1
|
Iring-Sanchez S, Dungan ME, Jones A, Malakhov M, Mohan S, Yaramothu C. OculoMotor & Vestibular Endurance Screening (MoVES) Normative, Repeatability, and Reliability Data. Brain Sci 2024; 14:704. [PMID: 39061444 PMCID: PMC11274463 DOI: 10.3390/brainsci14070704] [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: 05/29/2024] [Revised: 06/12/2024] [Accepted: 07/10/2024] [Indexed: 07/28/2024] Open
Abstract
This study aims to assess oculomotor and vestibular endurance by utilizing the Oculomotor and Vestibular Endurance Screening (MoVES) assessment in athletes' pre-season and post-season and after a suspected head injury to detect impairment. Athletes (N = 311, 19.4 ± 1.3 years) were recruited to perform the following seven tasks: (1) horizontal saccades, (2) vertical saccades, (3) vergence jumps, (4) horizontal vestibular-oculomotor reflex (VOR), (5) vertical VOR, (6) amplitude of accommodation (AoA), and (7) near point of convergence (NPC). At pre-season, the observed number of eye movements in 60 s are horizontal saccades (74 ± 13 initial 30 s; 67 ± 11 latter 30 s), vertical saccades (70 ± 13; 66 ± 10), vergence jumps (48 ± 12; 45 ± 13), horizontal VOR (38 ± 11; 38 ± 11), and vertical VOR (8 ± 11; 38 ± 11). These results establish a normative database for eye movements within the MoVES assessment and show consistency in the number of movements from pre-season to post-season. The initial results show a trending decrease in the number of eye movements in the initial days post-head injury, which improves to pre-season measures 14-21 days post-injury. This foundation can be used by future studies to explore the extent of binocular and vestibular endurance dysfunctions caused by head injuries that subside within two weeks.
Collapse
Affiliation(s)
- Stephanie Iring-Sanchez
- Massachusetts Eye and Ear, Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, MA 02114, USA;
| | - Michaela E. Dungan
- School of Applied Engineering and Technology, New Jersey Institute of Technology, Newark, NJ 07102, USA; (M.E.D.); (A.J.); (M.M.); (S.M.)
| | - Andrew Jones
- School of Applied Engineering and Technology, New Jersey Institute of Technology, Newark, NJ 07102, USA; (M.E.D.); (A.J.); (M.M.); (S.M.)
| | - Mitchell Malakhov
- School of Applied Engineering and Technology, New Jersey Institute of Technology, Newark, NJ 07102, USA; (M.E.D.); (A.J.); (M.M.); (S.M.)
| | - Stuti Mohan
- School of Applied Engineering and Technology, New Jersey Institute of Technology, Newark, NJ 07102, USA; (M.E.D.); (A.J.); (M.M.); (S.M.)
| | - Chang Yaramothu
- School of Applied Engineering and Technology, New Jersey Institute of Technology, Newark, NJ 07102, USA; (M.E.D.); (A.J.); (M.M.); (S.M.)
| |
Collapse
|
2
|
Fan H, Feng J, Ding Y, Gu P, Wang L, Chen X, Geng X. Performance of antisaccades in patients with cerebral small vessel disease accompanied by white matter hyperintensities. Neurol Res 2024:1-8. [PMID: 38888450 DOI: 10.1080/01616412.2024.2367934] [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: 05/03/2023] [Accepted: 06/09/2024] [Indexed: 06/20/2024]
Abstract
OBJECTIVES The antisaccades (AS) task is considered a reliable indicator of inhibitory control of eye movements in humans. Achieving good AS performance requires efficient cognitive processes that are sensitive to changes in brain structure. White matter hyperintensities (WMH) can cause subcortical-cortical dysconnectivity, affecting diverse cognitive domains. Thus, the AS task was investigated in patients with WMH in cerebral small vessel disease (CSVD). METHODS In this retrospective study, 75 participants with WMH, determined by neuroimaging standards for CSVD research, were admitted to the Department of Neurology of Beijing Luhe Hospital, Capital Medical University from January 2021 to December 2022. All subjects underwent the AS task, Montreal Cognitive Assessment (MoCA), Mini-Mental State Examination (MMSE), and 3.0T brain MRI. Additionally, 61 healthy subjects were recruited to characterize WMH profiles. RESULTS Compared to the control group, patients with WMH had a significantly increased AS error rate (49.81%, p = 0.001) and lower gain (76.00%, p = 0.042). The AS error rate was significantly higher in patients with WMH in the frontal lobe than in those without WMH (p = 0.004). After adjusting for confounders (age), a positive correlation was found between the AS error rate and MoCA scores for patients with WMH (coefficient = 0.262, p = 0.024). CONCLUSIONS Patients with WMH due to CSVD exhibited abnormal AS performances, particularly in the frontal lobe. The eye movement paradigms, the new diagnostic forms in neurology, can be utilized to investigate the distributed cortical and subcortical systems involved in cognitive control processes, offering simple, well-tolerated and highly sensitive advantages over traditional measures.
Collapse
Affiliation(s)
- Huimin Fan
- Department of Neurology and the Stroke Intervention and Translational Center (SITC), Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Jing Feng
- Department of Neurology and the Stroke Intervention and Translational Center (SITC), Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Pan Gu
- Department of Neurology and the Stroke Intervention and Translational Center (SITC), Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Liying Wang
- Department of Neurology and the Stroke Intervention and Translational Center (SITC), Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Xiaomeng Chen
- Department of Neurology and the Stroke Intervention and Translational Center (SITC), Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Xiaokun Geng
- Department of Neurology and the Stroke Intervention and Translational Center (SITC), Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
- China-America Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
3
|
Brooks JS, Dickey JP. Effect of Repetitive Head Impacts on Saccade Performance in Canadian University Football Players. Clin J Sport Med 2024; 34:280-287. [PMID: 38150378 PMCID: PMC11042529 DOI: 10.1097/jsm.0000000000001202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 11/07/2023] [Indexed: 12/29/2023]
Abstract
OBJECTIVE Investigate the effect of cumulative head impacts on saccade latency and errors, measured across two successive football seasons. DESIGN Participants were acquired from a sample of convenience-one Canadian university football team. Head impacts were collected during training camp, practices, eight regular season games, and four playoff games in each season. Saccade measurements were collected at five time points-before and after training camp, at midseason, after regular season, and after playoffs. SETTING Two seasons following players from a single USports football team during practices and games. PARTICIPANTS Players who completed a baseline saccade measurement and a minimum of one follow-up measurement were included in the study. A total of 127 players were monitored across two competitive seasons, including 61 players who participated in both seasons. INDEPENDENT VARIABLES Head impact measurements were collected using helmet-mounted sensors. MAIN OUTCOME MEASURES Saccade latency and number of errors were measured using high-speed video or electro-oculography. RESULTS On average, each head impact increased prosaccade latency by 5.16 × 10 -3 ms (95% confidence interval [CI], 2.26 × 10 -4 -1.00 × 10 -2 , P = 0.03) and antisaccade latency by 5.74 × 10 -3 ms (95% CI, 7.18 × 10 -4 -1.06 × 10 -2 , P = 0.02). These latency increases did not decrease between the two seasons; in fact, prosaccade latencies were 23.20 ms longer (95% CI, 19.40-27.14, P < 0.001) at the second season's baseline measurement than the first. The number of saccade errors was not affected by cumulative head impacts. CONCLUSIONS Repetitive head impacts in Canadian university football result in cumulative declines in brain function as measured by saccade performance. CLINICAL RELEVANCE Football organizations should consider implementing policies focused on reducing head impacts to improve player safety.
