Clinical predictors of vestibulo-ocular dysfunction in pediatric sports-related concussion

Concussion Characteristics in Adults With ADHD Seen in a Specialty Concussion Clinic

BACKGROUND

Concussions are a prevalent health concern, affecting millions of individuals in the United States yearly. Concussion symptomology overlaps with other conditions making diagnosis and management particularly challenging, particularly among individuals with ADHD. ADHD is a neurodevelopmental disorder that affects a significant portion of the adult population.

OBJECTIVE

To enhance our understanding of symptom resolution and identify factors that could influence concussion care management, the purpose of the current study was to examine the recovery trajectory of adults diagnosed with both ADHD and concussion compared to the trajectory of adults who have experienced a concussion but do not have an ADHD diagnosis.

METHODS

The study included a retrospective chart review of patients treated for concussion at a concussion specialty clinic.

RESULTS

The findings of the study revealed no significant differences in history of concussion or recovery time between patients with and without ADHD. It was observed that patients with ADHD had a higher prevalence of anxiety, depression, and other mental health conditions.

CONCLUSIONS

The findings of the current study underscore the need for additional research to guide the care of patients diagnosed with both ADHD and concussion.

Outcome measures used in adolescent sport-related concussion research: a scoping review

OBJECTIVES

To provide an overview of the outcome measures currently used after sports-related concussion (SRC) in adolescents, categorising by the constructs they assess, follow-up duration and their feasibility of use.

DESIGN

Scoping review.

DATA SOURCES

We searched three electronic databases (MEDLINE, EMBASE and CINAHL). We also undertook citation tracking of the included articles and searched for ongoing or unpublished trials using ClinicalTrials.gov and Theses Global.

ELIGIBILITY CRITERIA

Studies tracking concussion recovery in adolescent athletes.

RESULTS

15 782 records were identified. After initial title and abstract screening, we retrieved 87 studies for full-text screening, with 75 studies fulfilling the eligibility criteria and included in the review, comprising 13 107 participants (9480 male, 3615 female and 12 unreported), ranging in age from 5 to 19 years. 46 different outcome measures were used, with Post-Concussion Symptom Scale (n=42) and Immediate Post-Concussion Assessment and Cognitive Testing (n=21) the most common. Most outcome measures quantified aspects of sensorimotor function including balance, oculomotor function and cognition. Follow-up duration ranged from 7 days to 1 year. 60% of studies ceased follow-up assessments within 6 weeks post-SRC.

CONCLUSIONS

Adolescent SRC literature uses a wide range of outcome measures. Most research quantifies cognitive/fatigue domains in the acute/subacute stages post-SRC, using male participants. Other key domains such as anxiety/mood, migraine and key modifiers (cervical and sleep disturbance) are less well represented in the literature. Many of the outcome measures used in current research are associated with high cost and require highly qualified examiners, creating barriers to their implementation in some adolescent sporting environments.

STUDY REGISTRATION

https://doi.org/10.17605/OSF.IO/N937E.

Evolution of dizziness-related disability in children following concussion: a group-based trajectory analysis

OBJECTIVE

This study aimed to identify Dizziness-Related Disability (DRD) recovery trajectories in pediatric concussion and assess clinical predictors of disability groups.

MATERIALS AND METHODS

In this prospective cohort study, 81 children (8-17 years) diagnosed with an acute concussion took part in 3 evaluation sessions (baseline, 3-month, and 6-month). All sessions included the primary disability outcome, the Dizziness Handicap Inventory (DHI) to create the DRD recovery trajectories using group-based multi-trajectory modeling analysis. Each independent variable included general patients' characteristics, premorbid conditions, function and symptoms questionnaires, and clinical physical measures; and were compared between the trajectories with logistic regression models.

RESULTS

Low DRD (LD) trajectory (n = 64, 79%), and a High DRD (HD) trajectory (n = 17, 21%) were identified. The Predicting and Preventing Postconcussive Problems in Pediatrics (5P) total score (Odds Ratio (OR):1.50, 95% Confidence Interval (CI): 1.01-2.22), self-reported neck pain (OR:7.25, 95%CI: 1.24-42.36), and premorbid anxiety (OR:7.25, 95%CI: 1.24-42.36) were the strongest predictors of belonging to HD group.

CONCLUSIONS

Neck pain, premorbid anxiety, and the 5P score should be considered initially in clinical practice as to predict DRD at 3 and 6-month. Further research is needed to refine predictions and enhance personalized treatment strategies for pediatric concussion.

Neck Symptoms and Associated Clinical Outcomes in Patients Following Concussion

OBJECTIVE

To examine the frequency and association of neck pain symptoms in patients with a concussion.

STUDY SETTING AND PARTICIPANTS

Three-hundred and thirty-one consecutively enrolled patients aged 9 to 68 years with a diagnosed concussion 1 to 384 days post-injury were enrolled at a concussion clinic from a single integrated healthcare system in Western Pennsylvania between 2019 and 2021.

DESIGN

Retrospective cohort analysis of prospectively collected concussion screening tool intake survey responses and clinical outcomes data. The primary outcome was self-reported neck pain or difficulty with neck movement on the Concussion Clinical Profiles Screening (CP Screen) tool, recovery time, and incidence of treatment referral. Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) composite scores, Vestibular/Ocular Motor Screening (VOMS) item scores, type and severity of neck symptoms, mechanism of injury, time from injury to clinic presentation, medical history, and concussion symptom profile were secondary outcomes.

RESULTS

Of the 306 consecutively enrolled eligible patients in the registry, 145 (47%) reported neck pain, 68 (22.2%) reported difficulty moving their neck, and 146 (47.7%) reported either symptom. A total of 47 (15.4%) participants reported more severe neck symptoms, and this group took longer to recover (40 ± 27 days) than those not reporting neck symptoms (30 ± 28 days; U = 8316, P < .001). Stepwise logistic regression predicting more severe neck symptoms was significant (Nagelkerke R2 = 0.174, χ 2 = 9.315, P = .316) with older age ( P = .019) and mechanism of injury including motor vehicle collisions (MVCs) ( P = .047) and falls ( P = .044) as risk factors. MVCs and falls were associated with over 4 times and 2 times greater risk, respectively, for reporting more severe neck symptoms.

CONCLUSION

Neck pain and stiffness symptoms are common in patients with a concussion following high-energy mechanisms of injury including MVCs or falls from height. These symptoms are associated with prolonged recovery. Providers should evaluate neck symptoms and consider targeted treatment strategies to limit their effects in patients with a concussion.

Multisystem recovery after sport-related concussion in adolescent rugby players: a prospective study protocol

INTRODUCTION

Sport-related concussion is one of the most common injuries in adolescent rugby players with evidence of prolonged recovery in some concussed athletes. Concussion is a complex pathophysiological process that can affect a variety of subsystems with multifactorial presentation. Most research on adolescents recovery after concussion focuses on neurocognitive functioning and symptom outcomes over the short term. There is a need to explore concussion recovery over time across multiple subsystems in adolescent rugby players.

METHODS AND ANALYSIS

This prospective study will use sensorimotor and oculomotor outcomes in adolescent male and female rugby players aged 16-18 years. Players will be recruited from school or club rugby teams across the province of Ulster. Baseline assessment will be undertaken at the start of the playing season and will include questionnaires, Quantified Y Balance Test and Pupillary Light Reflex. Players who sustain a concussive event will be reassessed on all outcomes at 3 days, 7 days, 14 days, 23 days, 90 days, 180 days and 365 days postconcussion. For serial outcome data, we will examine response curves for each participant and make comparisons between known groups. We will use logistic regression to explore any association between demographic variables and recovery. The strength of the predictive model will be determined using R2, p values and ORs, with 95% CIs.

ETHICS AND DISSEMINATION

Ethical approval has been granted for this study from Ulster University Research Ethics Committee (REC/14/0060). This study will be published in an open-access research journal on completion.

TRIAL REGISTRATION NUMBER

ACTRN12622000931774p.

Beyond acute concussion assessment to office management: a systematic review informing the development of a Sport Concussion Office Assessment Tool (SCOAT6) for adults and children

OBJECTIVES

To systematically review the scientific literature regarding the assessment of sport-related concussion (SRC) in the subacute phase (3-30 days) and provide recommendations for developing a Sport Concussion Office Assessment Tool (SCOAT6).

