A Positive Vestibular/Ocular Motor Screening (VOMS) Is Associated With Increased Recovery Time After Sports-Related Concussion in Youth and Adolescent Athletes

Cervical spine proprioception and vestibular/oculomotor function: An observational study comparing young adults with and without a concussion history

OBJECTIVE

To investigate dizziness, vestibular/oculomotor symptoms, and cervical spine proprioception among adults with/without a concussion history.

METHODS

Adults ages 18-40 years with/without a concussion history completed: dizziness handicap inventory (DHI), visio-vestibular exam (VVE), and head repositioning accuracy (HRA, assesses cervical spine proprioception). Linear regression models were used to assess relationships between (1) concussion/no concussion history group and VVE, HRA, and DHI, and (2) DHI with HRA and VVE for the concussion history group.

RESULTS

We enrolled 42 participants with concussion history (age = 26.5 ± 4.5 years, 79% female, mean = 1.4± 0.8 years post-concussion) and 46 without (age = 27.0± 3.8 years, 74% female). Concussion history was associated with worse HRA (β = 1.23, 95% confidence interval [CI]: 0.77, 1.68; p < 0.001), more positive VVE subtests (β = 3.01, 95%CI: 2.32, 3.70; p < 0.001), and higher DHI scores (β = 9.79, 95%CI: 6.27, 13.32; p < 0.001) after covariate adjustment. For the concussion history group, number of positive VVE subtests was significantly associated with DHI score (β = 3.78, 95%CI: 2.30, 5.26; p < 0.001) after covariate adjustment, while HRA error was not (β = 1.10, 95%CI: -2.32, 4.51; p = 0.52).

CONCLUSIONS

Vestibular/oculomotor symptom provocation and cervical spine proprioception impairments may persist chronically (i.e., 3 years) after concussion. Assessing dizziness, vestibular/oculomotor and cervical spine function after concussion may inform patient-specific treatments to address ongoing dysfunction.

Relationships between vestibular issues, noise sensitivity, anxiety and prolonged recovery from mild traumatic brain injury among adults: a scoping review

BACKGROUND

We investigated the extent of literature and findings on relationships between vestibular issues, noise sensitivity (NS), and anxiety. We were interested in how relationships among these factors impacted adults' recovery three months or more after mild traumatic brain injury (mTBI).

METHODS

We conducted a scoping review to evaluate the extent of evidence linking relationships between vestibular issues, NS and anxiety with recovery after mTBI. Data relating to study characteristics and key findings were extracted and used to inform a critical narrative synthesis of findings.

RESULTS

After screening and full-text review, we included two studies. Both studies considered the combination of vestibular issues, NS and anxiety and mTBI recovery. Vestibular issues, NS and anxiety were all significantly associated with one another and their presence was the strongest indicator that symptoms would extend beyond three-months after mTBI.

CONCLUSION

Few studies have focused on the relationships that vestibular issues, NS and anxiety have with one another and recovery after mTBI. Given the apparent strong relationships between these factors and prolonged recovery, we highlight this as an area warranting further investigation.

A treadmill running research protocol to assess dynamic visual acuity and balance for athletes with and without recent concussion history

Athletes interpret dynamic visual scenes quickly and accurately during physical exertion. It is important to understand how increased exertion may impact vision and cognition following sport-related concussion (SRC).Purpose To examine the effect of a treadmill running research protocol on the assessment of dynamic visual acuity (DVA) and balance for athletes with and without recent history of SRC.Methods Varsity athletes following recent SRC (CONC=12) were compared to athletes without SRC (ATHLETE=19). The DVA task presented a Tumbling 'E' target in four possible orientations during random walk (RW) or horizontal (H) motion at a speed of 30°/s. Participants performed DVA trials standing on a force plate (1000Hz) at four time points: 1) pre-exercise (PRE-EX), 2) immediately (POST1), 3) 10-minutes (POST10), and 4) 20-minutes post- exercise (POST20). Performance was calculated as a change in DVA score from PRE-EX and median response time (RT, ms). Balance control was analyzed using the root mean square of centre of pressure displacement (dCOP).Results Both groups maintained DVA scores for both motion types and exhibited immediate exercise-induced benefits on RT. Both groups had similar change in balance control strategy following treadmill exercise.Conclusion Both groups elicited similar exercise-induced benefits on DVA following exercise. A repeated measures assessment following vigorous exercise may provide meaningful insights about visual and neurocognitive functions for athletes returning to sport following concussion.

The Association Among Clinical Profiles, Modifiers, and Prolonged Recovery in Adolescents With Sport-Related Concussion

OBJECTIVE

The purposes were to (1) describe the prevalence of clinical profiles and modifiers, (2) examine the association between clinical profiles and prolonged recovery, and (3) examine the interaction between clinical profiles and modifiers and prolonged recovery in adolescents with sport-related concussion (SRC).

DESIGN

Retrospective, cross-sectional.

SETTING

Interdisciplinary specialty sports concussion clinic.

PATIENTS

Patients (n = 299) aged 12 to 19 years who were diagnosed with SRC within 30 days of injury.

INDEPENDENT VARIABLES

Clinical profiles and modifiers were decided by the clinical judgment of the clinical neuropsychologist and sports medicine physician, using data from the Clinical Profile Screen and information gathered from the clinical interview, neurocognitive, and vestibular and ocular motor testing.

MAIN OUTCOME MEASURES

Prolonged recovery was defined as ≥28 days from the date of injury to the date of clearance.

RESULTS

The most common clinical profiles were migraine (34.8%) and cognitive-fatigue (23.4%). There were no significant relationships between clinical profiles and prolonged recovery (Wald = 5.89, df = 4, P = 0.21). The presence of a modifier did not significantly affect the relationship between clinical profiles and prolonged recovery ( = 6.5, df = 5, P = 0.26). The presence of any modifier yielded a 10-day increase in median recovery time within the cognitive/fatigue clinical profile (Wilcoxon rank-sum = 268.5, P = 0.01).

CONCLUSIONS

Although patients with a clinical profile and modifier may not experience prolonged recovery, they may experience longer recovery time than patients with a clinical profile and no modifier.

Headache in Children and Adolescents

OBJECTIVE

This article reviews the assessment of children and adolescents presenting with headache, provides an overview of primary headache disorders, and reviews evidence-based management of headache in this age group.

LATEST DEVELOPMENTS

In the last few years, new epidemiological data have shed light on less common pediatric headache disorders (eg, pediatric trigeminal autonomic cephalalgias) and psychosocial risk factors associated with primary headache disorders in children and adolescents. There has also recently been a substantial increase in interventions that target the calcitonin gene-related peptide pathway and that treat primary headache disorders using noninvasive neuromodulation. Although these interventions have primarily been studied in adults, there is emerging evidence of their use in the pediatric population.

ESSENTIAL POINTS

Primary headache disorders are very common in youth, and the most commonly encountered headache diagnosis in neurology practice is migraine, which affects approximately 10% of children and adolescents. Diagnosing and effectively treating primary headache disorders before adulthood may have a sustained impact on the patient by improving long-term headache and mental health outcomes, thereby significantly reducing the burden of disability over time. There are several available and emerging acute and preventive interventions for youth with primary headache disorders, and treatment decisions should be made in the context of available evidence using a shared decision-making approach.

Optimizing the Combination of Common Clinical Concussion Batteries to Predict Persistent Postconcussion Symptoms in a Prospective Cohort of Concussed Youth

BACKGROUND

Studies have evaluated individual factors associated with persistent postconcussion symptoms (PPCS) in youth concussion, but no study has combined individual elements of common concussion batteries with patient characteristics, comorbidities, and visio-vestibular deficits in assessing an optimal model to predict PPCS.

PURPOSE

To determine the combination of elements from 4 commonly used clinical concussion batteries and known patient characteristics and comorbid risk factors that maximize the ability to predict PPCS.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

We enrolled 198 concussed participants-87 developed PPCS and 111 did not-aged 8 to 19 years assessed within 14 days of injury from a suburban high school and the concussion program of a tertiary care academic medical center. We defined PPCS as a Post-Concussion Symptom Inventory (PCSI) score at 28 days from injury of ≥3 points compared with the preinjury PCSI score-scaled for younger children. Predictors included the individual elements of the visio-vestibular examination (VVE), Sport Concussion Assessment Tool, 5th Edition (SCAT-5), King-Devick test, and PCSI, in addition to age, sex, concussion history, and migraine headache history. The individual elements of these tests were grouped into interpretable factors using sparse principal component analysis. The 12 resultant factors were combined into a logistic regression and ranked by frequency of inclusion into the combined optimal model, whose predictive performance was compared with the VVE, initial PCSI, and the current existing predictive model (the Predicting and Prevention Postconcussive Problems in Pediatrics (5P) prediction rule) using the area under the receiver operating characteristic curve (AUC).