Collapse
Affiliation(s)
- Jeffrey S. Brooks
- School of Kinesiology, Faculty of Health Sciences, Western University, London, ON, Canada
- Department of Mechanical and Materials Engineering, Faculty of Engineering, Western University, London, ON, Canada; and
| | - James P. Dickey
- School of Kinesiology, Faculty of Health Sciences, Western University, London, ON, Canada
- School of Biomedical Engineering, Western University, London, ON, Canada
| |
Collapse
|
4
|
Shirzad M, Van Riesen J, Behboodpour N, Heath M. 10-min exposure to a 2.5% hypercapnic environment increases cerebral blood blow but does not impact executive function. LIFE SCIENCES IN SPACE RESEARCH 2024; 40:143-150. [PMID: 38245339 DOI: 10.1016/j.lssr.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 01/22/2024]
Abstract
Space travel and exploration are associated with increased ambient CO2 (i.e., a hypercapnic environment). Some work reported that the physiological changes (e.g., increased cerebral blood flow [CBF]) associated with a chronic hypercapnic environment contributes to a "space fog" that adversely impacts cognition and psychomotor performance, whereas other work reported no change or a positive change. Here, we employed the antisaccade task to evaluate whether transient exposure to a hypercapnic environment influences top-down executive function (EF). Antisaccades require a goal-directed eye movement mirror-symmetrical to a target and are an ideal tool for identifying subtle EF changes. Healthy young adults (aged 19-25 years) performed blocks of antisaccade trials prior to (i.e., pre-intervention), during (i.e., concurrent) and after (i.e., post-intervention) 10-min of breathing factional inspired CO2 (FiCO2) of 2.5% (i.e., hypercapnic condition) and during a normocapnic (i.e., control) condition. In both conditions, CBF, ventilatory and cardiorespiratory responses were measured. Results showed that the hypercapnic condition increased CBF, ventilation and end-tidal CO2 and thus demonstrated an expected physiological adaptation to increased FiCO2. Notably, however, null hypothesis and equivalence tests indicated that concurrent and post-intervention antisaccade reaction times were refractory to the hypercapnic environment; that is, transient exposure to a FiCO2 of 2.5% did not produce a real-time or lingering influence on an oculomotor-based measure of EF. Accordingly, results provide a framework that - in part - establishes the FiCO2 percentage and timeline by which high-level EF can be maintained. Future work will explore CBF and EF dynamics during chronic hypercapnic exposure as more direct proxy for the challenges of space flight and exploration.
Collapse
Affiliation(s)
- Mustafa Shirzad
- School of Kinesiology, Faculty of Health Sciences, University of Western Ontario, 1151 Richmond St, London, ON N6A 3K7, Canada
| | - James Van Riesen
- Canadian Centre for Activity and Aging, University of Western Ontario, 1201 Western Rd, London, ON N6G 1H1, Canada
| | - Nikan Behboodpour
- School of Kinesiology, Faculty of Health Sciences, University of Western Ontario, 1151 Richmond St, London, ON N6A 3K7, Canada
| | - Matthew Heath
- School of Kinesiology, Faculty of Health Sciences, University of Western Ontario, 1151 Richmond St, London, ON N6A 3K7, Canada; Canadian Centre for Activity and Aging, University of Western Ontario, 1201 Western Rd, London, ON N6G 1H1, Canada; Graduate Program in Neuroscience, University of Western Ontario, 1151 Richmond St, London, ON N6A 3K7, Canada.
| |
Collapse
|
5
|
Demian D, Petrak M, Zielinski G, Massingale S, Alexander A, Fuemmeler L, Lin CC. Clinical Saccadometry: Establishing Evaluative Standards Using a Simplified Video Oculography Protocol in the Adult Population. J Am Acad Audiol 2023. [PMID: 37989200 DOI: 10.1055/s-0043-1772582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
BACKGROUND Saccadometry is an advanced ocular motor test battery that allows for the functional evaluation of the varied brain regions and circuits involved in the generation of fast, purposeful, and accurate saccadic eye movements. The test battery is composed of prosaccade (PS) and antisaccade (AS) tests that progressively increase cognitive demand. Existing saccadometry protocols qualitatively describe trends across the lifespan, but have not been widely adopted by clinicians. PURPOSE The aims of this study are to design an efficient and simplified clinical saccadometry protocol using video oculography (VOG) equipment and establish associated evaluative standards across the lifespan. STUDY SAMPLE Data were reported on 273 adults ages 18 to 69 years. RESULTS Evaluative data on four measures: directional error rate (DE), latency (Lat), peak velocity (Vel), and accuracy (Acc) during PS and AS measurements were provided. Age-group differences were found in Lat (p < 0.01) and Vel (p = 0.04) during PS and age-group differences were found in DE (p = 0.04), Lat (p < 0.01) and Vel (p < 0.01) during AS. Gender differences were found in DE (p = 0.01) and Lat (p < 0.01) during AS. CONCLUSIONS This study established a standardized and time-efficient protocol with evaluative standards for individuals ages 18 to 69 years old to enable the use of saccadometry as an objective measure in the clinic. Saccadometry allows clinicians to look beyond the traditional saccade test and evaluate complex oculomotor and cognitive functions that will better help clinicians differentiate between peripheral and central diagnoses.
Collapse
Affiliation(s)
- Daniel Demian
- Venn Med, Toronto, Ontario, Canada
- Interacoustics, Middelfart, Denmark
| | - Michelle Petrak
- Interacoustics, Middelfart, Denmark
- Northwest Speech and Hearing, Arlington Heights, Illinois
| | - Glen Zielinski
- Interacoustics, Middelfart, Denmark
- Northwest Functional Neurology, Lake Oswego, Oregon
| | - Shelly Massingale
- Interacoustics, Middelfart, Denmark
- Banner Sports Medicine and Concussion Specialists, Phoenix, Arizona
| | - Amy Alexander
- Interacoustics, Middelfart, Denmark
- Banner Sports Medicine and Concussion Specialists, Phoenix, Arizona
| | - Liz Fuemmeler
- Interacoustics, Middelfart, Denmark
- Hearing and Balance Specialists of Kansas City, Kansas City, Missouri
| | - Chia-Cheng Lin
- Department of Physical Therapy, East Carolina University, Greenville, North Carolina
| |
Collapse
|
6
|
Symons GF, O’Brien WT, Abel L, Chen Z, Costello DM, O’Brien TJ, Kolbe S, Fielding J, Shultz SR, Clough M. Monitoring the acute and subacute recovery of cognitive ocular motor changes after a sports-related concussion. Cereb Cortex 2022; 33:5276-5288. [PMID: 36300614 DOI: 10.1093/cercor/bhac416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 09/15/2022] [Accepted: 09/17/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Identifying when recovery from a sports-related concussion (SRC) has occurred remains a challenge in clinical practice. This study investigated the utility of ocular motor (OM) assessment to monitor recovery post-SRC between sexes and compared to common clinical measures. From 139 preseason baseline assessments (i.e. before they sustained an SRC), 18 (12 males, 6 females) consequent SRCs were sustained and the longitudinal follow-ups were collected at 2, 6, and 13 days post-SRC. Participants completed visually guided, antisaccade (AS), and memory-guided saccade tasks requiring a saccade toward, away from, and to a remembered target, respectively. Changes in latency (processing speed), visual–spatial accuracy, and errors were measured. Clinical measures included The Sports Concussion Assessment Tool, King-Devick test, Stroop task, and Digit span. AS latency was significantly longer at 2 days and returned to baseline by 13-days post-SRC in females only (P < 0.001). Symptom numbers recovered from 2 to 6 days and 13 days (P < 0.05). Persistently poorer AS visual–spatial accuracy was identified at 2, 6 and 13 days post-SRC (P < 0.05) in both males and females but with differing trajectories. Clinical measures demonstrated consistent improvement reminiscent of practice effects. OM saccade assessment may have improved utility in tracking recovery compared to conventional measures and between sexes.