DATA SOURCES

MEDLINE, Embase, PsycINFO, Cochrane CENTRAL, CINAHL, SPORTDiscus and Web of Science searched from 2001 to 2022. Data extracted included study design, population, definition of SRC diagnosis, outcome measure(s) and results.

ELIGIBILITY CRITERIA

(1) Original research, cohort studies, case-control studies, diagnostic accuracy and case series with samples >10; (2) SRC; (3) screening/technology that assessed SRC in the subacute period and (4) low risk of bias (ROB). ROB was performed using adapted Scottish Intercollegiate Guidelines Network criteria. Quality of evidence was evaluated using the Strength of Recommendation Taxonomy classification.

RESULTS

Of 9913 studies screened, 127 met inclusion, assessing 12 overlapping domains. Results were summarised narratively. Studies of acceptable (81) or high (2) quality were used to inform the SCOAT6, finding sufficient evidence for including the assessment of autonomic function, dual gait, vestibular ocular motor screening (VOMS) and mental health screening.

CONCLUSION

Current SRC tools have limited utility beyond 72 hours. Incorporation of a multimodal clinical assessment in the subacute phase of SRC may include symptom evaluation, orthostatic hypotension screen, verbal neurocognitive tests, cervical spine evaluation, neurological screen, Modified Balance Error Scoring System, single/dual task tandem gait, modified VOMS and provocative exercise tests. Screens for sleep disturbance, anxiety and depression are recommended. Studies to evaluate the psychometric properties, clinical feasibility in different environments and time frames are needed.

PROSPERO REGISTRATION NUMBER

CRD42020154787.

Vestibular Rehabilitation as an Early Intervention in Athletes Who are Post-concussion: A Systematic Review

Background

Sports-related concussions (SRC) are a common injury sustained by many athletes of all different age groups and sports. The current standard treatment is rest followed by aerobic activity. Minimal research has been done on the effects of vestibular rehabilitation for concussion treatment, especially in physical therapy practice.

Objective

The purpose of this study was to examine the effects of early intervention of vestibular rehabilitation (VRT) on an athlete's time to return to play compared to rest alone.

Study Design

Systematic Review.

Methods

Two searches were conducted (August 2021 and January 2022) using databases: CINAHL complete, MEDLINE, PubMed, and Wiley online database. One hand search was performed to find relevant articles. Search terms included "vestibular rehabilitation" or "vestibular therapy" and "concussion" or "mild traumatic brain injury" or "mTBI" and "athletes" or "sports" or "athletics" or "performance", and "early interventions" or "therapy" or "treatment". Inclusion criteria were athletes with a SRC, incorporation of vestibular rehabilitation in athletes' recovery, and early vestibular intervention tools. Tools used to assess quality and risk of bias were the PEDro scale and the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence. The PRISMA method for determining inclusion and exclusion criteria.

Results

Eleven articles were included, six randomized control trials and five retrospective cohort studies. Various balance interventions, visual interventions utilizing vestibulo-ocular reflex (VOR), and cervical manual therapy were used during VRT for athletes' post-concussion. Incorporating visual interventions and cervical manual therapy into early rehabilitation significantly reduced symptoms and time to return to sport. However, balance interventions did not have a significant effect on reducing time to return to sport when used as a sole intervention.

Conclusion

Addressing VRT deficits in the acute stages of a concussion may contribute to a quicker resolution of symptoms and a quicker return to sport. More research needs to be performed to determine the effectiveness of early intervention of VRT in concussion recovery.

Level of Evidence

1.

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.

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

OBJECTIVE

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

DESIGN

Cross-sectional.

SETTING

Sports medicine clinic.

PATIENTS

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

INDEPENDENT VARIABLE

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

OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

Acute effects of concussion among adolescents with attention-deficit/hyperactivity disorder

Adolescents with ADHD have a greater lifetime history of concussion and experience concussion-like symptoms in the absence of a concussion, complicating concussion assessment and management. It is well established that individuals who experience greater acute symptoms following concussion are at risk for slower recovery and persistent symptoms. We examined whether youth with ADHD experience worse acute effects, within the first 72 h following concussion, compared to youth without ADHD. We hypothesized that youth with ADHD would perform worse on neurocognitive testing and endorse more severe symptoms acutely following injury, but the magnitude of change from pre injury to post injury would be similar for both groups, and thus comparable to baseline group differences. The sample included 852 adolescents with pre-injury and post-injury ImPACT results (within 72 h); we also conducted supplementary case-control analyses on a subset of youth with and without ADHD matched on demographics and pre-injury health history. For both samples, there were significant interaction effects for the Verbal Memory and Visual Motor Speed composites (p < 0.01, η²=.01-.07, small-medium effect), such that youth with ADHD showed a greater magnitude of diminished cognitive functioning from pre-injury to post-injury testing. There were no significant differences in the magnitudes of changes from pre injury to post injury with regard to overall symptom reporting (i.e., total symptom severity scores, total number of symptoms endorsed); however, there were group differences in endorsement rates for several individual symptoms. Further research is needed to determine whether such differential acute effects are associated with recovery time in youth with ADHD.

Assault-Related Concussion in a Pediatric Population

OBJECTIVES

The aim of this study was to compare demographic characteristics, medical care, and outcomes among patients with assault-related concussion (ARC) versus sports and recreation-related concussion (SRC).

METHODS

We conducted a retrospective chart review of 124 patients (62 ARC, 62 SRC) aged 8 to 17 years presenting to the care network of a large tertiary care pediatric hospital between July 1, 2012, and June 30, 2014 with a concussion diagnosis at time of presentation. We abstracted patient demographics, initial medical care visit characteristics, and outcome data, and compared proportions using χ2 testing and Fisher exact test and medians using Wilcoxon rank sum test.

RESULTS

Patients with ARC were more likely to be Black, publicly insured, and present first for care to the emergency department. Significantly fewer patients with ARC received visio-vestibular testing at initial visit (27% vs 74%, P < 0.001). During recovery, the total number of reported physical, cognitive, emotional, and sleep symptoms did not differ between groups; however, more than twice as many patients with ARC reported decline in grades postinjury compared with patients with SRC (47% vs 20%, P = 0.012). There were trends toward prolonged symptom recovery and time to physician clearance for full return to activities among patients with ARC compared with SRC.

CONCLUSIONS

This study highlights potential disparities in the initial evaluation and outcomes of pediatric concussion patients based on mechanism of injury. Patients with ARC were less likely to receive a concussion-specific diagnostic evaluation and reported a greater impact on educational outcomes, suggesting differences in concussion diagnosis and management among assault-injured patients. Further examination in larger populations with prospective studies is needed to address potential inequities in concussion care and outcomes among patients with ARC.

Determining the Agreement Between Common Measures Related to Vestibulo-ocular Reflex Function After a Mild Traumatic Brain Injury in Children and Adolescents

•

A battery of complementary tests is needed to assess vestibulo-ocular reflex (VOR) in pediatric mild traumatic brain injury (mTBI).

•

This battery should include both symptom- and performance-based measures.

•

Best practice recommendation is needed for such a battery in clinical settings.

•

Cervical injury presence may influence symptoms induced during VOR testing.

•

There is value of assessing for cervical injury post pediatric mTBI.

Objective

To (1) determine the level of agreement between symptom provocation and performance-based tests of vestibulo-ocular reflex (VOR) function after pediatric mild traumatic brain injury (mTBI) and (2) describe the level of symptom provocation induced by a VOR task in individuals with and without cervical findings.

Design

Cross-sectional.

Setting

This study was conducted at a tertiary care pediatric hospital.

Participants

A total of 101 participants (N=101) aged 6-18 years within 3 weeks of mTBI diagnosis were included (54.5% female; mean age, 13.92±2.63 years; mean time since injury at assessment, 18.26±6.16 days).

Interventions

None.

Main Outcome Measures

Symptom provocation (Vestibular/Ocular Motor Screening tool), performance (clinician-observed VOR performance, head thrust test [HTT], computerized dynamic visual acuity test, video head impulse test), and cervical impairment (cervical flexion-rotation test, range of motion test, self-reported neck pain). Agreement was evaluated using Cohen's κ statistic.

Results

No outcomes demonstrated agreement with symptom provocation (κ=−0.15 to 0.14). Fair agreement demonstrated between clinician-observed VOR performance and HTT (κ=0.32), with little to no agreement demonstrated between other measures. Proportions reporting test-induced dizziness and headache were greater among individuals with cervical findings (29.1%-41.8%) than without (2.3%-6.8%).

