INTERVENTIONS

On the basis of a previous work classifying exercise volume following concussion, we grouped participants according to self-reported exercise volume between visits as high exercise volume (≥150 min/wk) or low exercise volume (<150 min/wk).

MAIN OUTCOME MEASURES

Participants completed assessments evaluating anxiety and depression (Hospital Anxiety and Depression Scale), dizziness (Dizziness Handicap Inventory), and postural stability (tandem gait and modified Balance Error Scoring System).

RESULTS

Thirty-eight participants completed the study, of which 22 were in the high exercise volume group (mean = 71 ± 40 min/wk; 16.8 ± 2.1 years; 59% female) and 16 were in the low exercise volume group (mean = 379 ± 187 min/wk; 17.5 ± 2.1 years; 31% female). Although depression symptoms were not significantly different initially (mean difference = 1.5; 95% CI, -0.68 to 3.68; P = .24), the high exercise volume group had significantly lower depression symptom scores at follow-up (mean difference = 3.0; 95% CI, 1.40 to 4.47; P < .001). Anxiety symptoms (mean difference = 2.8; 95% CI, 0.3 to 5.4; P = 0.03), dizziness symptoms (mean difference = 10.9; 95% CI, 0.2 to 21.5; P = .047), single-task tandem gait (mean difference = 3.1 seconds; 95% CI, 0.2 to 6.0; P = .04), and dual-task tandem gait (mean difference = 4.2 seconds; 95% CI, 0.2 to 8.2; P = .04) were significantly better among the high exercise volume group.

CONCLUSION

Greater exercise volumes were associated with lower depression, anxiety, and dizziness symptoms, and faster tandem gait performance. These preliminary findings suggest a potentially beneficial role for exercise within several different domains commonly affected by concussion.

Postconcussion Dizziness Severity Predicts Daily Step Count during Recovery among Adolescent Athletes

PURPOSE

Physical activity (PA) after concussion is an important aspect of appropriate clinical management. However, symptoms or functional deficits may reduce patient propensity toward PA, thereby negatively affecting recovery. Our purpose was to examine whether postconcussion dizziness, total symptom severity, or postural stability predicts PA level in the 2 wk after initial evaluation.

METHODS

We evaluated adolescent athletes within 14 d of concussion on assessments of symptoms, dizziness, and postural stability. Athletes were provided an activity monitor to track PA for 2 wk after the evaluation. Our primary outcome was step count (mean steps per day). Potential predictor variables included sex, Post-Concussion Symptom Inventory (PCSI) total symptom severity, individual PCSI ratings of dizziness and balance impairment, and postural stability assessments (single- and dual-task tandem gait, modified Balance Error Scoring System). To examine predictors of PA, we calculated correlation coefficients between steps per day and each potential predictor and included significantly correlated variables in a multivariable regression model.

RESULTS

Participants were ages 12-18 yr (n = 35, 15.2 ± 1.7 yr, 49% female) and initially evaluated 7.3 ± 3.0 d after concussion. Upon univariable evaluation, PCSI dizziness rating (Pearson R = -0.49, P = 0.003) and sex (mean difference, 2449 steps per day; P = 0.05) were associated with steps per day. Within the multivariable regression analysis, PCSI dizziness rating (β = -1035; 95% confidence interval, -191 to -1880; P = 0.018), but not sex, predicted average steps per day in the 2 wk after initial evaluation.

CONCLUSIONS

Self-reported dizziness, but not overall symptom severity or postural stability, assessed within 14 d of concussion predicted daily step count in the subsequent 2 wk. Given the importance of PA for concussion recovery, treating acute postconcussion dizziness can potentially reduce a barrier to PA and improve recovery trajectories.

A novel smartphone application is reliable for repeat administration and comparable to the Tekscan Strideway for spatiotemporal gait

Smartphone applications are increasingly being used to measure gait due to their portability and cost-effectiveness. Important reliability metrics are not available for most of these devices. The purpose of this article was to evaluate the test-retest reliability and concurrent validity of spatiotemporal gait using the novel Gait Analyzer smartphone application compared to the Tekscan Strideway. Healthy participants (n=23) completed 12 trials of 10-meter walking, at two separate time points, using Gait Analyzer and while walking across the Tekscan Strideway. The results suggest excellent test-retest reliability for the Gait Analyzer and good test-retest reliability for the Tekscan Strideway for both velocity and cadence. At both time points, these devices were moderately to strongly correlated to one another for both velocity and cadence. These data suggest that the Gait Analyzer and Tekscan Strideway are reliable over time and can comparably calculate velocity and cadence.

