Vision Diagnoses Are Common After Concussion in Adolescents

Charles Bonnet Syndrome Following a Mild Traumatic Brain Injury

Charles Bonnet syndrome (CBS) describes the presence of hallucinations in patients with poor or deteriorating vision. The physician awareness of CBS is low, despite reporting of CBS hallucinations occurring in a range of ocular and central nervous system conditions. Following mild traumatic brain injury (mTBI), patients can experience visual or oculomotor dysfunction. As such, it is possible that CBS might present following mTBI. An adult male suffered an mTBI and whiplash injury following a motor vehicle accident. He developed persistent post-concussion symptoms (PPCS) including headaches and vestibular and visual disturbances. He reported experiencing visual hallucinations eight months post-mTBI and was diagnosed with CBS. Interventions for PPCS and hallucinations have persisted for five years. The treatment options for CBS are limited and the patient's PPCS made participating in visual therapy challenging. Physicians assessing patients following mTBI should be aware of CBS and should take PPCS into consideration when recommending treatments for CBS.

Accommodative and Vergence Responses to a Moving Stimulus in Concussion

Purpose

Concussed adolescents often report visual symptoms, especially for moving targets, but the mechanisms resulting in oculomotor deficits remain unclear. We objectively measured accommodative and vergence responses to a moving target in concussed adolescents and controls.

Methods

Thirty-two symptomatic concussed participants (mean age, 14.4 ± 2.6 years; mean days since concussion, 107 days; range, 36-273 days) and 32 healthy controls (mean age, 12.7 ± 2.1 years) viewed a movie binocularly (closed-loop) and monocularly (vergence open-loop), as well as a Difference of Gaussians (DoG) target binocularly (accommodation open-loop). The movie or DoG target sinusoidally moved toward and away from participants at a 0.1-hertz (Hz) frequency at four separate stimulus amplitudes (1.50 diopters [D], 1.00 D, 0.50 D, 0.25 D) around a 2.50-D midpoint. Accommodation and vergence were continuously measured at 50 Hz using the PowerRef 3. Fourier analysis was used to assess the response amplitudes at the 0.1-Hz frequency. A 2 × 3 analysis of variance with the factors group (concussed, control) and viewing condition (binocular, monocular, DoG) was conducted on response amplitudes.

Results

Across groups, accommodative and vergence responses were significantly higher in binocular than monocular conditions (P < 0.001), but not DoG conditions. Compared to controls, concussed participants had significantly reduced monocular accommodative responses (P < 0.012; e.g., at 1.50 D, controls = 1.09 ± 0.47 D and concussed = 0.80 ± 0.36 D, P = 0.011). No group differences were observed for vergence responses in any viewing condition.

Conclusions

Accommodative and vergence responses to the moving target were largely driven by disparity cues for both groups, with only minimal improvements in the presence of additional blur cues. Concussed participants showed reduced accommodative responses to a 0.1-Hz stimulus in monocular conditions, indicating mild accommodative deficits in the absence of disparity cues.

Comparing clinical measures of near point of convergence and accommodation from the lateral canthus and browline in a paediatric and adolescent population

PURPOSE

Clinicians measure the near point of convergence (NPC) and the amplitude of accommodation (AA) from the spectacle plane, the bridge of the nose or the lateral canthus when assessing visual function. These values are compared to standard clinical criteria to diagnose vergence and accommodation deficits, despite varying reference points. This prospective study explored measuring relative to the spectacle plane and from the lateral canthus for NPC and monocular AA, and the resulting clinical implications of diagnosing visual deficits.

METHODS

Participants were seen by a single clinician for an eye examination. NPC was measured from the forehead and the lateral canthus of the right eye. Monocular AA was measured from the brow and the lateral canthus. Differences between measurements were analysed using non-parametric statistical tests including Wilcoxon Signed Rank, as well as linear regression and a linear mixed effects model to adjust for inter-eye correlation and repeated measures. Chi-square tests were used to assess differences in rates of abnormal findings.

RESULTS

Data were collected from 70 participants (53% female, median age 13 [11-15] years). On average, measuring NPC from the lateral canthus yielded a value 1.8 cm higher than measuring from the forehead. Measuring AA from the lateral canthus resulted in an average difference of 1.5 cm compared to measuring from the brow. A total of 39% and 76% of subjects failed NPC compared to clinical norms when measured from the forehead or the lateral canthus, respectively, while 7% and 40% failed AA when measured from the brow or the lateral canthus, respectively.

CONCLUSION

With the variable anatomy of the eye, it is imperative to account for the measurement point when assessing visual function. Measuring from the lateral canthus greatly increased the failure rates for NPC and AA compared with measuring from the forehead and brow, respectively.

Visual Impairment in Pre-Clinical Models of Mild Traumatic Brain Injury

Impairment in visual function is common after traumatic brain injury (TBI) in the clinical setting, a phenomenon that translates to pre-clinical animal models as well. In Morris et al. (2021), we reported histological changes following weight-drop-induced TBI in a rodent model including retinal ganglion cell (RGC) loss, decreased electroretinogram (ERG) evoked potential, optic nerve diameter reduction, induced inflammation and gliosis, and loss of myelin accompanied by markedly impaired visual acuity. In this review, we will describe several pre-clinical TBI models that result in injuries to the visual system, indicating that visual function may be impaired following brain injury induced by a number of different injury modalities. This underscores the importance of understanding the role of the visual system and the potential detrimental sequelae to this sensory modality post-TBI. Given that most commonly employed behavioral tests such as the Elevated Plus Maze and Morris Water Maze rely on an intact visual system, interpretation of functional deficits in diffuse models may be confounded by off- target effects on the visual system.

MICK (Mobile Integrated Cognitive Kit) App for Concussion Assessment in a Youth Ice Hockey League

BACKGROUND

Visual symptoms are common after concussion. Rapid automatized naming (RAN) tasks are simple performance measures that demonstrate worse time scores in the setting of acute or more remote injury.

METHODS

We evaluated the capacity for the Mobile Universal Lexicon Evaluation System (MULES) and Staggered Uneven Number (SUN) testing to be feasibly administered during preseason testing in a cohort of youth ice hockey athletes using a novel computerized app, the Mobile Integrated Cognitive Kit (MICK). Participants from a youth hockey league underwent preseason testing.

RESULTS

Among 60 participants, the median age was 13 years (range 6-17). The median best time for the MULES was 49.8 seconds (range = 34.2-141.0) and the median best time for the SUN was 70.1 (range = 36.6-200.0). As is characteristic of timed performance measures, there were learning effects between the first and second trials for both the MULES (median improvement = 10.6 seconds, range = -32.3 to 92.0, P < 0.001, Wilcoxon signed-rank test) and SUN (median improvement = 2.4 seconds, range= -8.0 to 15.1, P = 0.001, Wilcoxon signed-rank test). Age was a predictor of best baseline times, with longer (worse) times for younger participants for MULES (P < 0.001, rs = -0.67) and SUN (P < 0.001, rs = -0.54 Spearman rank correlation). Degrees of learning effect did not vary with age (P > 0.05, rs = -0.2).

CONCLUSIONS

Vision-based RAN tasks, such as the MULES and SUN, can be feasibly administered using the MICK app during preseason baseline testing in youth sports teams. The results suggest that more frequent baseline tests are necessary for preadolescent athletes because of the relation of RAN task performance to age.

OculoMotor & Vestibular Endurance Screening (MoVES) Normative, Repeatability, and Reliability Data

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.

Convergence insufficiency in patients with post-concussion syndrome is accompanied by a higher symptom load: a cross-sectional study

OBJECTIVE

To estimate the prevalence of convergence insufficiency (CI) in adult patients with post-concussion syndrome and determine the impact of CI on symptom load.

METHODS

Cross-sectional study of 103 patients with neurological symptoms 2-6 months after a concussion. Symptoms were assessed with the Rivermead Post Concussion Symptoms Questionnaire (RPQ), and CI was diagnosed using near point of convergence, vergence facility, and the Convergence Insufficiency Symptom Survey. The RPQ score for patients with and without CI was compared, and sensitivity, specificity, and area under the receiver operating characteristic curve for the two visually related RPQ questions as indicators of CI were calculated.

