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Roby PR, McDonald CC, Corwin DJ, Grady MF, Master CL, Arbogast KB. Characteristics of Pediatric Concussion across Different Mechanisms of Injury in 5 through 12-Year-Olds. J Pediatr 2024; 274:114157. [PMID: 38901776 DOI: 10.1016/j.jpeds.2024.114157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 05/10/2024] [Accepted: 06/11/2024] [Indexed: 06/22/2024]
Abstract
OBJECTIVE To investigate characteristics of sport-related concussion (SRC), recreation-related concussion (RRC), and nonsport or recreation-related concussion (non-SRRC) in patients 5 through 12 years old, an understudied population in youth concussion. STUDY DESIGN This observational study included patients aged 5 through 12 years presenting to a specialty care concussion setting at ≤28 days postinjury from 2018 through 2022. The following characteristics were assessed: demographics, injury mechanism (SRC, RRC, or SRRC), point of healthcare entry, and clinical signs and symptoms. Kruskal-Wallis and chi-square tests were used to assess group differences. Posthoc pairwise comparisons were employed for all analyses (α = 0.017). RESULTS One thousand one hundred forty-one patients reported at ≤28 days of injury (female = 42.9%, median age = 11, interquartile range (IQR) = 9-12) with the most common mechanism being RRC (37.3%), followed by non-SRRC (31.9%). More non-SRRCs (39.6%) and RRC (35.7%) were first seen in the emergency department (P < .001) compared with SRC (27.9%). Patients with RRC and non-SRRC were first evaluated at specialists 2 and 3 days later than SRC (P < .001). Patients with non-SRRC reported with higher symptom burden, more frequent visio-vestibular abnormalities, and more changes to sleep and daily habits (P < .001) compared with RRC and SRC (P < .001). CONCLUSIONS In concussion patients 5 through 12 years, RRCs and non-SRRC were more prevalent than SRC, presenting first more commonly to the emergency department and taking longer to present to specialists. Non-SRRC had more severe clinical features. RRC and non-SRRC are distinct from SRC in potential for less supervision at time of injury and less direct access to established concussion health care following injury.
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Affiliation(s)
- Patricia R Roby
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Catherine C McDonald
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA
| | - Daniel J Corwin
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Matthew F Grady
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Sports Medicine Performance Center, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christina L Master
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Sports Medicine Performance Center, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kristy B Arbogast
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA.
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Master CL, Corwin DJ, Fedonni D, Ampah SB, Housel KC, McDonald C, Arbogast KB, Grady MF. Dose-Response Effect of Mental Health Diagnoses on Concussion Recovery in Children and Adolescents. Sports Health 2024; 16:254-268. [PMID: 38349046 PMCID: PMC10916772 DOI: 10.1177/19417381241228870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Pre-existing mental health diagnoses may contribute to greater emotional symptom burden and prolonged recovery after concussion. HYPOTHESIS Youth with pre-existing mental health diagnoses will have greater emotional symptom burden, greater risk for delayed return to exercise, and more prolonged recovery from concussion than those without those diagnoses. STUDY DESIGN Prospective cohort. LEVEL OF EVIDENCE Level 3. METHODS A prospective registry of youth concussion was examined for differences in emotional symptom burden after injury to develop a predictive risk model for prolonged recovery. The impact of individual and total number of pre-existing mental health diagnoses (0, 1, 2, and 3+) was assessed, and multivariable logistic regression was performed to identify factors associated with prolonged recovery. RESULTS Among a cohort of 3105 youth with concussion, those with a history of mental health diagnoses, in a dose-response fashion, had greater postinjury emotional symptom burden (7 emotional symptoms vs 4; P < 0.01), visio-vestibular dysfunction (65% abnormal vs 56% abnormal; P < 0.01), later return to symptom-limited exercise (23 vs 21 days; P < 0.01), and overall longer concussion recovery (38 days, interquartile range [IQR] 18, 80) versus 25 days (IQR 13, 54; P < 0.01). Boys with prolonged recovery after concussion had greater emotional symptom burden than girls (5 emotional symptoms vs 3; P < 0.01). CONCLUSION Pre-existing mental health diagnoses are associated with greater postinjury emotional symptom burden and longer concussion recovery in a dose-response fashion. Visiovestibular deficits and delayed return to exercise are also associated with pre-existing mental health diagnoses and prolonged recovery. Boys with prolonged recovery from concussion experience greater emotional symptom burden than girls. CLINICAL RELEVANCE Addressing pre-existing mental health diagnoses is essential to concussion management. Boys with prolonged recovery from concussion may particularly benefit from interventions to address their higher emotional symptom burden. Interventions, including a home visio-vestibular exercise program and symptom-limited exercise, may contribute to improving time to concussion recovery.
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Affiliation(s)
- Christina L Master
- Sports Medicine and Performance Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Daniel J Corwin
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Daniele Fedonni
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Steven B Ampah
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kaitlyn C Housel
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Catherine McDonald
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Kristy B Arbogast
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew F Grady
- Sports Medicine and Performance Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Anderson M, Tomczyk CP, Zynda AJ, Pollard-McGrandy A, Loftin MC, Covassin T. Preliminary Baseline Vestibular Ocular Motor Screening Scores in Pediatric Soccer Athletes. J Sport Rehabil 2024; 33:5-11. [PMID: 37758258 DOI: 10.1123/jsr.2022-0327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 07/23/2023] [Accepted: 08/06/2023] [Indexed: 10/03/2023]
Abstract
CONTEXT The utility of baseline vestibular and ocular motor screening (VOMS) in high school and collegiate athletes is demonstrated throughout the literature; however, baseline VOMS data at the youth level are limited. In addition, with the recent adoption of the change scoring method, there is a need to document baseline VOMS total and change scores in a pediatric population. OBJECTIVE To document baseline VOMS total and change scores and to document the internal consistency of the VOMS in pediatric soccer athletes. We hypothesized that the VOMS would demonstrate strong internal consistency in pediatric soccer athletes. DESIGN Cross-sectional study. METHODS Pediatric soccer athletes (N = 110; range = 5-12 y) completed the VOMS at baseline. Descriptive statistics summarized demographic information, VOMS total scores, and VOMS change scores. Cronbach α assessed internal consistency for VOMS total scores and change scores. RESULTS Twenty-one (19.1%) participants had at least one total score above clinical cutoffs (≥2 on any VOMS component and ≥5 cm on average near point convergence). Forty (36.4%) participants had at least one change score above clinical cutoffs (≥1 on any VOMS component and ≥3 cm on average near point convergence). The internal consistency was strong for total scores with all VOMS components included (Cronbach α = .80) and change scores (Cronbach α = .89). CONCLUSIONS Although results suggest VOMS items measure distinct components of the vestibular and ocular motor systems, caution should be taken when interpreting VOMS total and change scores in pediatric athletes, as overreporting symptoms is common, thereby impacting the false-positive rate.