RESULTS

A cluster of 2 factors (SCAT-5/PCSI symptoms and VVE near point of convergence/accommodation) emerged. A model fit with these factors had an AUC of 0.805 (95% CI, 0.661-0.929). This was a higher AUC point estimate, with overlapping 95% CIs, compared with the PCSI (AUC, 0.773 [95% CI, 0.617-0.912]), VVE (AUC, 0.736 [95% CI, 0.569-0.878]), and 5P Prediction Rule (AUC, 0.728 [95% CI, 0.554-0.870]).

CONCLUSION

Among commonly used clinical assessments for youth concussion, a combination of symptom burden and the vision component of the VVE has the potential to augment predictive power for PPCS over either current risk models or individual batteries.

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.

Multidomain Predictors of Protracted Recovery following Concussion among 5- to 9-Year-Old Patients: A Preliminary Study

OBJECTIVE

To determine which components from a multidomain assessment best predict protracted recovery in pediatric patients with a concussion.

STUDY DESIGN

A prospective cohort of patients aged 5-9 years who presented within 21 days of concussion to a specialty clinic were categorized into normal (≤30 days) and protracted (>30 days) recovery. Participants provided demographic and medical history information, and completed the Child Sport Concussion Assessment Tool-5 symptom report and balance assessment, the Vestibular/Ocular Motor Screen-Child (VOMS-C), and the Pediatric Immediate Post-concussion Assessment and Cognitive Testing. Univariate logistic regressions (LR) were used to inform a follow-up forward stepwise LR to identify the best predictors of protracted recovery. Receiver operating characteristic analysis of the area under the curve (AUC) was used to identify which predictors retained from the LR model best discriminated recovery.

RESULTS

The final sample included 68 patients (7.52 ± 2.3 years; 56% male), 36 (52.9%) with normal and 32 (47.1%) with protracted recovery. Results of the LR to identify protracted recovery were significant (P < .001) and accounted for 39% of the variance. The model accurately classified 78% of patients, with days to first clinic visit (OR, 1.2; 95% CI, 1.1-1.4; P = .003) and positive VOMS-C findings (OR, 8.32; 95% CI, 2.4-28.8; P < .001) as significant predictors. A receiver operating characteristic analysis of the AUC of this 2-factor model discriminated protracted from normal recovery (AUC, 0.82; 95% CI, 0.71-0.92; P < .001).

CONCLUSIONS

Days to first clinic visit and positive findings on the VOMS-C were the most robust predictors of protracted recovery after concussion in young pediatric patients.

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.

Translation and validation of a Swedish version of the Visual Vertigo Analogue Scale

PURPOSE

The present study aimed to construct and validate a Swedish translation (VVAS-S) of the Visual Vertigo Analogue Scale (VVAS).

MATERIALS AND METHODS

The original English VVAS was translated into Swedish by the two authors and back-translated by an independent professional translator. Pilot-tests were performed on two healthy participants and five patients suffering from Visually Induced Dizziness (VID). The translation was deemed understandable by all subjects. Twenty-one patients with VID were recruited to complete the VVAS-S, once in-lab and once at home after 2-3 weeks. Cronbach's alpha, inter-item consistency and internal consistency were calculated.

RESULTS

Test-retest values were reliably strong across all items. Cronbach's alpha was 0.843, which is considered to represent very-high reliability. The corrected-item total-correlation was above 0.3 for all items, meaning they were appropriately associated with one-another. Fourteen out of 36 inter-item correlation interactions were within the 0.2-0.4 range.

CONCLUSIONS

The VVAS-S was found to be comparable to the original VVAS in terms of internal reliability. The translation was perceived as easy to implement by all participants and can be considered ready for clinical use in a Swedish-speaking setting. Item-specific correlations may be valuable for developing future vertigo questionnaires.Key messagesThe Swedish version of the Visual Vertigo Analogue Scale is a questionnaire suitable for evaluating visually induced dizziness in a Swedish population. This study found that the Swedish questionnaire was comparable to the original in terms of internal consistency. The Swedish Visual vertigo Analogue Scale can be found as an appendix to this article.

Visuo-vestibular and cognitive connections of the vestibular neuromatrix are conserved across age and injury populations

BACKGROUND AND PURPOSE

Given the prevalence of vestibular dysfunction in pediatric concussion, there is a need to better understand pathophysiological disruptions within vestibular and associated cognitive, affective, and sensory-integrative networks. Although current research leverages established intrinsic connectivity networks, these are nonspecific for vestibular function, suggesting that a pathologically guided approach is warranted. The purpose of this study was to evaluate the generalizability of the previously identified "vestibular neuromatrix" in adults with and without postconcussive vestibular dysfunction to young athletes aged 14-17.

METHODS

This retrospective study leveraged resting-state functional MRI data from two sites. Site A included adults with diagnosed postconcussive vestibular impairment and healthy adult controls and Site B consisted of young athletes with preseason, postconcussion, and postseason time points (prospective longitudinal data). Adjacency matrices were generated from preprocessed resting-state data from each sample and assessed for overlap and network structure in MATLAB.

RESULTS

Analyses indicated the presence of a conserved "core" network of vestibular regions as well as areas subserving visual, spatial, and attentional processing. Other vestibular connections were also conserved across samples but were not linked to the "core" subnetwork by regions of interest included in this study.

CONCLUSIONS

Our results suggest that connections between central vestibular, visuospatial, and known intrinsic connectivity networks are conserved across adult and pediatric participants with and without concussion, evincing the significance of this expanded, vestibular-associated network. Our findings thus support this network as a workable model for investigation in future studies of dysfunction in young athlete populations.

When should an athlete retire or discontinue participating in contact or collision sports following sport-related concussion? A systematic review

OBJECTIVE

To systematically review the scientific literature regarding factors to consider when providing advice or guidance to athletes about retirement from contact or collision sport following sport-related concussion (SRC), and to define contraindications to children/adolescent athletes entering or continuing with contact or collision sports after SRC.

DATA SOURCES

Medline, Embase, SPORTSDiscus, APA PsycINFO, CINAHL and Cochrane Central Register of Controlled Trials were searched systematically.

STUDY ELIGIBILITY CRITERIA

Studies were included if they were (1) original research, (2) reported on SRC as the primary source of injury, (3) evaluated the history, clinical assessment and/or investigation of findings that may preclude participation in sport and (4) evaluated mood disturbance and/or neurocognitive deficits, evidence of structural brain injury or risk factors for increased risk of subsequent SRC or prolonged recovery.

RESULTS

Of 4355 articles identified, 93 met the inclusion criteria. None of the included articles directly examined retirement and/or discontinuation from contact or collision sport. Included studies examined factors associated with increased risk of recurrent SRC or prolonged recovery following SRC. In general, these were low-quality cohort studies with heterogeneous results and moderate risk of bias. Higher number and/or severity of symptoms at presentation, sleep disturbance and symptom reproduction with Vestibular Ocular Motor Screen testing were associated with prolonged recovery and history of previous concussion was associated with a risk of further SRC.

CONCLUSION

No evidence was identified to support the inclusion of any patient-specific, injury-specific or other factors (eg, imaging findings) as absolute indications for retirement or discontinued participation in contact or collision sport following SRC.

PROSPERO REGISTRATION NUMBER

CRD42022155121.

Early Initiation of Vestibular Therapy Following Sports-Related Concussions: A Retrospective Cohort Study

BACKGROUND

Vestibular dysfunction is common following sports-related concussions (SRC). Within the current practice, it is theorized that patients with vestibular dysfunction as sequelae of sports-related concussion have a prolonged recovery time compared to those without vestibular dysfunction.

STUDY METHOD

 A retrospective, cohort investigation of 282 subjects with sports-related concussions with vestibular dysfunction was conducted at The Sports Medicine Concussion Clinic, Duke University. The primary endpoint was the return-to-play (RTP) date.

RESULTS

For every one-day increase in time from injury to initial vestibular therapy, the geometric mean time from injury to RTP increases by 1.02 days (exp{β}=1.02 days; 95% CI: 1.01, 1.02 days; p<0.001).