RESULTS

The proportion of patients diagnosed with symptomatic CI was 20.4% (95% confidence interval: 13.1-29.5%). The RPQ score was significantly higher for patients with symptomatic CI both before (p = .01) and after removal of the two visually related questions in the RPQ-questionnaire (p = .03). The two visually related RPQ questions were unable to detect CI.

CONCLUSION

In patients with post-concussion syndrome, the load of nonvisual symptoms is higher in the presence of CI. A prospective interventional study on CI is required to study the relationship between CI and other post-concussion symptoms.

Neurovascular Coupling in Acutely Concussed Adolescent Patients

Neurovascular coupling (NVC) uniquely describes cerebrovascular response to neural activation and has demonstrated impairments following concussion in adult patients. It is currently unclear how adolescent patients experience impaired NVC acutely following concussion during this dynamic phase of physiological development. The purpose of this study was to investigate NVC in acutely concussed adolescent patients relative to controls. We recruited patients presenting to a sports medicine practice within 28 days of a concussion or a musculoskeletal injury (controls). Transcranial Doppler ultrasound was used to measure changes in patients' posterior cerebral artery (PCA) velocity in response to two progressively challenging visual tasks: (1) reading and (2) visual search. Each task was presented in five 1-min trials (20 sec eyes closed/40 sec eyes open). Resting PCA velocity data were derived by averaging PCA velocity across a 2-min baseline period that preceded the visual tasks. Filtered task data were converted to time-series curves representing 40 consecutive 1-sec averages for each trial. Curves were then averaged across the five trials and time-aligned to stimulus onset (eyes open) to generate a single ensemble-averaged 40-sec curve representing NVC response for each participant for each task. Independent t tests were used to assess group differences (concussion vs. control) in resting PCA velocity. Separate linear mixed-effects models were used to evaluate group differences (concussion vs. control) in NVC response profiles for both visual tasks and group-by-task interaction. Twenty-one concussion patients (female = 8 [38.1%]; age = 14.4 ± 1.9 years) and 20 controls (female = 7 [35.0%]; age = 14.4 ± 1.9 years) were included in our analysis. Average resting PCA velocity did not significantly differ between concussion patients (36.6 ± 8.0 cm/sec) and controls (39.3 ± 8.5 cm/sec) (t39 = 1.06; p = 0.30). There were no significant group differences in relative NVC response curves during the reading task (F1,1560 = 2.23; p = 0.14) or the visual search task (F1,1521 = 2.04; p = 0.15). In contrast, the differential response to task (e.g., increase from reading task to visual search task) was significantly greater in concussion patients than in controls (p < 0.0001). The NVC response to the visual search task was 7.1% higher than the response to reading in concussion patients relative to being 5.5% higher in controls. Our data indicate that concussed patients present with a significantly greater response to more difficult tasks than do controls, suggesting that concussed adolescents require increased neural resource allocation as task difficulty increases. The study provides insight into the neurophysiological consequences of concussion in adolescent patients.

Altered Oculomotor and Vestibulo-ocular Function in Children and Adolescents Postconcussion

OBJECTIVE

To document (1) oculomotor (OM) and vestibulo-ocular (VO) function in children with concussion who were symptomatic at the time of assessment and to compare it with that in children with concussion who were clinically recovered (asymptomatic) and in children with no concussive injury, and (2) the extent to which OM and VO function relates to postconcussion symptom severity in injured children.

SETTING

Participants were recruited from a concussion clinic or the community.

PARTICIPANTS

A total of 108 youth with concussion (72 symptomatic; 36 recovered) and 79 healthy youth (aged 9-18 years). Youth with concussion were included if aged 9 to 18 years, had no previous concussion within the last 12 months, less than 90 days since injury, and no known existing visual disorders or learning disabilities.

STUDY DESIGN

A prospective cross-sectional study.

MAIN MEASURES

All participants were tested for OM and VO function with a commercial virtual reality (VR) eye-tracking system (Neuroflex ® , Montreal,Québec, Canada). Participants in the concussion group who completed the postconcussion symptoms were scored with the Post-Concussion Symptom Inventory.

RESULTS

There was a significant group effect for vergence during smooth pursuit ( F2,176 = 10.90; P < .05), mean latency during saccades ( F2,171 = 5.99; P = .003), and mean response delay during antisaccades ( F2,177 = 9.07; P < .05), where children with symptomatic concussion showed poorer performance than clinically recovered and healthy children. Similar results were found in VO for average vestibular ocular reflex gain in the horizontal leftward ( F2,168 = 7; P = .001) and rightward directions ( F2,163 = 13.08; P < .05) and vertical upward ( F2,147 = 7.60; P = .001) and downward directions ( F2,144 = 13.70; P < .05). Mean saccade error was positively correlated to total Post-Concussion Symptom Inventory scores in younger clinically recovered children.

CONCLUSION

VR eye tracking may be an effective tool for identifying OM and VO deficits in the subacute phase (<90 days) postconcussion.

Efficacy of restitutive interventions for oculomotor deficits in adults with mild traumatic brain injury: a systematic review and meta-analysis

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.

Contemporary diagnosis and management of mild TBI (concussions): What you need to know

ABSTRACT

Concussion is a common injury in children and adolescents and is a form of mild traumatic brain injury that surgeons will see in their acute care practice. With a rapidly changing evidence base for diagnosis and management, we will focus on the importance of timely identification and diagnosis, as well as the early initiation of active management of pediatric concussion immediately after injury through recovery. This approach involves the application of targeted therapies for specific deficits identified after concussion, addressing the individual pattern of symptoms experienced by patients following concussion. We will review what is known about the underlying pathophysiology that drives the clinical manifestations of concussion, the targeted clinical assessments that can both aid in the diagnosis of concussion, as well as drive the active rehabilitation of deficits seen after concussion. The standardized approach to the return to activities will also be described, including return to learning and sports.

Assessment of post-concussion emotional symptom load using PCSS and PROMIS instruments in pediatric patients

OBJECTIVES

The purpose of this study is to evaluate the utility of the Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and depressive symptom domains in conjunction with the Post-Concussion Symptom Scale (PCSS)for identifying pediatric patients with emotional symptoms following a concussion, and to identify predictors of higher emotional symptom loads.

METHODS

We recruited English-speaking patients aged 8-17 years presenting to a tertiary-care concussion clinic from 2014 to 2018 (n = 458). Demographics and clinical data including PCSS, injury date, previous history of anxiety/depression, and Vestibular/Ocular-Motor Screen (VOMS) were collected from patients' electronic medical records. Participants completed surveys in the PROMISTM Pediatric Item Bank v1.1-Anxiety and Depressive Symptoms domains at their initial clinic visit. Multivariable linear regression identified predictors of higher emotional symptom loads.

RESULTS

Overall, 425 (92.8%) reported ≥1 emotional symptom on either PROMIS or PCSS. Predictors of higher emotional symptom loads were abnormal VOMS, female sex, history of anxiety or depression, and longer time since injury.

CONCLUSION

Our results suggest that adding PROMIS anxiety and depressive symptom surveys to pediatric concussion evaluations may identify more children with emotional symptoms, allowing clinicians to better direct post-concussion treatment and incorporate psychological support for patients if necessary. Future studies should examine whether earlier identification of emotional symptoms with these tools facilitates recovery and improves short- and/or long-term psychological outcomes in pediatric concussion.

Dose-Response Effect of Mental Health Diagnoses on Concussion Recovery in Children and Adolescents

BACKGROUND

Pre-existing mental health diagnoses may contribute to greater emotional symptom burden and prolonged recovery after concussion.

HYPOTHESIS

Youth with pre-existing mental health diagnoses will have greater emotional symptom burden, greater risk for delayed return to exercise, and more prolonged recovery from concussion than those without those diagnoses.