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Affiliation(s)
- Morgan Anderson
- Sports Therapy and Research, Baylor Scott & White Health, Frisco, TX, USA
| | | | - Aaron J Zynda
- Department of Kinesiology, Michigan State University, East Lansing, MI, USA
| | | | - Megan C Loftin
- Department of Kinesiology, Michigan State University, East Lansing, MI, USA
| | - Tracey Covassin
- Department of Kinesiology, Michigan State University, East Lansing, MI, USA
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Corwin DJ, Metzger KB, McDonald CC, Pfeiffer MR, Arbogast KB, Master CL. The Variability of Recovery From Pediatric Concussion Using Multimodal Clinical Definitions. Sports Health 2024; 16:79-88. [PMID: 36896665 PMCID: PMC10732108 DOI: 10.1177/19417381231152448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND While concussions are common pediatric injuries, a lack of agreement on a standard definition of recovery creates multiple challenges for clinicians and researchers alike. HYPOTHESIS The percentage of concussed youth deemed recovered as part of a prospective cohort study will differ depending on the recovery definition. STUDY DESIGN Descriptive epidemiologic study of a prospectively enrolled observational cohort. LEVEL OF EVIDENCE Level 3. METHODS Participants aged 11 to 18 years were enrolled from the concussion program of a tertiary care academic center. Data were collected from initial and follow-up clinical visits ≤12 weeks from injury. A total of 10 recovery definitions were assessed: (1) cleared to full return to sports; (2) return to full school; (3) self-reported return to normal; (4) self-reported full return to school; (5) self-reported full return to exercise; (6) symptom return to preinjury state; (7) complete symptom resolution; (8) symptoms below standardized threshold; (9) no abnormal visio-vestibular examination (VVE) elements; and (10) ≤1 abnormal VVE assessments. RESULTS In total, 174 participants were enrolled. By week 4, 63.8% met at least 1 recovery definition versus 78.2% by week 8 versus 88.5% by week 12. For individual measures of recovery at week 4, percent recovered ranged from 5% by self-reported full return to exercise to 45% for ≤1 VVE abnormality (similar trends at 8 and 12 weeks). CONCLUSION There is wide variability in the proportion of youth considered recovered at various points following concussion depending on the definition of recovery, with higher proportions using physiologic examination-based measures and lower proportions using patient-reported measures. CLINICAL RELEVANCE These results further emphasize the need for a multimodal assessment of recovery by clinicians as a single and standardized definition of recovery that captures the broad impact of concussion on a given patient continues to be elusive.
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Affiliation(s)
- Daniel J. Corwin
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Emergency Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kristina B. Metzger
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Catherine C. McDonald
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melissa R. Pfeiffer
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kristy B. Arbogast
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Emergency Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christina L. Master
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Sports Medicine and Performance Center, and The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Corwin DJ, Mandel F, McDonald CC, Mohammed FN, Margulies S, Barnett I, Arbogast KB, Master CL. Maximizing the Accuracy of Adolescent Concussion Diagnosis Using Individual Elements of Common Standardized Clinical Assessment Tools. J Athl Train 2023; 58:962-973. [PMID: 36645832 PMCID: PMC10784885 DOI: 10.4085/1062-6050-0020.22] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
CONTEXT Multiple clinical evaluation tools exist for adolescent concussion with various degrees of correlation, presenting challenges for clinicians in identifying which elements of these tools provide the greatest diagnostic utility. OBJECTIVE To determine the combination of elements from 4 commonly used clinical concussion batteries that maximize discrimination of adolescents with concussion from those without concussion. DESIGN Cross-sectional study. SETTING Suburban school and concussion program of a tertiary care academic center. PATIENTS OR OTHER PARTICIPANTS A total of 231 participants with concussion (from a suburban school and a concussion program) and 166 participants without concussion (from a suburban school) between the ages of 13 and 19 years. MAIN OUTCOME MEASURE(S) Individual elements of the visio-vestibular examination (VVE), Sport Concussion Assessment Tool, fifth edition (SCAT5; including the modified Balance Error Scoring System), King-Devick test (K-D), and Postconcussion Symptom Inventory (PCSI) were evaluated. The 24 subcomponents of these tests were grouped into interpretable factors using sparse principal component analysis. The 13 resultant factors were combined with demographic and clinical covariates into a logistic regression model and ranked by frequency of inclusion into the ideal model, and the predictive performance of the ideal model was compared with each of the clinical batteries using the area under the receiver operating characteristic curve (AUC). RESULTS A cluster of 4 factors (factor 1 [VVE saccades and vestibulo-ocular reflex], factor 2 [modified Balance Error Scoring System double-legged stance], factor 3 [SCAT5/PCSI symptom scores], and factor 4 [K-D completion time]) emerged. A model fit with the top factors performed as well as each battery in predicting concussion status (AUC = 0.816 [95% CI = 0.731, 0.889]) compared with the SCAT5 (AUC = 0.784 [95% CI = 0.692, 0.866]), PCSI (AUC = 0.776 [95% CI = 0.674, 0.863]), VVE (AUC = 0.711 [95% CI = 0.602, 0.814]), and K-D (AUC = 0.708 [95% CI = 0.590, 0.819]). CONCLUSIONS A multifaceted assessment for adolescents with concussion, comprising symptoms, attention, balance, and the visio-vestibular system, is critical. Current diagnostic batteries likely measure overlapping domains, and the sparse principal component analysis demonstrated strategies for streamlining comprehensive concussion assessment across a variety of settings.
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Affiliation(s)
- Daniel J. Corwin
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, PA
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, PA
| | - Francesca Mandel
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | - Catherine C. McDonald
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, PA
- School of Nursing, University of Pennsylvania, Philadelphia
| | - Fairuz N. Mohammed
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, PA
| | - Susan Margulies
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta
| | - Ian Barnett
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | - Kristy B. Arbogast
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, PA
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, PA
| | - Christina L. Master
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, PA
- Sports Medicine and Performance Center, Children’s Hospital of Philadelphia, PA
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de Souza DN, Jarmol M, Bell CA, Marini C, Balcer LJ, Galetta SL, Grossman SN. Precision Concussion Management: Approaches to Quantifying Head Injury Severity and Recovery. Brain Sci 2023; 13:1352. [PMID: 37759953 PMCID: PMC10526525 DOI: 10.3390/brainsci13091352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023] Open
Abstract
Mitigating the substantial public health impact of concussion is a particularly difficult challenge. This is partly because concussion is a highly prevalent condition, and diagnosis is predominantly symptom-based. Much of contemporary concussion management relies on symptom interpretation and accurate reporting by patients. These types of reports may be influenced by a variety of factors for each individual, such as preexisting mental health conditions, headache disorders, and sleep conditions, among other factors. This can all be contributory to non-specific and potentially misleading clinical manifestations in the aftermath of a concussion. This review aimed to conduct an examination of the existing literature on emerging approaches for objectively evaluating potential concussion, as well as to highlight current gaps in understanding where further research is necessary. Objective assessments of visual and ocular motor concussion symptoms, specialized imaging techniques, and tissue-based concentrations of specific biomarkers have all shown promise for specifically characterizing diffuse brain injuries, and will be important to the future of concussion diagnosis and management. The consolidation of these approaches into a comprehensive examination progression will be the next horizon for increased precision in concussion diagnosis and treatment.
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Affiliation(s)
- Daniel N. de Souza
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10017, USA; (D.N.d.S.); (M.J.); (C.A.B.); (C.M.); (L.J.B.); (S.L.G.)
| | - Mitchell Jarmol
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10017, USA; (D.N.d.S.); (M.J.); (C.A.B.); (C.M.); (L.J.B.); (S.L.G.)
| | - Carter A. Bell
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10017, USA; (D.N.d.S.); (M.J.); (C.A.B.); (C.M.); (L.J.B.); (S.L.G.)
| | - Christina Marini
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10017, USA; (D.N.d.S.); (M.J.); (C.A.B.); (C.M.); (L.J.B.); (S.L.G.)
| | - Laura J. Balcer
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10017, USA; (D.N.d.S.); (M.J.); (C.A.B.); (C.M.); (L.J.B.); (S.L.G.)
- Department of Ophthalmology, New York University Grossman School of Medicine, New York, NY 10017, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, NY 10017, USA
| | - Steven L. Galetta
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10017, USA; (D.N.d.S.); (M.J.); (C.A.B.); (C.M.); (L.J.B.); (S.L.G.)
- Department of Ophthalmology, New York University Grossman School of Medicine, New York, NY 10017, USA
| | - Scott N. Grossman
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10017, USA; (D.N.d.S.); (M.J.); (C.A.B.); (C.M.); (L.J.B.); (S.L.G.)