Post-Concussion Dizziness, Sleep Quality, and Postural Instability: A Cross-Sectional Investigation

CONTEXT

Dizziness, postural instability, and poor sleep quality are all commonly reported post-concussion and individually relate to poor outcomes.

OBJECTIVE

To examine sleep quality and postural stability among adolescents who did and did not report dizziness within two weeks of concussion.

DESIGN

Cross-sectional study.

SETTING

Research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Participants ages 12-18 years within 14 days of concussion (n=58, 15.2±1.8 years; 50% female; 7.1±3.1 days post-injury) and uninjured controls (n=73; 15.8±1.3 years; 42% female).

MAIN OUTCOME MEASURES

Participants completed pre-injury and current dizziness ratings on the Post-Concussion Symptom Inventory (PCSI) and current sleep quality on the Pittsburgh Sleep Quality Index (PSQI). Participants also completed postural stability assessments (single/dual-task tandem gait and modified Balance Error Scoring System [mBESS]).

RESULTS

We grouped concussion patients into dizzy (n=21) or not dizzy (n=37) groups based on PCSI dizziness ratings: difference between current and pre-injury dizziness rating >3=dizzy; difference <3=not dizzy. The dizzy and not dizzy groups both reported significantly worse sleep quality than the control group (PSQI score: mean=9.6±3.7 vs 7.2±3.5 vs 4.3±2.6; p<0.001) upon univariable comparison. Similarly, the dizzy group performed slowest on single and dual-task tandem gait, followed by the not dizzy group, then the control group (single-task TG: mean= 27.2±11.7 sec vs 21.2±6.3 vs 14.7±3.6; p<0.001); (dual-task TG: mean=38.4±16.2 sec vs 29.9±7.2 vs 21.6±7.5; p<0.001). Both concussion groups demonstrated significantly more errors than the control group on the mBESS (mean=9.8±5.1 vs 6.9±5.8 vs 3.8±3.5; p<0.001). After controlling for total symptom severity in the multivariable model, tandem gait, but not mBESS or sleep quality, was associated with dizziness.

CONCLUSION

Individuals with post-concussion dizziness also demonstrated impaired tandem gait performance, while poor sleep quality was associated with total symptom severity. Identifying and treating the underlying dysfunction contributing to dizziness and postural instability may guide individualized rehabilitation strategies and facilitate recovery.

Symptom and clinical recovery outcomes for pediatric concussion following early physical activity

OBJECTIVE

Recent research supports initiating physical activity as soon as 24 to 48 hours after concussion to reduce persistent postconcussive symptoms. However, this practice has not been widely adopted. The objective of this study was to evaluate the association of early physical activity with patient-reported and functional outcomes for pediatric patients following a concussion.

METHODS

A retrospective cohort of patients who presented to a pediatric sports medicine clinic (48% female, mean age14.3 ± 2.6 years, and mean 9.8 ± 5.7 days postconcussion) were evaluated. Patients were grouped based on whether they reported engaging in physical activity prior to presenting to the clinic. Patient- and parent-reported symptom frequency (Health and Behavior Inventory), 11 different clinical outcomes (including missed school, memory recall, and balance assessments), the presence of symptoms persisting beyond 28 days, and a subgroup analysis of those patients receiving exercise versus symptom-limiting activity prescriptions were examined. Outcomes were compared between physical activity groups using the Mann-Whitney U-test and the chi-square test. To adjust for the effect of potential confounders, a logistic binary regression model was constructed.