STUDY DESIGN

Prospective cohort.

LEVEL OF EVIDENCE

Level 3.

METHODS

A prospective registry of youth concussion was examined for differences in emotional symptom burden after injury to develop a predictive risk model for prolonged recovery. The impact of individual and total number of pre-existing mental health diagnoses (0, 1, 2, and 3+) was assessed, and multivariable logistic regression was performed to identify factors associated with prolonged recovery.

RESULTS

Among a cohort of 3105 youth with concussion, those with a history of mental health diagnoses, in a dose-response fashion, had greater postinjury emotional symptom burden (7 emotional symptoms vs 4; P < 0.01), visio-vestibular dysfunction (65% abnormal vs 56% abnormal; P < 0.01), later return to symptom-limited exercise (23 vs 21 days; P < 0.01), and overall longer concussion recovery (38 days, interquartile range [IQR] 18, 80) versus 25 days (IQR 13, 54; P < 0.01). Boys with prolonged recovery after concussion had greater emotional symptom burden than girls (5 emotional symptoms vs 3; P < 0.01).

CONCLUSION

Pre-existing mental health diagnoses are associated with greater postinjury emotional symptom burden and longer concussion recovery in a dose-response fashion. Visiovestibular deficits and delayed return to exercise are also associated with pre-existing mental health diagnoses and prolonged recovery. Boys with prolonged recovery from concussion experience greater emotional symptom burden than girls.

CLINICAL RELEVANCE

Addressing pre-existing mental health diagnoses is essential to concussion management. Boys with prolonged recovery from concussion may particularly benefit from interventions to address their higher emotional symptom burden. Interventions, including a home visio-vestibular exercise program and symptom-limited exercise, may contribute to improving time to concussion recovery.

Comparison of Visual Symptom Frequency and Occupational Issues Between Patients With and Without Concussion

IMPORTANCE

Occupational therapy practitioners' knowledge of and advocacy for clients with visual symptoms postconcussion can have a considerable impact on recovery.

OBJECTIVE

To compare the frequency of vision symptoms and occupational performance deficits in a sample of participants with and without concussion.

DESIGN

Cross-sectional study.

SETTING

Sports medicine clinic.

PARTICIPANTS

Adolescents and adults with concussion (n = 20) and musculoskeletal injuries (n = 19).

OUTCOMES AND MEASURES

Measures included monocular amplitude of accommodation, near point of convergence, Binocular Vision Assessment (BVA) computerized screening for phoria, BVA computerized screening for fusional vergence, the Developmental Eye Movement Test, the Canadian Occupational Performance Measure, and the Convergence Insufficiency Symptom Survey-Concussion Version (CISS-CON).

RESULTS

We found significant differences between participants with and without concussion using the CISS-CON (p = .001), positive fusional vergence (p = .02), and near point of convergence (p = .02). Participants with concussion scoring above cutoffs on multiple measures reported poorer performance (p = .005) and satisfaction (p = .004) with valued occupations.

CONCLUSIONS AND RELEVANCE

Concussion has a detrimental effect on vision and occupation, and occupational therapy practitioners are well-positioned to assess and address issues arising from this relationship. Plain-Language Summary: Vision symptoms commonly experienced after a concussion are associated with reduced occupational performance and satisfaction and can have a considerable impact on recovery. Occupational therapy assessment for clients with concussion should include screening for vision difficulties.

National Athletic Trainers' Association Bridge Statement: Management of Sport-Related Concussion

OBJECTIVE

To provide athletic trainers and team physicians with updated recommendations to the 2014 National Athletic Trainers' Association (NATA) concussion position statement regarding concussion management, specifically in the areas of education, assessment, prognostic factors, mental health, return to academics, physical activity, rest, treatment, and return to sport.

BACKGROUND

Athletic trainers have benefited from the 2 previous NATA position statements on concussion management, and although the most recent NATA position statement is a decade old, knowledge gains in the medical literature warrant updating several (but not all) recommendations. Furthermore, in various areas of the body of literature, current evidence now exists to address items not adequately addressed in the 2014 statement, necessitating the new recommendations. This document therefore serves as a bridge from the 2014 position statement to the current state of concussion evidence, recommendations from other organizations, and discrepancies between policy and practice.

RECOMMENDATIONS

These recommendations are intended to update the state of the evidence concerning the management of patients with sport-related concussion, specifically in the areas of education; assessment advances; prognostic recovery indicators; mental health considerations; academic considerations; and exercise, activity, and rehabilitation management strategies.

Temporal Changes in Fixational Eye Movements After Concussion in Adolescents and Adults: Preliminary Findings

Concussions often involve ocular impairment and symptoms such as convergence insufficiency, accommodative insufficiency, blurred vision, diplopia, eye strain, and pain. Current clinical assessments of ocular function and symptoms rely on subjective symptom reporting and/or involve lengthy administration time. More objective, brief assessments of ocular function following concussion are warranted. The purpose of this study was to evaluate changes in fixational eye movements (FEMs) and their association with clinical outcomes including recovery time, symptoms, cognitive and vestibular/ocular motor impairment. Thirty-three athletes (13-27 years of age; 54.5% female) within 21 days of a diagnosed concussion participated in the study. A tracking scanning laser ophthalmoscope (TSLO) evaluated FEMs metrics during fixation on a center and corner target. Participants completed symptom (Post-Concussion Symptom Scale [PCSS]), cognitive (Immediate Post-concussion Assessment and Cognitive Testing [ImPACT], and Vestibular/Ocular Motor Screening (VOMS) evaluations. All measures were administered at the initial visit and following medical clearance, which was defined as clinical recovery. Changes in FEMs were calculated using paired-samples t tests. Linear regression (LR) models were used to evaluate the association of FEMs with clinical recovery. Pearson product-moment correlations were used to evaluate the associations among FEMs and clinical outcomes. On the center task, changes across time were supported for average microsaccade amplitude (p = 0.005; Cohen's d = 0.53), peak velocity of microsaccades (p = 0.01; d = 0.48), peak acceleration of microsaccades (p = 0.02; d = 0.48), duration of microsaccade (p < 0.001; d = 0.72), and drift vertical (p = 0.017; d = -0.154). The LR model for clinical recovery was significant (R2 = 0.37; p = 0.023) and retained average instantaneous drift amplitude (β = 0.547) and peak acceleration of microsaccade (β = 0.414). On the corner task, changes across time were supported for drift proportion (p = 0.03; d = 0.43). The LR model to predict clinical recovery was significant (R2 = 0.85; p = 0.004) and retained average amplitude of microsaccades (β = 2.66), peak velocity of microsaccades (β = -15.11), peak acceleration of microsaccades (β = 12.56), drift horizontal (β = 7.95), drift vertical (β = 1.29), drift amplitude (β = -8.34), drift proportion (β = 0.584), instantaneous drift direction (β = -0.26), and instantaneous drift amplitude (β = 0.819). FEMs metrics were also associated with reports of nausea and performance within the domain of visual memory. The FEMs metric were also associated with PCSS, ImPACT, and VOMS clinical concussion outcomes, with the highest magnitude correlations between average saccade amplitude and VOMS symptoms of nausea and average instantaneous drift speed and ImPACT visual memory, respectively. FEMs metrics changed across time following concussion, were useful in predicting clinical recovery, and were correlated with clinical outcomes. FEMs measurements may provide objective data to augment clinical assessments and inform prognosis following this injury.

Preliminary assessment of a standardized vision screening guideline in a pediatric inpatient rehabilitation unit

OBJECTIVE

This study aimed to evaluate the impact of a standardized vision screen guideline on occupational therapy vision screens in a pediatric inpatient rehabilitation unit.

METHODS

Charts of patients admitted to a pediatric inpatient rehabilitation before guideline implementation (n = 47) versus charts after implementation (n = 47) were randomly, retrospectively reviewed to explore differences in visual skills screened and use of standardized assessments.