Conclusions

Findings support that symptom provocation and performance-based tests measure different constructs and thus have distinct roles when assessing VOR function. Findings suggest results from measures of symptom provocation may be influenced by coexisting cervical impairments, underlining the value of assessing for cervical injury after pediatric mTBI.

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.

Intelligent Recognition of Sports Players' Wrong Actions in view of Computer Pattern Recognition

In the context of the vigorous development of the sports industry and rapid technological innovation, the wrong actions of sports athletes can also be intelligently recognized. Human action recognition based on computer pattern recognition is becoming more and more popular and ubiquitous in life. This article aims to study how to recognize the human body based on the computer model and how to apply intelligent recognition to the wrong actions of sports athletes. The study of the application of intelligent recognition to the wrong actions of sports athletes is of great significance to sports athletes. This article proposes how to intelligently recognize the wrong actions of sports athletes based on computer pattern recognition. In the experiment in this article, wrong sports actions can cause a series of undesirable consequences, such as joint sprains and muscle damage. Among them, the proportion of joint damage caused by wrong actions has reached 24% and has been rising with the increase of the number of experiments and finally reached 35%, which shows that the probability is still very high. After the pull-up adopts intelligent recognition, the error of the pull-up action can be quickly identified and corrected in time, with the correct rate reaching 78%. Therefore, in order to reduce the physical damage caused by sports athletes' wrong movements, it is necessary to study the intelligent recognition of sports athletes' wrong movements. The recognition of wrong actions of sports athletes can be carried out through intelligent recognition based on 3D convolutional neural networks, which is of great significance to intelligent recognition.

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.

Clinical Outcome Following Sport-Related Concussion Among Children and Adolescents with a History of Prior Concussion: A Systematic Review

Authoritative sources advise clinicians and parents that a history of prior concussion confers increased risk for worse outcome from a future concussion. However, the strength of the evidence supporting such pronouncements and thus the extent to which clinicians should incorporate this information into their care and management of pediatric concussion is unclear. This systematic review critically analyzed and synthesized the literature on the association between a history of prior concussion and prognosis/clinical outcome following a subsequent sport-related concussion among children and adolescents. The online databases PubMed, MEDLINE®, PsycINFO®, CINAHL, Cochrane Library, EMBASE, SPORTDiscus, Scopus, and Web of Science were searched from inception to May 15, 2021. From 5,118 total records screened, 51 studies (46 cohort studies and 5 case-control studies) met inclusion criteria, reporting concussion recovery or outcome for 26,643 youth. A median of 36% had a prior history of concussion. Across all studies and outcomes, the majority (k=37, 72.5%) did not find a statistically significant association between lifetime history of concussion and outcome from a subsequent concussion. Important methodological limitations in the literature were identified. Available studies do not provide consistent or compelling evidence that children and adolescents with a history of concussions are at increased risk for worse clinical outcome following a subsequent sport-related concussion-although methodological limitations temper the strength of this conclusion. Clinicians are cautioned against routinely treating children and adolescents with one or more prior injuries differently, and more conservatively, because doing so, in some cases, might be counterproductive.

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.

Sensorimotor system changes in adolescent rugby players post-concussion: A prospective investigation from the subacute period through to return-to-sport

BACKGROUND

The pathophysiology of concussion is complex. Altered sensorimotor function post-concussion may contribute to the wide range of symptoms and impairments reported. There is currently limited evidence documenting changes in sensorimotor function during the recovery period. The aim of this study was to investigate the effect of concussion on the sensorimotor system in adolescents post-concussion using a multifaceted approach.

STUDY DESIGN

Prospective nested case-control study.

METHODS

A total of 285 male adolescent rugby players underwent assessment of sensorimotor function during preseason. Players who sustained a concussion during the season and control players, matched for age and playing position, were assessed in the subacute period (3-5 days) and after return-to-sport (3 weeks). Tests of sensorimotor function included balance, cervical spine and vestibulo-ocular function, and measurement of the size and contraction of lumbopelvic muscles (ultrasound imaging).

RESULTS

Twenty-three players (8%) sustained a concussion. Of these, 20 players were assessed during the subacute period and 17 players following return-to-sport. The prevalence of vestibulo-ocular dysfunction increased from 38.9% to 72.2% during the subacute period and dysfunction was present in 83.3% of players after return-to-sport (p = 0.01). Changes in lumbar multifidus muscle size (p = 0.002) and thickness (p = 0.05) at the L5 vertebral level were observed. No statistically significant changes in balance, cervical spine proprioception, or contraction of lumbopelvic muscles were found (p > 0.05).

CONCLUSION

Changes in sensorimotor function were observed in the subacute period post-concussion, with some persisting after return-to-sport. Using symptom-based criteria for return-to-sport may not adequately reflect the sequelae of concussion on the sensorimotor system.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Review of wearable technologies and machine learning methodologies for systematic detection of mild traumatic brain injuries

Mild traumatic brain injuries (mTBIs) are the most common type of brain injury. Timely diagnosis of mTBI is crucial in making 'go/no-go' decision in order to prevent repeated injury, avoid strenuous activities which may prolong recovery, and assure capabilities of high-level performance of the subject. If undiagnosed, mTBI may lead to various short- and long-term abnormalities, which include, but are not limited to impaired cognitive function, fatigue, depression, irritability, and headaches. Existing screening and diagnostic tools to detect acute andearly-stagemTBIs have insufficient sensitivity and specificity. This results in uncertainty in clinical decision-making regarding diagnosis and returning to activity or requiring further medical treatment. Therefore, it is important to identify relevant physiological biomarkers that can be integrated into a mutually complementary set and provide a combination of data modalities for improved on-site diagnostic sensitivity of mTBI. In recent years, the processing power, signal fidelity, and the number of recording channels and modalities of wearable healthcare devices have improved tremendously and generated an enormous amount of data. During the same period, there have been incredible advances in machine learning tools and data processing methodologies. These achievements are enabling clinicians and engineers to develop and implement multiparametric high-precision diagnostic tools for mTBI. In this review, we first assess clinical challenges in the diagnosis of acute mTBI, and then consider recording modalities and hardware implementation of various sensing technologies used to assess physiological biomarkers that may be related to mTBI. Finally, we discuss the state of the art in machine learning-based detection of mTBI and consider how a more diverse list of quantitative physiological biomarker features may improve current data-driven approaches in providing mTBI patients timely diagnosis and treatment.

Vestibular, Oculomotor, and Balance Functions in Children With and Without Concussion

OBJECTIVE

The main objective of this study was to assess whether objective vestibular, oculomotor, and balance functions were impaired in children with a current diagnosis of concussion with vestibular and/or ocular symptoms.

SETTING

Data were collected in a vestibular/ocular clinical laboratory. Patient participants were recruited from a concussion clinic in a children's hospital.

PARTICIPANTS

Thirty-three children aged 8 to 17 years with a current diagnosis of concussion and vestibular and/or ocular symptoms and 30 children without concussion.

DESIGN

Cross-sectional single-visit study.

MAIN OUTCOME MEASURES

Eye-tracking rotary chair oculomotor and vestibular measures, vestibular evoked potentials, and static posturography.

RESULTS

There were no statistically significant differences on any clinical measure between children with concussion and children without concussion. Younger children without concussion performed significantly worse on several rotary chair and balance measures compared with older children without concussion.

CONCLUSIONS

No vestibular, oculomotor, or balance measures were significantly different between children with concussion and children without concussion, suggesting these measures may not be useful in the evaluation of a child with concussion and vestibular and/or oculomotor symptoms. Future research should investigate age effects and other vestibular and oculomotor tests to identify objective findings that better relate to vestibular and/or ocular symptoms in children with concussion.

Pre-participation Vision Screening and Comprehensive Eye Care in National Collegiate Athletic Association Athletes

SIGNIFICANCE

Pre-participation physical evaluation and its vision screenings have been the mainstay of medical clearance for competitive play for decades. The ability of screening to address athlete's sports-specific vision needs is unknown.

METHODS

Fifty-eight intercollegiate football players consented to participate in a comprehensive, sports-specific eye examination in addition to the standard pre-participation vision screening. Sensitivity, specificity, and positive and negative predictive values were determined for screening's ability to detect athletes whose vision might improve with correction, athletes who had significant ocular findings that impact safety, and either of the two conditions together. The effect no recent eye examination added to pre-participation vision screening results was evaluated for change in screening yield. Descriptive statistics of the cohort and associations with no recent comprehensive eye examination were generated.

