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Beard K, Gauff AK, Pennington AM, Marion DW, Smith J, Sloley S. Biofluid, Imaging, Physiological, and Functional Biomarkers of Mild Traumatic Brain Injury and Subconcussive Head Impacts. J Neurotrauma 2024. [PMID: 38943278 DOI: 10.1089/neu.2024.0136] [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: 07/01/2024] Open
Abstract
Post-concussive symptoms are frequently reported by individuals who sustain mild traumatic brain injuries (mTBIs) and subconcussive head impacts, even when evidence of intracranial pathology is lacking. Current strategies used to evaluate head injuries, which primarily rely on self-report, have a limited ability to predict the incidence, severity, and duration of post-concussive symptoms that will develop in an individual patient. In addition, these self-report measures have little association with the underlying mechanisms of pathology that may contribute to persisting symptoms, impeding advancement in precision treatment for TBI. Emerging evidence suggests that biofluid, imaging, physiological, and functional biomarkers associated with mTBI and subconcussive head impacts may address these shortcomings by providing more objective measures of injury severity and underlying pathology. Interest in the use of biomarker data has rapidly accelerated, which is reflected by the recent efforts of organizations such as the National Institute of Neurological Disorders and Stroke and the National Academies of Sciences, Engineering, and Medicine to prioritize the collection of biomarker data during TBI characterization in acute-care settings. Thus, this review aims to describe recent progress in the identification and development of biomarkers of mTBI and subconcussive head impacts and to discuss important considerations for the implementation of these biomarkers in clinical practice.
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Affiliation(s)
- Kryshawna Beard
- General Dynamics Information Technology Fairfax, Falls Church, Virginia, USA
- Traumatic Brain Injury Center of Excellence, Silver Spring, Maryland, USA
| | - Amina K Gauff
- Traumatic Brain Injury Center of Excellence, Silver Spring, Maryland, USA
- Xynergie Federal, LLC, San Juan, United States Minor Outlying Islands
| | - Ashley M Pennington
- Traumatic Brain Injury Center of Excellence, Silver Spring, Maryland, USA
- Xynergie Federal, LLC, San Juan, United States Minor Outlying Islands
| | - Donald W Marion
- General Dynamics Information Technology Fairfax, Falls Church, Virginia, USA
- Traumatic Brain Injury Center of Excellence, Silver Spring, Maryland, USA
| | - Johanna Smith
- Traumatic Brain Injury Center of Excellence, Silver Spring, Maryland, USA
| | - Stephanie Sloley
- Traumatic Brain Injury Center of Excellence, Silver Spring, Maryland, USA
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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 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.
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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
| | - Andrew Jones
- School of Applied Engineering and Technology, New Jersey Institute of Technology, Newark, NJ 07102, USA
| | - Mitchell Malakhov
- School of Applied Engineering and Technology, New Jersey Institute of Technology, Newark, NJ 07102, USA
| | - Stuti Mohan
- School of Applied Engineering and Technology, New Jersey Institute of Technology, Newark, NJ 07102, USA
| | - Chang Yaramothu
- School of Applied Engineering and Technology, New Jersey Institute of Technology, Newark, NJ 07102, USA
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Biscardi M, Grossinger Z, Colantonio A, Bayley M, Mollayeva T. Efficacy of restitutive interventions for oculomotor deficits in adults with mild traumatic brain injury: a systematic review and meta-analysis. Brain Inj 2024; 38:499-513. [PMID: 38433498 DOI: 10.1080/02699052.2024.2320163] [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: 07/31/2023] [Accepted: 02/13/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Mild traumatic brain injury (mTBI) can cause persistent symptoms suggestive of oculomotor deficits. This research synthesized evidence on restitutive interventions for reducing oculomotor deficits in adults with mTBI to understand if these interventions have clinical utility for improving recovery. METHODS Medline, EMBASE, CINHAL, PsychInfo, and Scopus, databases were searched for experimental studies published in English. We rated risk of bias (RoB) using recommended tools, and the certainty of the evidence according to GRADE guidelines. We conducted meta-analyses for similar outcomes reported in at least two studies. RESULTS Out of 5,328 citations, 12 studies (seven case series and five crossover design), with a combined sample size of 354 participants; (43% males) met the inclusion criteria and were analyzed. The analysis revealed a trend toward improvement of oculomotor deficits and visual tasks in response to restitutive intervention. None of the studies addressed sex or gender effects. All studies had high RoB, suggesting low certainty in the reported results. DISCUSSION Restitutive interventions may be beneficial for adults with oculomotor deficits after mTBI, however overall certainty of the evidence remains low. Future efforts must include enhancing attention to study methodology and reporting, sex and gender analyses, and reaching a consensus on outcome measures. PROSPERO REGISTRATION NUMBER CRD42022352276.
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Affiliation(s)
- Melissa Biscardi
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Zane Grossinger
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Angela Colantonio
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Mark Bayley
- Hull Ellis Concussion and Research Clinic, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Tatyana Mollayeva
- KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
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Roberts M, Popovich M, Almeida A. The Evaluation and Management of Concussion to Optimize Safe Recovery. Prim Care 2024; 51:269-282. [PMID: 38692774 DOI: 10.1016/j.pop.2024.02.009] [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: 05/03/2024]
Abstract
Concussion is a mild traumatic brain injury causing temporary neurologic dysfunction. Symptoms following concussion are variable and generally are expected to resolve within about 1 month, but some patients experience persistent and prolonged symptoms. An early return to safe, symptom-limited activity is now favored, using targeted rehabilitation and treatments. Accommodations may be needed to facilitate return-to-school and work following concussion. Athletes should not be cleared for a full return to sport until they have recovered from a concussion and completed a return-to-play progression, in addition to returning to work/school fully.
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Affiliation(s)
- Mark Roberts
- Department of Neurology, University of Michigan, 2901 Hubbard Road, Suite 2723, Ann Arbor, MI 48109, USA
| | - Michael Popovich
- Department of Neurology, University of Michigan, 2901 Hubbard Road, Suite 2723, Ann Arbor, MI 48109, USA.
| | - Andrea Almeida
- Department of Neurology, University of Michigan, 2901 Hubbard Road, Suite 2723, Ann Arbor, MI 48109, USA
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Barnhart M, McLeod TV, Bay RC. The Ability of Vestibular and Oculomotor Screenings to Predict Recovery in Patients After Concussion: A Systematic Review of the Literature. J Athl Train 2024; 59:49-65. [PMID: 36913634 PMCID: PMC10783467 DOI: 10.4085/1062-6050-0429.22] [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: 03/14/2023]
Abstract
OBJECTIVE The objective of this systematic review was to investigate if a positive vestibular or oculomotor screening is predictive of recovery in patients after concussion. DATA SOURCES Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to search through PubMed, Ovid MEDLINE, SPORTDiscus, and the Cochrane Central Register of Controlled Trials (CENTRAL) and hand searches of included articles. STUDY SELECTION Two authors evaluated all articles for inclusion and assessed their quality using the Mixed Methods Assessment Tool. DATA EXTRACTION After quality assessment was completed, the authors extracted recovery time, vestibular or ocular assessment results, study population demographics, number of participants, inclusion and exclusion criteria, symptom scores, and any other outcomes of assessments reported in the included studies. DATA SYNTHESIS Data were critically analyzed by 2 of the authors and categorized into tables regarding the ability of researchers of each article to answer the research question. Many patients who have vision, vestibular, or oculomotor dysfunction appear to have longer recovery times than patients who do not. CONCLUSIONS Researchers routinely reported that vestibular and oculomotor screenings are prognostic of time to recovery. Specifically, a positive Vestibular Ocular Motor Screening test appears to consistently predict longer recovery.
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Affiliation(s)
- Mitchell Barnhart
- Athletic Training Programs, A.T. Still University, Mesa, AZ; Phoenix Country Day School, Paradise Valley, AZ
| | - Tamara Valovich McLeod
- Department of Athletic Training, Athletic Training Programs and School of Osteopathic Medicine, A.T. Still University, Mesa, AZ
| | - R. Curtis Bay
- Department of Interdisciplinary Health Sciences, A.T. Still University, Mesa, AZ
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Song A, Gabriel R, Mohiuddin O, Whitaker D, Wisely CE, Kim T. Automated Eye Tracking Enables Saccade Performance Evaluation of Patients with Concussion History. Optom Vis Sci 2023; 100:855-860. [PMID: 38033013 DOI: 10.1097/opx.0000000000002090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023] Open
Abstract
SIGNIFICANCE Automated eye tracking could be used to evaluate saccade performance of patients with concussion history, providing quantitative insights about the degree of oculomotor impairment and potential vision rehabilitation strategies for this patient population. PURPOSE To evaluate the saccade performance of patients with concussion history based on automated eye-tracking test results. METHODS We conducted a retrospective study of patients with concussion history, primarily from sports participation, who underwent oculomotor testing based on an eye-tracking technology at the Duke Eye Center vision rehabilitation clinic between June 30, 2017, and January 10, 2022. Patients' saccade test results were reviewed, including saccade fixation and saccade speed/accuracy ratio. The outcomes were compared with age-matched normative population data derived from healthy individuals. Multiple linear regression analyses were performed to identify factors associated with saccade performance among patients with concussion history. RESULTS On hundred fifteen patients with concussion history were included in the study. Patients with concussion, on average, had fewer fixations on self-paced horizontal and vertical saccade tests and lower horizontal and vertical saccade speed/accuracy ratios compared with normative ranges. Among patients with concussion history, multiple linear regression analyses showed that older age was associated with fewer fixations on horizontal and vertical saccade tests, whereas male sex was associated with more fixations on horizontal and vertical saccade tests (all P < .01). In addition, older age was associated with lower horizontal saccade speed/accuracy ratio, after adjusting for sex, number of concussion(s), and time from most recent concussion to oculomotor testing ( P < .001). CONCLUSIONS Patients with concussion history had lower saccade performance based on eye tracking compared with healthy individuals. We additionally identified risk factors for lower saccade performance among patients with concussion history. These findings support the use of saccade test results as biomarkers for concussion and have implications for post-concussion rehabilitation strategies.