- Department of Ophthalmology, New York University Grossman School of Medicine, New York, NY 10017, USA
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Trbovich AM, Fazio-Sumrok V, Preszler J, Shaffer MA, Kegel N, Kissinger-Knox A, Collins MW, Kontos AP. Discriminating Young Children with Concussion in an Outpatient Specialty Clinic from Healthy Controls Using the Child SCAT5. J Pediatr 2023:113380. [PMID: 36889630 DOI: 10.1016/j.jpeds.2023.02.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 02/16/2023] [Accepted: 02/22/2023] [Indexed: 03/10/2023]
Abstract
OBJECTIVE To evaluate the clinical utility of the Child SCAT5 in an outpatient specialty clinic sample of children ages 5-9. STUDY DESIGN Ninety-six children within 30 days of a concussion (M=8.90+5.78 days) and 43 age and sex-matched healthy controls completed the Child SCAT5, including balance items, cognitive screening, parent and child symptom and severity reports, as well as each individual parent- and child-rated symptom severity (0-3). A series of receiver operating characteristic (ROC) curves with area under the curve (AUC) analysis were performed to evaluate the clinical utility of the Child SCAT5 components to discriminate concussion. RESULTS The AUC values were non-discriminate for cognitive screening (.32) and poor for balance (.61) items. The AUC values were acceptable for parent-reported symptoms worsening after physical activity (.73) and mental activity (.72). The AUCs for symptom severity items were excellent for parent (.89) and child-reported (.81) headaches, and were acceptable for parent-reported tired a lot (.75), and both parent (.72) and child-reported (.72) tired easily. CONCLUSION With the exception of parent and child-reported symptoms, the Child SCAT5 provides limited clinical utility for evaluating concussion in children aged 5-9 years seen at an outpatient concussion specialty clinic. The cognitive screening and balance testing items were not useful in discriminating concussion. Parent and child-reported headache were the only Child SCAT5 items with excellent ability to differentiate concussion from controls in the age group.
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Affiliation(s)
- Alicia M Trbovich
- University of Pittsburgh Medical Center Concussion Program, Pittsburgh, PA.
| | | | - Jonathan Preszler
- University of Pittsburgh Medical Center Concussion Program, Pittsburgh, PA
| | - Madelyn A Shaffer
- University of Pittsburgh Medical Center Concussion Program, Pittsburgh, PA
| | - Nathan Kegel
- University of Pittsburgh Medical Center Concussion Program, Pittsburgh, PA
| | - Alicia Kissinger-Knox
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA
| | - Michael W Collins
- University of Pittsburgh Medical Center Concussion Program, Pittsburgh, PA
| | - Anthony P Kontos
- University of Pittsburgh Medical Center Concussion Program, Pittsburgh, PA
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Roby PR, Podolak OE, Grady M, Arbogast KB, Master CL. The effect of a home exercise program on visio-vestibular function in concussed pediatric patients. Front Sports Act Living 2023; 5:1064771. [PMID: 36935886 PMCID: PMC10020172 DOI: 10.3389/fspor.2023.1064771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 02/13/2023] [Indexed: 03/06/2023] Open
Abstract
Background A visio-vestibular home exercise program (VV-HEP) can provide an equitable and cost-effective method for therapy targeted towards visio-vestibular deficits that are common following concussion. The effects of a VV-HEP on improving concussion symptoms and visio-vestibular function are unclear. Purpose Determine the effect of VV-HEP on symptoms and visio-vestibular function in concussed pediatric patients. Methods This study included 527 patients [294 female (55.8%); age = 14.4 ± 2.1 years] reporting to a specialty care concussion center within 28 days of injury and for a first follow-up within 60 days of injury. Patients completed the Post-Concussion Symptom Inventory (PCSI) and Visio-Vestibular Examination (VVE). Patients were prescribed the VV-HEP at initial visit, with exercises including saccades, gaze stability, convergence, and balance, and instructed to complete these 1-2 times/day. At follow-up, patients self-reported their VV-HEP progress as (1) has not done, (2) in progress, or (3) completed. Primary outcomes included VV-HEP progress at follow-up, PCSI endorsement and severity, VVE subtests (normal/abnormal), and total VVE score (abnormal = 2 + abnormal subtests). Kruskal-Wallis tests and chi-square were used to determine if concussion symptoms or the proportion of abnormal VVE outcomes, respectively, were associated with VV-HEP status. Post-hoc pairwise comparisons with Bonferonni corrections were used to determine concussion symptom (α = 0.017 a priori) and VVE (α = 0.005 a priori) differences in VV-HEP status. Results At follow-up, patients who had completed the VV-HEP reported lower symptom endorsement (median = 1, IQR = 0-3) and lower symptom severity (median = 1, IQR = 0-4) relative to patients who had not started the VV-HEP (endorsement median = 7, IQR = 1-13, p < 0.0001; severity median = 15.5, IQR = 2-32.5, p < 0.0001) and those in progress (endorsement median = 8, IQR = 3-14, p < 0.0001; severity median = 15, IQR = 4-30, p < 0.0001). A lower proportion of patients who completed the VV-HEP reported with abnormal vestibular-ocular reflex (22.2%), tandem gait (0%), and total VVE score (22.2%) relative to those who had not started or those in progress (p < 0.005). Conclusion Our findings indicate that patients who completed the VV-HEP had lower symptom burden and improved visio-vestibular function relative to those who did not start or were in progress. This suggests that a VV-HEP can effectively reduce visio-vestibular dysfunction following concussion and may serve as a means to minimize inequities in access to care.
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Affiliation(s)
- Patricia R. Roby
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Olivia E. Podolak
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Matthew Grady
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Sports Medicine Performance Center, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Kristy B. Arbogast
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Division of Emergency Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Correspondence: Kristy B. Arbogast
| | - Christina L. Master
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Sports Medicine Performance Center, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
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9
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Trbovich AM, Mucha A, Eagle S, Mehmel BM, Kegel N, Fazio Sumrok V, Collins MW, Kontos AP. The Vestibular/Ocular Motor Screening-Child (VOMS-C) tool for concussion evaluation in 5- to 9-year-old pediatric patients: preliminary evidence. J Neurosurg Pediatr 2022; 30:609-615. [PMID: 36152332 DOI: 10.3171/2022.8.peds22234] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/10/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Vestibular and ocular motor dysfunction occurs in an estimated 60%-90% of concussion patients. The Vestibular/Ocular Motor Screening (VOMS) tool is validated for use in concussion patients older than 9 years. The goal of the current study was to adapt the current VOMS tool for a pediatric sample of children aged 5-9 years and establish its clinical utility in this patient population. METHODS In this case-control study, 80 symptomatic concussion patients (n = 33 [41%] female) aged 5-9 years (mean age 7.40 ± 1.09 years) and 40 (n = 18 [45%] female) age- and sex-matched uninjured controls (mean age 7.10 ± 1.26 years) completed the VOMS-Child (VOMS-C), a version of the VOMS adapted for younger patients. Differences in binary "yes" or "no" symptom provocation for headache, dizziness, and nausea/"tummy ache" across the 7 items of the VOMS-C, and near point of convergence (NPC) distance, were examined. Logistic regression (LR) models were built to classify concussion and controls. Predicted probabilities were generated from the LR model and entered into receiver operating characteristic (ROC) curve models to generate area under the curve (AUC) values. RESULTS VOMS-C item provocation ranged from 13% to 30% for concussed patients and 3% to 20% for controls. The LR model distinguished concussed participants from controls (R2 = 0.39; p < 0.001), with significant predictors being smooth pursuits, family depression history, and NPC distance. The ROC analysis had an AUC of 0.81 (95% CI 0.73-0.89; p < 0.001) in the good range. CONCLUSIONS Accurate diagnosis of concussion in the clinic setting requires comprehensive evaluation in multiple domains, including detailed clinical interview, neurocognitive testing, and vestibular/ocular motor assessment, regardless of patient age. Our results provide preliminary support for the VOMS-C as a developmentally appropriate tool for concussion management.