RESULTS

The pre-participation vision screening was able to identify three athletes not meeting visual acuity requirements for medical clearance to play without a comprehensive assessment. A failed screening was poorly able to identify athletes who might benefit from improved acuity (sensitivity, 9.1%; specificity, 100%), have sports-specific significant ocular findings (sensitivity, 10.5%; specificity, 97.3%), or have either together (sensitivity, 7.5%; specificity, 100%). Sixty percent (33/55) of athletes reported never having a comprehensive examination or one within the last 10 years. Fifty-eight percent (34/58) had improved best-corrected visual acuity after comprehensive examination, and 81% (47/58) had improved acuity or a sports-specific significant finding.

CONCLUSIONS

The pre-participation vision screening was largely able to identify athletes meeting the minimum visual acuity requirement for athlete clearance. It poorly identified those who might benefit from improved vision with refractive correction and those in whom sport-specific significant eye findings were noted. Comprehensive eye care had a clear benefit for the majority of athletes tested. This benefit needs to be balanced with the potential added costs and time constraints to players and athletic department staff.

Contributions of PCSS, BESS, Tandem Gait, and Romberg Test for Identifying Balance Deficits in Pediatric Concussions

OBJECTIVE

Balance deficits are common after concussions in pediatric patients. This study evaluates 3 clinical tools for identifying postconcussion balance deficits in a pediatric population: (1) Post-Concussion Symptom Scale (PCSS); (2) Balance Error Scoring System (BESS); and (3) physical examination measures of balance: tandem gait (TG) and Romberg test.

SETTING

Data were collected in a tertiary care outpatient pediatric sports medicine clinic.

PARTICIPANTS

English-speaking patients aged 8 to 17 years who presented to a tertiary care hospital-based pediatric sports medicine clinic and diagnosed with concussion between August 2014 and February 2018 were invited to participate. A total of 614 patients were screened and/or approached during the inclusion period and 500 were enrolled. Of those enrolled, 423 patients had complete data collected and analyzed.

DESIGN

This is a cross-sectional, observational data set from a longitudinal, prospective study.

MAIN MEASURES

Data extracted from patients' electronic medical records included physical examination, PCSS, and BESS scores from their initial visit. Descriptive statistics were calculated for the outcome measures. A logistic regression was performed to evaluate significant contributors to abnormal BESS score (≥25).

RESULTS

There were 423 patients (56.7% female; 14.7 ± 2.01 years old) included in the study. Overall, we identified 336 patients (79.4%) with balance difficulties. Of the 336 with balance difficulties, 284 (84.5%) reported "balance problems" and/or "dizziness" on PCSS, 153 (45.5%) had abnormal BESS scores (≥25), and 100 (29.8%) had an abnormality on either TG or Romberg test.

CONCLUSION

Balance difficulties were identified in close to 80% of children with concussions. Using PCSS and BESS along with physical examination measures, TG and Romberg test, identified more patients with balance deficits than using TG and Romberg test alone.

Comparison of Dizziness Factors for Mild Traumatic Brain Injury Patients with and without Dizziness: A Factor Analysis and Propensity Score Model Study

Traumatic brain injury (TBI) causes major socioeconomic problems worldwide. In the United States, nearly three-quarters of patients with TBI have mild TBI (mTBI). 32% of these patients may develop dizziness. In this study, we analyzed the factor structure of the traditional Chinese version of the DHI and evaluate the differences in DHI factors between dizziness and nondizziness groups. In total, 315 patients with mTBI, comprising 158 with self-reported dizziness and 157 without dizziness, were recruited from three hospitals. The responses for Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Epworth Sleepiness Scale (ESS), and Pittsburgh Sleep Quality Index (PSQI) demonstrated between-group differences. The Chinese DHI had internal validity and had four factors that differed from the English version (3 aspects). The group effects for the physical subscale remained significantly different even after adjustments in the propensity score model. For the Chinese version, two of four factors remained significantly different in the effects between self-reported dizziness and nondizziness groups. The factors of our Chinese DHI differed from those of the original English version of DHI. After adjustments using the propensity score model, the physical subscale demonstrated significant differences between the self-reported dizziness and nondizziness groups. Only two factors from our Chinese DHI were significantly different; moreover, it contained only three physical, five functional, and three emotional items.

Clinical Outcomes of Pediatric Acute Sport- and Non-Sport-Related Concussions

OBJECTIVES

The objectives were to examine clinical characteristics, length of recovery, and the prevalence of delayed physician-documented recovery, compare clinical outcomes among those with sport-related concussion (SRC) and non-sport-related concussion (nSRC), and identify risk factors for delayed recovery.

METHODS

Included patients (8-18 years) were assessed ≤14 days post-injury at a multidisciplinary concussion program and diagnosed with an acute SRC or nSRC. Physician-documented clinical recovery was defined as returning to pre-injury symptom status, attending full-time school without symptoms, completing Return-to-Sport strategy as needed, and normal physical examination. Delayed physician-documented recovery was defined as >28 days post-injury.

RESULTS

Four hundred and fifteen patients were included (77.8% SRC). There was no difference in loss of consciousness (SRC: 9.9% vs nSRC: 13.0%, p = 0.39) or post-traumatic amnesia (SRC: 24.1% vs SRC: 31.5%, p = 0.15) at the time of injury or any differences in median Post-Concussion Symptom Scale scores (SRC: 20 vs nSRC: 23, p = 0.15) at initial assessment. Among those with complete clinical follow-up, the median physician-documented clinical recovery was 20 days (SRC: 19 vs nSRC: 23; p = 0.37). There was no difference in the proportion of patients who developed delayed physician-documented recovery (SRC: 27.7% vs nSRC: 36.1%; p = 0.19). Higher initial symptom score increased the risk of delayed physician-documented recovery (IRR: 1.39; 95% CI: 1.29, 1.49). Greater material deprivation and social deprivation were associated with an increased risk of delayed physician-documented recovery.

CONCLUSIONS

Most pediatric concussion patients who undergo early medical assessment and complete follow-up appear to make a complete clinical recovery within 4 weeks, regardless of mechanism.

Predicting Sport-related mTBI Symptom Resolution Trajectory Using Initial Clinical Assessment Findings: A Retrospective Cohort Study

OBJECTIVES

To identify which aspects of initial clinical assessment for sport-related mild traumatic brain injury (SR-mTBI) predict whether an athlete achieves symptom resolution within 14 days of the injury.

RESEARCH DESIGN

Retrospective cohort study using prospectively collected data.

METHODS

Clinical assessment data were collected from 568 patients diagnosed with SR-mTBI at a single medical clinic between February 2017 and December 2018. Demographic data, medical history, SCAT-5 testing, and physician notes were included in the data set. Data were processed and analysed to identify a shortlist of predictor variables to develop a logistic regression model to discriminate between SR-mTBI symptom resolution that occurred in ≤ 14-days or > 14-days. The data were randomly divided into model development and validation subsamples. The top 15 models were analysed to determine the predictor variables to be included in the final logistic regression model. The final model was then applied to the validation subsample.

RESULTS

Half of the athlete participants in this study experienced > 14-day symptom resolution. The final logistic regression model included sex, symptom reporting at initial assessment and presentation with a physiological predominant symptom cluster. The model accounted for 0.90 and 0.85 of the area under the curve and predicted recovery trajectory with 81% and 76% accuracy for the training and validation subsamples, respectively.

CONCLUSIONS

Being female, reporting a higher Positive Symptom Total at initial assessment, and being less likely to have a physiological predominant symptom cluster at initial assessment predicted > 14 versus ≤ 14-day SR-mTBI symptom resolution with a high level of accuracy.