CONCLUSION

 Our data suggest an association between the timing of vestibular therapy in SRC and a direct relationship to earlier recovery and return to sport.

Combined Neurocognitive and Exercise Tolerance Testing Improves Objectivity of Buffalo Concussion Treadmill Test

CONTEXT

The Buffalo Concussion Treadmill Test (BCTT) is a standard assessment of exercise tolerance utilized for exercise prescription following concussion and to inform decisions regarding return to play. One limitation of the BCTT is that interpretation of test results is dependent on individuals' self-report of symptom exacerbation with exertion. Symptoms following concussion are significantly underreported or unreported. Combining objective neurocognitive assessment with exercise tolerance testing may enable clinicians to objectively identify those requiring further assessment or rehabilitation before return to play. The purpose of this study was to investigate how performance on a neurocognitive assessment battery is affected by provocative exercise testing.

DESIGN

Prospective cohort study, pretest/posttest.

METHODS

A total of 30 participants included 13 women (43.3%), age 23.4 (1.93) years, height 173.56 (10) cm, weight 77.35 (16.3) kg, and 11 (36.7%) with history of concussion. All participants completed a neurocognitive assessment battery, including the Stroop Test and standardized assessments of working memory, attention, and information processing speed/accuracy in single-task (seated position) and dual-task conditions (walking on a treadmill at 2.0 miles per hour). The neurocognitive assessment battery was performed at baseline and after the standard BCTT test protocol.

RESULTS

BCTT: Average percentage of heart rate maximum (%HRmax) = 93.97% (4.8%); average maximum rating of perceived exertion = 18.6 (1.5). Time-based performance in single-task and dual-task conditions significantly improved from baseline (P < .05) following maximal exercise testing on the BCTT for the following neurocognitive assessments: concentration-reverse digits, Stroop congruent, and Stroop incongruent.

CONCLUSIONS

Healthy participants demonstrated improvements across multiple domains of neurocognitive performance following the exercise tolerance testing on the BCTT. Understanding normal responses in neurocognitive performance for healthy individuals following exercise tolerance testing may allow clinicians to more objectively monitor the trajectory of recovery following sports-related concussion.

Adults are not older adolescents: comparing physical therapy findings among adolescents, young adults and older adults with persistent post-concussive symptoms

OBJECTIVE

Individuals with persistent post-concussive symptoms (PPCS) may present with a myriad of physical symptoms. There is limited research available comparing the presence of examination findings among individuals with PPCS from different age groups.

METHODS

Retrospective case-control chart review of 481 patients with PPCS and 271 non-trauma controls. Physical assessments were categorized as ocular, cervical, and vestibular/balance. Differences in presentation were compared between PPCS and controls as well as between individuals with PPCS in three age groups: adolescents, young adults, and older adults.

RESULTS

All three PPCS groups had more abnormal oculomotor findings than their age-matched counterparts. When comparing PPCS patients from different age groups, no differences were seen in prevalence of abnormal smooth pursuits or saccades; however, adolescents with PPCS had more abnormal cervical findings and a lower prevalence of abnormal NPC, vestibular and balance findings.

CONCLUSION

Patients with PPCS presented with a different constellation of clinical findings based on their age. Adolescents were more likely to demonstrate evidence of cervical injury compared to younger and older adults, and adults were more likely to present with vestibular findings and impaired NPC. Adults with PPCS were more likely to present with abnormal oculomotor findings compared to adults with non-traumatic causes of dizziness.

Concussed patients with visually induced dizziness exhibit increased ocular torsion and vertical vergence during optokinetic gaze-stabilization

Visually Induced Dizziness (VID) is a common post-concussion sequalae that remains poorly understood and difficult to quantify. The present study aims to identify biomarkers for VID in the form of gaze-stabilizing eye movements. Nine patients with post-commotio VID and nine age-matched healthy controls were recruited by physiotherapists at a local neurorehabilitation centre. Torsional and vergence eye movements were recorded while participants viewed a series of optokinetic rotations where the central- and peripheral regions moved coherently, incoherently, or semi-randomly. Results showed that vergence and torsional velocities were increased in VID patients, reflecting increased oculomotor gain to visual motion, and that responses correlated with symptom severity. Coherent stimulation produced fastest torsional slow-phases across all participants; when faced with confliction directional information, eye movements tended to follow the direction of the central visual field, albeit at slower velocities than during coherent motion, meaning that while torsion was sensitive to visual content of the entire visual field it expressed directional preference to the central stimulation. In conclusion, post-commotio VID was associated with faster slow-phases during optokinetic gaze-stabilization, with both vergence and torsion being correlated to symptom intensity. As torsional tracking remains inaccessible using commercial eye-trackers, vertical vergence may prove particularly accessible for clinical utility.

Median Time to Return to Sports After Concussion Is Within 21 Days in 80% of Published Studies

PURPOSE

To perform a systematic review of the literature and evaluate the return to play (RTP) time frame after a concussion diagnosis. Our secondary purpose was to analyze and compare different prognostic variables affecting concussions, time to return to school, time to symptom resolution of concussive symptoms, and time each patient spent in the RTP protocol.

METHODS

A PubMed, Scopus, Medline, Embase, and Cochrane Library database literature review was performed in August 2022. The studies needed to report, in days, the length of time a patient/athlete was removed from play due to concussion management. The Risk of Bias in Non-Randomized Studies of Interventions tool was used for risk of bias for each study, and Methodological Index for Non-Randomized Studies criteria were used for quality assessment.

RESULTS

There were 65 studies included in the systematic review and a total of 21,966 patients evaluated. The RTP time intervals ranged from 1 to 1,820 days, with 80.7% of the median RTP time frames for each study within 21 days. Preconcussion risk factors for prolonged RTP included female sex, younger age, presence of psychiatric disorders, and history of previous concussion. Postconcussion risk factors included severe symptom scores at initial clinic visit, loss of consciousness, nonelite athletes, and delayed removal from competition. The most common sports resulting in concussion were contact sports, most commonly football and soccer. Median time to return to school was 3 to 23 days. Median time to symptom resolution ranged from 2 to 11 days. Median time in RTP protocol was 1 to 6 days.

CONCLUSIONS

Median time to return to sports after concussion is within 21 days in 80% of published studies.

LEVEL OF EVIDENCE

IV, systematic review of Level I to IV studies.

Long-term test-retest reliability of the vestibular/ocular motor screening for concussion in child athletes: A preliminary study

The Vestibular/Ocular Motor Screening (VOMS) is a sport-related concussion screening tool that assesses vestibular ocular reflex (VOR) and oculomotor symptom provocation. Long-term test-retest reliability of the VOMS over multiple athletic seasons has not yet been established in a pediatric population. Fifty-one child athletes (females = 28, 54.9%) 8-13 years of age, completed a baseline VOMS assessment at two timepoints, 18 months apart. Cronbach's alpha was used to examine the internal consistency at both time points. Two-way mixed intra-class correlation coefficients and Cohen's Kappa statistics were used to evaluate test-retest reliability. High internal consistency existed at both initial (α = 0.91) and follow-up (α = 0.95) for VOMS symptom provocation items. Strong inter-item correlations were noted between vertical VOR (r = ≥0.70) and visual motion sensitivity (VMS) (r = ≥0.70). Fair agreement was produced for convergence (κ = 0.23, vertical VOR (κ = 0.25) and VMS (κ = 0.25), as well as reliability on NPC distance (ICC2,k = 0.31). All other VOMS scores yielded poor agreement between time points. Symptom provocation was the same for 49% of athletes between timepoints, while 31.4% had a decrease in scoring at follow-up. Symptom provocation from VOMS tasks lessened with increasing age and time; therefore, clinicians should consider annual baseline testing to improve accuracy for concussion evaluation and management in pediatrics.

Vestibular/ocular motor screening (VOMS) score for identification of concussion in cases of non-severe head injury: A systematic review

Background

and importance Each year, 1.4 million patients attend a UK ED with a head injury. Mild traumatic brain injury affects up to 300/100 000 admitted patients/year and a greater number of non-admitted patients. Identifying those patients with a head injury that have concussion, and of those, which will have a prolonged recovery, is critical for discharge planning. The Vestibular/Ocular Motor Screening test (VOMS) has been reported as a useful “sideline tool” to evaluate for sports-related concussion (SRC). VOMS has been assessed for utility primarily for predicting in head-injured, which cases will have concussion, and secondarily in predicting in concussed patients, which will have prolonged recovery. Originally described in 2014, VOMS has not been subject to systematic review or meta-analysis, with regard to its predictive performance for concussion.