Collapse
Affiliation(s)
- Georgia F Symons
- Monash University Department of Neuroscience, , The Alfred Centre, 99 Commercial Road, Melbourne, Victoria (VIC) 3004, Australia
| | - William T O’Brien
- Monash University Department of Neuroscience, , The Alfred Centre, 99 Commercial Road, Melbourne, Victoria (VIC) 3004, Australia
| | - Larry Abel
- Department of Optometry and Vision science, The University of Melbourne , Grattan street, Parkville, Victoria (VIC) 3010, Australia
| | - Zhibin Chen
- Monash University Department of Neuroscience, , The Alfred Centre, 99 Commercial Road, Melbourne, Victoria (VIC) 3004, Australia
- Department of Medicine, The University of Melbourne, The Royal Melbourne Hospital , Grattan street, Parkville, Victoria (VIC) 3010, Australia
| | - Daniel M Costello
- Department of Medicine, The University of Melbourne, The Royal Melbourne Hospital , Grattan street, Parkville, Victoria (VIC) 3010, Australia
| | - Terence J O’Brien
- Monash University Department of Neuroscience, , The Alfred Centre, 99 Commercial Road, Melbourne, Victoria (VIC) 3004, Australia
- Department of Medicine, The University of Melbourne, The Royal Melbourne Hospital , Grattan street, Parkville, Victoria (VIC) 3010, Australia
| | - Scott Kolbe
- Monash University Department of Neuroscience, , The Alfred Centre, 99 Commercial Road, Melbourne, Victoria (VIC) 3004, Australia
| | - Joanne Fielding
- Monash University Department of Neuroscience, , The Alfred Centre, 99 Commercial Road, Melbourne, Victoria (VIC) 3004, Australia
- Department of Medicine, The University of Melbourne, The Royal Melbourne Hospital , Grattan street, Parkville, Victoria (VIC) 3010, Australia
| | - Sandy R Shultz
- Monash University Department of Neuroscience, , The Alfred Centre, 99 Commercial Road, Melbourne, Victoria (VIC) 3004, Australia
- Department of Medicine, The University of Melbourne, The Royal Melbourne Hospital , Grattan street, Parkville, Victoria (VIC) 3010, Australia
- Department of Nursing, Health and Huan services, Vancouver Island University , 900 Fifth St, Nanaimo, British Columbia (BC), V9R 6S5, Canada
| | - Meaghan Clough
- Monash University Department of Neuroscience, , The Alfred Centre, 99 Commercial Road, Melbourne, Victoria (VIC) 3004, Australia
| |
Collapse
|
7
|
McDonald MA, Tayebi M, McGeown JP, Kwon EE, Holdsworth SJ, Danesh-Meyer HV. A window into eye movement dysfunction following mTBI: A scoping review of magnetic resonance imaging and eye tracking findings. Brain Behav 2022; 12:e2714. [PMID: 35861623 PMCID: PMC9392543 DOI: 10.1002/brb3.2714] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 04/11/2022] [Accepted: 05/23/2022] [Indexed: 12/01/2022] Open
Abstract
Mild traumatic brain injury (mTBI), commonly known as concussion, is a complex neurobehavioral phenomenon affecting six in 1000 people globally each year. Symptoms last between days and years as microstructural damage to axons and neurometabolic changes result in brain network disruption. There is no clinically available objective biomarker to diagnose the severity of injury or monitor recovery. However, emerging evidence suggests eye movement dysfunction (e.g., saccades and smooth pursuits) in patients with mTBI. Patients with a higher symptom burden and prolonged recovery time following injury may show higher degrees of eye movement dysfunction. Likewise, recent advances in magnetic resonance imaging (MRI) have revealed both white matter tract damage and functional network alterations in mTBI patients, which involve areas responsible for the ocular motor control. This scoping review is presented in three sections: Section 1 explores the anatomical control of eye movements to aid the reader with interpreting the discussion in subsequent sections. Section 2 examines the relationship between abnormal MRI findings and eye tracking after mTBI based on the available evidence. Finally, Section 3 communicates gaps in our knowledge about MRI and eye tracking, which should be addressed in order to substantiate this emerging field.
Collapse
Affiliation(s)
- Matthew A McDonald
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand.,Mātai Medical Research Institute, Gisborne, New Zealand
| | - Maryam Tayebi
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand.,Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Joshua P McGeown
- Mātai Medical Research Institute, Gisborne, New Zealand.,Auckland University of Technology Traumatic Brain Injury Network, Auckland, New Zealand
| | - Eryn E Kwon
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand.,Mātai Medical Research Institute, Gisborne, New Zealand.,Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Samantha J Holdsworth
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand.,Mātai Medical Research Institute, Gisborne, New Zealand.,Department of Anatomy and Medical Imaging, University of Auckland, Auckland, New Zealand
| | - Helen V Danesh-Meyer
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand.,Eye Institute, Auckland, New Zealand
| |
Collapse
|
8
|
Master CL, Bacal D, Grady MF, Hertle R, Shah AS, Strominger M, Whitecross S, Bradford GE, Lum F, Donahue SP. Vision and Concussion: Symptoms, Signs, Evaluation, and Treatment. Pediatrics 2022; 150:188533. [PMID: 35843991 DOI: 10.1542/peds.2021-056047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2021] [Indexed: 01/24/2023] Open
Abstract
Visual symptoms are common after concussion in children and adolescents, making it essential for clinicians to understand how to screen, identify, and initiate clinical management of visual symptoms in pediatric patients after this common childhood injury. Although most children and adolescents with visual symptoms after concussion will recover on their own by 4 weeks, for a subset who do not have spontaneous recovery, referral to a specialist with experience in comprehensive concussion management (eg, sports medicine, neurology, neuropsychology, physiatry, ophthalmology, otorhinolaryngology) for additional assessment and treatment may be necessary. A vision-specific history and a thorough visual system examination are warranted, including an assessment of visual acuity, ocular alignment in all positions of gaze, smooth pursuit (visual tracking of a moving object), saccades (visual fixation shifting between stationary targets), vestibulo-ocular reflex (maintaining image focus during movement), near point of convergence (focusing with both eyes at near and accommodation (focusing with one eye at near because any of these functions may be disturbed after concussion. These deficits may contribute to difficulty with returning to both play and the learning setting at school, making the identification of these problems early after injury important for the clinician to provide relevant learning accommodations, such as larger font, preprinted notes, and temporary use of audio books. Early identification and appropriate management of visual symptoms, such as convergence insufficiency or accommodative insufficiency, may mitigate the negative effects of concussion on children and adolescents and their quality of life.