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Affiliation(s)
- Ailin Song
- Duke University School of Medicine, Durham, North Carolina
| | - Rami Gabriel
- Department of Ophthalmology, Duke University, Durham, North Carolina
| | - Omar Mohiuddin
- Department of Ophthalmology, Duke University, Durham, North Carolina
| | - Diane Whitaker
- Department of Ophthalmology, Duke University, Durham, North Carolina
| | | | - Terry Kim
- Department of Ophthalmology, Duke University, Durham, North Carolina
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McLoughlin J. Concussion Rehabilitation and the Application of Ten Movement Training Principles. Cureus 2023; 15:e46520. [PMID: 37927640 PMCID: PMC10625311 DOI: 10.7759/cureus.46520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 11/07/2023] Open
Abstract
Concussion awareness continues to grow in all aspects of healthcare, including the areas of prevention, acute care, and ongoing rehabilitation. Most of the concussion research to date has focussed on the challenges around screening and diagnosing what can be a complex mix of brain impairments that overlay with additional pre-existing comorbidities. While we expect further progress in concussion diagnosis, progress also continues to be made around proactive rehabilitation, with the emergence of interventions that can enhance the recovery process, maximise function and independence with a return to study, work, and play. Traditionally, optimal multimodal assessments of concussion have treated the physical, cognitive, and psychological domains of brain injury separately, which supports diagnosis, and informs appropriate follow-up care. Due to the complex nature of brain injury, multimodal assessments direct care toward professionals from many different disciplines including medicine, physiotherapy, psychology, neuropsychology, ophthalmology, and exercise physiology. In addition, these professionals may work in different fields such as sports, neurorehabilitation, vestibular, musculoskeletal, community, vocational, and general practice clinical settings. Rehabilitation interventions for concussions employed in practice are also likely to use a blend of theoretical principles from motor control, cognitive, and psychological sciences. This scale of diversity can make information dissemination, collaboration, and innovation challenging. The Ten Movement Training Principles (MTPs) have been proposed as a usable and relevant concept to guide and support clinical reasoning in neurorehabilitation. When applied to concussion rehabilitation, these same 10 principles provide a comprehensive overview of key rehabilitation strategies for current and future practice. Future collaborations can use these training principles to support clinical and research innovations including the rapid rise of technologies in this growing field of rehabilitation practice.
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Affiliation(s)
- James McLoughlin
- College of Nursing and Health Sciences, Flinders University, Adelaide, AUS
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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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Dungan ME, Scheiman M, Yaramothu C. Vision Quality of Life with Time Survey: Normative Data and Repeatability. CLINICAL OPTOMETRY 2023; 15:205-212. [PMID: 37719026 PMCID: PMC10505015 DOI: 10.2147/opto.s406407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 06/12/2023] [Indexed: 09/19/2023]
Abstract
Purpose To develop a novel Vision Quality of Life (QoL) survey that emphasizes the amount of time a visual activity can be performed before symptoms occur. Methods The Vision Quality of Life with Time (VisQuaL-T) survey was developed with 10 daily activities and a list of common visual symptoms. Participants were recruited from a university campus. Participants were not excluded based on binocular impairments to obtain a normative dataset. Participants were instructed to denote when they first experience symptoms within certain time ranges. If participants did not engage in one of the 10 activities, they were instructed to denote "N/A". A composite score (range 0-3) was determined by only accounting for the questions that were answered. Results The normative data cohort had a sample size of 376 participants and the repeatability cohort had 54 participants. The normative, test, and retest datasets had a mean composite score of 2.47±0.54, 2.69±0.42, and 2.67±0.49 and 95% confidence interval of 2.38-2.71, 2.58-2.81, 2.54-2.80, respectively. There was good reliability and high correlation between the test and retest timepoints with an ICC of 0.825 and a Pearson correlation coefficient of 0.839 in the repeatability cohort. The normative data cohort showed good internal consistency with a Cronbach's alpha value of 0.803. Test and retest timepoints showed no statistical significance among the individual questions (p > 0.1). Conclusion A lower bound score of 2.4 can potentially be used to differentiate visually normal and symptomatic participants. Statistical analysis showed the survey is repeatable and reliable. Using time as a metric for assessing symptomology could be a useful method for identifying patients with QoL issues and for assessing effectiveness of binocular vision, accommodative, and eye movement treatments.
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Affiliation(s)
- Michaela E Dungan
- School of Applied Engineering and Technology, New Jersey Institute of Technology, Newark, NJ, USA
| | - Mitchell Scheiman
- Pennsylvania College of Optometry, Salus University, Philadelphia, PA, USA
| | - Chang Yaramothu
- School of Applied Engineering and Technology, New Jersey Institute of Technology, Newark, NJ, USA
- Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ, USA
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10
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Moore M, Sandsmark DK. Clinical Updates in Mild Traumatic Brain Injury (Concussion). Neuroimaging Clin N Am 2023; 33:271-278. [PMID: 36965945 DOI: 10.1016/j.nic.2023.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Traumatic brain injury (TBI) affects > 3 million people in the United States annually. Although the number of deaths related to severe TBIs has stabalized, mild TBIs, often termed concussions, are increasing. As evidence indicates that a significant proportion of these mild injuries are associated with long-lasting functional deficits that impact work performance, social integration, and may predispose to later cognitive decline, it is important that we (a) recognize these injuries, (b) identify those at highest risk of poor recovery, and (c) initiate appropriate treatments promptly. We discuss the epidemiology of TBI, the most common persistent symptoms, and treatment approaches.
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Affiliation(s)
- Megan Moore
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 51 North 39th Street, Andrew Mutch Building 4th Floor, Philadelphia, PA 19104, USA
| | - Danielle K Sandsmark
- Department of Neurology, Division of Neurocritical Care, University of Pennsylvania Perelman School of Medicine, 51 North 39th Street, Medical Office Building Suite 205, Philadelphia, PA 19104, USA.
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11
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Dutta P. Characteristics of binocular vision and oculomotor function among sports-concussed athletes. Indian J Ophthalmol 2023; 71:2076-2082. [PMID: 37203084 PMCID: PMC10391497 DOI: 10.4103/ijo.ijo_1932_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023] Open
Abstract
Purpose To compare the binocular vision and oculomotor function between sports-concussed athletes and aged-matched controls. Methods Thirty mild concussed athletes were recruited and compared with aged-matched controls. All the participants underwent a comprehensive ocular assessment followed by an oculomotor assessment which included tests for accommodation, vergence, eye movements, and reading parameters. Results Three categories of oculomotor-based deficits were found: convergence insufficiency (40%), accommodative insufficiency (25%), and oculomotor-based reading dysfunctions (20%). A statistically significant reduction in the mean ± SD of the following parameters was noted in concussed athletes v/s controls:- binocular accommodative amplitude: 7.13 ± 1.59 v/s 15.35 ± 2.95 (P < 0.001), convergence amplitude: 14.23 ± 5.00 v/s 5.65 ± 0.90 (P < 0.001), positive fusional vergence for distance: 21.17 ± 8.97 v/s 31.32 ± 6.23 (P < 0.001), vergence facility: 6.47 ± 1.47 v/s 11.84 ± 1.00 (P < 0.001), accommodative facility: 7.10 ± 4.57 v/s 11.67 ± 1.83 (P < 0.001), reading speed: 66.97 ± 17.82 v/s 144.13 ± 24.45 (P = 0.03) and Developmental Eye Movement ratio: 1.40 ± 0.19 v/s 1.17 ± 0.06 (P < 0.001). Conclusion Concussions caused by sports have a considerable impact on binocular vision and oculomotor parameters. These findings have substantial therapeutic implications in terms of establishing a periodic screening program for athletes so that essential therapy can be provided for a better outcome.
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Affiliation(s)
- Pritam Dutta
- Department of Optometry, Chandraprabha Eye Hospital, Jorhat, Assam, India
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12
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Saha R, Bhushan K, Satgunam P. Feasibility of measuring eye–hand coordination in children with developmental delay using Sanet Vision Integrator. BRITISH JOURNAL OF VISUAL IMPAIRMENT 2023. [DOI: 10.1177/02646196221148321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Eye–hand coordination is a visuomotor task that enables one to look, localize, and touch objects. Eye–hand coordination is known to be poor in children with developmental delay. In this study, we assessed the feasibility of measuring eye–hand coordination task in children with developmental delay using Sanet Vision Integrator (SVI), a commercially available device. Children (age: 3–16 years) with developmental delay and their age-similar typically developing peers were enrolled. White circles (5.5°) on a black background were presented on the SVI touch screen monitor. Participants popped these circles by touching it. Reaction time, accuracy, and an overall performance score were computed. Participants could perform the task from 4 years of age and with visual acuity 20/400 (6/120) or better. This resulted in 85% (17/20) of children with developmental delay and 95% (19/20) of typically developing children completing the task. Children with developmental delay were significantly ( p < .001) less accurate (56%) and took longer (2.63 s) to complete the task when compared with their peers (accuracy = 93%, reaction time = 1.46 s). The overall performance score of children with developmental delay was also lower than their peers by a factor of 3.3. Eye–hand coordination performance can be measured and quantified with SVI. The quantification of speed and accuracy is possible and a unitary measure combining speed-accuracy can be computed. The task can be performed both by typically developing children and by children with developmental delay. Thus, it is feasible to measure eye–hand coordination using SVI. Such quantification will be useful for children undergoing interdisciplinary therapies for their medical conditions.
