Frequency of oculomotor disorders in adolescents 11 to 17 years of age with concussion, 4 to 12 weeks post injury

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

BACKGROUND

Mild traumatic brain injury (mTBI) can cause persistent symptoms suggestive of oculomotor deficits. This research synthesized evidence on restitutive interventions for reducing oculomotor deficits in adults with mTBI to understand if these interventions have clinical utility for improving recovery.

METHODS

Medline, EMBASE, CINHAL, PsychInfo, and Scopus, databases were searched for experimental studies published in English. We rated risk of bias (RoB) using recommended tools, and the certainty of the evidence according to GRADE guidelines. We conducted meta-analyses for similar outcomes reported in at least two studies.

RESULTS

Out of 5,328 citations, 12 studies (seven case series and five crossover design), with a combined sample size of 354 participants; (43% males) met the inclusion criteria and were analyzed. The analysis revealed a trend toward improvement of oculomotor deficits and visual tasks in response to restitutive intervention. None of the studies addressed sex or gender effects. All studies had high RoB, suggesting low certainty in the reported results.

DISCUSSION

Restitutive interventions may be beneficial for adults with oculomotor deficits after mTBI, however overall certainty of the evidence remains low. Future efforts must include enhancing attention to study methodology and reporting, sex and gender analyses, and reaching a consensus on outcome measures.

PROSPERO REGISTRATION NUMBER

CRD42022352276.

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

IMPORTANCE

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

OBJECTIVE

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

DESIGN

Cross-sectional study.

SETTING

Sports medicine clinic.

PARTICIPANTS

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

OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

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

Purpose

To develop a novel Vision Quality of Life (QoL) survey that emphasizes the amount of time a visual activity can be performed before symptoms occur.

Methods

The Vision Quality of Life with Time (VisQuaL-T) survey was developed with 10 daily activities and a list of common visual symptoms. Participants were recruited from a university campus. Participants were not excluded based on binocular impairments to obtain a normative dataset. Participants were instructed to denote when they first experience symptoms within certain time ranges. If participants did not engage in one of the 10 activities, they were instructed to denote "N/A". A composite score (range 0-3) was determined by only accounting for the questions that were answered.

Results

The normative data cohort had a sample size of 376 participants and the repeatability cohort had 54 participants. The normative, test, and retest datasets had a mean composite score of 2.47±0.54, 2.69±0.42, and 2.67±0.49 and 95% confidence interval of 2.38-2.71, 2.58-2.81, 2.54-2.80, respectively. There was good reliability and high correlation between the test and retest timepoints with an ICC of 0.825 and a Pearson correlation coefficient of 0.839 in the repeatability cohort. The normative data cohort showed good internal consistency with a Cronbach's alpha value of 0.803. Test and retest timepoints showed no statistical significance among the individual questions (p > 0.1).

Conclusion

A lower bound score of 2.4 can potentially be used to differentiate visually normal and symptomatic participants. Statistical analysis showed the survey is repeatable and reliable. Using time as a metric for assessing symptomology could be a useful method for identifying patients with QoL issues and for assessing effectiveness of binocular vision, accommodative, and eye movement treatments.

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

Purpose

To compare the binocular vision and oculomotor function between sports-concussed athletes and aged-matched controls.

Methods

Thirty mild concussed athletes were recruited and compared with aged-matched controls. All the participants underwent a comprehensive ocular assessment followed by an oculomotor assessment which included tests for accommodation, vergence, eye movements, and reading parameters.