Examining Criteria for Defining Persistent Post-concussion Symptoms in Children and Adolescents

Researchers operationalize persistent post-concussion symptoms in children and adolescents using varied definitions. Many pre-existing conditions, personal characteristics, and current health issues can affect symptom endorsement rates in the absence of, or in combination with, a recent concussion, and the use of varied definitions can lead to differences in conclusions about persistent symptoms and recovery across studies. This study examined how endorsement rates varied by 14 different operational definitions of persistent post-concussion symptoms for uninjured boys and girls with and without pre-existing or current health problems. This cross-sectional study included a large sample (age range: 11–18) of girls (n = 21,923) and boys (n = 26,556) without a recent concussion who completed the Post-Concussion Symptom Scale at preseason baseline. Endorsements rates varied substantially by definition, health history, and current health issues. The most lenient definition (i.e., a single mild symptom) was endorsed by most participants (54.5% of boys/65.3% of girls). A large portion of participants with pre-existing mental health problems (42.7% of boys/51.5% of girls), current moderate psychological distress (70.9% of boys/72.4% of girls), and insufficient sleep prior to testing (33.4% of boys/47.6% of girls) endorsed symptoms consistent with mild ICD-10 postconcussional syndrome; whereas participants with no current or prior health problems rarely met this definition (1.6% of boys/1.6% of girls). The results illustrate the tremendous variability in the case definitions of persistent symptoms and the importance of harmonizing definitions across future studies.

Contributions of PCSS, CISS, and VOMS for Identifying Vestibular/Ocular Motor Deficits in Pediatric Concussions

BACKGROUND

Vestibular/ocular motor dysfunction can occur in pediatric concussions, which can impair reading, learning, and participation in athletics. This study evaluated 3 clinical tools for identifying postconcussion vestibular/ocular motor dysfunction: (1) Post-Concussion Symptom Scale (PCSS), (2) Convergence Insufficiency Symptom Survey (CISS), and (3) Vestibular/Ocular Motor Screening (VOMS).

HYPOTHESIS

Evaluating vestibular/ocular motor dysfunction with multiple clinical tools will capture more symptomatic patients than any 1 tool alone.

STUDY DESIGN

Cross-sectional data from a prospective cohort study.

LEVEL OF EVIDENCE

Level 4.

METHODS

Patients were between 8 and 17 years old and seen in a tertiary care pediatric sports medicine clinic between August 2014 and February 2018. Data were collected from initial visit and included VOMS, PCSS, and CISS. Descriptive statistics, Pearson's correlations, and logistic regressions were used to describe relationships between clinical tools.

RESULTS

Of the 156 patients (55.1% female; 14.35 ± 2.26 years old) included, this study identified 129 (82.7%) with vestibular/ocular motor dysfunction. Of these 129, 65 (50.4%) reported "visual problems" on PCSS, 93 (72.1%) had abnormal CISS, and 99 (76.7%) had abnormal VOMS. Together, VOMS and CISS identified 64 (49.6%) patients without reported "visual problems" on PCSS. Higher total PCSS scores predicted abnormal CISS (odds ratio [OR], = 1.11; 95% CI, 1.07-1.17) and abnormal VOMS (OR, 1.03; 95% CI, 1.01-1.06). "Visual problems" on PCSS did not predict abnormal CISS or VOMS.

CONCLUSIONS

Vestibular/ocular motor dysfunction were identified in nearly 83% of study subjects when PCSS, CISS, and VOMS are used together.

CLINICAL RELEVANCE

These results suggest adding CISS and VOMS to the clinical evaluation of concussions can help clinicians identify post-concussion vestibular/ocular motor dysfunction.

Vestibular-ocular reflex dysfunction following mild traumatic brain injury: A narrative review

Mild traumatic brain injury (mTBI) is a prevalent injury which occurs across many populations, including children and adolescents, athletes, military personnel, and the elderly. mTBI can result in various subjective symptoms and clinical deficits, such as abnormalities to the vestibulo-ocular reflex (VOR). Over 50% of individuals with mTBI are reported to have VOR abnormalities, which strongly contribute to feelings of dizziness and unsteadiness. Dizziness is a strong predictor for prolonged recovery following mTBI and is additionally linked with mental health difficulties and functional limitations affecting likelihood of return to work. Early diagnosis, and subsequent treatment, of VOR deficits following mTBI may greatly improve recovery outcomes and a patient's quality of life, but a thorough comprehension of the related pathophysiology is necessary to understand the assessments used to diagnose VOR abnormalities. Therefore, the purpose of this article is i) provide readers with an introduction on the VOR physiology to facilitate understanding about mTBI-related abnormalities, and ii) to discuss current assessments that are commonly used to measure VOR function following mTBI. As the VOR and oculomotor (OM) systems are heavily linked and often work in tandem, discussion of the relevant aspects of the OM system is also provided.

Derivation of a Focused, Brief Concussion Physical Examination for Adolescents With Sport-Related Concussion

OBJECTIVE

To describe the derivation of a brief but pertinent physical examination (PE) for adolescents who have sustained sport-related concussion (SRC).

DESIGN

Prospective cohort.

SETTING

University concussion management clinic.

PARTICIPANTS

Acutely concussed (AC, n = 52, 15.5 ± 1.4 years, 4.4 ± 2 days since injury, 26.2 ± 38 days to recovery, 71% males) and healthy control (HC) adolescents (n = 30, 15.8 ± 1.4 years, 73% males).

INTERVENTION

Acutely concussed had a PE on visit 1 and were retested at visit 2 (13.6 ± 1 day after visit 1). Acutely concussed were further characterized as normal recovery (NR, n = 41, 15.5 ± 1.5 years, recovery time 13.0 ± 7 days) and delayed recovery (DR, n = 11, 15.5 ± 1.2 years, recovery time 75.4 ± 63 days).

MAIN OUTCOME MEASURE

Physical examination findings, including cervical, vestibular, and oculomotor systems.

RESULTS

Visit 1 abnormal PE signs were significantly greater in AC versus HC (2.79 ± 2.13 vs 0.07 ± 0.37, P < 0.0001) but not in NR versus DR (2.61 ± 2.2 vs 3.45 ± 1.8, P = 0.246). Visit 2 abnormal PE signs differentiated NR versus DR (0.17 ± 0.7 vs 2.45 ± 2.1, P < 0.0001).

CONCLUSIONS

A brief focused PE can help to diagnose SRC, establish recovery, and may have prognostic value.

First-time sports-related concussion recovery revisited: management changes and impact on recovery

Context

Concussion is among the most common injuries in athletes. Over the past 10 years, concussion knowledge has expanded, and guidelines for management have changed. Recent changes include recommendations against strict mental and physical rest after sustaining a concussion, a better recognition of preexisting conditions predisposing protracted concussion recovery, and the addition of preliminary patient counseling and education about the expected course of concussion recovery.

Objective

To assess the impact of changes in concussion management on the duration of symptoms in middle school and high school athletes after sustaining a first-time, sports-related concussion.

Methods

A retrospective review was performed of medical records of athletes who sustained a concussion between 2016 and 2018 and were treated by the same primary care physician (J.M.N) using the revised approach to concussion management described. Patients were included if they were 11 to 18 years old and had a diagnosis of first-time concussion sustained while playing organized sports. Athletes who sustained a concomitant injury or sustained a concussion outside of organized sports were excluded from the study; athletes lost to follow-up or with incomplete forms were also excluded. Each athlete's length of symptomatic time from his or her concussion was calculated. This data was then compared with a previously-published data set of athletes who sustained a concussion between 2011 and 2013, with the same inclusion criteria but a different approach to concussion management.

Results

A total of 110 male and 72 female athletes (N=182) met the study's eligibility criteria. Collectively, athletes of both sexes from the 2016-2018 data set reported a higher incidence of preexisting conditions associated with prolonged concussion recovery compared with the data set of 2011-2013 athletes. However, both sexes from the 2016-2018 data set also reported a shorter median duration of concussion symptoms compared with the 2011-2013 athletes (median duration 5 vs. 11 days for male athletes and 7 vs. 28 days for female athletes, respectively; p<0.001).

Conclusion

Recent changes in concussion management have led to decreased duration of symptoms among 11- to 18-year-old athletes with first-time, sports-related concussions. These management changes include advocating for early activity, recognizing preexisting conditions, and educating athletes about the realities of concussion recovery.

Preliminary clinical algorithm to optimise remote delivery of paediatric concussion care in Canada's North

Concussion is a form of traumatic brain injury that affects thousands of children and adolescents across Canada annually. With timely access to comprehensive medical care, the majority of patients with acute concussion will recover within 1–4 weeks. Those who develop persistent post-concussion symptoms often benefit from early recognition and referral to multi-disciplinary concussion clinics that have the personnel and resources to meet their complex needs. Youth who live in remote and isolated communities within Canada’s North, a significant proportion of whom are Indigenous, face unique barriers and obstacles to accessing primary and specialised concussion care. Although telemedicine has recently emerged as a tool that can help address these gaps in care, there are presently no clinical guidelines or tools available to assist multi-disciplinary concussion clinics in providing remote concussion care to these medically underserved patients. Here we incorporate literature from a scoping review and our early institutional experience to present an evidence-informed preliminary clinical algorithm and resources to help guide and optimise remote paediatric concussion care delivery in Canada’s North. We also discuss how innovative technologies and partnerships can be leveraged to enhance the delivery of safe, equitable, cost-effective and culturally appropriate care to these communities.

