Female adolescents demonstrate greater oculomotor and vestibular dysfunction than male adolescents following concussion

Utility of pre-injury risk factors and the concussion clinical profiles screening (CP screen) tool for identifying concussion profiles in adolescents

This study determined the combined utility of pre-injury risk factors and Concussion Clinical Profile Screen (CP Screen) items to identify clinician-adjudicated concussion profiles in adolescents. This was a retrospective study of 236 adolescents aged 12-18 who presented to a concussion specialty clinic between 2019 and 2020 within 30 days of injury. Participants completed the CP Screen at their initial evaluation, and clinicians provided blindly adjudicated clinical profiles for each participant. Stepwise logistic regressions and receiver operating characteristic (ROC) curves were conducted. Participants (n = 236; 60.2% male) had a mean age of 14.79 ± 1.62 years, and most injuries were sport-related (n = 185, 78.4%). Combined pre-injury risk factor and CP Screen item predictors of anxiety/mood (AUC = 0.903) demonstrated outstanding utility; vestibular (AUC = 0.802) demonstrated excellent utility; and ocular (AUC = 0.766), PTM (AUC = 0.729), and cognitive (AUC = 0.723) demonstrated acceptable utility. Select pre-injury risk factors and CP Screen items provided acceptable to outstanding predictive utility for all clinical profiles in adolescents following concussion, highlighting their clinical utility for identifying concussion clinical profiles and subsequent targeted interventions. However, certain pre-injury risk factors and CP Screen items represented multiple profiles, highlighting the potential overlap and the need for clinicians to consider a multidomain evaluation to inform the best treatment approach.

Comparing peer relationship ratings among adolescents with sport and Non-sport Related Concussions

OBJECTIVE

To evaluate if peer relationship ratings differ among adolescents who sustain a sport-related concussion compared to those who sustain a non-sport-related concussion.

STUDY DESIGN

We conducted a cross-sectional investigation of 123 adolescents who sustained a concussion within 21 days before their initial post-injury evaluation (mean = 9.2 ± 3.9 days post-concussion). Participants reported whether their injury occurred during organized sport participation (sport-related concussion group) or not (non-sport-related concussion group). Participants completed the PROMIS Global Pediatric 25 assessment, as well as the Post-Concussion Symptom Inventory (PCSI) to rate concussion symptom severity and a background/demographic intake form during the evaluation. We compared PROMIS peer relationship ratings between groups using independent t-tests and evaluated the association between peer relationship ratings and sport-related concussion using multiple linear regression after adjusting for covariates including PROMIS anxiety rating, age, sex, concussion and musculoskeletal injury history, loss of consciousness at time of concussion, physical activity participation prior to study evaluation, and concussion symptom severity.

RESULTS

Most (N = 96, 78%) participants reported sustaining a concussion during sports. The group who sustained sport-related concussion reported significantly better post-concussion peer relationship ratings compared to the group who sustained a non-sport-related concussion (52.7 ± 7.7 vs. 47.7 ± 10.4; p = 0.009, Cohen's d = 0.60). After covariate adjustment, those who sustained a sport-related concussion had a significantly greater post-concussion peer relationship rating than those who sustained a non-sport-related concussion (β = 4.19, 95% CI = 0.39, 8.00; p = 0.03). Higher peer relationship ratings were also associated with lower anxiety ratings following concussion (β= -0.21, 95% CI= -0.38, -0.04; p = 0.03).

CONCLUSION

Adolescents who sustained a concussion during sports reported significantly greater post-concussion peer relationship ratings than those in non-sport settings. Better peer relationship ratings were associated with less anxiety in the post-injury period. These findings suggest the potential effects of contextual factors (e.g. peer support) to facilitate improved outcomes following adolescent concussion.

Patterns of vestibular dysfunction in chronic traumatic brain injury

Background

Dizziness and imbalance are common following traumatic brain injury (TBI). While these symptoms are often attributed to vestibular dysfunction, the relative contribution of peripheral vs. central mechanisms is unclear. This study investigated the prevalence of semicircular canal and otolith abnormalities in a cohort of patients with chronic TBI and symptoms of dizziness or imbalance. The relationship between vestibular, oculomotor and posturography results was further explored.

Methods

Clinical records of patients attending the New Zealand Dizziness and Balance Centre from January 2015 to December 2019 were reviewed for consideration in the study. Inclusion required: an age of 18–80 years, a diagnosed TBI, and vestibular assessment using three-dimensional video head impulses (vHIT), cervical and ocular vestibular-evoked myogenic potentials (c and o VEMPs, respectively) and caloric testing. Severe TBI, pre-existing vestibular diagnoses, and incomplete test results were excluded. Rates of abnormalities were determined for each test and compared with results of oculomotor function testing and postural control, measured using the sensory organization test (SOT).