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13
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Mucha A, Pardini JE, Herring SA, Murphy J, Elbin RJ, Bauer RM, Schmidt JD, Resch JE, Broshek DK. Persisting symptoms after concussion: Considerations for active treatment. PM R 2022; 15:663-673. [PMID: 36507616 DOI: 10.1002/pmrj.12931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/04/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Anne Mucha
- UPMC Centers for Rehab Services, UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Jamie E Pardini
- Departments of Internal Medicine and Neurology, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona, USA
| | - Stanley A Herring
- Departments of Rehabilitation Medicine, Orthopaedics and Sports Medicine and Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Justin Murphy
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - R J Elbin
- Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville, Arkansas, USA
| | - Russell M Bauer
- Department of Clinical & Health Psychology, University of Florida Department of Clinical & Health Psychology, Gainesville, Florida, USA
| | - Julianne D Schmidt
- UGA Concussion Research Laboratory, Department of Kinesiology, University of Georgia, Athens, Georgia, USA
| | - Jacob E Resch
- Department of Kinesiology, University of Virginia, Charlottesville, Virginia, USA
| | - Donna K Broshek
- Department of Psychiatry & Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville, Virginia, USA
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14
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Vision Therapy: A Primer and Caution for Pediatricians. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121873. [PMID: 36553317 PMCID: PMC9777217 DOI: 10.3390/children9121873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 11/25/2022] [Accepted: 11/28/2022] [Indexed: 12/02/2022]
Abstract
Vision therapy, also known as behavioral therapy, is theorized by its practitioners to treat a variety of visual disorders, including learning disability in children. However, the utility of vision therapy to treat various learning disabilities is challenged by the American Academy of Pediatrics, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and the American Association of Certified Orthoptists. The purpose of this review is to (1) provide an overview of vision therapy, (2) evaluate the evidence for vision therapy, and (3) give practical recommendations for pediatric primary care providers regarding vision therapy. A review of the literature demonstrates evidence that vision therapy is useful in the management of convergence insufficiency only. There is insufficient evidence to recommend in-office vision therapy for the management of other types of strabismus, amblyopia, or learning disability in the pediatric population.
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15
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Erdinest N, London N. Comment on Rauchman et al. Mild-to-Moderate Traumatic Brain Injury: A Review with Focus on the Visual System. Neurol. Int. 2022, 14, 453-470. Neurol Int 2022; 14:839-840. [PMID: 36278692 PMCID: PMC9590062 DOI: 10.3390/neurolint14040068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 10/10/2022] [Accepted: 10/11/2022] [Indexed: 11/16/2022] Open
Abstract
This letter is regarding the article, "Mild-to-Moderate Traumatic Brain Injury: A Review with Focus on the Visual System" [...].
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Affiliation(s)
- Nir Erdinest
- Department of Ophthalmology, Hadassah-Hebrew University Medical Center, Jerusalem 9112001, Israel
| | - Naomi London
- Private Practice, Jerusalem 9422805, Israel
- Correspondence: ; Tel.: +972-545406646; Fax: +972-25004333
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16
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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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17
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Xiang L, Bansal S, Wu AY, Roberts TL. Pathway of care for visual and vestibular rehabilitation after mild traumatic brain injury: a critical review. Brain Inj 2022; 36:911-920. [PMID: 35918848 PMCID: PMC10134507 DOI: 10.1080/02699052.2022.2105399] [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: 11/02/2022]
Abstract
PRIMARY OBJECTIVE To review the pathway to care for treatment and management of patients receiving visual and vestibular rehabilitation after mild traumatic brain injury (mTBI). METHODS & PROCEDURES English scientific peer-reviewed articles from PubMed, CINAHL, Embase, and PsycINFO between 2000 and 2020 were first screened by title and abstract, then those selected underwent full-text review and analysis. MAIN OUTCOMES & RESULTS The database search yielded 1640 results and after title and abstract review, 75 articles were selected for full-text screening, from which 8 were included in the qualitative synthesis. Current evidence includes a limited number of retrospective cohort studies and case studies. CONCLUSIONS Many patients with visual and vestibular deficits following mTBI do not receive rehabilitation services until months following their injury as there is no standardized pathway to care for patients for visual and vestibular rehabilitation. Barriers to establishing a standardized pathway are the lack of natural history data for visual and vestibular function following mTBI and the lack of randomized clinical trials establishing the efficacy of rehabilitation in patients following mTBI.
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Affiliation(s)
- Lucille Xiang
- School of Physical and Occupational Therapy, McGill University Faculty of Medicine and Health Sciences, Montreal, Quebec, Canada.,School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Surbhi Bansal
- Spencer Center for Vision Research, Byers Eye Institute at Stanford University, Palo Alto, California, USA
| | - Albert Y Wu
- Spencer Center for Vision Research, Byers Eye Institute at Stanford University, Palo Alto, California, USA
| | - Tawna L Roberts
- Spencer Center for Vision Research, Byers Eye Institute at Stanford University, Palo Alto, California, USA
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18
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Factor Structure for the Sport Concussion Assessment Tool Symptom Scale in Adolescents After Concussion. Clin J Sport Med 2022; 32:400-407. [PMID: 34342297 DOI: 10.1097/jsm.0000000000000959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 05/19/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To examine the factor structure of the Sport Concussion Assessment Tool-5 (SCAT5) symptom scale in adolescents on their initial presentation to a concussion clinic within the typical recovery period after concussion (ie, <30 days). We hypothesize that the SCAT5 symptoms represent various clinically meaningful groups. A secondary purpose was to examine the effects of sex on the factor structure of the SCAT5 symptom scale. STUDY DESIGN Retrospective cross-sectional analysis. SETTING Tertiary, institutional. PATIENTS Nine hundred eighty-one adolescents (45% women) aged between 13 and 18 years. INDEPENDENT VARIABLES Adolescents completed the SCAT5 symptom scale. MAIN OUTCOME MEASURES The factor structure of SCAT5 examined using a principal axis factor analysis. RESULTS A 5-factor structure model explained 61% of the variance in symptoms. These 5 factors are identified as Energy (17%), Mental Health (13%), Migrainous (13%), Cognitive (9%), and Vestibulo-Ocular (9%). A similar 5-factor model emerged for each sex, and the proportion of variance in symptoms explained by the 5-factor model was comparable between the sexes. CONCLUSIONS The findings of this report indicate that the SCAT5 symptoms aggregated into 5 delineated factors, and these factors were largely consistent across the sexes. The delineation of symptoms into 5 factors provides preliminary validation for the presence of different concussion phenotypes. Confirmatory factor analysis is warranted to examine the applicability and clinical utility of the use of the 5-factor structure in a clinical setting.
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19
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Podolak OE, Arbogast KB, Master CL, Sleet D, Grady MF. Pediatric Sports-Related Concussion: An Approach to Care. Am J Lifestyle Med 2022; 16:469-484. [PMID: 35860366 PMCID: PMC9290185 DOI: 10.1177/1559827620984995] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 11/18/2020] [Accepted: 12/11/2020] [Indexed: 08/14/2023] Open
Abstract
Sports-related concussion (SRC) is a common sports injury in children and adolescents. With the vast amount of youth sports participation, an increase in awareness of concussion and evidence that the injury can lead to consequences for school, sports and overall quality of life, it has become increasingly important to properly diagnose and manage concussion. SRC in the student athlete is a unique and complex injury, and it is important to highlight the differences in the management of child and adolescent concussion compared with adults. This review focuses on the importance of developing a multimodal systematic approach to diagnosing and managing pediatric sports-related concussion, from the sidelines through recovery.
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Affiliation(s)
- Olivia E. Podolak
- 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
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Christina L. Master
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Sports Medicine and Performance Center, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - David Sleet
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew F. Grady
- Sports Medicine and Performance Center, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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20
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McDonald MA, Holdsworth SJ, Danesh-Meyer HV. Eye Movements in Mild Traumatic Brain Injury: Ocular Biomarkers. J Eye Mov Res 2022; 15:10.16910/jemr.15.2.4. [PMID: 36439911 PMCID: PMC9682364 DOI: 10.16910/jemr.15.2.4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023] Open
Abstract
Mild traumatic brain injury (mTBI, or concussion), results from direct and indirect trauma to the head (i.e. a closed injury of transmitted forces), with or without loss of consciousness. The current method of diagnosis is largely based on symptom assessment and clinical history. There is an urgent need to identify an objective biomarker which can not only detect injury, but inform prognosis and recovery. Ocular motor impairment is argued to be ubiquitous across mTBI subtypes and may serve as a valuable clinical biomarker with the recent advent of more affordable and portable eye tracking technology. Many groups have positively correlated the degree of ocular motor impairment to symptom severity with a minority attempting to validate these findings with diffusion tract imaging and functional MRI. However, numerous methodological issues limit the interpretation of results, preventing any singular ocular biomarker from prevailing. This review will comprehensively describe the anatomical susceptibility, clinical measurement, and current eye tracking literature surrounding saccades, smooth pursuit, vestibulo-ocular reflex, vergence, pupillary light reflex, and accommodation in mTBI.
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Affiliation(s)
- Matthew A McDonald
- Department of Ophthalmology, University of Auckland, New Zealand
- Mātai Medical Research Institute, Gisborne, New Zealand
| | - Samantha J Holdsworth
- Department of Anatomy and Medical Imaging, University of Auckland, New Zealand
- Mātai Medical Research Institute, Gisborne, New Zealand
| | - Helen V Danesh-Meyer
- Department of Ophthalmology, University of Auckland, New Zealand
- Eye Institute, Auckland, New Zealand
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21
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Theis J. Visual disturbances in acquired brain injury. NeuroRehabilitation 2022; 50:259-260. [DOI: 10.3233/nre-228010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jacqueline Theis
- Virginia Neuro-Optometry/Concussion Care Centre of Virginia 3721 Westerre Parkway, Suite B, Richmond, VA 23233, USA.Tel.: +1 804-387-2902, Fax: +1 804-509-0543. E-mail:
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22
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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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23
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Abstract
BACKGROUND: Post-traumatic headache is the most common sequela of brain injury and can last months or years after the damaging event. Many headache types are associated with visual concerns also known to stem from concussion. OBJECTIVES: To describe the various headache types seen after head injury and demonstrate how they impact or are impacted by the visual system. METHODS: We will mirror the International Classification of Headache Disorders (ICHD) format to demonstrate the variety of headaches following brain injury and relate correlates to the visual pathways. The PubMed database was searched using terms such as headache, head pain, vision, concussion, traumatic brain injury, glare, visuomotor pathways. RESULTS: Every type of headache described in the International Classification of Headache Disorders Edition III can be initiated or worsened after head trauma. Furthermore, there is very often a direct or indirect impact upon the visual system for each of these headaches. CONCLUSION: Headaches of every described type in the ICHD can be caused by brain injury and all are related in some way to the afferent, efferent or association areas of the visual system.