Systematic Review of Preinjury Mental Health Problems as a Vulnerability Factor for Worse Outcome After Sport-Related Concussion

Background:

It is difficult to predict who will experience prolonged health problems after sustaining a sport-related concussion.

Purpose:

To synthesize the literature and conduct a gap analysis on the association between preinjury mental health problems and clinical outcome from sport-related concussion.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

Data sources were PubMed, PsycINFO, MEDLINE (and MEDLINE in Process), CINAHL, Cochrane Library, EMBASE, SPORTDiscus, Scopus, and Web of Science. Studies published before February 2019 that addressed preinjury mental health problems as a possible predictor of worse clinical outcome or clinical recovery from concussion were eligible for inclusion.

Results:

Of 4013 studies screened, 358 full texts were reviewed, and 12 studies involving 3761 participants (n = 471 [12.5%] with preexisting mental health problems) were ultimately included. The participants with a preinjury history of mental health problems were at greater risk for having persistent symptoms or worse outcome in 9 of 12 studies. The studies had major methodological differences, and most studies were not focused on mental health as a primary predictor or prognostic factor. Rather, they included it as a secondary or tertiary predictor. The sample sizes with preinjury mental health problems in most studies were small or very small (ie, <25). The age of onset, type, course, severity, and duration of mental health problems were not defined. The extent to which mental health problems were present before the season, during baseline testing, was not reported.

Conclusion:

Preinjury mental health problems appear to confer risk for worse clinical outcome after sport-related concussion. Future research is needed to (1) examine this risk factor in large representative populations of middle school students, high school students, and collegiate athletes; (2) quantify the risk for each mental health condition; (3) understand the mechanisms underlying this increased risk; and (4) develop more refined treatment and rehabilitation approaches for these student-athletes.

Eye Tracking as a Biomarker for Concussion in Children

OBJECTIVE

Concussion is the most common type of brain injury in both pediatric and adult populations and can potentially result in persistent postconcussion symptoms. Objective assessment of physiologic "mild" traumatic brain injury in concussion patients remains challenging. This study evaluates an automated eye-tracking algorithm as a biomarker for concussion as defined by its symptoms and the clinical signs of convergence insufficiency and accommodation dysfunction in a pediatric population.

DESIGN

Cross-sectional case-control study.

SETTING

Primary care.

PATIENTS

Concussed children (N = 56; mean age = 13 years), evaluated at a mean of 22-week post-injury, compared with 83 uninjured controls.

INDEPENDENT VARIABLES

Metrics comparing velocity and conjugacy of eye movements over time were obtained and were compared with the correlation between Acute Concussion Evaluation (ACE) scores, convergence, and accommodation dysfunction.

MAIN OUTCOME MEASURES

Subjects' eye movements recorded with an automated eye tracker while they watched a 220-second cartoon film clip played continuously while moving within an aperture.

RESULTS

Twelve eye-tracking metrics were significantly different between concussed and nonconcussed children. A model to classify concussion as diagnosed by its symptoms assessed using the ACE achieved an area under the curve (AUC) = 0.854 (71.9% sensitivity, 84.4% specificity, a cross-validated AUC = 0.789). An eye-tracking model built to identify near point of convergence (NPC) disability achieved 95.8% specificity and 57.1% sensitivity for an AUC = 0.810. Reduced binocular amplitude of accommodation had a Spearman correlation of 0.752(P value <0.001) with NPC.

CONCLUSION

Eye tracking correlated with concussion symptoms and detected convergence and accommodative abnormalities associated with concussion in the pediatric population. It demonstrates utility as a rapid, objective, noninvasive aid in the diagnosis of concussion.

Attention-Deficit/Hyperactivity Disorder and Outcome After Concussion: A Systematic Review

OBJECTIVE

To synthesize the literature and conduct a gap analysis on the association between attention-deficit/hyperactivity disorder (ADHD) and clinical outcome from sport-related concussion.

METHOD

The electronic search for this systematic review (PROSPERO ID: CRD42019128281) was conducted in February 2019 using terms related to concussion, sports/athletics, and predictors/modifiers of outcome to search the PubMed, PsycINFO, MEDLINE, CINAHL, Cochrane Library, EMBASE, SPORTDiscus, Scopus, and Web of Science databases. Eligible studies evaluated the association between ADHD and outcome from sport-related concussion. Of 4014 studies screened, 359 full-text articles were reviewed, with 14 studies ultimately included, involving 3623 participants (n = 359 [9.9%] with ADHD).

RESULTS

Study samples were primarily from specialty medical clinics (57.1%) and high school or college athletic groups (28.6%). Only 2 studies reported a statistically significant association between ADHD and worse clinical outcome. Of these, 1 included 13 participants with ADHD and the other included only 8 participants with ADHD. Only 1 previous study in this review was designed specifically to examine ADHD and prolonged concussion recovery, and that study did not report a statistically significant association.

CONCLUSION

There is not a clear association between ADHD and worse clinical outcome from concussion. However, eligible studies had limitations in research design, and nearly all studies were underpowered and evaluated the association between ADHD and concussion outcome as a secondary focus rather than the primary research question, precluding definitive conclusions. The association between ADHD and clinical outcomes remains unclear, and future research specifically examining ADHD and concussion recovery is needed.

Reliability of Objective Eye-Tracking Measures Among Healthy Adolescent Athletes

OBJECTIVE

To determine the test-retest correlation of an objective eye-tracking device among uninjured youth athletes.

DESIGN

Repeated-measures study.

SETTING

Sports-medicine clinic.

PARTICIPANTS

Healthy youth athletes (mean age = 14.6 ± 2.2 years; 39% women) completed a brief, automated, and objective eye-tracking assessment.

INDEPENDENT VARIABLES

Participants completed the eye-tracking assessment at 2 different testing sessions.

MAIN OUTCOME MEASURES

During the assessment, participants watched a 220-second video clip while it moved around a computer monitor in a clockwise direction as an eye tracker recorded eye movements. We obtained 13 eye movement outcome variables and assessed correlations between the assessments made at the 2 time points using Spearman's Rho (rs).

RESULTS

Thirty-one participants completed the eye-tracking evaluation at 2 time points [median = 7 (interquartile range = 6-9) days between tests]. No significant differences in outcomes were found between the 2 testing times. Several eye movement variables demonstrated moderate to moderately high test-retest reliability. Combined eye conjugacy metric (BOX score, rs = 0.529, P = 0.008), the variance of the ratio for both eye movements in the horizontal (rs = 0.497, P = 0.013) and vertical (rs = 0.446; P = 0.029) movement planes along the top/bottom of the computer screen, and the variance of the left and right eye movement along the bottom segment of the computer screen (rs = 0.565; P = 0.004) each demonstrated moderate between-test correlations.

CONCLUSIONS

Automated and quantitative eye movement and conjugacy metrics provide relatively stable measurements among a group of healthy youth athletes. Thus, their inclusion as a visual tracking metric may be complementary to other visual examination techniques when monitoring concussion recovery across time.

Benign Paroxysmal Positional Vertigo After Pediatric Sports-Related Concussion

OBJECTIVE

Report the clinical findings and outcomes among pediatric patients diagnosed with benign paroxysmal positional vertigo (BPPV) after sports-related concussion (SRC).

DESIGN

Retrospective case series.

SETTING

Multidisciplinary pediatric concussion program.

PATIENTS

Patients younger than 19 years with a sport or recreation activity-related concussion referred for comprehensive vestibular physiotherapy assessment.

MAIN OUTCOME MEASURE

Symptom resolution after targeted particle repositioning (PR).

RESULTS

During the study period, 115 pediatric SRC patients underwent vestibular physiotherapy assessment including 12 (10.4%) who were diagnosed with BPPV. Unilateral posterior semicircular canal (SCC) BPPV was diagnosed in 8/12 (75%) patients, and unilateral anterior SCC BPPV diagnosed in 4/12 (25%) patients. Benign paroxysmal positional vertigo was successfully treated in all patients with a mean of 1.58 targeted PR maneuvers (range = 1-4).