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Affiliation(s)
| | - Anne Mucha
- 2Center for Rehab Services, Pittsburgh; and
| | - Shawn Eagle
- 1University of Pittsburgh Medical Center, Pittsburgh
- 3Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Nathan Kegel
- 1University of Pittsburgh Medical Center, Pittsburgh
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Arbogast KB, Ghosh RP, Corwin DJ, McDonald CC, Mohammed FN, Margulies SS, Barnett I, Master CL. Trajectories of Visual and Vestibular Markers of Youth Concussion. J Neurotrauma 2022; 39:1382-1390. [PMID: 35785959 PMCID: PMC9529314 DOI: 10.1089/neu.2022.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Visual and vestibular deficits, as measured by a visio-vestibular examination (VVE), are markers of concussion in youth. Little is known about VVE evolution post-injury, nor influence of age or sex on trajectory. The objective was to describe the time trend of abnormal VVE elements after concussion. Two cohorts, 11-18 years, were enrolled: healthy adolescents (n = 171) from a high school with VVE assessment before or immediately after their sport seasons and concussed participants (n = 255) from a specialty care concussion program, with initial assessment ≤28 days from injury and VVE repeated throughout recovery during clinical visits. The primary outcome, compared between groups, is the time course of recovery of the VVE examination, defined as the probability of an abnormal VVE (≥2/9 abnormal elements) and modeled as a cubic polynomial of days after injury. We explored whether probability trajectories differed by: age (<14 years vs. 14+ years), sex, concussion history (0 versus 1+), and days from injury to last assessment (≤28 days vs. 29+ days). Overall, abnormal VVE probability peaked at 0.57 at day 8 post-injury, compared with an underlying prevalence of 0.083 for uninjured adolescents. Abnormal VVE probability peaked higher for those 14+ years, female, with a concussion history and whose recovery course was longer than 28 days post-injury, compared with their appropriate strata subgroups. Females and those <14 years demonstrated slower resolution of VVE abnormalities. VVE deficits are common in adolescents after concussion, and the trajectory of resolution varies by age, sex, and concussion history. These data provide insight to clinicians managing concussions on the timing of deficit resolution after injury.
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Affiliation(s)
- Kristy B. Arbogast
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Riddhi P. Ghosh
- Department of Mathematics and Statistics, Bowling Green State University, Bowling Green, Ohio, USA
| | - Daniel J. Corwin
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Catherine C. McDonald
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fairuz N. Mohammed
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Susan S. Margulies
- Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Ian Barnett
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christina L. Master
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Sports Medicine and Performance Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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11
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Roby PR, Metzger KB, Storey EP, Master CL, Arbogast KB. Influence of concussion history and age of first concussion on visio-vestibular function. J Sci Med Sport 2022; 25:715-719. [PMID: 35821211 PMCID: PMC9489638 DOI: 10.1016/j.jsams.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 06/16/2022] [Accepted: 06/18/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess if abnormalities on visio-vestibular examination (VVE) are associated with concussion history (first vs. repeat) or age of first concussion in acutely concussed adolescents. DESIGN Cross-sectional. METHODS Data were queried from the Children's Hospital of Philadelphia Minds Matter concussion registry. Patients aged 14-18 years old presenting for their initial visit to the specialty care concussion program within 28 days of injury were included. Demographics, including age, sex, concussion history, and age of first concussion, were collected before the exam. The VVE consisted of 9 subtests: smooth pursuit, horizontal/vertical saccades and vestibulo-ocular reflex (VOR), binocular convergence, left/right monocular accommodation, and complex tandem gait. Primary outcomes included VVE subtests (normal/abnormal), and total VVE score (abnormal = 2+ abnormal subtests). RESULTS Among 1051 patients included (female = 604(57.5 %); age = 15.6 ± 1.2; median lifetime concussions = 1 [IQR = 1,3]), 518 had repeat concussion. Controlling for age and sex, first vs. repeat concussion was not associated with any VVE subtest or total score (Total VVE Score RR = 1.35, 99.5%CI = 0.70,2.61). Of those with repeat concussion, 190 had valid age of first concussion data. Controlling for age, sex, and number of lifetime concussions, age of first concussion was not significantly associated with any VVE subtest or total score (Total VVE Score RR = 1.11, 99.5%CI = 0.78,1.57). CONCLUSIONS Adolescents with concussion history present with similar visio-vestibular function to those with no concussion history. Additionally, clinical effects of early age of first concussion may not be evident in children. This study provides foundational data regarding potential cumulative effects of concussion in younger athletes.
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Affiliation(s)
- Patricia R Roby
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, United States of America
| | - Kristina B Metzger
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, United States of America
| | - Eileen P Storey
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, United States of America
| | - Christina L Master
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, United States of America; Perelman School of Medicine, University of Pennsylvania, United States of America; Sports Medicine Performance Center, The Children's Hospital of Philadelphia, United States of America
| | - Kristy B Arbogast
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, United States of America; Perelman School of Medicine, University of Pennsylvania, United States of America; Division of Emergency Medicine, The Children's Hospital of Philadelphia, United States of America.
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12
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Corwin DJ, McDonald CC, Arbogast KB, Mohammed FN, Grady MF, Master CL. Visio-Vestibular Deficits in Healthy Child and Adolescent Athletes. Clin J Sport Med 2022; 32:376-384. [PMID: 34173781 PMCID: PMC8692490 DOI: 10.1097/jsm.0000000000000955] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 05/05/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the relationship between patient characteristics and performance on the visio-vestibular examination (VVE) in a cohort of healthy youth athletes and explore the potential association between the VVE and other standardized concussion batteries. DESIGN Cross-sectional. SETTING Suburban middle and high school. PATIENTS One hundred ninety subjects age 11 to 18 enrolled before their respective scholastic sport season between August 2017 and March 2020. ASSESSMENT OF INDEPENDENT VARIABLES Patient age, sex, concussion history, comorbidities, hours of weekly exercise, Sport Concussion Assessment Tool, 5th edition (SCAT-5), King-Devick (K-D), Postconcussion Symptom Inventory (PCSI). MAIN OUTCOME MEASURES Visio-vestibular examination abnormalities (smooth pursuit, horizontal and vertical saccades, horizontal and vertical gaze stability, convergence, right and left monocular accommodation, complex tandem gait). RESULTS Overall, 29.5% of subjects had at least one of 9 VVE elements abnormal, 7.9% at least 2, and 3.2% at least 3. None of 72 comparisons of the VVE elements, when stratified by age, sex, concussion history, history of headaches, attention deficit hyperactivity disorder, learning issues, psychiatric problems, motion sickness, or weekly hours of exercise, reached significance using the Benjamini-Hochberg procedure at a false discovery rate of 5%. There were no significant associations between VVE elements and the SCAT-5, K-D, or PCSI. CONCLUSIONS The VVE is robust across multiple patient characteristics. Although healthy subjects may have one abnormal element, multiple abnormal elements are a less common feature, making multiple abnormal elements more indicative of concussion, highlighting the use of this assessment in the setting of injury. The VVE tests unique domains when compared with the PCSI, SCAT-5, and K-D.