Results

Three categories of oculomotor-based deficits were found: convergence insufficiency (40%), accommodative insufficiency (25%), and oculomotor-based reading dysfunctions (20%). A statistically significant reduction in the mean ± SD of the following parameters was noted in concussed athletes v/s controls:- binocular accommodative amplitude: 7.13 ± 1.59 v/s 15.35 ± 2.95 (P < 0.001), convergence amplitude: 14.23 ± 5.00 v/s 5.65 ± 0.90 (P < 0.001), positive fusional vergence for distance: 21.17 ± 8.97 v/s 31.32 ± 6.23 (P < 0.001), vergence facility: 6.47 ± 1.47 v/s 11.84 ± 1.00 (P < 0.001), accommodative facility: 7.10 ± 4.57 v/s 11.67 ± 1.83 (P < 0.001), reading speed: 66.97 ± 17.82 v/s 144.13 ± 24.45 (P = 0.03) and Developmental Eye Movement ratio: 1.40 ± 0.19 v/s 1.17 ± 0.06 (P < 0.001).

Conclusion

Concussions caused by sports have a considerable impact on binocular vision and oculomotor parameters. These findings have substantial therapeutic implications in terms of establishing a periodic screening program for athletes so that essential therapy can be provided for a better outcome.

Pupillary Light Response Deficits in 4-Week-Old Piglets and Adolescent Children after Low-Velocity Head Rotations and Sports-Related Concussions

Neurological disorders and traumatic brain injury (TBI) are among the leading causes of death and disability. The pupillary light reflex (PLR) is an emerging diagnostic tool for concussion in humans. We compared PLR obtained with a commercially available pupillometer in the 4 week old piglet model of the adolescent brain subject to rapid nonimpact head rotation (RNR), and in human adolescents with and without sports-related concussion (SRC). The 95% PLR reference ranges (RR, for maximum and minimum pupil diameter, latency, and average and peak constriction velocities) were established in healthy piglets (N = 13), and response reliability was validated in nine additional healthy piglets. PLR assessments were obtained in female piglets allocated to anesthetized sham (N = 10), single (sRNR, N = 13), and repeated (rRNR, N = 14) sagittal low-velocity RNR at pre-injury, as well as days 1, 4, and 7 post injury, and evaluated against RRs. In parallel, we established human PLR RRs in healthy adolescents (both sexes, N = 167) and compared healthy PLR to values obtained <28 days from a SRC (N = 177). In piglets, maximum and minimum diameter deficits were greater in rRNR than sRNR. Alterations peaked on day 1 post sRNR and rRNR, and remained altered at day 4 and 7. In SRC adolescents, the proportion of adolescents within the RR was significantly lower for maximum pupil diameter only (85.8%). We show that PLR deficits may persist in humans and piglets after low-velocity head rotations. Differences in timing of assessment after injury, developmental response to injury, and the number and magnitude of impacts may contribute to the differences observed between species. We conclude that PLR is a feasible, quantifiable involuntary physiological metric of neurological dysfunction in pigs, as well as humans. Healthy PLR porcine and human reference ranges established can be used for neurofunctional assessments after TBI or hypoxic exposures (e.g., stroke, apnea, or cardiac arrest).

Effectiveness of non-pharmacological treatments for vestibular and oculomotor dysfunction in patients with persistent post-concussive symptoms: protocol for a systematic review and meta-analysis

INTRODUCTION

Concussion is a form of mild traumatic brain injury that disrupts brain function. Although symptoms are mostly transient, recovery can be delayed and result in persistent postconcussive symptoms (PPCS). Vestibular and oculomotor dysfunction are among the most debilitating impairments associated with PPCS. However, pharmacological interventions for these impairments are associated with deleterious side effects. Accordingly, increasing research has examined the utility of non-pharmacological interventions for PPCS. The aim of this review is to synthesise and evaluate the effectiveness of non-pharmacological interventions for the treatment of vestibular and oculomotor dysfunction for patients with PPCS.