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Affiliation(s)
- Patrick T. Quaid
- Head of Optometry, VUE Cubed Vision Therapy Clinics, ON, Canada
- College of Optometrists of Ontario (Regulatory Body), ON, Canada
| | - Eric L. Singman
- Ophthalmology & Visual Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
- Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
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24
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Mani R, Ngo S, Walz J, Khuu SK. Evaluating the extent of change in near point of convergence in traumatic brain injury: a systematic review and meta-analysis. Brain Inj 2022; 36:306-320. [DOI: 10.1080/02699052.2022.2034188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- Revathy Mani
- School of Optometry and Vision Science, The University of New South Wales (UNSW) Sydney, Sydney, NSW, Australia
| | - Steven Ngo
- School of Optometry and Vision Science, The University of New South Wales (UNSW) Sydney, Sydney, NSW, Australia
| | - Jacinta Walz
- School of Optometry and Vision Science, The University of New South Wales (UNSW) Sydney, Sydney, NSW, Australia
| | - Sieu K. Khuu
- School of Optometry and Vision Science, The University of New South Wales (UNSW) Sydney, Sydney, NSW, Australia
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25
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Smaakjær P, Wachner LG, Rasmussen RS. Vision therapy improves binocular visual dysfunction in patients with mild traumatic brain injury. Neurol Res 2021; 44:439-445. [PMID: 34781837 DOI: 10.1080/01616412.2021.2000825] [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: 10/19/2022]
Abstract
OBJECTIVE To evaluate benefits of binocular vision and ocular motility training in patients with long-term sequelae after mild traumatic brain injury (mTBI). METHODS Twenty-eight mTBI (concussion) patients from 25 to 61 years of age with oculomotor dysfunction were selected by optometric examination. The vision therapy was designed to improve convergence, pursuit and saccades as well as to increase fusional reserves. The vision therapy was conducted by a neurooptometrist and a speech therapist, and took place weekly for 1 hour during 10 continuous weeks. Between vision training sessions, patients trained at home for 15-20 minutes daily. Before and after vision therapy, patients completed a test battery including the Groffman Visual Tracing Test, King-Devick test (K-D), a reading speed test, Multidimensional Fatigue Inventory (MFI-20) and patient interviews based on a modified version of the Canadian Occupational Performance Measure (COPM). RESULTS Twenty-seven patients completed the vision therapy. After the therapy, improvements were measured on all test parameters, e.g. Groffman Visual Tracing Test (p < 0.05), K-D-Test (p = 0.01), Reading Speed Test (p < 0.01) and MFI-20 total (p < 0.05). The results for the modified COPM were significantly improved for both performance and satisfaction (0.0001 < p < 0.01). CONCLUSION Vision therapy improved fixation stability and endurance. Reading speed measured by the numbers of saccades and regressions time consumption per read word increased. There was also an improvement in visual attention, possibly making patients safer in traffic and outdoor activities.
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Affiliation(s)
- Peter Smaakjær
- Department of Vision, CSU-Slagelse, Center of Communication, Slagelse, Denmark
| | - Lone Grønnegaard Wachner
- Department of Speech & Brain Pathology, CSU-Slagelse, Center of Communication, Slagelse, Denmark
| | - Rune Skovgaard Rasmussen
- Department of Speech & Brain Pathology, CSU-Slagelse, Center of Communication, Slagelse, Denmark
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26
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Rytter HM, Graff HJ, Henriksen HK, Aaen N, Hartvigsen J, Hoegh M, Nisted I, Næss-Schmidt ET, Pedersen LL, Schytz HW, Thastum MM, Zerlang B, Callesen HE. Nonpharmacological Treatment of Persistent Postconcussion Symptoms in Adults: A Systematic Review and Meta-analysis and Guideline Recommendation. JAMA Netw Open 2021; 4:e2132221. [PMID: 34751759 PMCID: PMC8579233 DOI: 10.1001/jamanetworkopen.2021.32221] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
IMPORTANCE Persistent (>4 weeks) postconcussion symptoms (PPCS) are challenging for both patients and clinicians. There is uncertainty about the effect of commonly applied nonpharmacological treatments for the management of PPCS. OBJECTIVE To systematically assess and summarize evidence for outcomes related to 7 nonpharmacological interventions for PPCS in adults (aged >18 years) and provide recommendations for clinical practice. DATA SOURCES Systematic literature searches were performed via Embase, MEDLINE, PsycINFO, CINAHL, PEDro, OTseeker, and Cochrane Reviews (via MEDLINE and Embase) from earliest possible publication year to March 3, 2020. The literature was searched for prior systematic reviews and primary studies. To be included, studies had to be intervention studies with a control group and focus on PPCS. STUDY SELECTION A multidisciplinary guideline panel selected interventions based on frequency of use and need for decision support among clinicians, including early information and advice, graded physical exercise, vestibular rehabilitation, manual treatment of neck and back, oculomotor vision treatment, psychological treatment, and interdisciplinary coordinated rehabilitative treatment. To be included, studies had to be intervention studies within the areas of the predefined clinical questions, include a control group, and focus on symptoms after concussion or mild traumatic brain injury. DATA EXTRACTION AND SYNTHESIS Extraction was performed independently by multiple observers. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for data abstraction and data quality assessment. Included studies were assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) tool and the Cochrane Risk of Bias (randomized clinical trials) tool. Meta-analysis was performed for all interventions where possible. Random-effects models were used to calculate pooled estimates of effects. The level and certainty of evidence was rated and recommendations formulated according to the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. MAIN OUTCOMES AND MEASURES All outcomes were planned before data collection began according to a specified protocol. The primary outcomes were the collective burden of PPCS and another outcome reflecting the focus of a particular intervention (eg, physical functioning after graded exercise intervention). RESULTS Eleven systematic reviews were identified but did not contribute any primary studies; 19 randomized clinical trials comprising 2007 participants (1064 women [53.0%]) were separately identified and included. Evidence for the 7 interventions ranged from no evidence meeting the inclusion criteria to very low and low levels of evidence. Recommendations were weak for early information and advice, graded physical exercise, vestibular rehabilitation, manual treatment of the neck and back, psychological treatment, and interdisciplinary coordinated rehabilitative treatment. No relevant evidence was identified for oculomotor vision treatment, so the panel provided a good clinical practice recommendation based on consensus. CONCLUSIONS AND RELEVANCE Based on very low to low certainty of evidence or based on consensus, the guideline panel found weak scientific support for commonly applied nonpharmacological interventions to treat PPCS. Results align with recommendations in international guidelines. Intensified research into all types of intervention for PPCS is needed.
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Affiliation(s)
- Hana Malá Rytter
- Danish Concussion Center, Copenhagen, Denmark
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Bispebjerg-Frederiksberg University Hospital, Copenhagen, Denmark
| | | | - Henriette K. Henriksen
- Danish Concussion Center, Copenhagen, Denmark
- Center for Rehabilitation of Brain Injury, Copenhagen, Denmark
| | - Nicolai Aaen
- The Danish Concussion Association, Copenhagen, Denmark
| | - Jan Hartvigsen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Chiropractic Knowledge Hub, Odense, Denmark
| | - Morten Hoegh
- Musculoskeletal Health and Implementation, Department of Medicine, Aalborg University, Aalborg, Denmark
- Pain Science Educator, Aarhus, Denmark
| | - Ivan Nisted
- Danish College of Optometry, Dania Academy, Randers, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | | | - Henrik Winther Schytz
- Danish Headache Center, Rigshospitalet-Glostrup, University of Copenhagen, Copenhagen, Denmark
| | - Mille Møller Thastum
- Hammel Neurorehabilitation Centre–University Clinic for Neurorehabilitation, Aarhus University, Aarhus, Denmark
| | - Bente Zerlang
- Exercise and Health Training Center, Roskilde Municipality, Roskilde, Denmark
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27
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Gowrisankaran S, Shah AS, Roberts TL, Wiecek E, Chinn RN, Hawash KK, O'Brien MJ, Howell DR, Meehan WP, Raghuram A. Association between post-concussion symptoms and oculomotor deficits among adolescents. Brain Inj 2021; 35:1218-1228. [PMID: 34383619 DOI: 10.1080/02699052.2021.1959065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To examine the association between Post-Concussion Symptom Scale (PCSS) scores, Convergence Insufficiency Symptom Survey (CISS) scores, and oculomotor deficits post-concussion. METHODS Records of adolescent patients examined in a multidisciplinary concussion clinic between July 2014 and May 2019 were reviewed. PCSS and CISS scores, results of eye examination and oculomotor assessment, concussion history, and demographics were abstracted. RESULTS One hundred and forty patient records (median age, 15.3 years; 52 males, presented 109 days (median) from their most recent concussion) met inclusion criteria. Mean total scores on PCSS and CISS were 46.67 ± 25.89 and 27.13 ± 13.22, respectively, and were moderately correlated with each other (r = 0.53, p < .001). Oculomotor deficits were observed in 123 (88%) patients. Step-wise linear regression identified increased PCSS total score to be significantly associated with decreased amplitude of accommodation (p < .001). Increased CISS total score was significantly associated with receded near point of convergence, developmental eye movement test error scores, and cause of concussion. CONCLUSION High PCSS scores may indicate an accommodation deficit and thus prompt an oculomotor assessment in patients following a concussion. Using the CISS and a detailed oculomotor assessment may reveal underlying oculomotor deficits, which may benefit from treatment.