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Affiliation(s)
- Daniel J Corwin
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Catherine C McDonald
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Kristy B Arbogast
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fairuz N Mohammed
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew F Grady
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Sports Medicine and Performance Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christina L Master
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Sports Medicine and Performance Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Kaae C, Cadigan K, Lai K, Theis J. Vestibulo-ocular dysfunction in mTBI: Utility of the VOMS for evaluation and management – A review. NeuroRehabilitation 2022; 50:279-296. [DOI: 10.3233/nre-228012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Individuals who have suffered a concussion/mild traumatic brain injury (mTBI) frequently report symptoms associated with vestibular and/or oculomotor dysfunction (VOD) like dizziness, nausea, fatigue, brain fog, headache, gait and neurocognitive impairments which are associated with the development of chronic symptoms. The Vestibular/Ocular Motor Screening (VOMS) tool has been established as a reliable and clinically relevant complement to use alongside a battery of post-concussion tests to improve screening and referral for further evaluation and treatment of VOD. OBJECTIVES: This paper will review the pathoanatomy and symptomatology of common vestibular and oculomotor disorders after concussion, as well as the utility of the VOMS to assist in diagnosis, referral, and management. METHODS: Primary articles were identified using a search via PubMed, Google Scholar, OneSearch, and CINAHL. Search key terms were combinations of “mild traumatic brain injury” or “concussion” or “pursuit” or “accommodation” or “vergence” or “convergence insufficiency” or “saccades” or “vestibulo-ocular reflex” or “vestibular ocular motor screen” or “vestibular rehabilitation”, or “vision rehabilitation” including adult and pediatric populations that were published in print or electronically from 1989 to 2021 in English. Classic papers on anatomy of eye movements, vestibular system and pathological changes in mTBI were also included, regardless of publication date. RESULTS: Objective impairments are commonly found during testing of smooth pursuit, saccades, vergence, accommodation, vestibular ocular reflex, and visual motion sensitivity after mTBI. These deficits can be actively treated with vestibular physical therapy and oculomotor/neuro-optometric vision therapy. VOMS is an efficient and reliable tool that can be used by all healthcare and rehabilitation providers to aid in diagnosis of post-concussion VOD, to help facilitate the decision to refer for further evaluation and treatment to expedite symptomatic post-concussion recovery. CONCLUSIONS: VOD is common after concussion in acute, post-acute, and chronic phases. Once areas of impairments are identified through proper assessment, clinicians can maximize recovery by referring to vestibular physical therapy and/or neuro-optometry to design a targeted treatment program to address individual deficits.
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Affiliation(s)
- Cristen Kaae
- Kaiser Permanente Medical Center, Vallejo, CA, USA
| | | | - Katherine Lai
- Kaiser Permanente Medical Center, Oakland, CA, USA
- Herbert Wertheim School of Optometry & Vision Science at the University of California, Berkeley, CA, USA
| | - Jacqueline Theis
- Herbert Wertheim School of Optometry & Vision Science at the University of California, Berkeley, CA, USA
- Virginia Neuro-Optometry at Concussion Care Centre of Virginia, Richmond VA, USA
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Patterson Gentile C, Aguirre GK, Arbogast KB, Master CL. Relationship between Visually Evoked Effects and Concussion in Youth. J Neurotrauma 2022; 39:841-849. [PMID: 35166126 PMCID: PMC9225424 DOI: 10.1089/neu.2021.0475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Increased sensitivity to light is common after concussion. Viewing a flickering light can also produce uncomfortable somatic sensations like nausea or headache. We examined effects evoked by viewing a patterned, flickering screen in a cohort of 81 uninjured youth athletes and 84 concussed youth. We used Multiple correspondence analysis and identified two primary dimensions of variation: the presence or absence of visually evoked effects and variation in the tendency to manifest effects that localized to the eyes (e.g., eye watering) versus more generalized neurological effects (e.g., headache). Based on these two primary dimensions, we grouped participants into three categories of evoked symptomatology: no effects, eye-predominant effects, and brain-predominant effects. A similar proportion of participants reported eye-predominant effects in the uninjured (33.3%) and concussed (32.1%) groups. By contrast, participants who experienced brain-predominant effects were almost entirely from the concussed group (1.2% of uninjured, 35.7% of concussed). The presence of brain-predominant effects was associated with a higher concussion symptom burden and reduced performance on visio-vestibular tasks. Our findings indicate that the experience of negative constitutional, somatic sensations in response to a dynamic visual stimulus is a salient marker of concussion and is indicative of more severe concussion symptomatology. We speculate that differences in visually evoked effects reflect varying levels of activation of the trigeminal nociceptive system.
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Affiliation(s)
- Carlyn Patterson Gentile
- Department of Pediatrics, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Injury Research and Prevention, Children”s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Geoffrey K. Aguirre
- Department of Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kristy B. Arbogast
- Department of Pediatrics, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Injury Research and Prevention, Children”s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christina L. Master
- Department of Pediatrics, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Injury Research and Prevention, Children”s Hospital of Philadelphia, Philadelphia, Pennsylvania
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15
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Assessment of Saccades and Gaze Stability in the Diagnosis of Pediatric Concussion. Clin J Sport Med 2022; 32:108-113. [PMID: 35234741 PMCID: PMC8891655 DOI: 10.1097/jsm.0000000000000897] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 08/31/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the discriminatory ability of different repetition increments of saccades and gaze stability testing for diagnosing concussion in adolescents. DESIGN Cross-sectional. SETTING Suburban high school and academic pediatric tertiary care center. PARTICIPANTS Sixty-nine adolescent athletes within 28 days of a sports- or recreation-related concussion and 69 adolescent athletes without recent concussion. ASSESSMENT OF INDEPENDENT VARIABLES Symptom provocation with horizontal and vertical saccades and gaze stability testing performed up to 30 repetitions. MAIN OUTCOME MEASURES Sensitivity and specificity at 10-repetition increments (≤10, ≤20, ≤30) and area under the receiver operating characteristic curves (AUC) of a visio-vestibular examination (VVE) subscore, scored 0 to 4 based on the number of assessments with symptom provocation, at each repetition increment. RESULTS Sensitivity improved when increasing from ≤10 to ≤20 to ≤30 repetitions for horizontal (25% to 50% to 69%) and vertical (32% to 52% to 74%) saccades and horizontal (19% to 45% to 71%) and vertical (23% to 45% to 72%) gaze stability. Specificity was comparable at ≤10 and ≤20 repetitions, but decreased at ≤30 repetitions across assessments. For a VVE subscore (0-4) based on the number of symptomatic assessments, the discriminatory ability of the test was highest at ≤20 repetitions (AUC of 0.79) with an optimal subscore of one (sensitivity 59%, specificity 96%). CONCLUSIONS A VVE including a higher threshold level of repetitions for saccades and gaze stability has improved discriminatory ability for concussion, with an optimized AUC of 0.79 at ≤20 repetitions. CLINICAL RELEVANCE The findings in this study suggest that a higher threshold level of repetitions of 2 commonly used visio-vestibular assessments enables clinicians to more accurately diagnose youth concussion.
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Leung FT, Mendis MD, Franettovich Smith MM, Rahmann A, Treleaven J, Hides JA. Sensorimotor system changes in adolescent rugby players post-concussion: A prospective investigation from the subacute period through to return-to-sport. Musculoskelet Sci Pract 2022; 57:102492. [PMID: 34922255 DOI: 10.1016/j.msksp.2021.102492] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/26/2021] [Accepted: 12/07/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The pathophysiology of concussion is complex. Altered sensorimotor function post-concussion may contribute to the wide range of symptoms and impairments reported. There is currently limited evidence documenting changes in sensorimotor function during the recovery period. The aim of this study was to investigate the effect of concussion on the sensorimotor system in adolescents post-concussion using a multifaceted approach. STUDY DESIGN Prospective nested case-control study. METHODS A total of 285 male adolescent rugby players underwent assessment of sensorimotor function during preseason. Players who sustained a concussion during the season and control players, matched for age and playing position, were assessed in the subacute period (3-5 days) and after return-to-sport (3 weeks). Tests of sensorimotor function included balance, cervical spine and vestibulo-ocular function, and measurement of the size and contraction of lumbopelvic muscles (ultrasound imaging). RESULTS Twenty-three players (8%) sustained a concussion. Of these, 20 players were assessed during the subacute period and 17 players following return-to-sport. The prevalence of vestibulo-ocular dysfunction increased from 38.9% to 72.2% during the subacute period and dysfunction was present in 83.3% of players after return-to-sport (p = 0.01). Changes in lumbar multifidus muscle size (p = 0.002) and thickness (p = 0.05) at the L5 vertebral level were observed. No statistically significant changes in balance, cervical spine proprioception, or contraction of lumbopelvic muscles were found (p > 0.05). CONCLUSION Changes in sensorimotor function were observed in the subacute period post-concussion, with some persisting after return-to-sport. Using symptom-based criteria for return-to-sport may not adequately reflect the sequelae of concussion on the sensorimotor system.