Collapse
Affiliation(s)
- Christina L Master
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine.,Minds Matter Concussion Program.,Pediatric and Adolescent Sports Medicine, Division of Pediatric Orthopaedics, Karabots Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Darron Bacal
- Department of Ophthalmology and Visual Science, Yale University, New Haven, Connecticut.,Eye Physicians and Surgeons, PC, New Haven, Connecticut
| | - Matthew F Grady
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine.,Pediatric and Adolescent Sports Medicine, Division of Pediatric Orthopaedics, Karabots Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Richard Hertle
- Department of Surgery, College of Medicine, Northeast Ohio Medical College, Rootstown, Ohio.,Department of Specialty Medicine, Ohio University College of Osteopathic Medicine, Athens, Ohio; and Akron Children's Hospital Vision Center, Akron, Ohio
| | - Ankoor S Shah
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts.,Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts.,Massachusetts Eye and Ear, Boston, Massachusetts
| | - Mitchell Strominger
- Departments of Surgery.,Ophthalmology.,Pediatrics.,Clinical Internal Medicine, University of Nevada Reno School of Medicine, Renown Medical Center, Reno, Nevada
| | - Sarah Whitecross
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts
| | - Geoffrey E Bradford
- Departments of Ophthalmology.,Pediatrics, West Virginia University, Morgantown, West Virginia
| | - Flora Lum
- Quality and Data Science Division, American Academy of Ophthalmology, San Francisco, California
| | - Sean P Donahue
- Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
| | | |
Collapse
|
9
|
Snegireva N, Derman W, Patricios J, Welman KE. Blink duration is increased in concussed youth athletes: a validity study using eye tracking in male youth and adult athletes of selected contact sports. Physiol Meas 2022; 43. [PMID: 35709708 DOI: 10.1088/1361-6579/ac799b] [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: 12/30/2021] [Accepted: 06/16/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Diagnosing a sports-related concussion (SRC) remains challenging, and research into diagnostic tools is limited. This study investigated whether selected eye tracking variables would be a valid tool to diagnose and monitor SRC in adult and youth participants in selected contact sports, such as Rugby Union (rugby) and football (soccer). METHODS This prospective cohort study, with 70 concussed and 92 non-concussed adult and youth athletes, assessed the validity of five previously selected eye tracking variables for SRC diagnostics and management. The performance between concussed and age-matched control (non-concussed) athletes, as well as between three successive testing sessions in the concussed athletes were compared. Self-paced saccade count in adult group; blink duration in the memory-guided saccade and sinusoidal smooth pursuit tasks, proportion of antisaccade errors, and gain of diagonal smooth pursuit in the youth group were assessed. RESULTS The youth concussed group had higher blink duration in the fast memory-guided saccades task (p = 0.001, η2 = 0.17) and a tendency for higher blink duration in the sinusoidal smooth pursuit task (p = 0.016, η2 = 0.06) compared to the youth control group. In both tasks the blink duration in the concussed youth group decreased from session 1 to session 2 by 24% and 18%, accordingly, although statistical significance was not reached. The concussed adult group demonstrated a lower number of self-paced saccades compared to controls (p = 0.05, η2 = 0.09), which gradually increased, with the largest difference between session 1 and session 3 (p = 0.02). CONCLUSIONS Blink duration in youth athletes holds promise as a valid metric for concussion diagnostics and monitoring. It is recommended to focus future studies on comparing eye tracking performance within the same concussed athletes over time rather than comparing them to healthy controls.
Collapse
Affiliation(s)
- Nadja Snegireva
- Sports Science, Stellenbosch University Faculty of Medicine and Health Sciences, Suidwal Road, Coetzenburg, Cape Town, Western Cape, 7601, SOUTH AFRICA
| | - Wayne Derman
- Institute of Sport and Exercise Medicine, Stellenbosch University Faculty of Medicine and Health Sciences, Francie Van Zijl Dr, Parow, Cape Town, Western Cape, 7505, SOUTH AFRICA
| | - Jon Patricios
- Wits Institute for Sport and Health, University of the Witwatersrand Faculty of Health Sciences, 27 St Andrews Rd, Parktown, Johannesburg, Gauteng, 2193, SOUTH AFRICA
| | - Karen Estelle Welman
- Sports Science, Stellenbosch University Faculty of Medicine and Health Sciences, Suidwal Road, Coetzenburg, Cape Town, Western Cape, 7601, SOUTH AFRICA
| |
Collapse
|
10
|
Gallagher VT, Murthy P, Stocks J, Vesci B, Mjaanes J, Chen Y, Breiter HC, LaBella C, Herrold AA, Reilly JL. Eye Movements Detect Differential Change after Participation in Male Collegiate Collision versus Non-Collision Sports. Neurotrauma Rep 2021; 2:440-452. [PMID: 34901940 PMCID: PMC8655805 DOI: 10.1089/neur.2021.0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Although neuroimaging studies of collision (COLL) sport athletes demonstrate alterations in brain structure and function from pre- to post-season, reliable tools to detect behavioral/cognitive change relevant to functional networks associated with participation in collision sports are lacking. This study evaluated the use of eye-movement testing to detect change in cognitive and sensorimotor processing among male club collegiate athletes after one season of participation in collision sports of variable exposure. We predicted that COLL (High Dose [hockey], n = 8; Low Dose [rugby], n = 9) would demonstrate longer reaction times (antisaccade and memory-guided saccade [MGS] latencies), increased inhibitory errors (antisaccade error rate), and poorer spatial working memory (MGS spatial accuracy) at post-season, relative to pre-season, whereas non-collision collegiate athletes (NON-COLL; n = 17) would remain stable. We also predicted that whereas eye-movement performance would detect pre- to post-season change, ImPACT (Immediate Post-Concussion Assessment and Cognitive Test) performance would remain stable. Our data showed that NON-COLL had shorter (improved performance) post- versus pre-season antisaccade and MGS latencies, whereas COLL groups showed stable, longer, or attenuated reduction in latency (ps ≤ 0.001). Groups did not differ in antisaccade error rate. On the MGS task, NON-COLL demonstrated improved spatial accuracy over time, whereas COLL groups showed reduced spatial accuracy (p < 0.05, uncorrected). No differential change was observed on ImPACT. This study provides preliminary evidence for eye-movement testing as a sensitive marker of subtle changes in attentional control and working memory resulting from participation in sports with varying levels of subconcussive exposure.
Collapse
Affiliation(s)
| | - Prianka Murthy
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jane Stocks
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Brian Vesci
- Department of Sports Medicine, Northwestern University, Evanston, Illinois, USA
| | - Jeffrey Mjaanes
- Department of Sports Medicine, Northwestern University, Evanston, Illinois, USA
| | - Yufen Chen
- Center for Translational Imaging, Northwestern University, Evanston, Illinois, USA
| | - Hans C Breiter
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Cynthia LaBella
- Division of Orthopedics and Sports Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Amy A Herrold
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - James L Reilly
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| |
Collapse
|
11
|
Gold DM, Rizzo JR, Lee YSC, Childs A, Hudson TE, Martone J, Matsuzawa YK, Fraser F, Ricker JH, Dai W, Selesnick I, Balcer LJ, Galetta SL, Rucker JC. King-Devick Test Performance and Cognitive Dysfunction after Concussion: A Pilot Eye Movement Study. Brain Sci 2021; 11:brainsci11121571. [PMID: 34942873 PMCID: PMC8699706 DOI: 10.3390/brainsci11121571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/17/2021] [Accepted: 11/24/2021] [Indexed: 11/30/2022] Open
Abstract
(1) Background: The King-Devick (KD) rapid number naming test is sensitive for concussion diagnosis, with increased test time from baseline as the outcome measure. Eye tracking during KD performance in concussed individuals shows an association between inter-saccadic interval (ISI) (the time between saccades) prolongation and prolonged testing time. This pilot study retrospectively assesses the relation between ISI prolongation during KD testing and cognitive performance in persistently-symptomatic individuals post-concussion. (2) Results: Fourteen participants (median age 34 years; 6 women) with prior neuropsychological assessment and KD testing with eye tracking were included. KD test times (72.6 ± 20.7 s) and median ISI (379.1 ± 199.1 msec) were prolonged compared to published normative values. Greater ISI prolongation was associated with lower scores for processing speed (WAIS-IV Coding, r = 0.72, p = 0.0017), attention/working memory (Trails Making A, r = −0.65, p = 0.006) (Digit Span Forward, r = 0.57, p = −0.017) (Digit Span Backward, r= −0.55, p = 0.021) (Digit Span Total, r = −0.74, p = 0.001), and executive function (Stroop Color Word Interference, r = −0.8, p = 0.0003). (3) Conclusions: This pilot study provides preliminary evidence suggesting that cognitive dysfunction may be associated with prolonged ISI and KD test times in concussion.
Collapse
Affiliation(s)
- Doria M. Gold
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10016, USA; (D.M.G.); (J.-R.R.); (T.E.H.); (J.M.); (W.D.); (L.J.B.); (S.L.G.)
| | - John-Ross Rizzo
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10016, USA; (D.M.G.); (J.-R.R.); (T.E.H.); (J.M.); (W.D.); (L.J.B.); (S.L.G.)
- Department of Physical Medicine & Rehabilitation, New York University Grossman School of Medicine, New York, NY 10016, USA; (Y.S.C.L.); (A.C.); (Y.K.M.); (J.H.R.)