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Affiliation(s)
| | - Ankoor S Shah
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Ophthalmology, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Tawna L Roberts
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, California, USA
| | - Emily Wiecek
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Ryan N Chinn
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Karameh K Hawash
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael J O'Brien
- Micheli Center for Sports Injury Prevention, Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, Massachusetts, USA.,Brain Injury Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - David R Howell
- Sports Medicine Center, Children's Hospital Colorado, Aurora, Colorado, USA.,Department of Orthopedics, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - William P Meehan
- Micheli Center for Sports Injury Prevention, Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, Massachusetts, USA.,Brain Injury Center, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Aparna Raghuram
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
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Walz JA, Mani R, Alnawmasi MM, Khuu SK. Visuospatial Attention Allocation as an Indicator of Cognitive Deficit in Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Front Hum Neurosci 2021; 15:675376. [PMID: 34354575 PMCID: PMC8329082 DOI: 10.3389/fnhum.2021.675376] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/23/2021] [Indexed: 01/02/2023] Open
Abstract
Traumatic Brain Injury (TBI) is defined by changes in brain function resulting from external forces acting on the brain and is typically characterized by a host of physiological and functional changes such as cognitive deficits including attention problems. In the present study, we focused on the effect of TBI on the ability to allocate attention in vision (i.e., the use of endogenous and exogenous visual cues) by systematically reviewing previous literature on the topic. We conducted quantitative synthesis of 16 selected studies of visual attention following TBI, calculating 80 effect size estimates. The combined effect size was large (g = 0.79, p < 0.0001) with medium heterogeneity (I2 = 68.39%). Subgroup analyses revealed an increase in deficit with moderate-to-severe and severe TBI as compared to mild TBI [F(2, 76) = 24.14, p < 0.0001]. Task type was another key source of variability and subgroup analyses indicated that higher order attention processes were severely affected by TBI [F(2, 77) = 5.66, p = 0.0051). Meta-regression analyses revealed significant improvement in visual attention deficit with time [p(mild) = 0.031, p(moderate-to-severe) = 0.002, p(severe) < 0.0001]. Taken together, these results demonstrate that visual attention is affected by TBI and that regular assessment of visual attention, using a systematic attention allocation task, may provide a useful clinical measure of cognitive impairment and change after TBI.
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Affiliation(s)
- Jacinta A Walz
- School of Optometry and Vision Science, The University of New South Wales, Sydney, NSW, Australia
| | - Revathy Mani
- School of Optometry and Vision Science, The University of New South Wales, Sydney, NSW, Australia
| | - Mohammed M Alnawmasi
- School of Optometry and Vision Science, The University of New South Wales, Sydney, NSW, Australia
| | - Sieu K Khuu
- School of Optometry and Vision Science, The University of New South Wales, Sydney, NSW, Australia
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Singman E. From Provider to Advocate: The Complexities of Traumatic Brain Injury Prompt the Evolution of Provider Engagement. J Clin Med 2021; 10:jcm10122598. [PMID: 34204619 PMCID: PMC8231255 DOI: 10.3390/jcm10122598] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/09/2021] [Accepted: 06/11/2021] [Indexed: 12/18/2022] Open
Abstract
Treating a patient with traumatic brain injury requires an interdisciplinary approach because of the pervasive, profound and protean manifestations of this condition. In this review, key aspects of the medical history and review of systems will be described in order to highlight how the role of any provider must evolve to become a better patient advocate. Although this review is written from the vantage point of a vision care provider, it is hoped that patients, caregivers and providers will recognize the need for a team approach.
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Affiliation(s)
- Eric Singman
- Wilmer Eye Institute, Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD 21287, USA
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The Role of Social Media in Sports Vision. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18105354. [PMID: 34069821 PMCID: PMC8157247 DOI: 10.3390/ijerph18105354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/14/2021] [Accepted: 05/16/2021] [Indexed: 11/21/2022]
Abstract
Background: Sports vision is a relatively new specialty. The objective is to provide ophthalmological and optometric care services for the care of vision in the sports field. An increasing number of athletes and coaches are trying to improve visual skills and they seek information on social media. The current excess of information has made it increasingly difficult to identify high quality articles. For this reason, alternative metrics are useful tools to identify publications that draw attention to society. This research aims to study the influence of social networks on the importance of vision in sport. Methods: Altmetric Explorer was used to perform a search using “sport”, “vision” and “eye” as keywords. The 100 outcomes with the most attention were analyzed and correlated with the number of citations in the Web of Science (WoS) using the Spearman correlation coefficient. Results: The 100 best Altmetric Attention Scores (AASs) were published in 67 journals and had a mean AAS value of 30.22 ± 62.37 The results were discussed mainly on Twitter, with a mean of 113.99 ± 43.86 tweets and retweets and a mean of 75.92 ± 79.92 readers in Mendeley. There was no correlation between AAS and WoS Cites for the top 100 outcomes and the correlation was low if we considered the total research results rather than the top 100. Conclusions: The citations are not related to the impact of scientific articles on social networks. Sports vision is a specialty with a growing interest in social media.
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Disparity vergence differences between typically occurring and concussion-related convergence insufficiency pediatric patients. Vision Res 2021; 185:58-67. [PMID: 33895648 DOI: 10.1016/j.visres.2021.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 11/21/2022]
Abstract
This study sought to test the hypothesis that significant differences would be observed in clinical measures, symptoms, and objective assessments of vergence eye movements between children with typically developing convergence insufficiency (TYP-CI) and children with persistent post-concussion symptoms with convergence insufficiency (PPCS-CI). Data from age-matched binocularly normal controls (BNC) were used for comparison. Data from three groups of children 11 to 17 years of age are presented: BNC (N = 11), TYP-CI (N = 10), and PPCS-CI (N = 15). Clinical measures of vergence, accommodation, and symptom severity were collected. Symmetrical 4° disparity vergence eye movements were quantified with an eye tracker integrated into a head-mounted display (Oculus DK2). Peak velocity and final response amplitude of convergence and divergence eye movement responses were assessed. The mean near point of convergence (break) was more receded (worse), the amplitude of accommodation more deficient, and convergent and divergent peak velocities slower in the PPCS-CI group compared with the TYP-CI and BNC groups. These results suggest that PPCS-CI may be a different clinical entity than TYP-CI. Hence, more research is warranted to determine whether the therapeutic interventions that are effective for TYP-CI can also be used for PPCS-CI populations.
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Abstract
Several children struggle with vision difficulties caused by problematic coordination between their left and right eye muscles, i.e., oculomotor dysfunction (OMD). Many OMDs can be improved by training the eyes via physical exercises defined and supervised by vision experts. The aim of this paper is to investigate the feasibility of utilizing Serious Games (SGs) and eye-tracking technologies (ETs) for training the eyes of children having OMD. Via these activities, a trainee can, with her eye gaze, follow objects which are moving, change their directions and speed, or pop up on the screen. The results present mapping the current physical training goals to activities for SGs using input from ETs, and illustrate this correspondence for designing and developing six games. The games’ feasibility evaluation is done via semistructured interviews and evaluating user experiences. Three vision teachers (VTs) were involved in design and development, ensuring achievement of training goals, and five VT students in evaluations. The findings demonstrate the potential of using SGs and ETs to train OMD and point to future needs for improvements.
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Rehabilitation of visual disorders. HANDBOOK OF CLINICAL NEUROLOGY 2021; 178:361-386. [PMID: 33832686 DOI: 10.1016/b978-0-12-821377-3.00015-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
While there is a long history of rehabilitation for motor deficits following cerebral lesions, less is known about our ability to improve visual deficits. Vision therapy, prisms, occluders, and filters have been advocated for patients with mild traumatic brain injury, on the premise that some of their symptoms may reflect abnormal visual or ocular motor function, but the evidence for their efficacy is modest. For hemianopia, attempts to restore vision have had unimpressive results, though it appears possible to generate blindsight through training. Strategic approaches that train more efficient use of visual search in hemianopia have shown consistent benefit in visual function, while prism aids may help some patients. There are many varieties of alexia. Strategic adaptation of saccades can improve hemianopic alexia, but there has been less work and mixed results for pure alexia, neglect dyslexia, attentional dyslexia, and the central dyslexias. A number of approaches have been tried in prosopagnosia, with recent studies of small groups suggesting that face perception of prosopagnosic subjects can be enhanced through perceptual learning.
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Vergence, accommodation, and visual tracking in children and adolescents evaluated in a multidisciplinary concussion clinic. Vision Res 2021; 184:30-36. [PMID: 33838503 DOI: 10.1016/j.visres.2021.03.002] [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: 07/08/2020] [Revised: 02/22/2021] [Accepted: 03/03/2021] [Indexed: 11/23/2022]
Abstract
Many patients with concussion experience visual symptoms following injury that lead to a diagnosis of convergence insufficiency, accommodative insufficiency, or saccadic dysfunction. However, these diagnostic categories are based on aggregates of clinical tests developed from a non-concussed population and therefore may not accurately describe visual deficits in the concussed population. Thus, we sought to understand individual metrics of visual dysfunction in chronically symptomatic post-concussion patients. This retrospective cross-sectional study included patients examined at the multidisciplinary concussion clinic (MDCC) at Boston Children's Hospital over four years. Patients aged 5-21 years who had a complete assessment of eye alignment, vergence, accommodation, and visual tracking, and had visual acuity better than or equal to 20/30 in each eye were included. Patients with history of amblyopia, strabismus, or ocular pathology were excluded. Chart review yielded 116 patients who met inclusion criteria (median age 15 years, 64% female). The majority of patients (52%) experienced a single concussion and most were sports-related (50%). Clinical data show vergence, accommodation, or visual tracking deficits in 95% of patients. A receded near point of convergence (NPC, 70/116) and reduced accommodative amplitude (63/116) were the most common deficits. Both NPC and accommodative amplitude were significantly correlated with one another (r = -0.5) and with measures of visual tracking (r = -0.34). Patients with chronic post-concussion symptoms show deficits in individual metrics of vergence, accommodation and visual tracking. The high incidence of these deficits, specifically NPC and accommodative amplitude, highlights the need for a detailed sensorimotor evaluation to guide personalized treatment following concussion.