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Affiliation(s)
- Felix T Leung
- School of Health Sciences and Social Work, Griffith University, Nathan, QLD, 4111, Australia.
| | - M Dilani Mendis
- School of Health Sciences and Social Work, Griffith University, Nathan, QLD, 4111, Australia
| | | | - Ann Rahmann
- School of Allied Health, Australian Catholic University, Banyo, QLD, 4014, Australia
| | - Julia Treleaven
- The University of Queensland, School of Health and Rehabilitation Sciences, St Lucia, QLD, 4072, Australia
| | - Julie A Hides
- School of Health Sciences and Social Work, Griffith University, Nathan, QLD, 4111, Australia; Mater Back Stability Research Clinic, Mater Health Services, South Brisbane, QLD, 4101, Australia
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17
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Pieroth EM. Assessment and Management of Persistent Post-Concussion Symptoms. OPER TECHN SPORT MED 2022. [DOI: 10.1016/j.otsm.2022.150894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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An Investigation of Sensorimotor Impairments in Individuals 4 weeks to 6 months following mild traumatic brain injury. Arch Phys Med Rehabil 2021; 103:921-928. [PMID: 34861233 DOI: 10.1016/j.apmr.2021.10.029] [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: 09/27/2021] [Revised: 10/22/2021] [Accepted: 10/31/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To identify whether adults 4 weeks to 6 months post mild traumatic brain injury (mTBI) have sensorimotor impairments when compared to healthy controls. A secondary aim was to determine if impairments were evident irrespective of participant perceived absence of symptoms. DESIGN Observational cohort study SETTING: Tertiary University and Hospital PARTICIPANTS: Participants included 113 individuals aged 18 to 60 years consisting of 39 controls with no prior concussion history, and 74 individuals, 4 weeks to 6 months post mTBI of which 35 considered themselves asymptomatic (Asymp), and 37 symptomatic (Symp). MAIN OUTCOME MEASURES Assessments of oculomotor, vestibulo-ocular reflex (VOR) control, balance, single and dual task tandem walk (TTW-S, TTW-D) and vestibular positional testing. RESULTS Poorer balance and tandem walk performance, and a higher frequency of positive oculomotor, VOR and vestibular positional tests were evident in the mTBI group compared to controls. In particular ≥ 2 positive oculomotor findings were evident in 53.7% of the participants with mTBI compared to 10.8 % of controls. The mTBI group who considered themselves recovered (Asymp) demonstrated significantly increased TWT-D time, and a higher proportion 53% had ≥ 2 positive oculomotor tests compared to controls. CONCLUSION Persistent sensorimotor impairments, particularly evidenced by disturbed oculomotor function and deficits in dual task tandem walking were identified among adults 4 weeks to 6 months post mTBI. These disturbances were evident regardless of whether ongoing symptoms were reported. The findings support recommendations for routine clinical assessment of sensorimotor function post mTBI with implications for injury prevention.
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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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20
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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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Scheiman M, Grady MF, Jenewein E, Shoge R, Podolak OE, Howell DH, Master CL. Frequency of oculomotor disorders in adolescents 11 to 17 years of age with concussion, 4 to 12 weeks post injury. Vision Res 2021; 183:73-80. [PMID: 33735759 DOI: 10.1016/j.visres.2020.09.011] [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: 03/11/2020] [Revised: 08/31/2020] [Accepted: 09/03/2020] [Indexed: 10/21/2022]
Abstract
The purpose of the study was to determine the frequency of vision diagnoses after concussion in adolescents and evaluate the sensitivity and specificity of physician-administered screening for detecting convergence and accommodative disorders post-concussion. We enrolled participants 11 to 17 years old, assessed 4 to 12 weeks following a diagnosed concussion. During the initial concussion examination, a sports medicine physician measured the near point of convergence (NPC), monocular accommodative amplitude (AA), and symptoms using the Convergence Insufficiency Symptom Survey (CISS). A comprehensive oculomotor evaluation was performed by an optometrist. One hundred and thirteen adolescents were enrolled, with a mean age of 15.2 years. Seventy-nine of the 113 (70%) participants had at least one oculomotor diagnosis after concussion, with the most common problems being vergence disorders (60%) and accommodative disorders (57%). The most common vergence disorder was convergence insufficiency (35%). Among accommodative disorders, the most common problem was accommodative insufficiency (35%). In all, 47% of the participants had more than one oculomotor diagnosis following concussion. The sensitivity of physician screening using measures of NPC, AA, and CISS for detecting convergence and accommodative insufficiency was 63%, 43%, 48%, respectively. The results of this study provide additional evidence that vision problems are common in adolescents with persistent concussion symptoms in the sub-acute phase 4 to 12 weeks post-concussion, and current physician screening methods using the NPC, AA, or the CISS underperform. Thus, it is prudent that adolescents with post-concussion symptoms lasting more than 4 weeks post injury receive a comprehensive oculomotor examination.
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Affiliation(s)
- Mitchell Scheiman
- Pennsylvania College of Optometry at Salus University, Elkins Park, PA, United States.
| | - Matthew F Grady
- Divisions of Orthopedics and General Pediatrics, The Children's Hospital of Philadelphia, 3400 Civic Center Boulevard, Philadelphia, PA 19104, United States; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Erin Jenewein
- Pennsylvania College of Optometry at Salus University, Elkins Park, PA, United States
| | - Ruth Shoge
- Pennsylvania College of Optometry at Salus University, Elkins Park, PA, United States
| | - Olivia E Podolak
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - David H Howell
- Children's Hospital Colorado, Sports Medicine Center, University of Colorado School of Medicine, Department of Orthopedics Aurora, CO, United States
| | - Christina L Master
- Divisions of Orthopedics and General Pediatrics, The Children's Hospital of Philadelphia, 3400 Civic Center Boulevard, Philadelphia, PA 19104, United States; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
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22
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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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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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24
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Neidecker JM, Gealt DB, Lambert K, Luksch JR, Weaver MD. First-time sports-related concussion recovery revisited: management changes and impact on recovery. J Osteopath Med 2021; 121:49-56. [PMID: 33512393 DOI: 10.1515/jom-2020-0106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Context Concussion is among the most common injuries in athletes. Over the past 10 years, concussion knowledge has expanded, and guidelines for management have changed. Recent changes include recommendations against strict mental and physical rest after sustaining a concussion, a better recognition of preexisting conditions predisposing protracted concussion recovery, and the addition of preliminary patient counseling and education about the expected course of concussion recovery. Objective To assess the impact of changes in concussion management on the duration of symptoms in middle school and high school athletes after sustaining a first-time, sports-related concussion. Methods A retrospective review was performed of medical records of athletes who sustained a concussion between 2016 and 2018 and were treated by the same primary care physician (J.M.N) using the revised approach to concussion management described. Patients were included if they were 11 to 18 years old and had a diagnosis of first-time concussion sustained while playing organized sports. Athletes who sustained a concomitant injury or sustained a concussion outside of organized sports were excluded from the study; athletes lost to follow-up or with incomplete forms were also excluded. Each athlete's length of symptomatic time from his or her concussion was calculated. This data was then compared with a previously-published data set of athletes who sustained a concussion between 2011 and 2013, with the same inclusion criteria but a different approach to concussion management. Results A total of 110 male and 72 female athletes (N=182) met the study's eligibility criteria. Collectively, athletes of both sexes from the 2016-2018 data set reported a higher incidence of preexisting conditions associated with prolonged concussion recovery compared with the data set of 2011-2013 athletes. However, both sexes from the 2016-2018 data set also reported a shorter median duration of concussion symptoms compared with the 2011-2013 athletes (median duration 5 vs. 11 days for male athletes and 7 vs. 28 days for female athletes, respectively; p<0.001). Conclusion Recent changes in concussion management have led to decreased duration of symptoms among 11- to 18-year-old athletes with first-time, sports-related concussions. These management changes include advocating for early activity, recognizing preexisting conditions, and educating athletes about the realities of concussion recovery.