- Department of Mechanical & Aerospace Engineering, New York University Tandon School of Engineering, New York, NY 11201, USA
- Department of Biomedical Engineering, New York University Tandon School of Engineering, New York, NY 11201, USA
| | - Yuen Shan Christine Lee
- Department of Physical Medicine & Rehabilitation, New York University Grossman School of Medicine, New York, NY 10016, USA; (Y.S.C.L.); (A.C.); (Y.K.M.); (J.H.R.)
| | - Amanda Childs
- Department of Physical Medicine & Rehabilitation, New York University Grossman School of Medicine, New York, NY 10016, USA; (Y.S.C.L.); (A.C.); (Y.K.M.); (J.H.R.)
| | - Todd E. Hudson
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10016, USA; (D.M.G.); (J.-R.R.); (T.E.H.); (J.M.); (W.D.); (L.J.B.); (S.L.G.)
- Department of Physical Medicine & Rehabilitation, New York University Grossman School of Medicine, New York, NY 10016, USA; (Y.S.C.L.); (A.C.); (Y.K.M.); (J.H.R.)
| | - John Martone
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10016, USA; (D.M.G.); (J.-R.R.); (T.E.H.); (J.M.); (W.D.); (L.J.B.); (S.L.G.)
| | - Yuka K. Matsuzawa
- Department of Physical Medicine & Rehabilitation, New York University Grossman School of Medicine, New York, NY 10016, USA; (Y.S.C.L.); (A.C.); (Y.K.M.); (J.H.R.)
| | - Felicia Fraser
- Department of Physical Medicine & Rehabilitation, MetroHeath System, Cleveland, OH 44109, USA;
| | - Joseph H. Ricker
- Department of Physical Medicine & Rehabilitation, New York University Grossman School of Medicine, New York, NY 10016, USA; (Y.S.C.L.); (A.C.); (Y.K.M.); (J.H.R.)
| | - Weiwei Dai
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10016, USA; (D.M.G.); (J.-R.R.); (T.E.H.); (J.M.); (W.D.); (L.J.B.); (S.L.G.)
- Department of Electrical & Computer Engineering, New York University Tandon School of Engineering, New York, NY 11201, USA;
| | - Ivan Selesnick
- Department of Electrical & Computer Engineering, New York University Tandon School of Engineering, New York, NY 11201, USA;
| | - Laura J. Balcer
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10016, USA; (D.M.G.); (J.-R.R.); (T.E.H.); (J.M.); (W.D.); (L.J.B.); (S.L.G.)
- Department of Population Health, New York University Grossman School of Medicine, New York, NY 10016, USA
- Department of Ophthalmology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Steven L. Galetta
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10016, USA; (D.M.G.); (J.-R.R.); (T.E.H.); (J.M.); (W.D.); (L.J.B.); (S.L.G.)
- Department of Ophthalmology, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Janet C. Rucker
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10016, USA; (D.M.G.); (J.-R.R.); (T.E.H.); (J.M.); (W.D.); (L.J.B.); (S.L.G.)
- Department of Ophthalmology, New York University Grossman School of Medicine, New York, NY 10016, USA
- Correspondence: ; Tel.: +1-212-263-7744
| |
Collapse
|
12
|
Lirani-Silva E, Stuart S, Parrington L, Campbell K, King L. Saccade and Fixation Eye Movements During Walking in People With Mild Traumatic Brain Injury. Front Bioeng Biotechnol 2021; 9:701712. [PMID: 34805104 PMCID: PMC8602343 DOI: 10.3389/fbioe.2021.701712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 10/15/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Clinical and laboratory assessment of people with mild traumatic brain injury (mTBI) indicate impairments in eye movements. These tests are typically done in a static, seated position. Recently, the use of mobile eye-tracking systems has been proposed to quantify subtle deficits in eye movements and visual sampling during different tasks. However, the impact of mTBI on eye movements during functional tasks such as walking remains unknown. Objective: Evaluate differences in eye-tracking measures collected during gait between healthy controls (HC) and patients in the sub-acute stages of mTBI recovery and to determine if there are associations between eye-tracking measures and gait speed. Methods: Thirty-seven HC participants and 67individuals with mTBI were instructed to walk back and forth over 10-m, at a comfortable self-selected speed. A single 1-min trial was performed. Eye-tracking measures were recorded using a mobile eye-tracking system (head-mounted infra-red Tobbii Pro Glasses 2, 100 Hz, Tobii Technology Inc. VA, United States). Eye-tracking measures included saccadic (frequency, mean and peak velocity, duration and distance) and fixation measurements (frequency and duration). Gait was assessed using six inertial sensors (both feet, sternum, right wrist, lumbar vertebrae and the forehead) and gait velocity was selected as the primary outcome. General linear model was used to compare the groups and association between gait and eye-tracking outcomes were explored using partial correlations. Results: Individuals with mTBI showed significantly reduced saccade frequency (p = 0.016), duration (p = 0.028) and peak velocity (p = 0.032) compared to the HC group. No significant differences between groups were observed for the saccade distance, fixation measures and gait velocity (p > 0.05). A positive correlation was observed between saccade duration and gait velocity only for participants with mTBI (p = 0.025). Conclusion: Findings suggest impaired saccadic eye movement, but not fixations, during walking in individuals with mTBI. These findings have implications in real-world function including return to sport for athletes and return to duty for military service members. Future research should investigate whether or not saccade outcomes are influenced by the time after the trauma and rehabilitation.
Collapse
Affiliation(s)
- Ellen Lirani-Silva
- Balance Disorders Laboratory, Department of Neurology, Oregon Health and Science University, Portland, OR, United States
| | - Samuel Stuart
- Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle Upon Tyne, United Kingdom.,Northumbria Healthcare NHS Foundation Trust, North Shields, United Kingdom
| | - Lucy Parrington
- Balance Disorders Laboratory, Department of Neurology, Oregon Health and Science University, Portland, OR, United States.,Veterans Affairs Portland Oregon Health Care System, Portland, OR, United States
| | - Kody Campbell
- Balance Disorders Laboratory, Department of Neurology, Oregon Health and Science University, Portland, OR, United States.,Veterans Affairs Portland Oregon Health Care System, Portland, OR, United States
| | - Laurie King
- Balance Disorders Laboratory, Department of Neurology, Oregon Health and Science University, Portland, OR, United States.,Veterans Affairs Portland Oregon Health Care System, Portland, OR, United States
| |
Collapse
|
13
|
Symons GF, Clough M, Fielding J, O'Brien WT, Shepherd CE, Wright DK, Shultz SR. The Neurological Consequences of Engaging in Australian Collision Sports. J Neurotrauma 2021; 37:792-809. [PMID: 32056505 DOI: 10.1089/neu.2019.6884] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Collision sports are an integral part of Australian culture. The most common collision sports in Australia are Australian rules football, rugby union, and rugby league. Each of these sports often results in participants sustaining mild brain traumas, such as concussive and subconcussive injuries. However, the majority of previous studies and reviews pertaining to the neurological implications of sustaining mild brain traumas, while engaging in collision sports, have focused on those popular in North America and Europe. As part of this 2020 International Neurotrauma Symposium special issue, which highlights Australian neurotrauma research, this article will therefore review the burden of mild brain traumas in Australian collision sports athletes. Specifically, this review will first provide an overview of the consequences of mild brain trauma in Australian collision sports, followed by a summary of the previous studies that have investigated neurocognition, ocular motor function, neuroimaging, and fluid biomarkers, as well as neuropathological outcomes in Australian collision sports athletes. A review of the literature indicates that although Australians have contributed to the field, several knowledge gaps and limitations currently exist. These include important questions related to sex differences, the identification and implementation of blood and imaging biomarkers, the need for consistent study designs and common data elements, as well as more multi-modal studies. We conclude that although Australia has had an active history of investigating the neurological impact of collision sports participation, further research is clearly needed to better understand these consequences in Australian athletes and how they can be mitigated.