Results

Of 158 reviewed records, 99 patients aged 49 ± 15 years (59 female) fulfilled criteria for inclusion in the study. The median time between the head injury and the clinical assessment was 12 (IQR 6–21) months. Abnormalities involving one or more components of the vestibular labyrinth and/or nerve divisions were identified in 33 of 99 patients (33.3%). The horizontal semicircular canal was most frequently affected (18.2%), followed by the saccule (14.1%), utricle (8.1%), posterior (7.1%) and anterior (2.0%) semicircular canals. Vestibular test abnormalities were associated with skull-base fractures, superior canal dehiscence, and focal ear trauma. Oculomotor dysfunction and postural instability were recorded in 41.1 and 75.5% of patients, respectively. Postural instability correlated with abnormal oculomotor function (p = 0.008) but not peripheral vestibular hypofunction (p = 0.336).

Conclusions

Dizziness and/or imbalance in chronic TBI was associated with impaired postural stability for tasks requiring high levels of use of vestibular and visual input for balance. Vestibular hypofunction identified through vHIT, VEMP and caloric testing was recorded but was less common, except when the injury involved a fractured skull-base. There was no specific pattern of end-organ or nerve involvement which characterized this group of patients.

Trajectories of Visual and Vestibular Markers of Youth Concussion

Visual and vestibular deficits, as measured by a visio-vestibular examination (VVE), are markers of concussion in youth. Little is known about VVE evolution post-injury, nor influence of age or sex on trajectory. The objective was to describe the time trend of abnormal VVE elements after concussion. Two cohorts, 11-18 years, were enrolled: healthy adolescents (n = 171) from a high school with VVE assessment before or immediately after their sport seasons and concussed participants (n = 255) from a specialty care concussion program, with initial assessment ≤28 days from injury and VVE repeated throughout recovery during clinical visits. The primary outcome, compared between groups, is the time course of recovery of the VVE examination, defined as the probability of an abnormal VVE (≥2/9 abnormal elements) and modeled as a cubic polynomial of days after injury. We explored whether probability trajectories differed by: age (<14 years vs. 14+ years), sex, concussion history (0 versus 1+), and days from injury to last assessment (≤28 days vs. 29+ days). Overall, abnormal VVE probability peaked at 0.57 at day 8 post-injury, compared with an underlying prevalence of 0.083 for uninjured adolescents. Abnormal VVE probability peaked higher for those 14+ years, female, with a concussion history and whose recovery course was longer than 28 days post-injury, compared with their appropriate strata subgroups. Females and those <14 years demonstrated slower resolution of VVE abnormalities. VVE deficits are common in adolescents after concussion, and the trajectory of resolution varies by age, sex, and concussion history. These data provide insight to clinicians managing concussions on the timing of deficit resolution after injury.

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

SIGNIFICANCE

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Background

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

Objectives

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

Design

Prospective longitudinal design.

Setting

Tertiary care pediatric hospital.

Participants

36 participants with mTBI aged 6 to18.

Procedures

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

Outcome measures

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

Analysis

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

Results

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

Discussion

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

Implications

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

A Dynamic Nomogram to Predict the Risk of Stroke in Emergency Department Patients With Acute Dizziness

Objective

To develop a risk prediction tool for acute ischemic stroke (AIS) for patients presenting to the emergency department (ED) with acute dizziness/vertigo or imbalance.

Method

A prospective, multicenter cohort study was designed, and adult patients presenting with dizziness/vertigo or imbalance within 14 days were consecutively enrolled from the EDs of 4 tertiary hospitals between August 10, 2020, and June 10, 2021. Stroke was diagnosed by CT or MRI performed within 14 days of symptom onset. Participants were followed-up for 30 days. The least absolute shrinkage and selection operator (LASSO) logistic regression analysis was conducted to extract predictive factors that best identified patients at high risk of stroke to establish a prediction model. Model discrimination and calibration were assessed and its prediction performance was compared with the age, blood pressure, clinical features, duration, and diabetes (ABCD2) score, nystagmus scheme, and finger to nose test.