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Affiliation(s)
- John M Neidecker
- School of Osteopathic Medicine , Campbell University , Buies Creek , NC , USA
- Orthopaedic Specialists of North Carolina , Raleigh , NC , USA
| | - David B Gealt
- Cooper Bone and Joint Institute, Cooper University Hospital , Camden , NJ , USA
| | - Kathryn Lambert
- School of Osteopathic Medicine , Rowan University , Stratford , NJ , USA
| | | | - Martin D Weaver
- Miller School of Medicine , University of Miami , Miami , FL , USA
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25
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Corwin DJ, McDonald CC, Arbogast KB, Mohammed FN, Metzger KB, Pfeiffer MR, Patton DA, Huber CM, Margulies SS, Grady MF, Master CL. Clinical and Device-based Metrics of Gait and Balance in Diagnosing Youth Concussion. Med Sci Sports Exerc 2020; 52:542-548. [PMID: 31524833 DOI: 10.1249/mss.0000000000002163] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE Evaluate the discriminatory ability of two clinical measures and one device-based measure of gait and balance for concussed youth. METHODS We enrolled 81 cases and 90 controls age 14-18 yr old from August 2017 to June 2018. Controls were recruited from a suburban high school, and cases were recruited from the concussion program of an academic pediatric tertiary care center. Tests included two clinical measures: 1) complex tandem gait, scored as sway/errors walking forward and backward eyes open and closed; 2) Modified Balance Error Scoring System (mBESS), scored as total number of errors on three standing tasks; and one device-based measure; 3) Modified Clinical Test of Sensory Interaction and Balance (mCTSIB) using the Biodex Biosway Balance System, scored as a sway index. Sensitivity, specificity, ideal cutpoint, and area under the receiver operating characteristic curve (AUC) were calculated for all test components. RESULTS Ideal cutpoint for total number of sway/errors for tandem gait = 5, sensitivity 41%, specificity 90%. Ideal cutpoint for total mBESS errors = 4, sensitivity 55%, specificity 75%. Ideal cutpoint for mCTSIB = 1.37, sensitivity 37%, specificity 88%. Among each test, some individual components outperformed overall composites, in particular tandem gait (specificity forward eyes open = 99%, sensitivity backward eyes closed = 81%). Among the 40 cases and 65 controls with all three assessments, AUC (95% CI) for tandem gait = 0.63 (0.52,0.75), mBESS = 0.70 (0.60,0.81), and mCTSIB = 0.54 (0.42,0.66). CONCLUSIONS A device-based measure of balance did not produce better discriminatory ability than two clinical assessments. Complex tandem gait has the additional benefit of being an easy-to-perform and graded test with highly sensitive and specific individual components.
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Affiliation(s)
| | | | | | - Fairuz N Mohammed
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kristina B Metzger
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Melissa R Pfeiffer
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Declan A Patton
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Colin M Huber
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA
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26
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Corwin DJ, Arbogast KB, Haber RA, Pettijohn KW, Zonfrillo MR, Grady MF, Master CL. Characteristics and Outcomes for Delayed Diagnosis of Concussion in Pediatric Patients Presenting to the Emergency Department. J Emerg Med 2020; 59:795-804. [PMID: 33036827 DOI: 10.1016/j.jemermed.2020.09.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/18/2020] [Accepted: 09/03/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND Concussions are common pediatric injuries. Previous studies have found concussed youth may be underdiagnosed in the emergency department (ED), but outcomes for those with delayed diagnosis have yet to be described. OBJECTIVE Our aim was to compare visit characteristics and outcomes of patients who present to the ED with head injury who receive immediate vs. delayed diagnosis. METHODS Retrospective chart review of patients aged 6 to 18 years diagnosed with concussion on their first ED or urgent care (UC) visit and patients requiring a second visit for diagnosis between July 1, 2017 and June 20, 2019. We compared demographic information, ED or UC visit features, and recovery outcomes using χ2 tests, Student's t-tests, and Wilcoxon rank-sum tests. RESULTS Overall, we included 85 patients with delayed concussion diagnosis and 159 with immediate diagnosis. Those with immediate diagnosis had more symptoms inquired at initial visit (5 vs. 4; p = 0.003) and a higher likelihood of receiving concussion-specific physical examinations (80% vs. 36.5%; p < 0.001); 76.5% of delayed diagnosis patients had at least 1 symptom at follow-up visit that was not inquired about at initial visit. Those with delayed diagnosis had more medical visits during recovery (3 vs. 2; p < 0.001), longer average time to symptom resolution (21 vs. 11 days; p = 0.004), and a higher likelihood of having persistent concussion symptoms (odds ratio 2.9; 95% confidence interval 1.4-5.9). CONCLUSIONS Concussed children evaluated acutely for head injury who do not receive an immediate diagnosis may be at risk for persistent symptoms. Performance of a concussion-specific physical examination and use of a standardized symptom scale may aid in identification of concussed youth acutely.
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Affiliation(s)
- Daniel J Corwin
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kristy B Arbogast
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rebecca A Haber
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kevin W Pettijohn
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mark R Zonfrillo
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island; Department of Pediatrics, Hasbro Children's Hospital, Providence, Rhode Island
| | - Matthew F Grady
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Sports Medicine and Performance Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christina L Master
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Sports Medicine and Performance Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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27
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Sorek G, Gagnon I, Schneider K, Chevignard M, Stern N, Fadida Y, Kalderon L, Shaklai S, Katz-Leurer M. The integrated functions of the cardiac autonomic and vestibular/oculomotor systems in adolescents following severe traumatic brain injury and typically developing controls. Brain Inj 2020; 34:1480-1488. [PMID: 32809873 DOI: 10.1080/02699052.2020.1807055] [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] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The cardiac autonomic control system (CACS) is frequently impaired post-traumatic brain injury (TBI). However, the prevalence of vestibular/oculomotor impairment is less studied. These two systems interact during position change and contribute to blood-pressure regulation through the vestibulo-sympathetic reflex. Aim: To assess the CACS, the vestibular/oculomotor systems and their integrative function in adolescents post-TBI compared to typically-developing (TD) adolescents. Methods: 19 adolescents in the subacute stage following a severe TBI (14-117 days post injury) and 19 age and sex matched TD controls were recruited. Heart Rate Variability (HRV) was assessed at rest and during a modified tilt-test. A quantified version of the Vestibular/Ocular-Motor Screening (VOMS) was also administered. Results: At rest, the TBI group had higher HR and lower HRV values (p < .001). All participants with TBI demonstrated impairments in the VOMS (median of positive tests: 5 [range 2-9]) compared to only 6 out of 19 in the TD participants (median 0 [0-2]) (z = -5.34; p < .001). In response to the modified tilt test, the HRV increased significantly in the lifting period and decreased significantly once in standing only in the TBI group (z = -2.85, p = .025). Conclusion: Adolescents post severe TBI demonstrated impairments in the CACS, positive tests on the VOMS and significantly greater changes in the modified tilt test as compared to TD. Clinical trial gov. number: NCT03215082.