RESULTS

Significant improvements (p < = 0.05) were found in the number of visual skills screened (p = 0.034), use of standardized assessments (p = 0.005), and screening of the specific visual skills of accommodative amplitude (p = 0.05), suppression (p = 0.015), and double vision (p < 0.001).

CONCLUSION

Implementation of a standardized vision screen guideline improved the frequency of vision screens during occupational therapy evaluations in a pediatric inpatient rehabilitation unit. The use of standardized assessments may also improve the quality of vision screens by encouraging staff to complete more comprehensive vision screens, including screening more visual skills, and by prompting use of standardized assessments, which can improve accuracy of screening procedures.

The Ability of Vestibular and Oculomotor Screenings to Predict Recovery in Patients After Concussion: A Systematic Review of the Literature

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.

Ocular motor disorders in children and adults with mTBI: a scoping review protocol

INTRODUCTION

Ocular motor function is susceptible to neurological injury because it requires a large portion of brain circuitry including every lobe of the brain, brainstem, thalamus, basal ganglia, cerebellum, cranial nerves and visual tracts. While reports of a high frequency of ocular motor dysfunctions after mild traumatic brain injury (mTBI) span multidisciplinary journals, there is no scoping review of the signs, diagnostic assessments and criteria, and appropriate management of ocular motor disorders post-mTBI. Post-mTBI ocular motor dysfunction has been reported to respond to active treatment. The objective of this scoping review is to map the available evidence on the diagnostic assessment and treatment modalities currently used in the management of mTBI-related ocular motor disorders in children and adults. This scoping review also aims to identify gaps in the current literature and provide suggestions for future research.

METHODS AND ANALYSIS

This review will include populations with reported concussion and/or mTBI without restrictions on age, race, sex or time since injury. The review will evaluate the reported symptoms related to ocular motor dysfunction, types of assessments and diagnostic criteria used, reported treatments, and the level of evidence supporting the reported treatments. This review will exclude literature on brain injury of non-traumatic aetiology and moderate/severe traumatic brain injury. Ocular motor dysfunction after mTBI appears in journals across multiple disciplines. Thus, multiple databases will be evaluated including Pubmed, Embase, PEDro, OVID, Clinical Key, Google Scholar and REHABDATA. Literature will be searched from inception to present day. Evidence sources will include experimental study designs including randomised controlled trials, non-randomised controlled trials and interrupted time-series. Additionally, analytical observational studies including prospective and retrospective cohort studies, case series, cross-sectional studies and clinical practice guidelines will be considered for inclusion. Data will be extracted on clinical presentation, frequency, assessment, diagnostic criteria management strategies and outcomes of concussion and mTBI-related ocular motor disorders.

ETHICS AND DISSEMINATION

This scoping review will use data from existing publications and does not require ethical approval by an institutional review board. Results will be disseminated through publication in a peer-reviewed scientific journal and presented at relevant conferences and as part of future workshops with professionals involved with diagnosis and management of patients with mTBI.

Precision Concussion Management: Approaches to Quantifying Head Injury Severity and Recovery

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.

Rehabilitation interventions for oculomotor deficits in adults with mild traumatic brain injury: a systematic review protocol

INTRODUCTION

Mild traumatic brain injury (mTBI) is the most common form of TBI with many individuals suffering from symptoms suggestive of deficits in oculomotor function. Although the symptoms are often experienced transiently, almost 50% of individuals will experience persistent symptoms. Oculomotor deficits can last months after injury and decrease function and the ability to participate in work, school and sport. To date, rehabilitation interventions targeting oculomotor deficits in mTBI have been reported on in several studies with varying study designs; however, the effectiveness of these interventions on measures of oculomotor function has not been established. The purpose of this paper is to present a protocol for a systematic review that aims to examine the effectiveness of rehabilitation interventions for improving function in adults with oculomotor deficits after mTBI.

METHODS AND ANALYSIS

Systematic searches in Medline Ovid, EMBASE, PsycINFO, CINAHL and Scopus will be conducted to identify experimental studies published in English from each databases inception date to present, involving adult patients with mTBI and oculomotor deficits. Citations will be saved and managed in EndNote V.20. Two independent reviewers will identify eligible studies and perform data abstraction. Any discrepancies will be solved by discussion, and a third reviewer will be consulted if necessary. A meta-analysis will be conducted for outcomes reported in two or more studies. The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol guidelines will be followed for reporting.

ETHICS AND DISSEMINATION

This study does not involve primary data collection; therefore, formal ethical approval by an institutional review board is not required. Final results will be disseminated through open-access peer-reviewed publications. Abstracts will be presented at suitable national and international conferences or workshops. Furthermore, important information will be shared with clinical authorities, clinicians and at affiliated research institution-based websites and relevant servers.

PROSPERO REGISTRATION NUMBER

CRD42022352276.

Vision Quality of Life with Time Survey: Normative Data and Repeatability

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.

International Olympic Committee (IOC) consensus paper on sports-related ophthalmology issues in elite sports

Vision plays an important role in an athletes' success. In sports, nearly 80% of perceptual input is visual, and eye health and sports medicine are closely intertwined fields of utmost importance to athletes. The physical nature of sports activities renders individuals more prone to various eye injuries than the general population. Ocular trauma can lead to lifelong sequelae, and impaired vision requires careful follow-up and management. Apart from injuries, athletes may also experience vision problems that can hamper their performance, including blurred vision, double vision, and light sensitivity. The interdisciplinary nature of sports medicine necessitates collaboration between sports medicine professionals and ophthalmologists. Through such collaborations, athletes can receive appropriate eye care, education on proper eye protection and guidance on adopting good eye health practices. If any inconspicuous symptoms are not detected and treated promptly, athletes may acquire systemic injuries because of defective vision, preventing them from achieving high level athletic performance in competitions. The protection of the elite athlete is the responsibility of all of us in sports medicine. To advance a more unified, evidence-informed approach to ophthalmic health assessment and management in athletes and as relevant for sports medicine physicians, the International Olympic Committee Consensus Group aims for a critical evaluation of the current state of the science and practice of ophthalmologic issues and illness in high-level sports, and present recommendations for a unified approach to this important issue.

Double Vision and Light Sensitivity Symptoms are Associated With Return-to-School Timing After Pediatric Concussion

OBJECTIVE

To determine the association between academic time loss postconcussion and vision symptoms/impairments among pediatric patients.

DESIGN

Cross-sectional.

SETTING

Sports medicine clinic.

PATIENTS

Pediatric patients seen for care in a sports medicine clinic between the ages 6 and 18 years (n = 212; mean age = 14.3, SD = 2.4 years; 48% female) were evaluated within 21 days of concussion (mean = 9.8, SD = 5.7 days).

INDEPENDENT VARIABLE

Patients were grouped based on academic time loss (missed >5 days vs ≤5 days of school) at their initial postconcussion evaluation.

OUTCOME MEASURES

Patients rated concussion symptoms using the Health and Behavior Inventory (HBI) and underwent near point of convergence (NPC) testing. We compared groups on specific HBI symptom ratings of dizziness, blurry vision, seeing double, and light sensitivity, as well as NPC break and recovery point distances.

RESULTS

Two hundred twelve patients were included; n = 36 (17%) who reported missing >5 days of school. After adjusting for time since injury, parental education level, mechanism of injury, and preinjury anxiety, patients who reported missing >5 days of school had higher ratings of double vision (β = 0.27; 95% confidence interval [CI], 0.01-0.53; P = 0.04) and light sensitivity (β = 0.506; 95% CI, 0.061-0.951; P = 0.02), but not dizziness (β = 0.390; 95% CI, -0.047 to 0.827; P = 0.08) or blurry vision (β = 0.026; 95% CI, -0.352 to 0.404; P = 0.89).

CONCLUSION

Missing >5 days of school was associated with worse double vision and light sensitivity symptoms. Given the importance of vision in learning, assessing postconcussion vision symptoms may facilitate a successful return to school. Clinicians should assess a wide spectrum of vision-specific symptoms to ensure appropriate support during the return-to-school process.