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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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Gunasekaran P, Fraser CL, Hodge C. The learning effect of the King-Devick test in semi-professional rugby union athletes. J Neurol Sci 2020; 419:117168. [PMID: 33038568 DOI: 10.1016/j.jns.2020.117168] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/21/2020] [Accepted: 09/30/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Abnormalities of eye movement and visual processing are common in traumatic brain injury. The King-Devick test (KDT) has been widely used in the detection and recovery of concussion. Current recommendations propose performing the initial test at baseline and then repeating annually to account for potential learning effects. In practice, this may still account for large deviations. The aim of this study was to determine the number of trials needed for a player to achieve a ceiling effect and to determine the validity of the existing protocol requiring two tests at baseline. METHODS One hundred and eighty-three semi-professional male rugby union players (median age = 22.5 (21.0-25.3) years) were recruited. Over the duration, all athletes performed the KDT on an iPad, under standardised baseline procedures and then repeated the test based on availability during weekly in-season training. RESULTS The improvement through each repeated trial was 0.60 ± 0.1 s (P < 0.001). The ceiling effect was determined at 30 trials. A median difference of 4.2 s (range 0-14.9) was calculated between the initial and best trial overall, although the greatest difference occurred within the first eight attempts. There was a significant positive correlation between the initial test value and the difference between first and fastest time (P < 0.001, r = 0.455). CONCLUSION We have shown continuous improvement with repeated attempts which suggests that administrators ideally should continue to perform the KDT over the duration of the season to optimise the value of the test.
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Affiliation(s)
- Premkumar Gunasekaran
- Discipline of Orthoptics, Graduate School of Health, University of Technology Sydney, NSW, Australia.
| | - Clare L Fraser
- Save Sight Institute, Discipline of Ophthalmology, Faculty of Health and Medicine, The University of Sydney, NSW, Australia.
| | - Christopher Hodge
- Discipline of Orthoptics, Graduate School of Health, University of Technology Sydney, NSW, Australia; Save Sight Institute, Discipline of Ophthalmology, Faculty of Health and Medicine, The University of Sydney, NSW, Australia.
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Scheiman M, Kulp MT, Cotter SA, Lawrenson JG, Wang L, Li T. Interventions for convergence insufficiency: a network meta-analysis. Cochrane Database Syst Rev 2020; 12:CD006768. [PMID: 33263359 PMCID: PMC8092638 DOI: 10.1002/14651858.cd006768.pub3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Convergence insufficiency is a common binocular vision disorder in which the eyes have a strong tendency to drift outward (exophoria) with difficulty turning the eyes inward when reading or doing close work. OBJECTIVES To assess the comparative effectiveness and relative ranking of non-surgical interventions for convergence insufficiency through a systematic review and network meta-analysis (NMA). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, PubMed and three trials registers up to 20 September 2019. SELECTION CRITERIA We included randomized controlled trials (RCTs) examining any form of non-surgical intervention versus placebo, no treatment, sham treatment, or other non-surgical interventions. Participants were children and adults with symptomatic convergence insufficiency. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methodology. We performed NMAs separately for children and adults. MAIN RESULTS We included 12 trials (six in children and six in adults) with a total of 1289 participants. Trials evaluated seven interventions: 1) office-based vergence/accommodative therapy with home reinforcement; 2) home-based pencil/target push-ups; 3) home-based computer vergence/accommodative therapy; 4) office-based vergence/accommodative therapy alone; 5) placebo vergence/accommodative therapy or other placebo intervention; 6) prism reading glasses; and 7) placebo reading glasses. Six RCTs in the pediatric population randomized 968 participants. Of these, the Convergence Insufficiency Treatment Trial (CITT) Investigator Group completed four RCTs with 737 participants. All four CITT RCTs were rated at low risk of bias. Diagnostic criteria and outcome measures were identical or similar among these trials. The four CITT RCTs contributed data to the pediatric NMA, incorporating interventions 1, 2, 3 and 5. When treatment success was defined by a composite outcome requiring both clinical measures of convergence to be normal, and also show a pre-specified magnitude of improvement, we found high-certainty evidence that office-based vergence/accommodative therapy with home reinforcement increases the chance of a successful outcome, compared with home-based computer vergence/accommodative therapy (risk ratio (RR) 1.96, 95% confidence interval (CI) 1.32 to 2.94), home-based pencil/target push-ups (RR 2.86, 95% CI 1.82 to 4.35); and placebo (RR 3.04, 95% CI 2.32 to 3.98). However, there may be no evidence of any treatment difference between home-based computer vergence/accommodative therapy and home-based pencil/target push-ups (RR 1.44, 95% CI 0.93 to 2.24; low-certainty evidence), or between either of the two home-based therapies and placebo therapy, for the outcome of treatment success. When treatment success was defined as the composite convergence and symptom success outcome, we found moderate-certainty evidence that participants who received office-based vergence/accommodative therapy with home reinforcement were 5.12 (95% CI 2.01 to 13.07) times more likely to achieve treatment success than those who received placebo therapy. We found low-certainty evidence that participants who received office-based vergence/accommodative therapy with home reinforcement might be 4.41 (95% CI 1.26 to 15.38) times more likely to achieve treatment success than those who received home-based pencil push-ups, and 4.65 (95% CI 1.23 to 17.54) times more likely than those who received home-based computer vergence/accommodative therapy. There was no evidence of any treatment difference between home-based pencil push-ups and home-based computer vergence/accommodative therapy, or between either of the two home-based therapies and placebo therapy. One RCT evaluated the effectiveness of base-in prism reading glasses in children. When base-in prism reading glasses were compared with placebo reading glasses, investigators found no evidence of a difference in the three outcome measures of near point convergence (NPC), positive fusional vergence (PFV), or symptom scores measured by the Convergence Insufficiency Symptom Survey (CISS). Six RCTs in the adult population randomized 321 participants. We rated only one RCT at low risk of bias. Because not all studies of adults included composite success data, we could not conduct NMAs for treatment success. We thus were limited to comparing the mean difference (MD) between interventions for improving NPC, PFV, and CISS scores individually using data from three RCTs (107 participants; interventions 1, 2, 4 and 5). Compared with placebo treatment, office-based vergence accommodative therapy was relatively more effective in improving PFV (MD 16.73, 95% CI 6.96 to 26.60), but there was no evidence of a difference for NPC or the CISS score. There was no evidence of difference for any other comparisons for any outcomes. One trial evaluated base-in prism glasses prescribed for near-work activities and found that the prism glasses group had fewer symptoms compared with the placebo glasses group at three months (MD -8.9, 95% CI -11.6 to -6.3). The trial found no evidence of a difference with this intervention in NPC or PFV. No adverse effects related to study treatments were reported for any of the included studies. Excellent adherence was reported for office-based vergence/accommodative therapy (96.6% or higher) in two trials. Reported adherence with home-based therapy was less consistent, with one study reporting decreasing adherence over time (weeks 7 to 12) and lower completion rates with home-based pencil/target push-ups. AUTHORS' CONCLUSIONS Current research suggests that office-based vergence/accommodative therapy with home reinforcement is more effective than home-based pencil/target push-ups or home-based computer vergence/accommodative therapy for children. In adults, evidence of the effectiveness of various non-surgical interventions is less clear.
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Affiliation(s)
| | - Marjean T Kulp
- College of Optometry, The Ohio State University, Columbus, Ohio, USA
| | - Susan A Cotter
- Southern California College of Optometry, Fullerton, California, USA
| | - John G Lawrenson
- Centre for Applied Vision Research, School of Health Sciences, City University of London, London, UK
| | - Lin Wang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Tianjing Li
- Department of Ophthalmology, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
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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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Changes in Vestibular/Ocular-Motor Screen Scores in Adolescents Treated With Vestibular Therapy After Concussion. Pediatr Phys Ther 2020; 32:331-337. [PMID: 32773522 DOI: 10.1097/pep.0000000000000729] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To examine interrelationships among Vestibular/Ocular-Motor Screen (VOMS) items and to characterize the recovery of VOMS performance in a sample of adolescents treated with vestibular physical therapy (VPT) after concussion. METHODS Seventy-seven patients with concussion and 77 participants without concussion completed the study. Adolescents with concussion received an individualized VPT intervention consisting of targeted exercises for gaze stability, postural stability, ocular-motor control, habituation, and aerobic activities. The exercises were performed during a weekly clinic visit and via a home exercise program. RESULTS Except for near-point convergence distance, all VOMS items were significantly interrelated. Over the course of VPT, significant improvements in VOMS performance were observed, and discharge scores were similar to scores observed in adolescents without concussion. CONCLUSIONS The VOMS measured moderately related functions and captured changes over the course of VPT. Clinicians should consider the contextual risk of "false positive" in their interpretation of VOMS.