RESULTS

In total, 211 pediatric patients were included, 35 (17%) of whom reported early physical activity. A greater proportion of the no physical activity group reported a headache (85% vs 60%, p = 0.001). The no physical activity group also reported higher patient-reported (23.1 ± 13.4 vs 15.0 ± 13.4, p < 0.001) and parent-reported (19.4 ± 12.7 vs 11.2 ± 10.3, p = 0.001) symptom frequency at the initial visit. The early physical activity group had a lower proportion of patients with persistent symptoms (44% vs 22%, p = 0.02) and a shorter time to symptom resolution (15.6 ± 12.4 days vs 27.2 ± 24.2 days, p = 0.02). After adjusting for potential confounders, early physical activity was associated with 5.8 lower odds of experiencing persistent symptoms (adjusted OR 5.83, 95% CI 2.05-16.61; p = 0.001).

CONCLUSIONS

A significant association between early physical activity and decreased symptom burden was observed. A lower proportion of those patients who engaged in early physical activity experienced persistent symptoms 28 days postinjury. However, low rates of early physical activity prior to the initial clinic visit were also observed, indicating that this approach may not be well known by acute care or primary care providers, or is not widely adopted by patients and families.

Reliability and Minimal Detectable Change for a Smartphone-Based Motor-Cognitive Assessment: Implications for Concussion Management

Our purpose was to investigate the reliability and minimal detectable change characteristics of a smartphone-based assessment of single- and dual-task gait and cognitive performance. Uninjured adolescent athletes (n = 17; mean age = 16.6, SD = 1.3 y; 47% female) completed assessments initially and again 4 weeks later. The authors collected data via an automated smartphone-based application while participants completed a series of tasks under (1) single-task cognitive, (2) single-task gait, and (3) dual-task cognitive-gait conditions. The cognitive task was a series of continuous auditory Stroop cues. Average gait speed was consistent between testing sessions in single-task (0.98, SD = 0.21 vs 0.96, SD = 0.19 m/s; P = .60; r = .89) and dual-task (0.92, SD = 0.22 vs 0.89, SD = 0.22 m/s; P = .37; r = .88) conditions. Response accuracy was moderately consistent between assessments in single-task standing (82.3% accurate, SD = 17.9% vs 84.6% accurate, SD = 20.1%; P = .64; r = .52) and dual-task gait (89.4% accurate, SD = 15.9% vs 85.8% accurate, SD = 20.2%; P = .23; r = .81) conditions. Our results indicate automated motor-cognitive dual-task outcomes obtained within a smartphone-based assessment are consistent across a 1-month period. Further research is required to understand how this assessment performs in the setting of sport-related concussion. Given the relative reliability of values obtained, a smartphone-based evaluation may be considered for use to evaluate changes across time among adolescents, postconcussion.

Is near point of convergence associated with symptom profiles or recovery in adolescents after concussion?

Our purpose was to compare the clinical and injury characteristics of concussion patients with a receded near point of convergence (NPC) vs those without a receded NPC. Concussion patients were seen within 14 days of injury. We compared those with receded a NPC (>6 cm) break point distance and those with a normal NPC distance on symptom, behavioral, and clinical assessments. We also compared NPC break points between those who did/did not recover within 28 days of injury. 123 patients completed the assessment. 77/123 (63%) of participants demonstrated a receded NPC when tested within 14 days of injury. Those with receded a NPC break point (n = 77; mean = 14.9, SD = 1.5 years; 47% female) were significantly younger than those with a normal NPC break point (n = 46; mean = 15.7, SD = 1.7 years; 46% female). The receded NPC break point group had a significantly greater proportion of patients reporting headaches (86% vs. 61%), as well as significantly greater cognitive (mean = 13.4, SD = 8.7 vs. mean = 8.8, SD = 8.6), somatic (mean = 10.0, SD = 5.9 vs. mean = 6.9, SD = 6.6), and overall (mean = 23.7, SD = 13.6 vs. mean = 15.8, SD = 14.4) symptom severity. Our multivariable model indicated among all potential predictor variables, more severe somatic symptoms were significantly associated with a greater NPC break point (β = 0.26; 95% CI = 0.01, 0.52). The group who went onto experience persistent symptoms had a significantly greater NPC break point at initial evaluation than those without persistent symptoms (mean = 9.7, SD = 7.5 cm vs. mean = 7.0, SD = 4.0 cm). Those with a receded NPC break point at initial evaluation showed an increased symptom burden, most notable with somatic symptoms, compared with those without a receded NPC break point.