Characteristics of binocular vision and oculomotor function among sports-concussed athletes

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.

Incidence of Remote Near-Point of Convergence in University Athletes After Sport-Related Concussion

OBJECTIVE

Near-point of convergence (NPC) testing is an attractive screening tool in the sport setting because it is rapid, requires few resources, and is easy to administer. Remote NPC has been reported after sport-related concussion (SRC), although the incidence among a university-aged population is not well defined. The purpose of the study was to examine the incidence of remote NPC after SRC in a cohort of Canadian interuniversity athletes.

DESIGN

Cross-sequential.

SETTING

University.

PARTICIPANTS

One hundred thirty-two university athletes [SRC, n = 68; musculoskeletal (MSK) injury, n = 64] were tested before the beginning of their competitive season and again after their injury.

INDEPENDENT VARIABLES

Healthy athletes measured preseason were compared with athletes after SRC or MSK injury using both longitudinal and cross-sectional designs.

MAIN OUTCOME MEASURES

Remote NPC (pass/fail), measured at 6 cm or greater, repeated 3 times.

RESULTS

After SRC, 22% of athletes failed their test postinjury (95% CI, 14%-33%). Comparatively, in the MSK group, 3% of athletes failed their test postinjury (95% CI, 1%-7%). A direct comparison of both injury groups yielded a mean 19% higher prevalence of failed NPC tests after SRC versus MSK injury (95% CI, 10%-30%). There seems to be no relationship between reported symptom burden and NPC performance after SRC.

CONCLUSION

Remote NPC occurs in approximately 1 of 5 athletes after SRC and is rarely observed after MSK injury.

Exercise-Induced Vision Dysfunction Early After Sport-Related Concussion Is Associated With Persistent Postconcussive Symptoms

OBJECTIVE

The purpose of this study was to determine if exercise-induced vision dysfunction [reduced performance and/or symptom exacerbation on a post-exercise King-Devick (KD) test] in adolescents early after sport-related concussion was associated with increased risk of persistent post-concussive symptoms (PPCS, recovery >28 days). We used exercise as a provocative maneuver before the KD test, hypothesizing that concussed adolescents with exercise-induced vision dysfunction would be more likely to develop PPCS.

DESIGN

Secondary analysis of data from a multi-center, randomized clinical trial comparing KD test performance before and after the Buffalo Concussion Treadmill Test in adolescents within 10 days of sport-related concussion who were randomized to aerobic exercise or placebo stretching program.

SETTING

Three university-associated sports medicine clinical programs.

PARTICIPANTS

Ninety-nine adolescents with sport-related concussion (exercise group: n = 50, 15.3 ± 1 years, 60% M, 22% with PPCS; stretching group: n = 49, 15.9 ± 1 years, 65% M, 35% with PPCS) tested a mean of 6 ± 2 days from injury.

INDEPENDENT VARIABLE

King-Devick test performed immediately before and 2 minutes after Buffalo Concussion Treadmill Test.

MAIN OUTCOME MEASURE

Persistent post-concussive symptoms.

RESULTS

Adolescents who demonstrated exercise-induced vision dysfunction upon initial evaluation developed PPCS at a significantly greater rate when compared with adolescents who did not (71% vs 34%, P < 0.001). Exercise-induced vision dysfunction corresponded to a relative risk of 3.13 for PPCS.

CONCLUSIONS

Adolescents with exercise-induced vision dysfunction had a 3-fold greater relative risk of developing PPCS than those without exercise-induced vision dysfunction.

The effect of a home exercise program on visio-vestibular function in concussed pediatric patients

Background

A visio-vestibular home exercise program (VV-HEP) can provide an equitable and cost-effective method for therapy targeted towards visio-vestibular deficits that are common following concussion. The effects of a VV-HEP on improving concussion symptoms and visio-vestibular function are unclear.

Purpose

Determine the effect of VV-HEP on symptoms and visio-vestibular function in concussed pediatric patients.

Methods

This study included 527 patients [294 female (55.8%); age = 14.4 ± 2.1 years] reporting to a specialty care concussion center within 28 days of injury and for a first follow-up within 60 days of injury. Patients completed the Post-Concussion Symptom Inventory (PCSI) and Visio-Vestibular Examination (VVE). Patients were prescribed the VV-HEP at initial visit, with exercises including saccades, gaze stability, convergence, and balance, and instructed to complete these 1-2 times/day. At follow-up, patients self-reported their VV-HEP progress as (1) has not done, (2) in progress, or (3) completed. Primary outcomes included VV-HEP progress at follow-up, PCSI endorsement and severity, VVE subtests (normal/abnormal), and total VVE score (abnormal = 2 + abnormal subtests). Kruskal-Wallis tests and chi-square were used to determine if concussion symptoms or the proportion of abnormal VVE outcomes, respectively, were associated with VV-HEP status. Post-hoc pairwise comparisons with Bonferonni corrections were used to determine concussion symptom (α = 0.017 a priori) and VVE (α = 0.005 a priori) differences in VV-HEP status.

Results

At follow-up, patients who had completed the VV-HEP reported lower symptom endorsement (median = 1, IQR = 0-3) and lower symptom severity (median = 1, IQR = 0-4) relative to patients who had not started the VV-HEP (endorsement median = 7, IQR = 1-13, p < 0.0001; severity median = 15.5, IQR = 2-32.5, p < 0.0001) and those in progress (endorsement median = 8, IQR = 3-14, p < 0.0001; severity median = 15, IQR = 4-30, p < 0.0001). A lower proportion of patients who completed the VV-HEP reported with abnormal vestibular-ocular reflex (22.2%), tandem gait (0%), and total VVE score (22.2%) relative to those who had not started or those in progress (p < 0.005).

Conclusion

Our findings indicate that patients who completed the VV-HEP had lower symptom burden and improved visio-vestibular function relative to those who did not start or were in progress. This suggests that a VV-HEP can effectively reduce visio-vestibular dysfunction following concussion and may serve as a means to minimize inequities in access to care.

Pre- and post-season visio-vestibular function in healthy adolescent athletes

OBJECTIVE

To evaluate pre - to post-season differences in individual subtests of the Visio-Vestibular Examination (VVE) in healthy middle and high school athletes.

METHODS

This prospective cohort study recruited participants from a private suburban United States secondary school. Participants completed a demographic questionnaire prior to the start of their season. A proxy for head impact exposure was estimated by incorporating previously published head impact frequencies by team and sport. The VVE was completed pre - and post-season and consisted of 9 subtests: smooth pursuit, horizontal/vertical saccades and gaze stability, binocular convergence, left/right monocular accommodation, and complex tandem gait. Generalized estimating equations were employed to assess the relative risk of an abnormal VVE outcome based on testing session (pre - vs. post-season).

RESULTS

Participants included middle and high school athletes (n = 115; female = 59 (51.3%); median age at first assessment = 14.9 years, [IQR = 13.6, 16.0]) during 2017/18 - 2019/20 school years. During pre-season testing, accommodation (10.0%) and complex tandem gait (9.2%) had the largest proportion of abnormal outcomes, while smooth pursuits (10.6%) and convergence (9.5%) had the largest proportion of abnormal outcomes post-season. When assessing the effect of testing session on the relative risk of any abnormal VVE subtest, there were no significant findings (P ≥ 0.25). Additionally, there were no significant effects of testing session when adjusting for estimated head impact exposure for any VVE subtest (P ≥ 0.25).

CONCLUSIONS

Visio-vestibular function as measured by the VVE does not change from pre - to post-season in otherwise healthy adolescent athletes. Our findings suggest that the VVE may be stable and robust to typical neurodevelopment occurring in this dynamic age group and help inform post-injury interpretation of visio-vestibular impairments.

Trajectories of Visual and Vestibular Markers of Youth Concussion

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.