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Characteristics of Concussion in Elementary School-Aged Children: Implications for Clinical Management. J Pediatr 2020; 223:128-135. [PMID: 32507622 PMCID: PMC7419017 DOI: 10.1016/j.jpeds.2020.04.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 03/11/2020] [Accepted: 04/01/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To comprehensively characterize the clinical presentation and course of care for concussion among 5- to 11-year-old children, identifying preinjury and injury factors potentially influencing clinical outcomes. STUDY DESIGN A single-institution retrospective cohort study using electronic health record data from children ages 5- to 11 years with a concussion from July 1, 2014, through June 30, 2015. Electronic health record data were abstracted for a 20% random sample of 292 patients. RESULTS Three-fourths of patients (74.3%) presenting for concussion care had a standardized visiovestibular assessment performed. Almost all of those who eventually sought specialty care (92.9%) also had such an assessment, and only 42.9% patients initially seen in the emergency department or urgent care were examined in this manner. Of those assessed, 62.7% (n = 136) demonstrated deficits, with children ages 9-11 years more frequently exhibiting deficits than their younger counterparts (67.9% vs 53.2%; P = .03). Almost all patients (95.9%) reported at least 1 somatic symptom (eg, headache, dizziness), and one-half to two-thirds reported problems with sleep (54.1%) and visiovestibular symptoms (66.1%). Only 11.6% of children were referred for rehabilitation therapies and less than one-half of concussed patients (43.8%) were provided with a letter recommending school accommodations. CONCLUSIONS Somatic symptoms, sleep problems, and visiovestibular deficits are common in elementary school-aged children with concussion, but specific visiovestibular clinical assessments are often not performed, particularly in the emergency department setting. Recommendations for school accommodations are often not provided at the time of concussion diagnosis. Incorporating a standardized visiovestibular assessment into practice could facilitate early targeted school accommodations and thereby improve return to learning for elementary school-aged children with concussion.
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Barton JJS, Ranalli PJ. Vision Therapy: Ocular Motor Training in Mild Traumatic Brain Injury. Ann Neurol 2020; 88:453-461. [DOI: 10.1002/ana.25820] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/28/2020] [Accepted: 06/07/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Jason J. S. Barton
- Departments of Medicine (Neurology), Ophthalmology and Visual Sciences, and PsychologyUniversity of British Columbia Vancouver British Columbia Canada
| | - Paul J. Ranalli
- Departments of Medicine (Neurology), Ophthalmology and Visual Sciences, and Oto‐LaryngologyUniversity of Toronto Toronto Ontario Canada
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Near Point of Convergence Deficits and Treatment Following Concussion: A Systematic Review. J Sport Rehabil 2020; 29:1179-1193. [PMID: 32131046 DOI: 10.1123/jsr.2019-0428] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 12/28/2019] [Accepted: 01/19/2020] [Indexed: 11/18/2022]
Abstract
CONTEXT Convergence dysfunction following concussion is common. Near point of convergence (NPC) is a quick and easy assessment that may detect oculomotor dysfunction such as convergence insufficiency (CI), but NPC measurements are rarely reported. Convergence dysfunction is treatable in otherwise healthy patients; the effectiveness of oculomotor therapy following concussion is unclear. OBJECTIVES The purpose of this article was to systematically review the literature and answer the following clinical questions: (1) Is performance on NPC negatively affected in patients diagnosed with a concussion compared with pre-injury levels or healthy controls? (2) In patients diagnosed with concussion, what is the effect of oculomotor/vision therapy on NPC break measurements? EVIDENCE ACQUISITION The search was conducted in CINAHL, SPORTDiscus, MEDLINE, and PubMed using terms related to concussion, mild traumatic brain injury, convergence, vision, and rehabilitation. Literature considered for review included original research publications that collected measures of NPC break in concussion patients, with a pretest-posttest comparison or comparison with a healthy control group. A literature review was completed; 242 relevant articles were reviewed, with 18 articles meeting criteria for inclusion in the review. EVIDENCE SYNTHESIS Articles were categorized according to the clinical question they addressed. The patient or participant sample (number, sex, age, and health status), study design, instrumentation, or intervention used, and main results were extracted from each article. CONCLUSIONS The authors' main findings suggest that there is a moderate level of evidence that patients have impaired NPC up to several months postconcussion, and a low level of evidence that impairments can be successfully treated with oculomotor therapy. These findings should be cautiously evaluated; the studies are limited by weak/moderate quality, small sample sizes, varied methodology, and nonrandomized treatment groups. Future research should explore factors affecting convergence postconcussion and include randomized, controlled studies to determine if performing vision therapy improves visual measures and promotes recovery.
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Alvarez TL, Scheiman M, Santos EM, Morales C, Yaramothu C, d'Antonio-Bertagnolli JV, Gohel S, Biswal BB, Li X. Clinical and Functional Imaging Changes Induced from Vision Therapy in Patients with Convergence Insufficiency. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2019:104-109. [PMID: 31945855 DOI: 10.1109/embc.2019.8857163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Office-Based Vergence/Accommodative Therapy (OBVAT) is an effective treatment for convergence insufficiency (CI) and remediates symptoms in about 75% of patients. Hence, the study of CI patients can serve as a systems-level model to understand the neural mechanisms evoked from rehabilitation. Symptomatic young adult CI patients (N=25) participated in 12 hours of OBVAT and were compared to 25 binocularly normal controls (BNC) using unpaired t-tests. CI patients have significantly lower near point of convergence and positive fusional vergence and were more symptomatic compared to BNC (p<; 0.0001). Using paired t-tests, significant differences (p<; 0.0001) were observed between CI patients' baseline and post-OBVAT measurements where the near point of convergence decreased, positive fusional vergence increased, and the results from the Convergence Insufficiency Symptom Survey (CISS) decreased. Using paired t-tests, the mean beta weights of the functional activity significantly increased for the frontal eye fields (p<; 0.01) and the oculomotor vermis (p<; 0.05) for CI patients post-OBVAT compared to baseline measurements. These data demonstrate that OBVAT increases functional activity within the brain and improves clinical function and visual symptoms in CI patients.
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Master CL, P. Storey E. Assessment, Management, and Rehabilitation of Pediatric Concussions. Concussion 2020. [DOI: 10.1016/b978-0-323-65384-8.00012-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Dagi LR, Velez FG, Archer SM, Atalay HT, Campolattaro BN, Holmes JM, Kerr NC, Kushner BJ, Mackinnon SE, Paysse EA, Pihlblad MS, Pineles SL, Strominger MB, Stager DR, Stager D, Capo H. Adult Strabismus Preferred Practice Pattern®. Ophthalmology 2020; 127:P182-P298. [DOI: 10.1016/j.ophtha.2019.09.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 09/20/2019] [Indexed: 11/25/2022] Open
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Effect of Vision Therapy on Accommodative Lag in Myopic Children: A Randomized Clinical Trial. Optom Vis Sci 2019; 96:17-26. [PMID: 30575616 DOI: 10.1097/opx.0000000000001316] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
SIGNIFICANCE Accommodative dysfunction has been suggested to be related to the development and progression of myopia. Office-based accommodative/vergence therapy (OBAVT) improved accommodative facility in Chinese myopic children, but it is unclear if such improvement has a role in decreasing myopic progression. PURPOSE The purpose of this study was to compare the effects of OBAVT with home reinforcement and office-based placebo therapy (OBPT) as a treatment to improve accommodative functions (i.e., lag, amplitude, and facility) in myopic children with poor accommodative accuracy. METHODS This was a prospective, single-masked, randomized clinical trial. Thirty-four Chinese children 8 to 12 years old with myopia and at least 1 diopter of lag of accommodation measured by autorefraction were enrolled. The participants were randomly assigned to the OBAVT or OBPT group. The primary outcome measure was the change in the monocular lag of accommodation from the baseline visit to the 13-week visit measured by a Shin-Nippon open-field autorefractor. Secondary outcome measures were changes in accommodative amplitude and monocular accommodative facility. RESULTS A total of 33 participants completed the study. After 12 weeks of treatment, there were significant improvements in the lag of accommodation in both the OBAVT and OBPT groups (OBAVT: -0.30 ± 0.29 diopters [P < .001; Cohen's d effect size, 1.29]; OBPT: -0.24 ± 0.30 diopters [P = .005; Cohen's d effect size, 1.24]). There was no statistically significant difference between the improvements in the two groups (P = .50). There was statistically significant improvement in monocular accommodative facility only in the OBAVT group (OBAVT: 7.7 ± 4.7 cycles per minute [P < .001; Cohen's d effect size, 2.20]; OBPT: 1.9 ± 4.4 cycles per minute [P = .072]). The change in the OBAVT group was statistically significantly larger than that in the OBPT group (P < .001). CONCLUSIONS Office-based accommodative/vergence therapy was no more effective than OBPT in reducing the lag of accommodation in children 8 to 12 years old with low to moderate myopia. It did improve accommodative facility in Chinese myopic children, but it is unclear if such an improvement has a role in decreasing myopic progression.
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Doperak J, Anderson K, Collins M, Emami K. Sport-Related Concussion Evaluation and Management. Clin Sports Med 2019; 38:497-511. [PMID: 31472762 DOI: 10.1016/j.csm.2019.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Concussion is a challenging and controversial medical diagnosis that can test even the most seasoned practitioner. Knowledge on this topic is ever evolving. It was not so long ago that grading guidelines were based on loss of consciousness and amnesia. Medicine has seen a renaissance of discovery over the past 20 years in concussion evaluation and management. A PubMed search for "concussion" between 1990 and 2000 produced just over 1000 articles and that same search including the last 18 years expands to over 10,000 publications. The most recent knowledge and recommendations are discussed based on the published evidence.