Objective

To assess the state of VOMS evidence for dichotomously classifying concussion status in patients with non-severe head injury

Design

Systematic review.

Setting and participants

Studies comprising the review enrolled ambulatory head-injured adults and children, usually from sports-related settings, in Europe or the USA.

Exposure

VOMS.

Outcome measures

Presence of concussion, presence of prolonged recovery in concussed patients

Main results

The review identified 17 studies, characterized by a wide variety of specific approaches to administering and scoring VOMS. While VOMS showed promise as a screening tool for concussion, marked study heterogeneity precluded generation of a pooled effect estimate for VOMS performance.

Conclusion

VOMS is potentially useful as a concussion screening tool. Available evidence from the SRC arena suggests sensitivity ranging from 58–96%, with specificity 46−92%. Directions for future VOMS research should include evaluation of standardized administration and scoring, potentially of a simpler VOMS (with fewer components), in a general head-injured population. Further analysis of precisely defined VOMS application may be useful to determine the proper place of VOMS screening for the head-injured.

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

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

Symptom Provocation Following Post-concussion Computerized Neurocognitive Testing and Its Relationship to Other Clinical Measures of Concussion

OBJECTIVE

The objective of this study was to document the prevalence of post-computerized neurocognitive test (post-CNT) increases in symptoms in athletes with sport-related concussion, and to examine the effect of post-CNT symptom increases on concussion neurocognitive and vestibular/ocular motor clinical outcomes.

METHODS

This was a retrospective analysis of medical records from a concussion specialty clinic. Two hundred and three athletes (M = 16.48 ± 1.97 years; 44% [90/203] female) completed a clinical visit for concussion within 30 days of injury (M = 7.73 ± 5.54 days). Computerized neurocognitive testing (the Immediate Post-concussion Assessment and Cognitive Testing: ImPACT), the Post-Concussion Symptom Scale (PCSS), and the Vestibular Ocular Motor Screening (VOMS) were the main outcome measures for the current study.

RESULTS

Sixty-nine percent (141/203) of the sample did not report significant increases in PCSS scores following post-concussion CNT and were classified into a No Provocation (NO PROV) group. Thirty-one percent (62/203) of participants did report a significant increase in symptoms following post-concussion CNT and were classified into a Provocation (PROV) group. Neurocognitive performance was similar between groups. However, the PROV group reported significantly higher scores on the VOMS symptom items than the NO PROV group.

CONCLUSIONS

The majority of adolescent athletes can complete a post-concussion CNT without experiencing significant increases in concussion symptoms. Individuals that report symptom increases from completing a post-concussion CNT are more likely to exhibit increased vestibular/ocular motor symptoms. These findings underscore the relationship between the clinical findings from both CNT and vestibular/ocular motor measures following concussion.

Concussion Recovery in Children and Adolescents: A Retrospective Study

Background

Concussion is a common injury among children and adolescents, with a growing body of literature supporting a variety of diagnostic and treatment modalities. Recovery is variable and depends on multiple factors that can be evaluated through a clinic visit: a thorough history, physical examination, and use of the Post-concussion Symptom Scale (PCSS).

Purpose/Hypothesis

The purpose of this study was to evaluate factors associated with overall recovery from concussion in children and adolescents in the clinical setting. It was hypothesized that the presence of 1 of a number of pre- or postinjury characteristics will be associated with poor concussion recovery.

Study Design

Case-control study; Level of evidence, 3.

Methods

We conducted a retrospective chart review of adolescents and children aged 6 to 17 years with a diagnosis of concussion who were evaluated at a single sports medicine center between January 2015 and December 2019. Cases were categorized into recovered (PCSS <7) and poorly recovered (PCSS ≥7) cohorts based on the last PCSS scores during clinical follow-ups for concussion management.

Results

Of the 162 charts reviewed, 110 cases met inclusion criteria. Significant statistical differences were found between the recovered and poorly recovered cohorts regarding mean days from injury to last clinic visit, previous migraine diagnosis, and emergency room (ER) visit before the first clinic visit (P < .01 for all). Binary logistic regression analysis revealed that the most predictive factors associated with poorer recovery were having an ER visit before the first clinic evaluation (P = .01) and previous migraine diagnosis (P = .04).

Conclusion

While many factors may contribute to overall recovery from concussion in pediatric populations, our study suggested that a history of migraine and an ER visit before clinic evaluation may be associated with poor recovery of concussive symptoms.

Long-term postural control in elite athletes following mild traumatic brain injury

Background

Traumas to the head and neck are common in sports and often affects otherwise healthy young individuals. Sports-related concussions (SRC), defined as a mild traumatic brain injury (mTBI), may inflict persistent neck and shoulder pain, and headache, but also more complex symptoms, such as imbalance, dizziness, and visual disturbances. These more complex symptoms are difficult to identify with standard health care diagnostic procedures.

Objective

To investigate postural control in a group of former elite athletes with persistent post-concussive symptoms (PPCS) at least 6 months after the incident.

Method

Postural control was examined using posturography during quiet stance and randomized balance perturbations with eyes open and eyes closed. Randomized balance perturbations were used to examine motor learning through sensorimotor adaptation. Force platform recordings were converted to reflect the energy used to maintain balance and spectrally categorized into total energy used, energy used for smooth corrective changes of posture (i.e., <0.1 Hz), and energy used for fast corrective movements to maintain balance (i.e., >0.1 Hz).

Results

The mTBI group included 20 (13 males, mean age 26.6 years) elite athletes with PPCS and the control group included 12 athletes (9 males, mean age 26.4 years) with no history of SRC. The mTBI group used significantly more energy during balance perturbations than controls: +143% total energy, p = 0.004; +122% low frequency energy, p = 0.007; and +162% high frequency energy, p = 0.004. The mTBI subjects also adapted less to the balance perturbations than controls in total (18% mTBI vs. 37% controls, p = 0.042), low frequency (24% mTBI vs. 42% controls, p = 0.046), and high frequency (6% mTBI vs. 28% controls, p = 0.040). The mTBI subjects used significantly more energy during quiet stance than controls: +128% total energy, p = 0.034; +136% low-frequency energy, p = 0.048; and +109% high-frequency energy, p = 0.015.

Conclusion

Athletes with previous mTBI and PPCS used more energy to stand compared to controls during balance perturbations and quiet stance and had diminished sensorimotor adaptation. Sports-related concussions are able to affect postural control and motor learning.

Comparison of Prescribed Physical Therapy to a Home Exercise Program for Pediatric Sports-Related Concussion Patients

The purpose of this retrospective chart review was to compare sports-related concussion (SRC) recovery time in protracted recovery (≥28 days) patients who were prescribed physical therapy (PPT) with those who were only provided a home exercise program (HEP). We hypothesized PPT would be associated with shorter recovery times relative to HEP. Associations were evaluated with multivariable zero-truncated negative binomial regressions. Among the 48 (30.2%) PPT and 111 (69.8%) HEP patients, the majority were female (57.9%), the mean age was 15.3 ± 1.4 (PPT) and 14.2 ± 2.8 (HEP), and time to clinic was a median 6.0 (IQR = 3.0–27.0; PPT) and 7.0 (IQR = 3.0–23.0; HEP) days. After adjusting for demographic (age, sex) and clinical measures (concussion history, convergence, VOMS, PCSS score, and days to clinic), PPT unexpectedly was associated with 1.21 (95% CI: 1.05, 1.41) additional recovery days compared with HEP. One reason for this could be related to patients adhering to the number of a priori prescribed PT sessions which may or may not have aligned with the patient’s symptom resolution. Future research should explore this hypothesis while aiming to evaluate the effect of PPT versus HEP using a randomized design. If confirmed, these findings are encouraging for patients who could not otherwise access or afford specialty rehabilitation.

Interdisciplinary Rehabilitation for Concussion Recovery (i-RECOveR): protocol of an investigator-blinded, randomised, case series with multiple baseline design to evaluate the feasibility and preliminary efficacy of a 12-week treatment for persistent post-concussion symptoms

BACKGROUND

Up to 25% of concussed individuals experience persistent post-concussion symptoms (PPCSs) which may interfere with the return to pre-injury activities and cause significant stress. Given that multiple etiological factors are thought to contribute to PPCSs, an interdisciplinary approach is recommended. This pilot study aims to primarily investigate the feasibility of a novel interdisciplinary treatment for PPCSs. Given this intervention is novel, uncertainty exists in terms of potential recruitment and retention rates, adverse events, and treatment adherence and fidelity. These factors will be explored to inform the feasibility of a phase-2 randomised controlled trial. Preliminary efficacy of this intervention will also be explored.