METHODS AND ANALYSIS

Systematic searches of MEDLINE, PubMed, Web of Science and Scopus will identify randomised controlled trials employing non-pharmacological treatments for vestibular and/or oculomotor dysfunction for PPCS. Such interventions may include, but are not limited to, vestibular rehabilitation, optokinetic stimulation and vestibulo-ocular reflex exercises. Assessments of oculomotor function will include versional eye movements, vergence eye movements, visual-fixation movements and accommodation response. Assessments of vestibular function will include the Fukuda Step test, functional balance tests, force displacement tests, and subjective reports of balance disruption or vertigo. Where appropriate, meta-analyses of standardised mean differences will be conducted using a random effects model for continuous outcomes. For dichotomous outcomes (improved vs not improved following treatment), effects will be expressed as relative risk. The impact of heterogeneity will be calculated using the I² statistic. The Physiotherapy Evidence Database scale will be used to determine the methodological quality of individual studies and Grading of Recommendations, Assessment, Development and Evaluations used to assess the certainty and quality of evidence for each outcome.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. Findings will be disseminated through peer-reviewed publications and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42021254720.

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.

OculoMotor Assessment Tool: Children Compared with Adults

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Validation of the Symptom Questionnaire for Visual Dysfunctions (SQVD): A Questionnaire to Evaluate Symptoms of any Type of Visual Dysfunctions

Purpose

To assess psychometric properties of the Symptom Questionnaire for Visual Dysfunctions (SQVD) questionnaire, including accuracy, validity, and reliability, in a clinical sample of patients having any type of visual dysfunction.

Methods

A clinical sample of 306 patients self-administered the SQVD. Rasch analysis was performed to analyze the functionality of the response categories, fit statistics, differential item functioning (DIF), person and item reliability, targeting, local dependency, unidimensionality, and transformation table. Accuracy was assessed by means of receiver operating characteristic (ROC) curves, using symptoms reported in each patient's clinical record as the gold standard for classifying patients with and without symptoms. The concurrent validity, known group validity, and test–retest reliability (repeatability, using the intraclass correlation coefficient [ICC]) were also examined.

Results

SQVD showed orderly category responses. The 14 items fit the Rasch model without significant DIF for gender, presbyopia, and dysfunctions. Person and item reliabilities were 0.81 and 0.85, respectively. Targeting was –1.49 logits. Yen's Q3 statistic showed no local dependency. SQVD was unidimensional (first contrast of the residual = 1.852 eigenvalue with a variance explained by measures of 52.23%). The area under the ROC curve was 0.836 (95% confidence interval [CI], 0.792–0.879) with a cutoff of ≥6 showing good accuracy (sensitivity = 0.759; specificity = 0.783). SQVD showed good concurrent and known group validity and high repeatability (ICC, 0.857; 95% CI, 0.710–0.933) when administered twice 1 week apart.

Conclusions

SQVD has shown good psychometric properties. It can be considered an accurate, valid, and reliable questionnaire to detect visual symptoms related to any type of refractive, accommodative, and binocular dysfunction.

Translational Relevance

SQVD may be used for diagnostic purposes, as it can accurately detect symptoms related to any sort of visual dysfunction. It may also be useful to monitor the treatment outcomes of these conditions.

Disparity vergence differences between typically occurring and concussion-related convergence insufficiency pediatric patients

This study sought to test the hypothesis that significant differences would be observed in clinical measures, symptoms, and objective assessments of vergence eye movements between children with typically developing convergence insufficiency (TYP-CI) and children with persistent post-concussion symptoms with convergence insufficiency (PPCS-CI). Data from age-matched binocularly normal controls (BNC) were used for comparison. Data from three groups of children 11 to 17 years of age are presented: BNC (N = 11), TYP-CI (N = 10), and PPCS-CI (N = 15). Clinical measures of vergence, accommodation, and symptom severity were collected. Symmetrical 4° disparity vergence eye movements were quantified with an eye tracker integrated into a head-mounted display (Oculus DK2). Peak velocity and final response amplitude of convergence and divergence eye movement responses were assessed. The mean near point of convergence (break) was more receded (worse), the amplitude of accommodation more deficient, and convergent and divergent peak velocities slower in the PPCS-CI group compared with the TYP-CI and BNC groups. These results suggest that PPCS-CI may be a different clinical entity than TYP-CI. Hence, more research is warranted to determine whether the therapeutic interventions that are effective for TYP-CI can also be used for PPCS-CI populations.