Collapse
Affiliation(s)
- Georgia F Symons
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Meaghan Clough
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Joanne Fielding
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - William T O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Claire E Shepherd
- Neuroscience Research Australia, The University of New South Wales, Sydney, New South Wales, Australia
| | - David K Wright
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Sandy R Shultz
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| |
Collapse
|
14
|
DeSimone JC, Davenport EM, Urban J, Xi Y, Holcomb JM, Kelley ME, Whitlow CT, Powers AK, Stitzel JD, Maldjian JA. Mapping default mode connectivity alterations following a single season of subconcussive impact exposure in youth football. Hum Brain Mapp 2021; 42:2529-2545. [PMID: 33734521 PMCID: PMC8090779 DOI: 10.1002/hbm.25384] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 12/14/2022] Open
Abstract
Repetitive head impact (RHI) exposure in collision sports may contribute to adverse neurological outcomes in former players. In contrast to a concussion, or mild traumatic brain injury, “subconcussive” RHIs represent a more frequent and asymptomatic form of exposure. The neural network‐level signatures characterizing subconcussive RHIs in youth collision‐sport cohorts such as American Football are not known. Here, we used resting‐state functional MRI to examine default mode network (DMN) functional connectivity (FC) following a single football season in youth players (n = 50, ages 8–14) without concussion. Football players demonstrated reduced FC across widespread DMN regions compared with non‐collision sport controls at postseason but not preseason. In a subsample from the original cohort (n = 17), players revealed a negative change in FC between preseason and postseason and a positive and compensatory change in FC during the offseason across the majority of DMN regions. Lastly, significant FC changes, including between preseason and postseason and between in‐ and off‐season, were specific to players at the upper end of the head impact frequency distribution. These findings represent initial evidence of network‐level FC abnormalities following repetitive, non‐concussive RHIs in youth football. Furthermore, the number of subconcussive RHIs proved to be a key factor influencing DMN FC.
Collapse
Affiliation(s)
- Jesse C. DeSimone
- Advanced Neuroscience Imaging Research (ANSIR) LaboratoryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
- Department of RadiologyUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Elizabeth M. Davenport
- Advanced Neuroscience Imaging Research (ANSIR) LaboratoryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
- Department of RadiologyUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Jillian Urban
- Department of Biomedical EngineeringWake Forest School of MedicineWinston SalemNorth CarolinaUSA
- Virginia Tech – Wake Forest School of Biomedical EngineeringWake Forest School of MedicineWinston SalemNorth CarolinaUSA
| | - Yin Xi
- Department of RadiologyUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - James M. Holcomb
- Advanced Neuroscience Imaging Research (ANSIR) LaboratoryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
- Department of RadiologyUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Mireille E. Kelley
- Department of Biomedical EngineeringWake Forest School of MedicineWinston SalemNorth CarolinaUSA
- Virginia Tech – Wake Forest School of Biomedical EngineeringWake Forest School of MedicineWinston SalemNorth CarolinaUSA
| | - Christopher T. Whitlow
- Virginia Tech – Wake Forest School of Biomedical EngineeringWake Forest School of MedicineWinston SalemNorth CarolinaUSA
- Department of Radiology – NeuroradiologyWake Forest School of MedicineWinston SalemNorth CarolinaUSA
- Clinical and Translational Sciences InstituteWake Forest School of MedicineWinston SalemNorth CarolinaUSA
| | - Alexander K. Powers
- Department of NeurosurgeryWake Forest School of MedicineWinston SalemNorth CarolinaUSA
| | - Joel D. Stitzel
- Department of Biomedical EngineeringWake Forest School of MedicineWinston SalemNorth CarolinaUSA
- Virginia Tech – Wake Forest School of Biomedical EngineeringWake Forest School of MedicineWinston SalemNorth CarolinaUSA
- Clinical and Translational Sciences InstituteWake Forest School of MedicineWinston SalemNorth CarolinaUSA
- Childress Institute for Pediatric TraumaWake Forest School of MedicineWinston SalemNorth CarolinaUSA
| | - Joseph A. Maldjian
- Advanced Neuroscience Imaging Research (ANSIR) LaboratoryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
- Department of RadiologyUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| |
Collapse
|
15
|
Feller CN, Goldenberg M, Asselin PD, Merchant-Borna K, Abar B, Jones CMC, Mannix R, Kawata K, Bazarian JJ. Classification of Comprehensive Neuro-Ophthalmologic Measures of Postacute Concussion. JAMA Netw Open 2021; 4:e210599. [PMID: 33656530 PMCID: PMC7930925 DOI: 10.1001/jamanetworkopen.2021.0599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Symptom-based methods of concussion diagnosis in contact sports result in underdiagnosis and repeated head injury exposure, increasing the risk of long-term disability. Measures of neuro-ophthalmologic (NO) function have the potential to serve as objective aids, but their diagnostic utility is unknown. OBJECTIVE To identify NO measures that accurately differentiate athletes with and without concussion. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted among athletes with and without concussion who were aged 17 to 22 years between 2016 and 2017. Eye movements and cognitive function were measured a median of 19 days after injury among patients who had an injury meeting the study definition of concussion while playing a sport (retrospectively selected from a concussion clinic), then compared with a control group of participants without concussion (enrolled from 104 noncontact collegiate athlete volunteers without prior head injury). Data analysis was conducted from November 2019 through May 2020. EXPOSURE Concussion. MAIN OUTCOMES AND MEASURES Classification accuracy of clinically important discriminator eye-tracking (ET) metrics. Participants' eye movements were evaluated with a 12-minute ET procedure, yielding 42 metrics related to smooth pursuit eye movement (SPEM), saccades, dynamic visual acuity, and reaction time. Clinically important discriminator metrics were defined as those with significantly different group differences and area under the receiver operator characteristic curves (AUROCs) of at least 0.70. RESULTS A total of 34 participants with concussions (mean [SD] age, 19.7 [2.4] years; 20 [63%] men) and 54 participants without concussions (mean [SD] age, 20.8 [2.2] years; 31 [57%] men) completed the study. Six ET metrics (ie, simple reaction time, discriminate reaction time, discriminate visual reaction speed, choice visual reaction speed, and reaction time on 2 measures of dynamic visual acuity 2) were found to be clinically important; all were measures of reaction time, and none were related to SPEM. Combined, these 6 metrics had an AUROC of 0.90 (95% CI, 0.80-0.99), a sensitivity of 77.8%, and a specificity of 92.6%. The 6 metrics remained significant on sensitivity testing. CONCLUSIONS AND RELEVANCE In this study, ET measures of slowed visual reaction time had high classification accuracy for concussion. Accurate, objective measures of NO function have the potential to improve concussion recognition and reduce the disability associated with underdiagnosis.