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Affiliation(s)
- Jeanne Doperak
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Kelley Anderson
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael Collins
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center Sports Medicine Concussion Program, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kouros Emami
- University of Pittsburgh Medical Center Sports Medicine Concussion Program, Pittsburgh, PA, USA
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Verma R, Swanson RL, Parker D, Ould Ismail AA, Shinohara RT, Alappatt JA, Doshi J, Davatzikos C, Gallaway M, Duda D, Chen HI, Kim JJ, Gur RC, Wolf RL, Grady MS, Hampton S, Diaz-Arrastia R, Smith DH. Neuroimaging Findings in US Government Personnel With Possible Exposure to Directional Phenomena in Havana, Cuba. JAMA 2019; 322:336-347. [PMID: 31334794 PMCID: PMC6652163 DOI: 10.1001/jama.2019.9269] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE United States government personnel experienced potential exposures to uncharacterized directional phenomena while serving in Havana, Cuba, from late 2016 through May 2018. The underlying neuroanatomical findings have not been described. OBJECTIVE To examine potential differences in brain tissue volume, microstructure, and functional connectivity in government personnel compared with individuals not exposed to directional phenomena. DESIGN, SETTING, AND PARTICIPANTS Forty government personnel (patients) who were potentially exposed and experienced neurological symptoms underwent evaluation at a US academic medical center from August 21, 2017, to June 8, 2018, including advanced structural and functional magnetic resonance imaging analytics. Findings were compared with imaging findings of 48 demographically similar healthy controls. EXPOSURES Potential exposure to uncharacterized directional phenomena of unknown etiology, manifesting as pressure, vibration, or sound. MAIN OUTCOMES AND MEASURES Potential imaging-based differences between patients and controls with regard to (1) white matter and gray matter total and regional brain volumes, (2) cerebellar tissue microstructure metrics (eg, mean diffusivity), and (3) functional connectivity in the visuospatial, auditory, and executive control subnetworks. RESULTS Imaging studies were completed for 40 patients (mean age, 40.4 years; 23 [57.5%] men; imaging performed a median of 188 [range, 4-403] days after initial exposure) and 48 controls (mean age, 37.6 years; 33 [68.8%] men). Mean whole brain white matter volume was significantly smaller in patients compared with controls (patients: 542.22 cm3; controls: 569.61 cm3; difference, -27.39 [95% CI, -37.93 to -16.84] cm3; P < .001), with no significant difference in the whole brain gray matter volume (patients: 698.55 cm3; controls: 691.83 cm3; difference, 6.72 [95% CI, -4.83 to 18.27] cm3; P = .25). Among patients compared with controls, there were significantly greater ventral diencephalon and cerebellar gray matter volumes and significantly smaller frontal, occipital, and parietal lobe white matter volumes; significantly lower mean diffusivity in the inferior vermis of the cerebellum (patients: 7.71 × 10-4 mm2/s; controls: 8.98 × 10-4 mm2/s; difference, -1.27 × 10-4 [95% CI, -1.93 × 10-4 to -6.17 × 10-5] mm2/s; P < .001); and significantly lower mean functional connectivity in the auditory subnetwork (patients: 0.45; controls: 0.61; difference, -0.16 [95% CI, -0.26 to -0.05]; P = .003) and visuospatial subnetwork (patients: 0.30; controls: 0.40; difference, -0.10 [95% CI, -0.16 to -0.04]; P = .002) but not in the executive control subnetwork (patients: 0.24; controls: 0.25; difference: -0.016 [95% CI, -0.04 to 0.01]; P = .23). CONCLUSIONS AND RELEVANCE Among US government personnel in Havana, Cuba, with potential exposure to directional phenomena, compared with healthy controls, advanced brain magnetic resonance imaging revealed significant differences in whole brain white matter volume, regional gray and white matter volumes, cerebellar tissue microstructural integrity, and functional connectivity in the auditory and visuospatial subnetworks but not in the executive control subnetwork. The clinical importance of these differences is uncertain and may require further study.
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Affiliation(s)
- Ragini Verma
- DiCIPHR (Diffusion and Connectomics in Precision Healthcare Research) Lab, Philadelphia, Pennsylvania
- Department of Radiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- Department of Neurosurgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- Center for Biomedical Image Computing and Analytics, University of Pennsylvania, Philadelphia
- Center for Brain Injury and Repair, University of Pennsylvania, Philadelphia
| | - Randel L. Swanson
- Center for Brain Injury and Repair, University of Pennsylvania, Philadelphia
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- Center for Neurotrauma, Neurodegeneration, and Restoration, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Rehabilitation Medicine Service, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Drew Parker
- DiCIPHR (Diffusion and Connectomics in Precision Healthcare Research) Lab, Philadelphia, Pennsylvania
- Department of Radiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- Center for Biomedical Image Computing and Analytics, University of Pennsylvania, Philadelphia
| | - Abdol Aziz Ould Ismail
- DiCIPHR (Diffusion and Connectomics in Precision Healthcare Research) Lab, Philadelphia, Pennsylvania
- Department of Radiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- Center for Biomedical Image Computing and Analytics, University of Pennsylvania, Philadelphia
| | - Russell T. Shinohara
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Perelman School of Medicine, Philadelphia
| | - Jacob A. Alappatt
- DiCIPHR (Diffusion and Connectomics in Precision Healthcare Research) Lab, Philadelphia, Pennsylvania
- Department of Radiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- Center for Biomedical Image Computing and Analytics, University of Pennsylvania, Philadelphia
| | - Jimit Doshi
- Department of Radiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- Center for Biomedical Image Computing and Analytics, University of Pennsylvania, Philadelphia
- Section for Biomedical Image Analysis, Department of Radiology, University of Pennsylvania, Philadelphia
| | - Christos Davatzikos
- Department of Radiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- Center for Biomedical Image Computing and Analytics, University of Pennsylvania, Philadelphia
- Section for Biomedical Image Analysis, Department of Radiology, University of Pennsylvania, Philadelphia
| | - Michael Gallaway
- Department of Optometry, Salus University, Elkins Park, Pennsylvania
| | - Diana Duda
- Good Shepherd Penn Partners, University of Pennsylvania, Philadelphia
| | - H. Isaac Chen
- Department of Neurosurgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- Center for Neurotrauma, Neurodegeneration, and Restoration, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Junghoon J. Kim
- Department of Molecular, Cellular, and Biomedical Sciences, CUNY School of Medicine, City College of New York, New York
| | - Ruben C. Gur
- Department of Psychiatry, University of Pennsylvania, Perelman School of Medicine, Philadelphia
| | - Ronald L. Wolf
- Department of Radiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- Center for Brain Injury and Repair, University of Pennsylvania, Philadelphia
| | - M. Sean Grady
- Department of Neurosurgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- Center for Brain Injury and Repair, University of Pennsylvania, Philadelphia
| | - Stephen Hampton
- Center for Brain Injury and Repair, University of Pennsylvania, Philadelphia
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania, Perelman School of Medicine, Philadelphia
| | - Ramon Diaz-Arrastia
- Center for Brain Injury and Repair, University of Pennsylvania, Philadelphia
- Department of Neurology, University of Pennsylvania, Perelman School of Medicine, Philadelphia
| | - Douglas H. Smith
- Department of Neurosurgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- Center for Brain Injury and Repair, University of Pennsylvania, Philadelphia
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Schneider KJ. Concussion part II: Rehabilitation - The need for a multifaceted approach. Musculoskelet Sci Pract 2019; 42:151-161. [PMID: 30745095 DOI: 10.1016/j.msksp.2019.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 12/09/2018] [Accepted: 01/15/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION While most individuals recover in the initial days to weeks following a concussion, in up to 30% of cases symptoms and functional limitations may persist beyond the initial four weeks. There is emerging evidence that multifaceted physiotherapy techniques for individuals who have ongoing symptoms following concussion may be of benefit. PURPOSE The purpose of this masterclass article is to summarize the evidence for rehabilitation, describe treatment techniques and multifaceted interventions following concussion. IMPLICATIONS Concussion is a heterogenous injury and multiple types of rehabilitation may be required to address ongoing alterations in function. A greater understanding of evidence based rehabilitative techniques will enable the clinician to direct treatment and facilitate recovery for individuals who have ongoing symptoms following concussion.
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Affiliation(s)
- Kathryn J Schneider
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, Hotchkiss Brain Institute and Alberta Children's Hospital Research Institute, KNB3300D 2500 University Drive NW, University of Calgary, Calgary, Alberta, T2N 1N4, Canada.
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Cochrane GD, Christy JB, Almutairi A, Busettini C, Swanson MW, Weise KK. Visuo-oculomotor Function and Reaction Times in Athletes with and without Concussion. Optom Vis Sci 2019; 96:256-265. [PMID: 30907863 PMCID: PMC6445703 DOI: 10.1097/opx.0000000000001364] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SIGNIFICANCE Oculomotor tests in concussion commonly show impairment in smooth pursuit and saccadic function. Honing in on the systems likely to be affected by concussion will streamline use of oculomotor function as a supplemental diagnostic and prognostic tool, as well as improve our understanding of the pathophysiology of concussion. PURPOSE This study investigates oculomotor function between concussed and healthy collegiate athletes and determines measurement test-retest reliability of those tools. METHODS Eighty-seven healthy athletes were recruited from a U.S. Division 1 sports university and completed a 30-minute vestibular ocular testing battery in an enclosed rotary chair system equipped with 100-Hz eye-tracking goggles. Forty-three individuals completed the battery twice. Twenty-eight individuals with a current diagnosis of concussion also completed the battery. All participants were aged 18 to 24 years. Bivariate statistical tests examined differences in scores across groups, and intraclass coefficients were computed to test reliability. RESULTS Concussed individuals had significantly longer saccadic, visual, and dual-task reaction times and reduced saccadic accuracy. There was no difference in optokinetic reflex gain, but few concussed individuals tolerated the task. Reaction time latencies and optokinetic gain show moderate test-retest reliability. Smooth pursuit tasks and saccadic accuracies showed poor test-retest reliability. CONCLUSIONS Saccadic latency was the most sensitive oculomotor function to change after concussion and was reliable over time. Saccadic accuracy was significantly lower in the concussed group but had poor retest reliability. Optokinetic gain may warrant more investigation because of its high test-retest reliability and symptom provocation in concussion, despite not showing a significant difference between groups.
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Affiliation(s)
| | - Jennifer B Christy
- Department of Physical Therapy, University of Alabama at Birmingham, Birmingham, Alabama
| | - Anwar Almutairi
- Department of Physical Therapy, University of Alabama at Birmingham, Birmingham, Alabama
| | - Claudio Busettini
- Department of Optometry and Vision Science, University of Alabama at Birmingham, Birmingham, Alabama
- Vision Science Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mark W Swanson
- Department of Optometry and Vision Science, University of Alabama at Birmingham, Birmingham, Alabama
| | - Katherine K Weise
- Department of Optometry and Vision Science, University of Alabama at Birmingham, Birmingham, Alabama
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