Examination of Near Point of Convergence Scores in High-School Athletes: Implications for Identifying Binocular Vision Dysfunction After Concussion Injury

OBJECTIVE

To identify normative near point of convergence (NPC) data for healthy high-school-aged athletes (13-19 years old) and determine the percentage of individuals with NPC scores that fall outside the currently accepted clinical cutoff value of 5 cm. Another objective was to determine the relationship between sex, concussion history, and attention deficit disorder/attention deficit hyperactivity disorder (ADD/ADHD) with NPC scores, if any.

DESIGN

Case series.

SETTING

High-school sports medicine clinic.

PATIENTS OR PARTICIPANTS

Near point of convergence was assessed in 718 high-school student athletes (141 females and 577 males) with an average age of 15.96 ± 1.16 years.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

An accommodation convergence ruler was used to measure NPC. Near point of convergence scores were repeated a total of 3 times and the mean used for all statistical analyses.

RESULTS

The NPC scores for all participants averaged 3.58 cm, and the intraclass correlation coefficient for the 3 repeated measurements was 0.956. Approximately 20% of mean NPC scores were above the accepted upper limit of 5 cm. Although a statistically significant effect for sex was identified, the difference between them was considered clinically insignificant. No relationship between NPC and history of concussion or ADD/ADHD was identified.

CONCLUSIONS

Results indicate that in high-school-aged subjects, approximately 20% of individuals may have NPC values that fall outside the current critical cutoff value and may lead to incorrect diagnosis of ocular dysfunction. In addition, NPC does not seem to be affected by the history of concussion or a diagnosis of ADD/ADHD.

Influence of concussion history and age of first concussion on visio-vestibular function

OBJECTIVES

To assess if abnormalities on visio-vestibular examination (VVE) are associated with concussion history (first vs. repeat) or age of first concussion in acutely concussed adolescents.

DESIGN

Cross-sectional.

METHODS

Data were queried from the Children's Hospital of Philadelphia Minds Matter concussion registry. Patients aged 14-18 years old presenting for their initial visit to the specialty care concussion program within 28 days of injury were included. Demographics, including age, sex, concussion history, and age of first concussion, were collected before the exam. The VVE consisted of 9 subtests: smooth pursuit, horizontal/vertical saccades and vestibulo-ocular reflex (VOR), binocular convergence, left/right monocular accommodation, and complex tandem gait. Primary outcomes included VVE subtests (normal/abnormal), and total VVE score (abnormal = 2+ abnormal subtests).

RESULTS

Among 1051 patients included (female = 604(57.5 %); age = 15.6 ± 1.2; median lifetime concussions = 1 [IQR = 1,3]), 518 had repeat concussion. Controlling for age and sex, first vs. repeat concussion was not associated with any VVE subtest or total score (Total VVE Score RR = 1.35, 99.5%CI = 0.70,2.61). Of those with repeat concussion, 190 had valid age of first concussion data. Controlling for age, sex, and number of lifetime concussions, age of first concussion was not significantly associated with any VVE subtest or total score (Total VVE Score RR = 1.11, 99.5%CI = 0.78,1.57).

CONCLUSIONS

Adolescents with concussion history present with similar visio-vestibular function to those with no concussion history. Additionally, clinical effects of early age of first concussion may not be evident in children. This study provides foundational data regarding potential cumulative effects of concussion in younger athletes.

The University of Kansas Health System Outpatient Clinical Concussion Comprehensive Protocol: An Interdisciplinary Approach

Objective:

The concussion team at The University of Kansas Health System outpatient rehabilitation spine center is comprised of experienced multi-disciplinary experts including physical therapists and a speech language pathologist. The team set forth with a purpose of creating and organizing an internal physical therapy clinical recommendation protocol for initial evaluations and subsequent treatments for the concussed patient. The aim of this paper is to share these recommendation protocols with other therapy teams and provide a foundational layout for treating the patient with post-concussion symptoms in an outpatient physical therapy clinical setting.

Study design:

Clinical recommendation protocol provides guidance for patients ages 10+ from initial evaluation through discharge with emphasis on evidence-based research in the areas of: oculomotor, cervical, vestibular, post-concussion migraine influence, mood disorders(such as anxiety and depression), exertion, and cognitive communicative dysfunction.

Results:

Finding a written, comprehensive clinical resource protocol for post-concussion outpatient evaluation(s) and treatment strategies can be difficult. This document serves as a resource for other outpatient concussion rehabilitation clinics, providing rationale, and objective measurement tools, for assessing and treating concussion patients. To the authors’ knowledge, no other research has produced a practical, efficient evaluation tool to be utilized at bed side, condensing evidence-based research into an easy-to-use form.

Conclusion:

The University of Kansas Health System outpatient concussion rehabilitation center developed clinical recommendation protocols for concussion care. The intent was to standardize assessment and treatment for concussion patients and to share these objective measurement tools and procedures, focused on a team approach of concussion providers, as a clinical outline for both the novice and seasoned clinician specializing in the field of concussion work in an outpatient rehabilitation setting.

Pathway of care for visual and vestibular rehabilitation after mild traumatic brain injury: a critical review

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.

Vision and Concussion: Symptoms, Signs, Evaluation, and Treatment

Visual symptoms are common after concussion in children and adolescents, making it essential for clinicians to understand how to screen, identify, and initiate clinical management of visual symptoms in pediatric patients after this common childhood injury. Although most children and adolescents with visual symptoms after concussion will recover on their own by 4 weeks, for a subset who do not have spontaneous recovery, referral to a specialist with experience in comprehensive concussion management (eg, sports medicine, neurology, neuropsychology, physiatry, ophthalmology, otorhinolaryngology) for additional assessment and treatment may be necessary. A vision-specific history and a thorough visual system examination are warranted, including an assessment of visual acuity, ocular alignment in all positions of gaze, smooth pursuit (visual tracking of a moving object), saccades (visual fixation shifting between stationary targets), vestibulo-ocular reflex (maintaining image focus during movement), near point of convergence (focusing with both eyes at near and accommodation (focusing with one eye at near because any of these functions may be disturbed after concussion. These deficits may contribute to difficulty with returning to both play and the learning setting at school, making the identification of these problems early after injury important for the clinician to provide relevant learning accommodations, such as larger font, preprinted notes, and temporary use of audio books. Early identification and appropriate management of visual symptoms, such as convergence insufficiency or accommodative insufficiency, may mitigate the negative effects of concussion on children and adolescents and their quality of life.

Eye Tracking Metrics Differences among Uninjured Adolescents and Those with Acute or Persistent Post-Concussion Symptoms

SIGNIFICANCE

Eye tracking assessments that include pupil metrics can supplement current clinical assessments of vision and autonomic dysfunction in concussed adolescents.

PURPOSE

This study aimed to explore the utility of a 220-second eye tracking assessment in distinguishing eye position, saccadic movement, and pupillary dynamics among uninjured adolescents, those with acute post-concussion symptoms (≤28 days since concussion), or those with persistent post-concussion symptoms (>28 days since concussion).

METHODS

Two hundred fifty-six eye tracking metrics across a prospective observational cohort of 180 uninjured adolescents recruited from a private suburban high school and 224 concussed adolescents, with acute or persistent symptoms, recruited from a tertiary care subspecialty concussion care program, 13 to 17 years old, from August 2017 to June 2021 were compared. Kruskal-Wallis tests were used, and Bonferroni corrections were applied to account for multiple comparisons and constructed receiver operating characteristic curves. Principal components analysis and regression models were applied to determine whether eye tracking metrics can augment clinical and demographic information in differentiating uninjured controls from concussed adolescents.

RESULTS

Two metrics of eye position were worse in those with concussion than uninjured adolescents, and only one metric was significantly different between acute cases and persistent cases. Concussed adolescents had larger left and right mean, median, minimum, and maximum pupil size than uninjured controls. Concussed adolescents had greater differences in mean, median, and variance of left and right pupil size. Twelve metrics distinguished female concussed participants from uninjured; only four were associated with concussion status in males. A logistic regression model including clinical and demographics data and transformed eye tracking metrics performed better in predicting concussion status than clinical and demographics data alone.