Collapse
Affiliation(s)
- Christina N. Feller
- University of Rochester School of Medicine and Dentistry, Rochester, New York
- Medical College of Wisconsin, Milwaukee
| | | | - Patrick D. Asselin
- University of Rochester School of Medicine and Dentistry, Rochester, New York
- Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kian Merchant-Borna
- Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Beau Abar
- Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Courtney Marie Cora Jones
- Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Rebekah Mannix
- Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Keisuke Kawata
- Department of Kinesiology, Indiana University, Bloomington
| | - Jeffrey J. Bazarian
- Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| |
Collapse
|
16
|
Gallagher VT, Murthy P, Stocks J, Vesci B, Colegrove D, Mjaanes J, Chen Y, Breiter H, LaBella C, Herrold AA, Reilly JL. Differential Change in Oculomotor Performance among Female Collegiate Soccer Players versus Non-Contact Athletes from Pre- to Post-Season. Neurotrauma Rep 2020; 1:169-180. [PMID: 33274345 PMCID: PMC7703496 DOI: 10.1089/neur.2020.0051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Sensitive and reliable tools are needed to evaluate potential behavioral and cognitive changes following head impact exposure in contact and collision sport participation. We evaluated change in oculomotor testing performance among female, varsity, collegiate athletes following variable exposure to head impacts across a season. Female, collegiate, contact sport (soccer, CONT) and non-contact sport (NON-CONT) athletes were assessed pre-season and post-season. Soccer athletes were grouped according to total season game headers into low dose (≤40 headers; CONT-Low Dose) or high dose (>40 headers; CONT-High Dose) groups. Performance on pro-saccade (reflexive visual response), anti-saccade (executive inhibition), and memory-guided saccade (MGS, spatial working memory) computer-based laboratory tasks were assessed. Primary saccade measures included latency/reaction time, inhibition error rate (anti-saccade only), and spatial accuracy (MGS only). NON-CONT (n = 20), CONT-Low Dose (n = 17), and CONT-High Dose (n = 7) groups significantly differed on pre-season versus post-season latency on tasks with executive functioning demands (anti-saccade and MGS, p ≤ 0.001). Specifically, NON-CONT and CONT-Low Dose demonstrated shorter (i.e., faster) anti-saccade (1.84% and 2.68%, respectively) and MGS (5.74% and 2.76%, respectively) latencies from pre-season to post-season, whereas CONT-High Dose showed 1.40% average longer anti-saccade, and 0.74% shorter MGS, latencies. NON-CONT and CONT-Low Dose demonstrated reduced (i.e., improved) inhibition error rate on the anti-saccade task at post-season versus pre-season, whereas CONT-High Dose demonstrated relative stability (p = 0.021). The results of this study suggest differential exposure to subconcussive head impacts in collegiate female athletes is associated with differential change in reaction time and inhibitory control performances on executive saccadic oculomotor testing.
Collapse
Affiliation(s)
- Virginia T Gallagher
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Prianka Murthy
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jane Stocks
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Brian Vesci
- Department of Sports Medicine, Northwestern University, Evanston, Illinois, USA
| | - Danielle Colegrove
- Department of Sports Medicine, Northwestern University, Evanston, Illinois, USA
| | - Jeffrey Mjaanes
- Department of Sports Medicine, Northwestern University, Evanston, Illinois, USA
| | - Yufen Chen
- Center for Translational Imaging, Northwestern University, Chicago, Illinois, USA
| | - Hans Breiter
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Cynthia LaBella
- Division of Orthopedics and Sports Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Amy A Herrold
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Edward Hines, Jr. VA Hospital, Hines, Illinois, USA
| | - James L Reilly
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| |
Collapse
|
17
|
Gallagher V, Vesci B, Mjaanes J, Breiter H, Chen Y, Herrold A, Reilly J. Eye movement performance and clinical outcomes among female athletes post-concussion. Brain Inj 2020; 34:1674-1684. [PMID: 33103479 DOI: 10.1080/02699052.2020.1830173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Most post-concussion eye movement (EM) research involves predominantly male samples. We evaluated pro- (PRO; reflexive shift of visual attention to target) and anti- (ANTI; executive control of visual attention away from target) computer-based saccade task performance among female, collegiate athletes with recent concussion (CON) versus healthy-control athletes (HC). We evaluated the relationship between EM performance and post-concussion outcomes. We hypothesized ANTI performance would differ among CON and HC due to greater executive control demands, and that EM performance (both tasks) would be associated with clinical outcomes in CON. METHODS 16 CON (assessed 4-10 days post-injury [M = 6.87, SD = 2.15 days]) and 16 age-matched HC athletes were recruited. General linear mixed modeling and Pearson's correlations were used. RESULTS On ANTI, CON demonstrated higher error rate [F(1,2863) = 12.650, p<.001] and shorter latency on error trials [F(1,469) = 5.976, p=.015] relative to HC. Multiple EM measures were associated with clinical outcomes: PRO duration predicted days to symptom remission (r=.44, p <.05); ANTI error rate was associated with symptom burden on the day of testing (r=.27, p <.05). CONCLUSION This study demonstrates promising utility of EM measures to detect cognitive control and sensorimotor effects of concussion among female athletes and their use as a prognostic indicators of recovery.
Collapse
Affiliation(s)
- Virginia Gallagher
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine , Chicago, Illinois, USA
| | - Brian Vesci
- Department of Sports Medicine, Northwestern University , Evanston, Illinois, USA
| | - Jeffrey Mjaanes
- Department of Sports Medicine, Northwestern University , Evanston, Illinois, USA
| | - Hans Breiter
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine , Chicago, Illinois, USA.,Warren Wright Adolescent Center, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine , Chicago, Illinois, USA
| | - Yufen Chen
- Center for Translational Imaging, Department of Radiology, Northwestern University Feinberg School of Medicine , Chicago, Illinois, USA
| | - Amy Herrold
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine , Chicago, Illinois, USA.,Research Health Scientist, Edward Hines, Jr. VA Hospital , Hines IL, Oregon, USA
| | - James Reilly
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine , Chicago, Illinois, USA
| |
Collapse
|
18
|
Ayala N, Heath M. Executive Dysfunction after a Sport-Related Concussion Is Independent of Task-Based Symptom Burden. J Neurotrauma 2020; 37:2558-2568. [PMID: 32438897 DOI: 10.1089/neu.2019.6865] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A sport-related concussion (SRC) results in short- and long-term deficits in oculomotor control; however, it is unclear whether this change reflects executive dysfunction and/or a performance decrement caused by an increase in task-based symptom burden. Here, individuals with a SRC - and age- and sex-matched controls - completed an antisaccade task (i.e., saccade mirror-symmetrical to a target) during the early (initial assessment ≤12 days) and later (follow-up assessment <30 days) stages of recovery. Antisaccades were used because they require top-down executive control and exhibit performance decrements following an SRC. Reaction time (RT) and directional errors were included with pupillometry, because pupil size in the antisaccade task has been shown to provide a neural proxy for executive control. In addition, the Sport-Concussion Assessment Tool (SCAT-5) symptom checklist was completed prior to and after each oculomotor assessment to identify a possible task-based increase in symptomology. The SRC group yielded longer initial assessment RTs, more directional errors, and larger task-evoked pupil dilations (TEPD) than the control group. At the follow-up assessment, RTs for the SRC and control group did not reliably differ; however, the former demonstrated more directional errors and larger TEPDs. SCAT-5 symptom severity scores did not vary from the pre- to post-oculomotor evaluation for either initial or follow-up assessments. Accordingly, an SRC imparts a persistent executive dysfunction to oculomotor planning independent of a task-based increase in symptom burden. These findings evince that antisaccades serve as an effective tool to identify subtle executive deficits during the early and later stages of SRC recovery.