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Affiliation(s)
- Gilad Sorek
- Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv Israel
| | - Isabelle Gagnon
- Montreal Children's Hospital, McGill University Health Center , Montreal, Canada
| | - Kathryn Schneider
- Sport Injury Research Prevention Centre, Faculty of Kinesiology, University of Calgary , Calgary, Canada
| | - Mathilde Chevignard
- Laboratoire d'Imagerie Biomédicale, LIB, & GRC, Sorbonne Université , Paris, France.,Rehabilitation Unit for Acquired Neurological Pathologies in Children, Saint-Maurice Hospital , Saint-Maurice, France
| | - Nurit Stern
- Alyn Children's Hospital and Rehabilitation Center , Jerusalem, Israel
| | - Yahaloma Fadida
- Children Rehabilitation Department, Lowenstein Rehabilitation Center Ra'anana , Israel
| | - Liran Kalderon
- Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv Israel
| | - Sharon Shaklai
- Children Rehabilitation Department, Lowenstein Rehabilitation Center Ra'anana , Israel
| | - Michal Katz-Leurer
- Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv Israel
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28
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Reliability of the visio-vestibular examination for concussion among providers in a pediatric emergency department. Am J Emerg Med 2020; 38:1847-1853. [PMID: 32745919 DOI: 10.1016/j.ajem.2020.06.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 05/28/2020] [Accepted: 06/04/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Visio-vestibular examination (VVE) deficits are common following pediatric concussion. Guidelines recommend assessing these deficits on all potentially concussed youth given their diagnostic and prognostic value, however test psychometrics of the VVE in the emergency department (ED) setting are unknown. Our objective was to determine the inter-rater (IRR) and test-retest reliability (TRR) of the VVE in a pediatric ED. METHODS We enrolled 155 patients (112 IRR; 43 TRR) age 6-18 years with head injury presenting to the ED of a tertiary care children's hospital. Exams were performed by a group of 65 attending/fellow physicians, pediatricians, and advanced practice providers. The VVE consisted of 9 maneuvers (smooth pursuits, horizontal/vertical saccades and gaze stability, binocular convergence, left/right monocular accommodation, complex tandem gait). Cohen's kappa was calculated for IRR and TRR for each element. RESULTS For IRR, 5/9 kappas (saccades, gaze stability, monocular accommodation) were in the moderate agreement range (0.40 to 0.60); remaining kappas showed fair agreement. For TRR, 6/9 maneuvers (saccades, horizontal gaze stability, monocular accommodation, tandem gait) showed substantial agreement (0.60 to 0.80). Kappas of 7/9 elements for subjects age 15-18 showed improved IRR and TRR. CONCLUSIONS The individual elements of the VVE show fair to moderate agreement between providers and moderate to substantial agreement among the same provider in the ED setting. These findings suggest a role in the VVE in evaluating concussion acutely, particularly given its previously demonstrated ability to assist in risk stratification of concussed youth and the importance of early diagnosis for improved outcomes.
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29
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White-Schwoch T, Krizman J, McCracken K, Burgess JK, Thompson EC, Nicol T, Kraus N, LaBella CR. Baseline profiles of auditory, vestibular, and visual functions in youth tackle football players. Concussion 2020; 4:CNC66. [PMID: 31984138 PMCID: PMC6964203 DOI: 10.2217/cnc-2019-0008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Aim Neurosensory tests have emerged as components of sport-related concussion management. Limited normative data are available in healthy, nonconcussed youth athletes. Patients & methods/results In 2017 and 2018, we tested 108 youth tackle football players immediately before their seasons on the frequency-following response, Balance Error Scoring System, and King-Devick test. We compared results with published data in older and/or and nonathlete populations. Performance on all tests improved with age. Frequency-following response and Balance Error Scoring System results aligned with socioeconomic status. Performance was not correlated across neurosensory domains. Conclusion Baseline neurosensory functions in seven 14-year-old male tackle football players are consistent with previously published data. Results reinforce the need for individual baselines or demographic-specific norms and the use of multiple neurosensory measures in sport-related concussion management.
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Affiliation(s)
- Travis White-Schwoch
- Auditory Neuroscience Laboratory & Department of Communication Sciences, Northwestern University, Evanston, IL 60208, USA
| | - Jennifer Krizman
- Auditory Neuroscience Laboratory & Department of Communication Sciences, Northwestern University, Evanston, IL 60208, USA
| | - Kristi McCracken
- Division of Orthopaedic Surgery & Sports Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA
| | - Jamie K Burgess
- Division of Orthopaedic Surgery & Sports Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA
| | - Elaine C Thompson
- Auditory Neuroscience Laboratory & Department of Communication Sciences, Northwestern University, Evanston, IL 60208, USA.,Now at Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Trent Nicol
- Auditory Neuroscience Laboratory & Department of Communication Sciences, Northwestern University, Evanston, IL 60208, USA
| | - Nina Kraus
- Auditory Neuroscience Laboratory & Department of Communication Sciences, Northwestern University, Evanston, IL 60208, USA.,Departments of Neurobiology and Otolaryngology, Northwestern University, Evanston, IL 60208, USA
| | - Cynthia R LaBella
- Division of Orthopaedic Surgery & Sports Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA.,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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30
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Storey EP, Wiebe DJ, DʼAlonzo BA, Nixon-Cave K, Jackson-Coty J, Goodman AM, Grady MF, Master CL. Vestibular Rehabilitation Is Associated With Visuovestibular Improvement in Pediatric Concussion. J Neurol Phys Ther 2019; 42:134-141. [PMID: 29912034 DOI: 10.1097/npt.0000000000000228] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Vision and vestibular-related deficits are common after concussion and are associated with prolonged recovery times, substantially impacting the quality of life for children. The utility of targeted vestibular rehabilitation for these deficits in children after concussion is unknown. The purpose of this study was to determine whether active vestibular rehabilitation is associated with an improvement in visuovestibular signs and symptoms in children with concussion. METHODS A retrospective cohort study of children diagnosed with concussion and referred to vestibular rehabilitation between 2012 and 2014 was conducted. Patient-reported symptoms and visuovestibular performance measures were assessed in the medical practice and physical therapy settings. RESULTS One hundred nine children were included in the study with a mean age of 11.8 (3.4) years. Among this group, 59 (54%) were male and 48 (44%) had a sports-related concussion. Children presented to a pediatric sports medicine office and physical therapy a median of 24 (interquartile range [IQR], 14-42) and 55 (IQR, 39-94) days after injury, respectively. Concussion symptoms decreased from a median of 9 (IQR, 5-13) symptoms at initial evaluation to a median of 0 (IQR, 0-2) symptoms at final assessment. Performance on all visuovestibular tasks improved significantly over the course of therapy except for near point of convergence. For the 45 children who completed the Balance Error Scoring System at both initial and final therapy visits, there was a significant improvement in mean level of performance (P < 0.0001). Characteristics between those who completed a full versus partial course of physical therapy were similar. DISCUSSION AND CONCLUSIONS Vestibular rehabilitation in children with concussion is associated with improvement in symptoms as well as visuovestibular performance. This active intervention may benefit children with persistent symptoms after concussion. Future prospective studies are needed to determine the efficacy and optimal postinjury timing of vestibular rehabilitation.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A208).
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Affiliation(s)
- Eileen P Storey
- The Children's Hospital of Philadelphia, Division of Orthopaedics, Sports Medicine and Performance Center, Philadelphia, Pennsylvania (E.P.S., K.N-C., J.J-C., M.F.G., C.L.M.); Perelman School of Medicine, University of Pennsylvania, Philadelphia (M.F.G., C.L.M.); Saint Peter's Sports Medicine Institute, Somerset, New Jersey (A.M.G.); and Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia (D.J.W., B.D.)
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31
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Recommendations for the Emergency Department Prevention of Sport-Related Concussion. Ann Emerg Med 2019; 75:471-482. [PMID: 31326205 DOI: 10.1016/j.annemergmed.2019.05.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/14/2019] [Accepted: 05/20/2019] [Indexed: 12/31/2022]
Abstract
Sport-related concussion refers to the subset of concussive injuries occurring during sport activities. Similar to concussion from nonsport mechanisms, sport-related concussion is associated with significant morbidity, including migrainous headaches, disruption in normal daily activities, and long-term depression and cognitive deficits. Unlike nonsport concussions, sport-related concussion may be uniquely amenable to prevention efforts to mitigate these problems. The emergency department (ED) visit for sport-related concussion represents an opportunity to reduce morbidity by timely diagnosis and management using best practices, and through education and counseling to prevent a subsequent sport-related concussion. This article provides recommendations to reduce sport-related concussion disability through primary, secondary, and tertiary preventive strategies enacted during the ED visit. Although many recommendations have a solid evidence base, several research gaps remain. The overarching goal of improving sport-related concussion outcome through enactment of ED-based prevention strategies needs to be explicitly studied.
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