CONCLUSIONS

Objective eye tracking technology is capable of quickly identifying vision and pupillary disturbances after concussion, augmenting traditional clinical concussion assessments. These metrics may add to existing clinical practice for monitoring recovery in a heterogeneous adolescent concussion population.

Characterizing the evolution of oculomotor and vestibulo-ocular function over time in children and adolescents after a mild traumatic brain injury

Background

Impairments to oculomotor (OM) and vestibulo-ocular reflex (VOR) function following pediatric mTBI have been demonstrated but are poorly understood. Such impairments can be associated with more negative prognosis, affecting physical and mental wellbeing, emphasizing the need to more fully understand how these evolve.

Objectives

to determine i) the extent to which performance on clinical and computerized tests of OM and VOR function varies over time in children and adolescents at 21 days, 3-, and 6-months post-mTBI; ii) the proportion of children and adolescents with mTBI presenting with abnormal scores on these tests at each timepoint.

Design

Prospective longitudinal design.

Setting

Tertiary care pediatric hospital.

Participants

36 participants with mTBI aged 6 to18.

Procedures

Participants were assessed on a battery of OM and VOR tests within 21 days, at 3- and 6-months post injury.

Outcome measures

Clinical measures: Vestibular/ocular motor screening tool (VOMS) (symptom provocation and performance); Computerized measures: reflexive saccade test (response latency), video head impulse test (VOR gain), and dynamic visual acuity test (LogMAR change).

Analysis

Generalized estimating equations (parameter estimates and odd ratios) estimated the effect of time. Proportions above and below normal cut-off values were determined.

Results

Our sample consisted of 52.8% females [mean age 13.98 (2.4) years, assessed on average 19.07 (8–33) days post-injury]. Older children performed better on visual motion sensitivity (OR 1.43, p = 0.03) and female participants worse on near point of convergence (OR 0.19, p = 0.03). Change over time (toward recovery) was demonstrated by VOMS overall symptom provocation (OR 9.90, p = 0.012), vertical smooth pursuit (OR 4.04, p = 0.03), voluntary saccade performance (OR 6.06, p = 0.005) and right VOR gain (0.068, p = 0.013). Version performance and VOR symptom provocation showed high abnormal proportions at initial assessment.

Discussion

Results indicate impairments to the VOR pathway may be present and driving symptom provocation. Vertical smooth pursuit and saccade findings underline the need to include these tasks in test batteries to comprehensively assess the integrity of OM and vestibular systems post-mTBI.

Implications

Findings demonstrate 1) added value in including symptom and performance-based measures in when OM and VOR assessments; 2) the relative stability of constructs measured beyond 3 months post mTBI.

Montreal Brain Injury Vision Screening Test for General Practitioners

Visual disturbances are amongst the most commonly reported symptoms after a traumatic brain injury (TBI) despite vision testing being uncommon at initial clinical evaluation. TBI patients consistently present a wide range of visual complaints, including photophobia, double vision, blurred vision, and loss of vision which can detrimentally affect reading abilities, postural balance, and mobility. In most cases, especially in rural areas, visual disturbances of TBI would have to be diagnosed and assessed by primary care physicians, who lack the specialized training of optometry. Given that TBI patients have a restricted set of visual concerns, an opportunity exists to develop a screening protocol for specialized evaluation by optometrists—one that a primary care physician could comfortably carry out and do so in a short time. Here, we designed a quick screening protocol that assesses the presence of core visual symptoms present post-TBI. The MOBIVIS (Montreal Brain Injury Vision Screening) protocol takes on average 5 min to perform and is composed of only “high-yield” tests that could be performed in the context of a primary care practice and questions most likely to reveal symptoms needing further vision care management. The composition of our proposed protocol and questionnaire are explained and discussed in light of existing protocols. Its potential impact and ability to shape a better collaboration and an integrative approach in the management of mild TBI (mTBI) patients is also discussed.

Visio-Vestibular Deficits in Healthy Child and Adolescent Athletes

OBJECTIVE

To determine the relationship between patient characteristics and performance on the visio-vestibular examination (VVE) in a cohort of healthy youth athletes and explore the potential association between the VVE and other standardized concussion batteries.

DESIGN

Cross-sectional.

SETTING

Suburban middle and high school.

PATIENTS

One hundred ninety subjects age 11 to 18 enrolled before their respective scholastic sport season between August 2017 and March 2020.

ASSESSMENT OF INDEPENDENT VARIABLES

Patient age, sex, concussion history, comorbidities, hours of weekly exercise, Sport Concussion Assessment Tool, 5th edition (SCAT-5), King-Devick (K-D), Postconcussion Symptom Inventory (PCSI).

MAIN OUTCOME MEASURES

Visio-vestibular examination abnormalities (smooth pursuit, horizontal and vertical saccades, horizontal and vertical gaze stability, convergence, right and left monocular accommodation, complex tandem gait).

RESULTS

Overall, 29.5% of subjects had at least one of 9 VVE elements abnormal, 7.9% at least 2, and 3.2% at least 3. None of 72 comparisons of the VVE elements, when stratified by age, sex, concussion history, history of headaches, attention deficit hyperactivity disorder, learning issues, psychiatric problems, motion sickness, or weekly hours of exercise, reached significance using the Benjamini-Hochberg procedure at a false discovery rate of 5%. There were no significant associations between VVE elements and the SCAT-5, K-D, or PCSI.

CONCLUSIONS

The VVE is robust across multiple patient characteristics. Although healthy subjects may have one abnormal element, multiple abnormal elements are a less common feature, making multiple abnormal elements more indicative of concussion, highlighting the use of this assessment in the setting of injury. The VVE tests unique domains when compared with the PCSI, SCAT-5, and K-D.

Pediatric Sports-Related Concussion: An Approach to Care

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.

Eye Movements in Mild Traumatic Brain Injury: Ocular Biomarkers

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.

OculoMotor Assessment Tool: Children Compared with Adults

PURPOSE

To provide additional normative data for the OculoMotor Assessment Tool (OMAT) for horizontal and vertical saccades and vergence jumps and to compare the results of children to adults.

METHODS

Participants with visual acuity of logMAR ≥0.0 (6/6) and Randot stereopsis of at least 250 sec of arc without binocular disorders were recruited. Horizontal and vertical saccades, near point of convergence (NPC), accommodation and vergence jumps were evaluated using the OMAT. Means and standard deviations were reported for all parameters in children and adults.

RESULTS

A total of 52 participants (ages 9-34, mean age 17.5 ± 7.2 years) participated in this study. Statistically significant differences were found for horizontal and vertical saccades with lower mean results in children, aged 9-18 (111.5 ± 20.9 and 112.5 ± 22.7, respectively) compared to adults, aged 19-34 (131.6 ± 23.9 and 126.2 ± 24.2, respectively) (P = 0.002 and 0.04, respectively). The mean of the last 30 seconds of both horizontal and vertical saccades were statistically significantly lower in the children's group (52.5 ± 10.6 and 52.1 ± 11.3, respectively) compared to the adults (63.2 ± 10.2 and 59.3 ± 13.4, respectively) (P = 0.001 and 0.04, respectively). The normative values for horizontal and vertical saccades were 119.6 ± 23.9 and 118.1 ± 24.1 saccades per minute, respectively. NPC break and recovery were 2.3 ± 2.3cm and 3.0 ± 3.3cm, respectively. The vergence jumps assessment was 79.3 ± 21.19 movements per minute.

CONCLUSION

Normative values for the OMAT test were found in this study for children and adults. Assessment of endurance found children norms significantly lower for horizontal and vertical saccades compared to adults.

Vestibulo-ocular dysfunction in mTBI: Utility of the VOMS for evaluation and management – A review

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.

Post-traumatic headaches and vision: A review

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.

Neuro-Visual and Vestibular Manifestations of Concussion and Mild TBI

PURPOSE OF REVIEW

Mild traumatic brain injury, or concussion, is a major cause of disability. Vestibular and visual dysfunction following concussion is common and can negatively affect patients' well-being and prolong recovery. Etiologies of visual and vestibular symptoms are numerous, including ocular, neuro-ophthalmic, otologic, and neuro-vestibular conditions. Some etiologies are benign and may be treatable, while others are potentially vision or life-threatening, making a focused history and examination essential. This review offers an approach to the evaluation and treatment of the most common neuro-visual and vestibular impairments that may result from concussion.