Results

In this study, 790 out of 2,360 patients were enrolled {median age, 60.0 years [interquartile range (IQR), 51–68 years]; 354 (44.8%) men}, with complete follow-up data available. AIS was identified in 80 patients. An online web service tool (https://neuroby.shinyapps.io/dynnomapp/) was developed for stroke risk prediction, including the variables of sex, trigger, isolated symptom, nausea, history of brief dizziness, high blood pressure, finger to nose test, and tandem gait test. The model exhibited excellent discrimination with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.889 (95% CI: 0.855–0.923), compared with the ABCD2 score, nystagmus scheme, and finger to nose test [0.712 (95% CI, 0.652–0.771), 0.602 (95% CI, 0.556–0.648), and 61.7 (95% CI, 0.568–0.666) respectively].

Conclusion

Our new prediction model exhibited good performance and could be useful for stroke identification in patients presenting with dizziness, vertigo, or imbalance. Further externally validation study is needed to increase the strength of our findings.

Sex Differences in the Outcomes of Mild Traumatic Brain Injury in Children Presenting to the Emergency Department

Sex differences after concussion have been studied largely in high school and college athletes, often without reference to comparison groups without concussion. This study sought to evaluate sex differences in outcomes among all children and adolescents presenting to the Emergency Department (ED) for either mild traumatic brain injury (TBI) or orthopedic injury (OI), regardless of mechanism of injury. The study involved a concurrent cohort, prospective study design with longitudinal follow-up. Participants were eight to 16 years old with mild TBI (n = 143) or OI (n = 73). They were recruited and completed an initial assessment at EDs at two children's hospitals. They returned for a post-acute assessment within two weeks of injury and for follow-up assessments at three and six months. Outcomes included child and parent proxy ratings of somatic and cognitive symptoms, and standardized tests of cognitive functioning and balance. Sex did not moderate group differences in balance, fluid or crystallized cognitive ability, or child or parent proxy ratings of somatic or cognitive symptoms. Both parents and children reported more somatic symptoms in girls than boys, but in both groups. Compared with the OI group, the mild TBI group showed significantly lower fluid cognitive ability at the post-acute assessment and significantly higher somatic and cognitive symptoms according to both child and parent proxy ratings across the first two weeks post-injury. The results suggest that sex does not moderate the outcomes of mild TBI in a pediatric ED population. Previous research pointing to sex differences after concussion may reflect the lack of comparison groups, as well as a focus on adolescents and young adults and sport-related concussion. Future research should investigate whether sex moderates the outcomes of pediatric mild TBI in adolescents but not in pre-adolescent children.

Prevalence and Risk Factors for Intimate Partner Physical Violence-Related Acquired Brain Injury Among Visitors to Justice Center in New York

OBJECTIVE

The recent United States Government Accountability Office report highlights the need for improved data on the prevalence of intimate partner violence (IPV)-related acquired brain injury (ABI) to help direct Health & Human Services public efforts. This article identifies the prevalence and risk factors for IPV-related ABI among survivors of IPV at a Justice Center in New York.

SETTING

Community Justice Center.

PARTICIPANTS

Forty survivors of IPV, aged 17 to 73 years (median 32, interquartile range: 25.25, 42) were assessed within 60 days of sustaining physical violence.

DESIGN

Retrospective chart review.

MAIN MEASURES

The HELPS and the Danger Assessment-Revised were used at the initial Center visit.

RESULTS

Of the 40 physical IPV survivors screened, all (100%) reported a prior history of partner-induced ABI within the past 60 days. Thirty-seven (92.5%) survivors also reported sustaining at least 1 potential hypoxic brain injury from strangulation. However, only 16 (40%) survivors screened positive on the HELPS for a history of IPV-related mild traumatic brain injury. Females (95%) and individuals with low income (67.5%) largely comprised our sample. Compared with the County's average, the proportion of African Americans/Blacks and refugees was 227% higher (42.5% vs 13%) and 650% higher (7.5% vs 1.09%), respectively. Refugee status (P = .017) also correlated with number of previous ABIs. On an exploratory binary logistic regression with stepwise selection, only balance difficulties (P = .023) and difficulty concentrating/remembering (P = .009) predicted a positive screen for mild traumatic brain injury.

CONCLUSIONS

Consistent with previous findings, our data indicate a high prevalence of IPV-related ABI among visitors to a New York Justice Center. An overrepresentation of African Americans/Blacks and refugees in our sample relative to the region signified a higher prevalence of IPV in these populations and warrants a provision of more trauma-informed ABI resources to these groups/communities. Intimate partner violence survivors visiting Justice Centers should be screened for motor/neurocognitive symptoms suggestive of mild traumatic brain injury. Further research to identify the prevalence and risk factors of IPV-related ABI statewide and nationwide is urgently needed to improve resource allocation and clinical management.