CONCLUSIONS

Comprehensive management of pediatric SRC requires a multidisciplinary approach to address the heterogeneous pathophysiology of persistent postconcussion symptoms. Pediatric SRC patients with coexisting BPPV should be considered for targeted PR.

Eye Movements, Dizziness, and Mild Traumatic Brain Injury (mTBI): A Topical Review of Emerging Evidence and Screening Measures

BACKGROUND AND PURPOSE

Eye movements may be adversely affected after mild traumatic brain injury (mTBI) and should be examined. The purpose of this topical review is to provide the clinician with the most up-to-date knowledge related to eye movement abnormalities, screening measures, and evidence related to exercise interventions that are designed to enhance outcomes in persons after mTBI.

SUMMARY OF KEY POINTS

Presence of eye misalignment such as tropias or phoria or symptoms with head/eye movements such as vestibulo-ocular reflex (VOR) × 1, saccades, or smooth pursuits may slow the person's recovery. Tools such as the Convergence Insufficiency Symptom Survey, the Vestibular/Ocular Motor Screening, the Pediatric Vestibular Symptom Questionnaire, and the Pediatric Visually Induced Dizziness questionnaire may aid in identifying visual concerns to target in the physical therapy intervention program. There is emerging evidence that vestibular rehabilitation enhances recovery in persons after mTBI.

RECOMMENDATIONS FOR CLINICAL PRACTICE

A thorough eye examination is highly recommended after mTBI to identify targeted areas for intervention.

Reliability of the visio-vestibular examination for concussion among providers in a pediatric emergency department

BACKGROUND

Visio-vestibular examination (VVE) deficits are common following pediatric concussion. Guidelines recommend assessing these deficits on all potentially concussed youth given their diagnostic and prognostic value, however test psychometrics of the VVE in the emergency department (ED) setting are unknown. Our objective was to determine the inter-rater (IRR) and test-retest reliability (TRR) of the VVE in a pediatric ED.

METHODS

We enrolled 155 patients (112 IRR; 43 TRR) age 6-18 years with head injury presenting to the ED of a tertiary care children's hospital. Exams were performed by a group of 65 attending/fellow physicians, pediatricians, and advanced practice providers. The VVE consisted of 9 maneuvers (smooth pursuits, horizontal/vertical saccades and gaze stability, binocular convergence, left/right monocular accommodation, complex tandem gait). Cohen's kappa was calculated for IRR and TRR for each element.

RESULTS

For IRR, 5/9 kappas (saccades, gaze stability, monocular accommodation) were in the moderate agreement range (0.40 to 0.60); remaining kappas showed fair agreement. For TRR, 6/9 maneuvers (saccades, horizontal gaze stability, monocular accommodation, tandem gait) showed substantial agreement (0.60 to 0.80). Kappas of 7/9 elements for subjects age 15-18 showed improved IRR and TRR.

CONCLUSIONS

The individual elements of the VVE show fair to moderate agreement between providers and moderate to substantial agreement among the same provider in the ED setting. These findings suggest a role in the VVE in evaluating concussion acutely, particularly given its previously demonstrated ability to assist in risk stratification of concussed youth and the importance of early diagnosis for improved outcomes.

Symptom Presentation After Concussion and Pre-existing Anxiety Among Youth Athletes

Our purpose was to evaluate the effect of self-reported pre-injury anxiety diagnosis on persistent symptom development, vestibular symptom severity, and balance control among youth who sustained a concussion. We performed a retrospective study of patients seen at a specialty pediatric concussion clinic. Patients were 18 years of age or younger, examined within 10 days of concussion, and received care until full recovery. A questionnaire was used to assess pre-existing medical and psychiatric conditions, including anxiety. Our main outcomes were prolonged symptom recovery defined as persistent symptoms for > 28 days after concussion) and severity of vestibular symptoms. Patients who reported pre-injury anxiety (n=43; median age=14.9 years; 37% female) were more likely to experience symptoms>28 days post-injury (76 vs. 54%; p=0.04) than those without pre-existing anxiety (n=241; median age=14.9 years; 53% female). After adjusting for sex, history of migraine, depression and ADHD, however, there was no independent association between pre-existing anxiety and prolonged symptom duration (adjusted odds ratio=2.34; 95% CI=0.083–6.63; p=0.11). Pre-existing anxiety was independently associated with self-reported nausea/vomiting severity (β coefficient=0.59, 95% CI=0.07–1.11). A pre-existing anxiety diagnosis does not appear to be associated with persistent symptoms after concussion, although it may be associated with post-injury nausea.

Correlation between Ocular and Vestibular Abnormalities and Convergence Insufficiency in Post-Concussion Syndrome

The vestibular and oculomotor/visual systems are commonly affected in post-concussion syndrome (PCS). Convergence insufficiency (CI) is the most common ocular abnormality after concussion. Electrovestibulography (EVestG) is a relatively new non-invasive method that measures the peripheral vestibular responses; it has shown abnormal vestibular responses in a PCS. Here, we report the results of investigating the correlation between the vestibular and oculomotor systems in PCS population using EVestG and CI measures. Forty-eight PCS patients were tested using EVestG, out of which 20 also completed the Rivermead post-concussion questionnaire (RPQ). An EVestG feature (Field Potential (FP)-area) was extracted from the stationary part of the EVestG signals. A neuro-ophthalmologist (author BM) measured participants' CI at near vision using cross-cover examination and a prism-bar. Results indicate: (1) vestibular abnormality (i.e. FP-area) and CI values are significantly correlated in PCS (R = 0.68, p < .01), and (2) there are significant correlations between severity of concussion (i.e. RPQ3) and CI (R = 0.70, p < .01) and between RPQ3 and FP-area (R = -0.56, p < .02). To the best of our knowledge, this is the first study that objectively demonstrates a significant positive correlation between the CI and vestibular systems' abnormality. These findings are scientifically important as they help localise the pathology of PCS, and are clinically valuable as they help physicians in their decision-making about PCS diagnosis and rehabilitation strategies.

Neurons in Subcortical Oculomotor Regions Are Vulnerable to Plasma Membrane Damage after Repetitive Diffuse Traumatic Brain Injury in Swine

Oculomotor deficits, such as insufficiencies in accommodation, convergence, and saccades, are common following traumatic brain injury (TBI). Previous studies in patients with mild TBI attributed these deficits to insufficient activation of subcortical oculomotor nuclei, although the exact mechanism is unknown. A possible cause for neuronal dysfunction in these regions is biomechanically induced plasma membrane permeability. We used our established porcine model of head rotational TBI to investigate whether cell permeability changes occurred in subcortical oculomotor areas following single or repetitive TBI, with repetitive injuries separated by 15 min, 3 days, or 7 days. Swine were subjected to sham conditions or head rotational acceleration in the sagittal plane using a HYGE pneumatic actuator. Two hours prior to the final injury, the cell-impermeant dye Lucifer Yellow was injected into the ventricles to diffuse throughout the interstitial space to assess plasmalemmal permeability. Animals were sacrificed 15 min after the final injury for immunohistological analysis. Brain regions examined for cell membrane permeability included caudate, substantia nigra pars reticulata, superior colliculus, and cranial nerve oculomotor nuclei. We found that the distribution of permeabilized neurons varied depending on the number and spacing of injuries. Repetitive injuries separated by 15 min or 3 days resulted in the most permeability. Many permeabilized cells lost neuron-specific nuclear protein reactivity, although no neuronal loss occurred acutely after injury. Microglia contacted and appeared to begin phagocytosing permeabilized neurons in repetitively injured animals. These pathologies within oculomotor areas may mediate transient dysfunction and/or degeneration that may contribute to oculomotor deficits following diffuse TBI.

Symptom Burden and Profiles in Concussed Children with and without Prolonged Recovery

Although symptom burden and symptom profile severity are independent predictors of post-concussion symptom duration, few studies have examined their effects on prolonged recovery simultaneously. This study examined differences in symptom burden and symptom profile scores between concussed children with prolonged recovery and those with typical recovery. We conducted a retrospective case-control study of concussed children aged 10–18 years. Prolonged recovery was defined as symptom duration beyond 28 days post-injury. Symptom burden was measured as total symptom score (TSS) at injury. Symptom profiles included: (1) vestibular, (2) ocular, (3) cognitive/fatigue, (4) migraine, and (5) anxiety. A total of 4380 unique concussions sustained by 3777 patients were included; 80.3% white, 60.0% male, and 44.0% aged 13–15 years. The prolonged recovery group had a significantly higher TSS and greater number of symptoms than the typical recovery group (p < 0.001 and p < 0.001, respectively). The prolonged recovery group had significantly higher scores on all five symptom profiles, including vestibular (p < 0.001), ocular (p < 0.001), cognitive/fatigue (p < 0.001), migraine (p < 0.001) and anxiety (p < 0.001), than the typical recovery group, even after adjusting for number of symptoms and other covariates. Further studies using prospective cohort designs are needed to better understand the influence of symptom burden and profiles on pediatric concussion recovery.