METHODS

Fifteen individuals with mild traumatic brain injury and PPCSs will receive up to 12 weeks of interdisciplinary treatments including psychology, physiotherapy, and medical interventions. Primary feasibility outcomes including data on recruitment and retention rates and treatment adherence will be explored descriptively. The cognitive therapy rating scale will be used to assess treatment fidelity. A single-case series with multiple baseline design will be used to explore preliminary efficacy. Participants will be randomly assigned to baseline phases of 2, 4, or 6 weeks. Regarding patient-centred secondary outcomes, the Rivermead Post-Concussion Symptoms Questionnaire will be assessed three times a week during baseline and treatment phases. Secondary outcomes also include measures of mood, sleep and fatigue, physical functioning, return to activity, and health-related quality of life. Patient-centred outcomes will be assessed at baseline, pretreatment, post-treatment, and one- and three-month follow-up. Thematic analysis of participant experiences will be explored through qualitative interviews.

DISCUSSION

Results from this trial will inform the feasibility and preliminary efficacy of this interdisciplinary concussion intervention and whether proceeding to a future definitive phase-2 randomised controlled trial is worthwhile. Understanding the end-user perspective of the treatment will also enable modifications to the treatment protocol for future trials to best suit the needs of individuals with PPCSs after mTBI. Outcomes from this trial can be directly translated into community rehabilitation programmes.

TRIAL REGISTRATION

ANZCTR, ACTRN12620001111965. Registered 27 October 2020, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379118.

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.

Factor Structure for the Sport Concussion Assessment Tool Symptom Scale in Adolescents After Concussion

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.

Exploring Vestibular/Ocular and Cognitive Dysfunction as Prognostic Factors for Protracted Recovery in Sports-Related Concussion Patients Aged 8 to 12 Years

OBJECTIVE

To explore the prognostic ability of the vestibular/ocular motor screening (VOMS), King-Devick (K-D) Test, and C3 Logix Trails A and B to identify protracted recovery from sports-related concussion (SRC) in patients aged 8 to 12 years.

DESIGN

Retrospective cohort analysis.

SETTING

Specialty pediatric sports concussion clinic.

PARTICIPANTS

A total of 114 youth athletes aged 8 to 12 years who were diagnosed with an SRC within 7 days of injury.

INDEPENDENT VARIABLES

A positive screen on the VOMS, K-D, and C3 Logix Trails A and Trails B. Combined positive screens on multiple tests (ie, 2, 3, or all 4 positive screens of 4 possible).

MAIN OUTCOME MEASURES

Recovery time in days and protracted recovery (recovery time ≥30-days) were the primary outcomes of interest.

RESULTS

A positive VOMS screen was associated with 1.31 greater days to SRC recovery ( P = 0.02) than a negative VOMS screen. The K-D and C3 Logix tests were not significantly associated with recovery time, nor were any combinations of tests ( P > 0.05). The VOMS demonstrated moderate prognostic ability to predict normal recovery (negative predictive value = 80.78% [95% CI = 63.73-90.95]). Overall predictive accuracy of normal versus protracted recovery was strongest when a participant screened positive on all 4 tests (Accuracy = 76.32% [95% CI = 67.45-83.78]).

CONCLUSIONS

The VOMS was associated with overall recovery time and proved to be a useful test to identify those who would experience a normal recovery time. Combining the 4 tests improved the prognostic accuracy of the protocol in predicting protracted versus normal recovery. These findings suggest that combining multiple, varied assessments of cognition and vestibular/ocular functions may better explain factors contributing to protracted recovery.

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.

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.

Factors Associated With a Prolonged Time to Return to Play After a Concussion

BACKGROUND

Prognosticating recovery times for individual athletes with a concussion remains a challenge for health care providers. Several preinjury and postinjury factors have been proposed to be predictive of prolonged return-to-play (RTP) times, but the data in this area are still sparse.

PURPOSES

This study aimed to identify risk factors associated with prolonged recovery times and determine which are most predictive of prolonged recovery times in a head-to-head comparison.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

All concussions occurring between September 2017 and August 2020 at a single National Collegiate Athletic Association Division I institution were reviewed and included in this study. Preinjury modifiers including age, sex, sport, concussion history, and past medical problems were collected from the electronic medical records. Postinjury modifiers analyzed included initial and follow-up Sport Concussion Assessment Tool 5th Edition scores, vestibular evaluation findings, and eye tracking results.

RESULTS

A total of 159 athletes and 187 concussion cases were included. Preinjury factors that were correlated with prolonged RTP times included a history of concussions (P = .015), a history of migraines (P = .013), and whether an athlete participated in an individual sport (P = .009). Postinjury factors correlated with prolonged RTP times included the total number (P = .020) and severity (P = .023) of symptoms as well as abnormal Vestibular Ocular Motor Screening findings (P = .002). Overall, 6 different symptoms (balance problems, difficulty concentrating, light sensitivity, drowsiness, fatigue/low energy, and difficulty remembering) were significantly correlated with prolonged RTP times. The study also found that the number and severity of symptoms were additive in a dose-dependent fashion. On multivariable analysis of all these factors, a history of concussions was found to be the most predictive of prolonged RTP times, while participation in an individual sport had the largest effect on recovery times.

CONCLUSION

Several preinjury and postinjury risk factors were identified as being correlated with prolonged recovery times. Many of these risk factors were also found to be additive in nature. This information provides clinicians with a valuable tool in prognosticating and estimating recovery times for athletes. The study also revealed that athletes participating in individual sports had longer RTP times compared with athletes in team sports, which is a novel finding that requires further research.

Recovery of symptoms, neurocognitive and vestibular-ocular-motor function and academic ability after sports-related concussion (SRC) in university-aged student-athletes: a systematic review

BACKGROUND

Physiological differences between a maturing and matured brain alters how Sports-Related Concussion (SRC) affects different age groups; therefore, a review specific to university-aged student-athletes is needed.

OBJECTIVES

Determine time to recovery for symptom burden, neurocognitive and Vestibular-Ocular-Motor (VOM) function and academic impact in university-aged student-athletes.

METHODS

Searches were conducted in PubMed, SpringerLink, PsycINFO, Science Direct, Scopus, Cochrane, Web of Science and EMBASE. Articles were included if they contained original data collected within 30 days in university-aged student-athletes, analysed SRC associated symptoms, neurocognitive or VOM function or academic ability and published in English. Two reviewers independently reviewed sources, using the Oxford Classification of Evidence-Based Medicine (CEBM) and the Downs and Black checklist, and independently extracting data before achieving consensus.

RESULTS

58 articles met the inclusion criteria. Recovery of symptoms occurred by 7 and 3-5.3 days for neurocognition. The evidence base did not allow for a conclusion on recovery time for VOM function or academic ability. Few papers investigated recovery times at specified re-assessment time-points and have used vastly differing methodologies.

CONCLUSIONS

To fully understand the implication of SRC on the university-aged student-athlete' studies using a multi-faceted approach at specific re-assessments time points are required.Systematic review registration number: CRD42019130685.

Post-Concussive Vestibular Dysfunction Is Related to Injury to the Inferior Vestibular Nerve

Symptoms of vestibular dysfunction such as dizziness and vertigo are common after sports-related concussions (SRC) and associated with a worse outcome and a prolonged recovery. Vestibular dysfunction after SRC can be because of an impairment of the peripheral or central neural parts of the vestibular system. The aim of the present study was to establish the cause of vestibular impairment in athletes with SRC who have persisting post-concussive symptoms (PPCS). We recruited 42 participants-21 athletes with previous SRCs and PPCS ≥6 months and 21 healthy athletic age- and sex-matched controls-who underwent symptom rating, a detailed test battery of vestibular function and 7T magnetic resonance imaging with diffusion tensor imaging (DTI) and diffusion kurtosis imaging (DKI) of cerebellar white matter tracts, and T1-weighted imaging for cerebellar volumetrics. Vestibular dysfunction was observed in 13 SRC athletes and three controls (p = 0.001). Athletes with vestibular dysfunction reported more pronounced symptoms on the Dizziness Handicap Inventory (DHI; p < 0.001) and the Hospital Anxiety and Depression Scale (HADS; p < 0.001). No significant differences in DTI metrics were found, while in DKI two metrics were observed in the superior and/or inferior cerebellar tracts. Cerebellar gray and white matter volumes were similar in athletes with SRC and controls. Compared with controls, pathological video head impulse test results (vHIT; p < 0.001) and cervical vestibular evoked myogenic potentials (cVEMP; p = 0.002) were observed in athletes with SRC, indicating peripheral vestibular dysfunction and specifically suggesting injury to the inferior vestibular nerve. In athletes with persisting symptoms after SRC, vestibular dysfunction is associated with injury to the inferior vestibular nerve.