Post-Concussion and Post-Traumatic Stress Symptoms after Pediatric Traumatic Brain Injury: Shared Vulnerability Factors?

Following pediatric traumatic brain injury (TBI), post-concussion symptoms (PCS) and post-traumatic stress symptoms (PTSS) occur commonly; however, it is unknown to what degree they overlap. The study examined PCS and PTSS persisting 7 weeks after injury in children and adolescents ages 8-15 years with TBI (n = 89) or extracranial injury (EI; n = 40) after vehicle collisions. TBI was divided into mild, complicated-mild/moderate, and severe groups. Parents retrospectively rated children's pre-injury symptoms and behavior problems, and children completed self-report measures after injury. PCS and PTSS total scores were significantly correlated in TBI and EI groups, respectively, for child (rs = 0.75; rs = 0.44), and adolescent (rs = 0.61; rs = 0.67) cohorts. Generalized linear models examined whether injury type and severity, age, sex, and pre-injury symptom ratings predicted PCS and PTSS total scores and factor scores. Specific PCS and PTSS factor scores were elevated in different TBI severity groups, with most frequent problems following mild or severe TBI. PCS did not differ by age; however, girls had more emotional symptoms than boys. Only PTSS were predicted by pre-injury externalizing behavior. Significant age by sex interactions indicated that adolescent girls had more total, avoidance, and hyperarousal PTSS symptoms than younger girls or all boys. PCS and PTSS significantly overlapped in both TBI and EI groups, highlighting shared persistent symptoms after injury. Shared vulnerability factors included female sex, milder TBI, and poorer pre-injury adjustment. Older age was a unique vulnerability factor for PTSS. Psychological health interventions after injury should be customized to address comorbid symptoms.

Vestibular and Ocular/Oculomotor Assessment Strategies and Outcomes Following Sports-Related Concussion: A Scoping Review

BACKGROUND

Recent literature has identified that the vestibular system is often involved following a sport-related concussion. Furthermore, the consequences of vestibular and ocular/oculomotor involvement have been explored and identified as potential predictors for prolonged recovery. Although vestibular and ocular/oculomotor involvement is common following head injury, the clinical assessment strategies for vestibular function are less commonly practiced in the sports medicine setting and have limited research. Therefore, despite the suspected link between vestibular consequences of concussion and prolonged recovery time, there is limited understanding on how these consequences affect outcomes following concussion and how to properly assess these functions.

OBJECTIVES

The objectives of this scoping review were to: (1) outline the current clinical assessment strategies for vestibular and ocular/oculomotor function in sports medicine to identify the best strategies for assessment, and (2) investigate the evidence regarding the influence of vestibular and ocular/oculomotor function on outcomes for patients with a sport-related concussion.

METHODS

Two separate and independent reviews of the current literature were conducted to provide evidence for each specified objective. Studies for potential inclusion were identified through electronic database searches. Inclusion criteria for each objective were used to identify the most effective studies and inquiries to address the outlined objectives.

RESULTS

The identified and included studies provided evidence-based information regarding the current assessment strategies as well as outcomes following concussion.

CONCLUSION

Despite agreement among studies, there was limited evidence to support each aim, identifying a need for further exploration into these objectives.

Tandem gait test performance in healthy, physically active adults: Clinical implications for concussion evaluation

OBJECTIVES

To identify factors affecting performance on the tandem gait test in healthy, physically active adults.

DESIGN

Cross-sectional.

METHODS

Participants completed the tandem gait test according to Sport Concussion Assessment Tool 3 (SCAT3) guidelines. Dependent variables included time for best trial (initial 3m, turn, final 3m and total) and whether the trial was "pass" or "fail". Independent variables included sex, concussion history, foot length, height and total number of trials.

RESULTS

55% (35/64) of participants passed the first trial of the tandem gait test; 19% (12/64) had a best time <14s. Sex and concussion history did not affect performance (p>0.05). There were no differences in turn times for those with and without a history of concussion (t=0.26, p=0.80). The number of trials was not significantly correlated with best time (þ=-0.04, p=0.74). There were low (þ=-0.31) to negligible (þ<0.30) correlations between foot length, height and all portions of the test. There was more variability in times for the turn (COV=27%) than during the straight portions (COV=18%).

CONCLUSIONS

Current recommendations for the tandem gait test led to a high false-positive rate in healthy, physically active adults. Sex, concussion history, number of trials and foot length had little to no influence on scores on the test. Turning times were more variable than times on the straight portions of the test. Clinicians may use these results as a guideline when interpreting performance on the tandem gait test in healthy physically active adults.