Collapse
Affiliation(s)
- Naila Ayala
- School of Kinesiology, University of Western Ontario, London, Ontario, Canada.,Graduate Program in Neuroscience, University of Western Ontario, London, Ontario, Canada
| | - Matthew Heath
- School of Kinesiology, University of Western Ontario, London, Ontario, Canada.,Graduate Program in Neuroscience, University of Western Ontario, London, Ontario, Canada
| |
Collapse
|
19
|
Stuart S, Parrington L, Martini D, Peterka R, Chesnutt J, King L. The Measurement of Eye Movements in Mild Traumatic Brain Injury: A Structured Review of an Emerging Area. Front Sports Act Living 2020; 2:5. [PMID: 33345000 PMCID: PMC7739790 DOI: 10.3389/fspor.2020.00005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/08/2020] [Indexed: 11/13/2022] Open
Abstract
Mild traumatic brain injury (mTBI), or concussion, occurs following a direct or indirect force to the head that causes a change in brain function. Many neurological signs and symptoms of mTBI can be subtle and transient, and some can persist beyond the usual recovery timeframe, such as balance, cognitive or sensory disturbance that may pre-dispose to further injury in the future. There is currently no accepted definition or diagnostic criteria for mTBI and therefore no single assessment has been developed or accepted as being able to identify those with an mTBI. Eye-movement assessment may be useful, as specific eye-movements and their metrics can be attributed to specific brain regions or functions, and eye-movement involves a multitude of brain regions. Recently, research has focused on quantitative eye-movement assessments using eye-tracking technology for diagnosis and monitoring symptoms of an mTBI. However, the approaches taken to objectively measure eye-movements varies with respect to instrumentation, protocols and recognition of factors that may influence results, such as cognitive function or basic visual function. This review aimed to examine previous work that has measured eye-movements within those with mTBI to inform the development of robust or standardized testing protocols. Medline/PubMed, CINAHL, PsychInfo and Scopus databases were searched. Twenty-two articles met inclusion/exclusion criteria and were reviewed, which examined saccades, smooth pursuits, fixations and nystagmus in mTBI compared to controls. Current methodologies for data collection, analysis and interpretation from eye-tracking technology in individuals following an mTBI are discussed. In brief, a wide range of eye-movement instruments and outcome measures were reported, but validity and reliability of devices and metrics were insufficiently reported across studies. Interpretation of outcomes was complicated by poor study reporting of demographics, mTBI-related features (e.g., time since injury), and few studies considered the influence that cognitive or visual functions may have on eye-movements. The reviewed evidence suggests that eye-movements are impaired in mTBI, but future research is required to accurately and robustly establish findings. Standardization and reporting of eye-movement instruments, data collection procedures, processing algorithms and analysis methods are required. Recommendations also include comprehensive reporting of demographics, mTBI-related features, and confounding variables.
Collapse
Affiliation(s)
- Samuel Stuart
- Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle upon Tyne, United Kingdom
- Department of Neurology, Oregon Health and Science University, Portland, OR, United States
- Veterans Affairs Portland Health Care System, Portland, OR, United States
| | - Lucy Parrington
- Department of Neurology, Oregon Health and Science University, Portland, OR, United States
- Veterans Affairs Portland Health Care System, Portland, OR, United States
| | - Douglas Martini
- Department of Neurology, Oregon Health and Science University, Portland, OR, United States
- Veterans Affairs Portland Health Care System, Portland, OR, United States
| | - Robert Peterka
- Department of Neurology, Oregon Health and Science University, Portland, OR, United States
- Veterans Affairs Portland Health Care System, Portland, OR, United States
- National Center for Rehabilitative Auditory Research, Veterans Affairs Portland Health Care System, Portland, OR, United States
| | - James Chesnutt
- Department of Neurology, Oregon Health and Science University, Portland, OR, United States
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, United States
- Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, United States
| | - Laurie King
- Department of Neurology, Oregon Health and Science University, Portland, OR, United States
- Veterans Affairs Portland Health Care System, Portland, OR, United States
| |
Collapse
|
20
|
Development and validation of a high-speed video system for measuring saccadic eye movement. Behav Res Methods 2020; 51:2302-2309. [PMID: 30706347 DOI: 10.3758/s13428-019-01197-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Laboratory-based retroreflective and magnetic scleral search-coil technologies are the current standards for collecting saccadometric data, but such equipment is costly and cumbersome. We have validated a novel, portable, high-speed video camera-based system (Exilim EX-FH20, Casio, Tokyo, Japan) for measuring saccade reaction time (RT) and error rate in a well-lit environment. This system would enable measurements of pro- and antisaccades in athletes, which is important because antisaccade metrics provide a valid tool for concussion diagnosis and determining an athlete's safe return to play. A total of 529 trials collected from 15 participants were used to compare saccade RT and error rate measurements of the high-speed camera system to a retroreflective video-based eye tracker (Eye-Trac 6: Applied Sciences Laboratories, Bedford, MA). Bland-Altman analysis revealed that the RT measurements made by the high-speed video system were 11 ms slower than those made by the retroreflective system. Error rate measurements were identical between the two systems. An excellent degree of reliability was found between the system measurements and in the ratings of independent researchers examining the video data. A strong association (r = .97) between the RTs determined via the retroreflective and high-speed camera systems was observed across all trials. Our high-speed camera system is portable and easily set up, does not require extensive equipment calibration, and can be used in a well-lit environment. Accordingly, the camera-based capture of saccadometric data may provide a valuable tool for neurological assessment following a concussive event and for the continued monitoring of recovery.
Collapse
|
21
|
Antipointing Reaches Do Not Adhere to Width-Based Manipulations of Fitts' (1954) Equation. Motor Control 2019; 24:222-237. [PMID: 31693993 DOI: 10.1123/mc.2019-0010] [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: 01/22/2019] [Revised: 09/03/2019] [Accepted: 09/24/2019] [Indexed: 11/18/2022]
Abstract
Reaches with overlapping stimulus-response spatial relations (propointing) adhere to speed-accuracy relations as defined by Paul Fitts' index of difficulty equation (IDFitts: in bits of information). This movement principle is attributed to response mediation via the "fast" visuomotor networks of the dorsal visual pathway. It is, however, unclear whether the executive demands of dissociating stimulus-response spatial relations by reaching mirror-symmetrical to a target (antipointing) elicits similar adherence to Fitts' equation. Here, pro- and antipointing responses were directed to a constant target amplitude with varying target widths to provide IDFitts values of 3.0, 3.5, 4.3, and 6.3 bits. Propointing movement times linearly increased with IDFitts-a result attributed to visually based trajectory corrections. In contrast, antipointing movement times, deceleration times, and endpoint precision did not adhere to Fitts' equation. These results indicate that antipointing renders a "slow" and offline mode of control mediated by the visuoperceptual networks of the ventral visual pathway.
Collapse
|
22
|
Tari B, Fadel MA, Heath M. Response suppression produces a switch-cost for spatially compatible saccades. Exp Brain Res 2019; 237:1195-1203. [PMID: 30809706 DOI: 10.1007/s00221-019-05497-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 02/19/2019] [Indexed: 11/29/2022]
Abstract
Executive function supports the rapid alternation between tasks for online reconfiguration of attentional and motor goals. The oculomotor literature has found that a prosaccade (i.e., saccade to veridical target location) preceded by an antisaccade (i.e., saccade mirror symmetrical to a target) elicits an increase in reaction time (RT), whereas the converse switch does not. This switch-cost has been attributed to the antisaccade task's requirement of inhibiting a prosaccade (i.e., response suppression) and transforming a target's coordinate (i.e., vector inversion)-executive processes thought to contribute to a task-set inertia that proactively interferes with the planning of a subsequent prosaccade. It is, however, unclear whether response suppression and vector inversion contribute to a task-set inertia or whether the phenomenon relates to a unitary component (e.g., response suppression). Here, the same stimulus-driven (SD) prosaccades (i.e., respond at target onset) as used in previous work were used with minimally delayed (MD) prosaccades (i.e., respond at target offset) and arranged in an AABB paradigm (i.e., A = SD prosaccade, B = MD prosaccade). MD prosaccades provide the same response suppression as antisaccades without the need for vector inversion. RTs for SD task-switch trials were longer and more variable than their task-repeat counterparts, whereas values for MD task-switch and task-repeat trials did not reliably differ. Moreover, SD task-repeat and task-switch movement times and amplitudes did not vary and thus demonstrate that a switch-cost is unrelated to a speed accuracy trade-off. Accordingly, results suggest the executive demands of response suppression is sufficient to engender the persistent activation of a non-standard task-set that selectively delays the planning of a subsequent SD prosaccade.
Collapse
Affiliation(s)
- Benjamin Tari
- School of Kinesiology, The University of Western Ontario, London, ON, N6A 3K7, Canada
| | - Mohammed A Fadel
- School of Kinesiology, The University of Western Ontario, London, ON, N6A 3K7, Canada
| | - Matthew Heath
- School of Kinesiology, The University of Western Ontario, London, ON, N6A 3K7, Canada.
| |
Collapse
|