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.

Machine learning to predict sports-related concussion recovery using clinical data

OBJECTIVES

Sport-related concussions (SRCs) are a concern for high school athletes. Understanding factors contributing to SRC recovery time may improve clinical management. However, the complexity of the many clinical measures of concussion data precludes many traditional methods. This study aimed to answer the question, what is the utility of modeling clinical concussion data using machine-learning algorithms for predicting SRC recovery time and protracted recovery?

METHODS

This was a retrospective case series of participants aged 8 to 18 years with a diagnosis of SRC. A 6-part measure was administered to assess pre-injury risk factors, initial injury severity, and post-concussion symptoms, including the Vestibular Ocular Motor Screening (VOMS) measure, King-Devick Test and C3 Logix Trails Test data. These measures were used to predict recovery time (days from injury to full medical clearance) and binary protracted recovery (recovery time > 21 days) according to several sex-stratified machine-learning models. The ability of the models to discriminate protracted recovery was compared to a human-driven model according to the area under the receiver operating characteristic curve (AUC).

RESULTS

For 293 males (mean age 14.0 years) and 362 females (mean age 13.7 years), the median (interquartile range) time to recover from an SRC was 26 (18-39) and 21 (14-31) days, respectively. Among 9 machine-learning models trained, the gradient boosting on decision-tree algorithms achieved the best performance to predict recovery time and protracted recovery in males and females. The models' performance improved when VOMS data were used in conjunction with the King-Devick Test and C3 Logix Trails Test data. For males and females, the AUC was 0.84 and 0.78 versus 0.74 and 0.73, respectively, for statistical models for predicting protracted recovery.

CONCLUSIONS

Machine-learning models were able to manage the complexity of the vestibular-ocular motor system data. These results demonstrate the clinical utility of machine-learning models to inform prognostic evaluation for SRC recovery time and protracted recovery.

Concussion reporting intentions for incoming military athletes and cadets

Cultures of concussion reporting exist outside athletics; however, athlete-only studies dominate the literature. Comparing athletes and similar high-risk populations broadens our understanding of concussion reporting acculturation. We aimed to (1) describe and compare concussion self-report willingness as measured by anticipated concussion reporting (ACR), perceived costs, perceived rewards, brain health knowledge, and correct symptom identification for incoming cadets at the United States Air Force Academy (USAFA) (n = 1,136; female = 276, 24.43%) and (2) determine whether those variables predict ACR. Univariate analyses were performed to compare intercollegiate status, sex, and parental income for perceived costs and rewards, and brain health knowledge (α = 0.05) and multinomial logistic regressions to determine if those variables predicted ACR. A $40,000 parental increase in income resulted in one additional symptom identified (β = 0.80, p = 0.026). Athletes demonstrated greater brain health knowledge by nearly one symptom correctly identified (β = 0.98, p = 0.002); non-athletes reported significantly greater ACR (β = 5.92; p < 0.001). Our model accounted for 37% of the variance in ACR (χ2 = 393.86, p < 0.001, Nagelkerke R2 = 0.37). Before military acculturation, athletes had less intention to seek medical care for concussion, likely from prior athletic experiences.

Wearables in rugby union: A protocol for multimodal digital sports-related concussion assessment

Background

Pragmatic challenges remain in the monitoring and return to play (RTP) decisions following suspected Sports Related Concussion (SRC). Reliance on traditional approaches (pen and paper) means players readiness for RTP is often based on self-reported symptom recognition as a marker for full physiological recovery. Non-digital approaches also limit opportunity for robust data analysis which may hinder understanding of the interconnected nature and relationships in deficit recovery. Digital approaches may provide more objectivity to measure and monitor impairments in SRC. Crucially, there is dearth of protocols for SRC assessment and digital devices have yet to be tested concurrently (multimodal) in SRC rugby union assessment. Here we propose a multimodal protocol for digital assessment in SRC, which could be used to enhance traditional sports concussion assessment approaches.

Methods

We aim to use a repeated measures observational study utilising a battery of multimodal assessment tools (symptom, cognitive, visual, motor). We aim to recruit 200 rugby players (male n≈100 and female n≈100) from University Rugby Union teams and local amateur rugby clubs in the North East of England. The multimodal battery assessment used in this study will compare metrics between digital methods and against traditional assessment.

Conclusion

This paper outlines a protocol for a multimodal approach for the use of digital technologies to augment traditional approaches to SRC, which may better inform RTP in rugby union. Findings may shed light on new ways of working with digital tools in SRC. Multimodal approaches may enhance understanding of the interconnected nature of impairments and provide insightful, more objective assessment and RTP in SRC.

Clinical trial registration

NCT04938570. https://clinicaltrials.gov/ct2/results?cond=NCT04938570&term=&cntry=&state=&city=&dist=

A Randomized Controlled Trial of Precision Vestibular Rehabilitation in Adolescents following Concussion: Preliminary Findings

OBJECTIVE

To compare the effectiveness of a 4-week precision vestibular rehabilitation intervention compared with a behavioral management control intervention for adolescents with vestibular symptoms/impairment within 21 days of a concussion.

STUDY DESIGN

This study used double-blind, randomized controlled trial design involving adolescent (12-18 years) patients with a diagnosed sport/recreation-related concussion with vestibular symptoms/impairment from a concussion-specialty clinic between October 2018 and February 2020. Eligible participants were randomized in a 1:1 to either a 4-week vestibular intervention group (VESTIB) or a behavioral management control group (CONTROL). CONTROLS (n = 25) were prescribed behavioral management strategies (eg, physical activity, sleep, hydration, nutrition, stress management) and instructed to perform stretching/physical activity (eg, walking, stationary cycle) 30 minutes/day. VESTIB (n = 25) were prescribed precision vestibular rehabilitation exercises and instructed to perform at-home exercises for 30 minutes/day. Primary outcomes were improvement in Vestibular/Ocular Motor Screening vestibular items (ie, horizontal/vertical vestibular-ocular reflex, visual motion sensitivity) at 4 weeks postenrollment.

RESULTS

We screened 310 and enrolled a total of 55 (18%) adolescent patients who were randomized to one of the interventions. Fifty of fifty-five (91%) participants completed all aspects of the study protocol. Participants in VESTIB improved significantly across the intervention period in horizontal (mean difference-1.628; 95% CI [-3.20, -0.06]; P = .04) and vertical (mean difference-2.24; 95% CI [-4.01, -0.48]; P = .01) vestibular-ocular reflex, but not visual motion sensitivity (mean difference-2.03; 95% CI [-4.26, 0.19]) of the Vestibular/Ocular Motor Screening score compared with CONTROLS.

CONCLUSIONS

Overall, the vestibular intervention group experienced greater clinical improvements in vestibular symptoms/impairment than controls across the 4-week intervention.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03555370.

Behavioral and Cognitive Aspects of Concussion

PURPOSE OF REVIEW

This review provides the reader with an overview of concussion and mild traumatic brain injury (TBI). Key aspects of the pathophysiology, signs, and symptoms, treatment and rehabilitation, and recovery from concussion/mild TBI are reviewed with an emphasis on the variety of factors that may contribute to cognitive concerns following injury.

RECENT FINDINGS

Concussion remains a clinical diagnosis based on symptoms that occur in the immediate aftermath of an applied force and in the hours, days, and weeks thereafter. Although advances have been made in advanced diagnostics, including neuroimaging and fluid biomarkers in hopes of developing objective indicators of injury, such markers currently lack sufficient specificity to be used in clinical diagnostics. The symptoms of concussion are heterogeneous and may be seen to form subtypes, each of which suggests a targeted rehabilitation by the interdisciplinary team. Although the majority of patients with concussion recover within the first 30 to 90 days after injury, some have persistent disabling symptoms. The concept of postconcussion syndrome, implying a chronic syndrome of injury-specific symptoms, is replaced by a broader concept of persistent symptoms after concussion. This concept emphasizes the fact that most persistent symptoms have their basis in complex somatic, cognitive, psychiatric, and psychosocial factors related to risk and resilience. This framework leads to the important conclusion that concussion is a treatable injury from which nearly all patients can be expected to recover.