Adolescents With ADHD Do Not Take Longer to Recover From Concussion

The objective of this study was to determine whether adolescents with attention-deficit/hyperactivity disorder (ADHD) have prolonged return to school and sports following concussion compared to those without ADHD and whether medication status or concussion history is associated with recovery time. We hypothesized that having ADHD would not be associated with longer recovery time. This prospective observational cohort study, conducted between 2014 and 2019, examined concussion recovery among school sponsored athletics throughout Maine, USA. The sample included 623 adolescents, aged 14-19 years (mean = 16.3, standard deviation = 1.3 years), 43.8% girls, and 90 (14.4%) reported having ADHD. Concussions were identified by certified athletic trainers. We computed days to return to school (full time without accommodations) and days to return to sports (completed return to play protocol) following concussion. Adolescents with ADHD [median days = 7, interquartile range (IQR) = 3-13, range = 0-45] did not take longer than those without ADHD (median days = 7, IQR = 3-13, range = 0-231) to return to school (U = 22,642.0, p = 0.81, r = 0.01; log rank: χ 1 2 = 0.059, p = 0.81). Adolescents with ADHD (median days = 14, IQR = 10-20, range = 2-80) did not take longer than those without ADHD (median days = 15, IQR = 10-21, range = 1-210) to return to sports (U = 20,295.0, p = 0.38, r = 0.04; log rank: χ 1 2 = 0.511, p = 0.48). Medication status and concussion history were not associated with longer recovery times. Adolescents with ADHD did not take longer to functionally recover following concussion. Recovery times did not differ based on whether adolescents with ADHD reported taking medication to treat their ADHD or whether they reported a prior history of concussion.

Effects of attention deficit hyperactivity disorder and learning disability on vestibular and ocular baseline concussion assessment in pediatric athletes

Vestibular and ocular motor assessment has gained popularity as a tool for sport-related concussion among healthcare professionals. With awareness of premorbid risk factors, such as attentional problems, it is imperative to understand their effects at baseline. The purpose of this study was to examine the effects of attention deficit/hyperactivity disorder (ADHD) and diagnosed learning disability (LD) on vestibular and oculomotor baseline concussion assessment in pediatrics. Pediatric athletes between the ages of 8 and 14 years with ADHD/LD (n = 30) and match controls without ADHD/LD (n = 30) completed baseline concussion testing, consisting of symptom provocation on the Vestibular/Ocular Motor Screening (VOMS) and oculomotor performance on near point of convergence (NPC) and King-Devick (K-D) tools. Those diagnosed with ADHD/LD performed worse on baseline saccades (p range = .02-.10), convergence (p = .04), vestibular ocular reflex (VOR) (p = .03) and visual motion sensitivity (VMS) (p = .04) of the VOMS. Base rate analyses revealed that 26% of athletes in the ADHD/LD group had ≥1 and 13.3% had ≥2 VOMS domains over clinical cutoff levels, compared to 3.3% (≥1 domain) and 0 (≥2 domains) of controls. Individuals with ADHD/LD also performed worse on K-D assessment (p = .005). However, no differences were reported on NPC distance (p = .19). These findings suggest worse baseline concussion assessment scores on vestibular/ocular motor assessment domains in pediatric athletes diagnosed with ADHD/LD. Additional research is needed on assessment outcomes to determine if special consideration to those diagnosed with ADHD/LD is warranted.

The Effect of Target Speed and Verbal Instruction on NPC Measures in a Young, Healthy, and Active Population

Purpose: Evaluate the effect of target speed and verbal instruction on near point of convergence (NPC) measurements in a young, healthy, and active population. Methods: NPC was measured in 20 individuals with three target speeds and two sets of verbal instruction. The target speeds used were 1 cm/s, 3 cm/s, 5 cm/s, and participant self-paced. The verbal instruction given was either to indicate when the target became “double” or “blurry”. Results: Paired-samples t-tests revealed significant differences between 5 cm/s (5.44 ± 2.01) and 1 cm/s (6.72 ± 2.39, p = .003), 3 cm/s (6.10 ± 2.36, p = .030) and self-paced (6.63 ± 2.26, p = .005). A significant difference (p < .001) was also found between the “double” (6.72 ± 2.39) and “blurry” (10.82 ± 3.08) conditions. Conclusion: For young, healthy and active individuals, target speed and verbal instruction matter when measuring NPC.

Postconcussion: Receded Near Point of Convergence is not Diagnostic of Convergence Insufficiency

PURPOSE

To determine the frequency of occurrence of receded near point of convergence (NPC) in patients with chronic concussion-related symptoms and in those with receded NPC to enumerate the frequency of convergence insufficiency and other oculomotor disorders.

DESIGN

Retrospective cross-sectional study.

METHODS

Clinic charts were retrospectively reviewed for the prior 3.5 years to identify all patients < 21 years old who were > 28 days postconcussion, had chronic concussion-related symptoms, had normal visual acuity, and had received a comprehensive sensorimotor examination. The frequency of receded NPC and oculomotor diagnoses were determined.

RESULTS

Of the 83 eligible patients, 74 (89%) had receded NPC. Of these, 70 (95%) had oculomotor disorders; 30 (41%) had disorders of accommodation only; 21 (28%) had convergence insufficiency and accommodation deficits; and 6 (8%) had convergence insufficiency only. Six (8%) had a convergence deficit other than convergence insufficiency (all with concurrent accommodative disorders); 4 (5%) had both a nonspecific vergence dysfunction and accommodation deficits; 2 (3%) had convergence excess only; and 1 (1%) had both convergence excess and accommodative deficits.

CONCLUSION

A receded NPC was present in the majority of young patients with chronic postconcussion symptoms. Associated with numerous underlying oculomotor dysfunctions, the clinical finding of a receded NPC is not synonymous with the diagnosis of convergence insufficiency. Because treatment options for the various oculomotor dysfunctions differ, it is prudent that these patients undergo a thorough examination of their vergence and accommodative systems so that an accurate diagnosis can be made and appropriate treatment prescribed.

Vestibular Rehabilitation Is Associated With Visuovestibular Improvement in Pediatric Concussion

BACKGROUND AND PURPOSE

Vision and vestibular-related deficits are common after concussion and are associated with prolonged recovery times, substantially impacting the quality of life for children. The utility of targeted vestibular rehabilitation for these deficits in children after concussion is unknown. The purpose of this study was to determine whether active vestibular rehabilitation is associated with an improvement in visuovestibular signs and symptoms in children with concussion.

METHODS

A retrospective cohort study of children diagnosed with concussion and referred to vestibular rehabilitation between 2012 and 2014 was conducted. Patient-reported symptoms and visuovestibular performance measures were assessed in the medical practice and physical therapy settings.

RESULTS

One hundred nine children were included in the study with a mean age of 11.8 (3.4) years. Among this group, 59 (54%) were male and 48 (44%) had a sports-related concussion. Children presented to a pediatric sports medicine office and physical therapy a median of 24 (interquartile range [IQR], 14-42) and 55 (IQR, 39-94) days after injury, respectively. Concussion symptoms decreased from a median of 9 (IQR, 5-13) symptoms at initial evaluation to a median of 0 (IQR, 0-2) symptoms at final assessment. Performance on all visuovestibular tasks improved significantly over the course of therapy except for near point of convergence. For the 45 children who completed the Balance Error Scoring System at both initial and final therapy visits, there was a significant improvement in mean level of performance (P < 0.0001). Characteristics between those who completed a full versus partial course of physical therapy were similar.

DISCUSSION AND CONCLUSIONS

Vestibular rehabilitation in children with concussion is associated with improvement in symptoms as well as visuovestibular performance. This active intervention may benefit children with persistent symptoms after concussion. Future prospective studies are needed to determine the efficacy and optimal postinjury timing of vestibular rehabilitation.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A208).