RECENT FINDINGS

Treatment of concussion including exercise, computerized programs, transcranial magnetic stimulation, gene therapy, stem cell therapy, and nanoparticles has shown promise. Many novel therapies are in the pipework for visual and vestibular recovery after concussion; however, the treatment mainstay remains therapy and evaluation for co-existing diseases.

Assessment of Saccades and Gaze Stability in the Diagnosis of Pediatric Concussion

OBJECTIVE

To evaluate the discriminatory ability of different repetition increments of saccades and gaze stability testing for diagnosing concussion in adolescents.

DESIGN

Cross-sectional.

SETTING

Suburban high school and academic pediatric tertiary care center.

PARTICIPANTS

Sixty-nine adolescent athletes within 28 days of a sports- or recreation-related concussion and 69 adolescent athletes without recent concussion.

ASSESSMENT OF INDEPENDENT VARIABLES

Symptom provocation with horizontal and vertical saccades and gaze stability testing performed up to 30 repetitions.

MAIN OUTCOME MEASURES

Sensitivity and specificity at 10-repetition increments (≤10, ≤20, ≤30) and area under the receiver operating characteristic curves (AUC) of a visio-vestibular examination (VVE) subscore, scored 0 to 4 based on the number of assessments with symptom provocation, at each repetition increment.

RESULTS

Sensitivity improved when increasing from ≤10 to ≤20 to ≤30 repetitions for horizontal (25% to 50% to 69%) and vertical (32% to 52% to 74%) saccades and horizontal (19% to 45% to 71%) and vertical (23% to 45% to 72%) gaze stability. Specificity was comparable at ≤10 and ≤20 repetitions, but decreased at ≤30 repetitions across assessments. For a VVE subscore (0-4) based on the number of symptomatic assessments, the discriminatory ability of the test was highest at ≤20 repetitions (AUC of 0.79) with an optimal subscore of one (sensitivity 59%, specificity 96%).

CONCLUSIONS

A VVE including a higher threshold level of repetitions for saccades and gaze stability has improved discriminatory ability for concussion, with an optimized AUC of 0.79 at ≤20 repetitions.

CLINICAL RELEVANCE

The findings in this study suggest that a higher threshold level of repetitions of 2 commonly used visio-vestibular assessments enables clinicians to more accurately diagnose youth concussion.

Specialty-Specific Diagnoses in Pediatric Patients With Postconcussion Syndrome: Experience From a Multidisciplinary Concussion Clinic

OBJECTIVE

To describe the collaborative findings across a broad array of subspecialties in children and adolescents with postconcussion syndrome (PCS) in a pediatric multidisciplinary concussion clinic (MDCC) setting.

DESIGN

Retrospective analysis.

SETTING

Multidisciplinary concussion clinic at a pediatric tertiary-level hospital.

PATIENTS

Fifty-seven patients seen in MDCC for evaluation and management of PCS between June 2014 and January 2016.

INTERVENTIONS

Clinical evaluation by neurology, sports medicine, otolaryngology, optometry, ophthalmology, physical therapy, and psychology.

MAIN OUTCOME MEASURES

Specialty-specific clinical findings and specific, treatable diagnoses relevant to PCS symptoms.

RESULTS

A wide variety of treatable, specialty-specific diagnoses were identified as potential contributing factors to patients' postconcussion symptoms. The most common treatable diagnoses included binocular vision dysfunction (76%), anxiety, (57.7%), depression (44.2%), new or change in refractive error (21.7%), myofascial pain syndrome (19.2%), and benign paroxysmal positional vertigo (17.5%).

CONCLUSIONS

Patients seen in a MDCC setting receive a high number of treatable diagnoses that are potentially related to patients' PCS symptoms. The MDCC approach may (1) increase access to interventions for PCS-related impairments, such as visual rehabilitation, physical therapy, and psychological counseling; (2) provide patients with coordinated medical care across specialties; and (3) hasten recovery from PCS.

Learning and Attention Deficit/Hyperactivity Disorders as Risk Factors for Prolonged Concussion Recovery in Children and Adolescents

OBJECTIVE

Examine pre-existing learning disorders (LD) and attention deficit/hyperactivity disorders (ADHD) as risk factors for prolonged recovery and increased symptomology following pediatric mild traumatic brain injury (mTBI).

METHODS

We conducted a retrospective cohort study of children/adolescents (5-17 years) with mTBI who presented to a Children's Minnesota Concussion Clinic between April 2018 and March 2019. Differences across strata of pre-existing conditions (present vs. absent) in time to recovery measures were estimated via Kaplan-Meier and Cox proportional hazards analyses and differences in symptom trajectories were examined via linear mixed-effects regression models. Regression models were adjusted for age, sex and other confounders.

RESULTS

In our cohort of 680 mTBI patients, those with LD (n = 70) or ADHD (n = 107) experienced significantly longer median durations of symptoms (58 and 68 days, respectively) than those without (43 days). Accordingly, LD was significantly associated with delayed symptom recovery (adjusted hazard ratio (aHR) = 1.63, 95% CI: 1.16-2.29), return to school (1.47, 1.08-2.00), and return to physical activity (1.50, 1.10-2.04). Likewise, ADHD was associated with delayed recovery (1.69, 1.28-2.23), return to school (1.52, 1.17-1.97) and physical activity (1.55, 1.19-2.01). Further, patients with LD or ADHD reported, on average, significantly more concussion symptoms and higher vision symptom scores throughout recovery versus those without. There was no evidence that concussion or vision symptom recovery trajectories varied over time between those with/without LD or ADHD (joint P-interactions > 0.05).

CONCLUSION

Pre-existing LD and ADHD are risk factors for prolonged and more symptomatic mTBI recovery in youth. These results can inform clinical concussion management and recovery expectations.

Vestibular/Ocular Motor Screening is Independently Associated With Concussion Symptom Severity in Youths

OBJECTIVE

To examine the independent contributions of the Vestibular/Ocular Motor Screening (VOMS) to concussion symptom severity in youths while controlling for computerized neurocognitive screening performance, demographics, and medical history.

STUDY DESIGN

Cross-sectional.

SETTING

Concussion specialty clinic.

PARTICIPANTS

A retrospective review of 278 concussed youths clinical charts resulted in a total of 158 participants (16.5 ± 2.8 years, 46.8% women, 4.3 ± 3.3 days post-injury) when exclusionary criteria (ie, neurological or substance use disorders, age >21, >14 days since injury, and missing/incomplete data) were applied.

INDEPENDENT VARIABLES

Vestibular/Ocular Motor Screening items and computerized neurocognitive test scores.

MAIN OUTCOME MEASURES

Standardized postconcussion symptom scale scores.

RESULTS

At the univariate level, all VOMS items were positively associated with concussion symptom severity at small to medium effect sizes (r range 0.26-0.42). Women and individuals with a concussion history and/or Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder diagnosis reported higher VOMS item scores (Ps < 0.10). In a multiple hierarchical regression, the contribution of VOMS item scores was significant and explained 9.6% of the variance in concussion symptom severity after adjustment for sex, baseline VOMS symptom ratings, and ImPACT scores [F(6, 141) = 3.90, P = 0.001]. Vertical saccades (b = 2.22, P = 0.003) and vertical vestibulo-ocular reflex (VOR; b = -1.46, P = 0.004) VOMS items significantly contributed to concussion symptom severity in the multivariable model.

CONCLUSIONS

Findings from this study provide support for the independent contributions of the VOMS items, particularly vertical saccades and vertical VOR, to acute concussion symptom severity in youths. Further work is warranted for a comparison of the VOMS to the full gold standard of concussion testing (ie, clinical interview, physical examination, balance testing, and neurocognitive assessment).