SUMMARY

Concussion/mild TBI is a significant public health problem in civilian, military, and organized athletic settings. Recent advances have led to a better understanding of underlying pathophysiology and symptom presentation and efficacious treatment and rehabilitation of the resulting symptoms. An interdisciplinary team is well-positioned to provide problem-oriented, integrated care to facilitate recovery and to advance the evidence base supporting effective practice in diagnosis, treatment, and prevention.

Vestibular/Ocular Motor Screening Assessment Outcomes After Sport-Related Concussion in High School and Collegiate Athletes

CONTEXT

Vestibular and ocular motor assessment is an emerging clinical assessment for patients with sport-related concussion (SRC). The increased use of these assessments by clinicians calls for the examination of outcomes that may affect clinical practice.

OBJECTIVE

To compare vestibular and ocular motor impairments in high school and collegiate athletes within 72 hours of SRC and examine the distribution of impairments in these populations based on pre-established clinical cutoff scores.

DESIGN

Cross-sectional study.

SETTING

High school and collegiate athletics.

PATIENTS OR OTHER PARTICIPANTS

Data were collected from 110 athletes (high school: n = 47, age = 15.40 ± 1.35 years; college: n = 63, age = 19.46 ± 1.28 years) within 72 hours of sustaining an SRC.

MAIN OUTCOME MEASURE(S)

Total and change scores were calculated for the Vestibular/Ocular Motor Screening (VOMS) tool, along with average near point of convergence (NPC) distance. Separate Mann-Whitney U tests were used to compare group differences, and χ2 analyses were used to examine the proportion of athletes with scores greater than clinical cutoff scores for all VOMS outputs. The α level was set a priori at .05.

RESULTS

No differences were found between high school and collegiate athletes for VOMS total and change scores and NPC distance. A larger proportion of the sample had scores greater than the cutoff for all total scores (P < .001) and change scores in horizontal vestibulo-ocular reflex (59.01%; P < .001), vertical vestibulo-ocular reflex (60.91%; P < .001), and visual motion sensitivity (60.91%; P < .001). However, a larger proportion demonstrated smooth pursuit change scores (85.45%; P < .001) and NPC distances (73.64%; P = .01) that were less than the cutoff scores.

CONCLUSIONS

During the acute phase of SRC, high school and collegiate athletes presented with similar vestibular and ocular motor impairments as measured using the VOMS, but vestibular tasks appeared to cause greater symptom provocation. Lastly, VOMS change scores may offer more clinical utility compared with total scores in assessing specific impairments after SRC.

Clinical Assessment of Concussion and Persistent Post-Concussive Symptoms for Neurologists

PURPOSE OF REVIEW

Concussion produces a variety of signs and symptoms. Most patients recover within 2-4 weeks, but a significant minority experiences persistent post-concussive symptoms (PPCS), some of which may be from associated cervical or persistent neurologic sub-system (e.g., vestibular) dysfunction. This review provides evidence-based information for a pertinent history and physical examination of patients with concussion.

RECENT FINDINGS

The differential diagnosis of PPCS is based on the mechanism of injury, a thorough medical history and concussion-pertinent neurological and cervical physical examinations. The concussion physical examination focuses on elements of autonomic function, oculomotor and vestibular function, and the cervical spine. Abnormalities identified on physical examination can inform specific forms of rehabilitation to help speed recovery. Emerging data show that there are specific symptom generators after concussion that can be identified by a thorough history, a pertinent physical examination, and adjunct tests when indicated.

Management of Concussion and Persistent Post-Concussive Symptoms for Neurologists

PURPOSE OF REVIEW

Concussion is a complex injury that may present as a variety of clinical profiles, which can overlap and reinforce one another. This review summarizes the medical management of patients with concussion and persistent post-concussive symptoms (PPCS).

RECENT FINDINGS

Management of concussion and PPCS relies on identifying underlying symptom generators. Treatment options include sub-symptom threshold aerobic exercise, cervical physical therapy, vestibular therapy, vision therapy, cognitive rehabilitation, cognitive behavioral therapy, pharmacological management, or a combination of treatments. Evidence-based treatments have emerged to treat post-concussion symptom generators for sport-related concussion and for patients with PPCS.

Concurrent validity of the Vestibular/Ocular Motor Screening (VOMS) tool with the Dizziness Handicap Inventory (DHI) among adolescents with vestibular symptoms/impairment following concussion

OBJECTIVE

To determine whether the Vestibular/Ocular Motor Screening (VOMS) tool demonstrates concurrent validity with the Dizziness Handicap Inventory (DHI) in a sample of concussed athletes referred for vestibular therapy and whether DHI items were predictive of VOMS outcomes.

DESIGN

Cross-sectional cohort study.

SETTING

Concussion specialty/vestibular therapy clinic.

METHODS

Adolescents (n = 55; 15.4 ± 1.6 years) with diagnosed sport-related concussion (SRC) with vestibular symptoms and/or impairment between October 2018-February 2020. Patients completed VOMS and DHI at initial visit. Seven individual VOMS and twenty-five DHI items, VOMS and DHI total score and three DHI sub-scales, were compared with Spearman correlations. Three backwards linear regression (LR) models were built to predict 1. VOMS vestibular symptoms, 2. VOMS ocular symptoms, and 3. near-point of convergence-distance (NPC-distance) using individual DHI items as predictors.

RESULTS

Spearman correlations (p) identified DHI items with moderate to strong associations for VOMS items. DHI sub-scales demonstrated moderate-to-strong correlations with VOMS items (p = 0.30-0.59). Total DHI score demonstrated a moderate-to-strong association with HSAC (p = 0.30), VSAC (p = 0.32), and SP (p = 0.61). Results from the LRs predicting VOMS ocular symptoms (R (Alsalaheen et al., 2010) = 0.56; p < 0.001), and VOMS vestibular symptoms (R (Alsalaheen et al., 2010) = 0.23; p = 0.01), and NPC-distance (R (Alsalaheen et al., 2010) = 0.56; p < 0.001) included significant DHI predictors.

CONCLUSIONS

There was moderate-to-strong associations between VOMS and 56% of DHI items (i.e., p > 0.30).

Prospective study with specific Re-Assessment time points to determine time to recovery following a Sports-Related Concussion in university-aged student-athletes

BACKGROUND

Time to recovery for symptom burden and neurocognition following a Sports-Related Concussion (SRC) has previously been determined by consolidating varying re-assessment time points into a singular point, and has not been established for Vestibular-Ocular-Motor (VOM) function or academic ability.

OBJECTIVES

Establish when recovery of symptom burden, neurocognition, VOM function, and academic ability occurs in university-aged student-athletes.

METHODS

Student-athletes completed an assessment battery (Post-Concussion Symptom Scale (PCSS), Immediate Post-Concussion Assessment and Cognitive Test (ImPACT), Vestibular Ocular-Motor Screening (VOMS), Perceived Academic Impairment Tool (PAIT)) during pre-season (n = 140), within 48 hours, 4, 8 and 14 days post-SRC and prior to Return To Play (RTP) and were managed according to the Rugby Football Union' community pathway (n = 42). Student-athletes were deemed recovered or impaired according to Reliable Change Index' (RCI) or compared to their individual baseline.

RESULTS

Symptom burden recovers by four days post-SRC on RCI and to baseline by eight days. VOM function and academic ability recovers by 8 days. Some student-athletes demonstrated worse performance at RTP on all tests by RCI and to baseline, except for on VOMS score and near point convergence by RCI change.

CONCLUSIONS

Variation in individual university-aged student-athletes requires a multi-faceted approach to establish what dysfunctions post-SRC exist and when recovery occurs.

Potential Mechanisms of Acute Standing Balance Deficits After Concussions and Subconcussive Head Impacts: A Review

Standing balance deficits are prevalent after concussions and have also been reported after subconcussive head impacts. However, the mechanisms underlying such deficits are not fully understood. The objective of this review is to consolidate evidence linking head impact biomechanics to standing balance deficits. Mechanical energy transferred to the head during impacts may deform neural and sensory components involved in the control of standing balance. From our review of acute balance-related changes, concussions frequently resulted in increased magnitude but reduced complexity of postural sway, while subconcussive studies showed inconsistent outcomes. Although vestibular and visual symptoms are common, potential injury to these sensors and their neural pathways are often neglected in biomechanics analyses. While current evidence implies a link between tissue deformations in deep brain regions including the brainstem and common post-concussion balance-related deficits, this link has not been adequately investigated. Key limitations in current studies include inadequate balance sampling duration, varying test time points, and lack of head impact biomechanics measurements. Future investigations should also employ targeted quantitative methods to probe the sensorimotor and neural components underlying balance control. A deeper understanding of the specific injury mechanisms will inform diagnosis and management of balance deficits after concussions and subconcussive head impact exposure.

Minimum detectable change and false positive rates of the vestibular/ocular motor screening (VOMS) tool: an NCAA-DoD care consortium analysis

OBJECTIVE

To derive minimum detectable change (MDC) across individual Vestibular-Ocular Motor Screening (VOMS) items and VOMS overall score in 17-25 years old collegiate athletes and to examine false positive rates.

METHOD

Participants (n = 378) completed VOMS pre-season for two consecutive years. MDC was identified for individual VOMS symptom items and NPC distance (cm). Both total and change methods of VOMS scoring were included in analysis.

RESULTS

Regarding total scoring, MDC for ocular VOMS symptom items was 1 and MDC for vestibular VOMS symptoms items was 2. MDC for NPC was 4 cm and for VOMS overall score was 10. Regarding change scoring, MDC for each VOMS symptom item was 1, and for VOMS overall score was 8. False positives ranged from 5.3% to 15.9%.

CONCLUSIONS

This study presents MDCs for each VOMS item and overall VOMS score, using total and change scoring. These values can be considered true change outside measurement error with 95% confidence in a 17-25 year old collegiate athlete population.

Derivation of the Buffalo Concussion Physical Examination risk of delayed recovery (RDR) score to identify children at risk for persistent postconcussive symptoms

OBJECTIVE

The Buffalo Concussion Physical Examination (BCPE) is a brief, but pertinent physical examination designed for the subacute, outpatient assessment of concussion. The purpose of this study was to perform the BCPE on a larger sample and derive a scoring system to identify children at risk for Persistent Post-Concussive Symptoms (PPCS, recovery ≥30 days).

METHODS

This prospective, observational cohort study from September 2016 to March 2019 was performed at three university-affiliated concussion clinics. Male and female children (n=270, 14.92±1.86 years, range 8-18, 38% female) were diagnosed with a concussion within 14 days of injury and followed-up until recovery. Logistic regression was used with history and physical examination variables to predict PPCS and a weighted scoring metric was derived.

RESULTS

Out of 15 predictor variables, the main effects of 1 preinjury variable (≥3 previous concussions), 2 injury characteristic variables (days-since-injury and type-of-injury), 3 physical examination variables (orthostatic intolerance (OI), vestibulo-ocular reflex (VOR) and tandem gait) and 2 interaction terms (OI/VOR and tandem gait/type-of-injury) produced a score that was 85% accurate for identifying children with low-risk, medium-risk and high-risk for PPCS on cross-validation.

CONCLUSION

The Risk for Delayed Recovery (RDR)-Score allows physicians in an outpatient setting to more accurately predict which children are at greater risk for PPCS early after their injury, and who would benefit most from targeted therapies. The RDR-Score is intended to be used as part of a comprehensive assessment that should include validated symptom checklists, mental health history and adjunct testing (eg, cognitive or physical exertion) where clinically indicated.

Neurosensory Screening and Symptom Provocation in Pediatric Mild Traumatic Brain Injury

OBJECTIVE

To evaluate diagnostic/prognostic implications of neurosensory testing during the subacute stage in patients with pediatric mild traumatic brain injury (pmTBI).

SETTING

Recruitment from pediatric emergency department and urgent care clinics, assessment in a controlled environment.

PARTICIPANTS

In total, 146 pmTBI patients evaluated 7.4 ± 2.3 days and approximately 4 months postinjury; 104 age/sex-matched healthy controls (HCs) at equivalent time points.

DESIGN

Prospective cohort study.

MAIN MEASURES

Neurosensory examination based on sequence of 10 established tests of vestibular-ocular, oculomotor, vestibulospinal, and visual functioning.

RESULTS

The amount of symptom provocation (positive change from pretest symptomatology) was significantly increased in pmTBI relative to HCs on every subtest 1 week postinjury, as were deficits in monocular accommodative amplitude and King-Devick Test errors. However, symptom provocation did not meaningfully alter diagnostic sensitivity/specificity relative to more easily obtained pretest symptom ratings. Evidence of clinically significant symptom provocation 1 week postinjury improved sensitivity (Δ = +12.9%) of identifying patients with persistent postconcussive symptoms 4 months postinjury on an independent symptom measure.

CONCLUSIONS

The diagnostic sensitivity/specificity of neurosensory testing in acutely concussed youth may be limited at 1 week postinjury as a function of natural recovery occurring in most emergency department cohorts. Neurosensory screening may have greater utility for identifying patients who experience delayed recovery.

Evaluating the Vestibulo-Ocular Reflex Following Traumatic Brain Injury: A Scoping Review

Purpose:To identify the tests and tools used to evaluate vestibulo-ocular reflex (VOR) function after traumatic brain injury (TBI) in all age groups and across TBI severity.Methods: An electronic search was conducted to include relevant peer-reviewed literature published up to November 2019. Studies included those done with humans, of all ages, and had assessments of oculomotor and/or vestibulo-ocular function in TBI.Results: Of the articles selected (N = 48), 50% were published in 2018/2019. A majority targeted mild TBI, with equal focus on non-computerized versus computerized measures of VOR. Computerized assessment tools used were videonystagmography, dynamic visual acuity/gaze stability, rotary chair, and caloric irrigation. Non-computerized tests included the head thrust, dynamic visual acuity, gaze stability, head shaking nystagmus, rotary chair tests and the vestibular/oculomotor screening tool. High variability in administration protocols were identified. Namely: testing environment, distances/positioning/equipment used, active/passive state, procedures, rotation frequencies, and variables observed.Conclusions: There is a rapid growth of literature incorporating VOR tests in mild TBI but moderate and severe TBI continues to be under-represented. Determining how to pair a clinical test with a computerized tool and developing standardized protocols when administering tests will help in developing an optimal battery assessing the VOR in TBI.

False Positive Rates and Associated Risk Factors on the VOMS and mBESS in U.S. Military Personnel

CONTEXT

In 2018, the U.S. military developed the Military Acute Concussion Evaluation-2 (MACE-2) to inform acute evaluation of mTBI. However, researchers have yet to investigate false positive rates for components of the MACE-2 including the Vestibular-Ocular Motor Screen (VOMS) and modified Balance Error Scoring System (mBESS) in military personnel.

OBJECTIVE

To examine factors associated with false positives in VOMS and mBESS in U.S. Army Special Operations Command (USASOC) personnel.

DESIGN

Cross-sectional study.

SETTING

Military medical clinic.

PARTICIPANTS

416 healthy USASOC personnel completed medical history, VOMS, and mBESS evaluations.

MAIN OUTCOME MEASURES

False positive rates for the VOMS (2+ on VOMS symptom item, ≥ 5 cm for near point of convergence [NPC] distance) and mBESS (total score >4) were determined using chi-square analyses and independent samples t-tests. Multivariable logistic regressions (LR) with adjusted odds ratios (aOR) were performed to identify risk factors for false positives on VOMS and mBESS. VOMS items false positive rates ranged from 10.6% (smooth pursuits) to 17.5% (NPC). mBESS total score false positive rate was 36.5%.

RESULTS

The multivariable LR model supported three significant predictors of VOMS false positives including age (OR= 1.07, 95% CI= 1.02-1.12, p=0.007), migraine (OR=2.49, 95% CI= 1.29-4.81, p=0.007), and motion sickness history (OR=2.46, 95% CI= 1.34-4.50, p=0.004). Results of the multivariable LR model supported only motion sickness history as a significant predictor (OR=2.34, 95% CI= 1.34-4.05, p=0.002) of mBESS false positives.

CONCLUSIONS

There were low false positive rates across VOMS items, which were associated with age, history of mTBI, migraine, and motion sickness. False positives for the mBESS total score were higher (36.5%) and were only associated with a history of motion sickness. These risk factors for false positives should be considered when administering and interpreting VOMS and mBESS components of the MACE-2 in this population.