Vestibular Rehabilitation Is Associated With Visuovestibular Improvement in Pediatric Concussion

The Evaluation and Management of Concussion to Optimize Safe Recovery

Concussion is a mild traumatic brain injury causing temporary neurologic dysfunction. Symptoms following concussion are variable and generally are expected to resolve within about 1 month, but some patients experience persistent and prolonged symptoms. An early return to safe, symptom-limited activity is now favored, using targeted rehabilitation and treatments. Accommodations may be needed to facilitate return-to-school and work following concussion. Athletes should not be cleared for a full return to sport until they have recovered from a concussion and completed a return-to-play progression, in addition to returning to work/school fully.

Guidelines of the French Society of Otorhinolaryngology and Head and Neck Surgery (SFORL) for vestibular rehabilitation in children with vestibular dysfunction. A systematic review

INTRODUCTION

The consequence of complete or partial uncompensated vestibular dysfunction in children is usually balance disorders, with the risk of falls and increased fatigue, particularly during tasks requiring postural control. The aim of these recommendations is to establish guidelines for vestibular rehabilitation (VR) in children with vestibular impairment.

MATERIAL AND METHODS

The guidelines were developed based on a systematic review of the international literature, validated by a multidisciplinary group of French-speaking otorhinolaryngologists, scientists, and physiotherapists. They are classified as grade A, B, C, or expert opinion according to a decreasing level of scientific evidence.

RESULTS

A PubMed search of studies published between January 1990 and December 2021 was carried out using the keywords "vestibular," "rehabilitation," and "children". After filtering and reviewing the articles, a total of 10 publications were included to establish the recommendations.

CONCLUSION

It is recommended that a vestibular assessment be carried out before VR, including a study of vestibulo-ocular reflex, otolithic function, and postural control. In cases of vestibular dysfunction, physiotherapy treatment is recommended from an early age to train different aspects of postural control, including anticipatory and reactive postural adjustments. VR adapted to the pediatric population is recommended for children whose vestibular dysfunction leads to functional disorders or symptoms of vertigo for those who have suffered head trauma. It is recommended that children with bilateral vestibular impairment be treated using gaze stabilization exercises for adaptation and substitution. Optokinetic stimulation and virtual reality are not recommended for children and young adolescents.

Head Injury Treatment With Healthy and Advanced Dietary Supplements: A Pilot Randomized Controlled Trial of the Tolerability, Safety, and Efficacy of Branched Chain Amino Acids in the Treatment of Concussion in Adolescents and Young Adults

Concussion is a common injury in the adolescent and young adult populations. Although branched chain amino acid (BCAA) supplementation has shown improvements in neurocognitive and sleep function in pre-clinical animal models of mild-to-moderate traumatic brain injury (TBI), to date, no studies have been performed evaluating the efficacy of BCAAs in concussed adolescents and young adults. The goal of this pilot trial was to determine the efficacy, tolerability, and safety of varied doses of oral BCAA supplementation in a group of concussed adolescents and young adults. The study was conducted as a pilot, double-blind, randomized controlled trial of participants ages 11-34 presenting with concussion to outpatient clinics (sports medicine and primary care), urgent care, and emergency departments of a tertiary care pediatric children's hospital and an urban tertiary care adult hospital, between June 24, 2014 and December 5, 2020. Participants were randomized to one of five study arms (placebo and 15 g, 30 g, 45 g, and 54 g BCAA treatment daily) and followed for 21 days after enrollment. Outcome measures included daily computerized neurocognitive tests (processing speed, the a priori primary outcome; and attention, visual learning, and working memory), symptom score, physical and cognitive activity, sleep/wake alterations, treatment compliance, and adverse events. In total, 42 participants were randomized, 38 of whom provided analyzable data. We found no difference in our primary outcome of processing speed between the arms; however, there was a significant reduction in total symptom score (decrease of 4.4 points on a 0-54 scale for every 500 g of study drug consumed, p value for trend = 0.0036, [uncorrected]) and return to physical activity (increase of 0.503 points on a 0-5 scale for every 500 g of study drug consumed, p value for trend = 0.005 [uncorrected]). There were no serious adverse events. Eight of 38 participants reported a mild (not interfering with daily activity) or moderate (limitation of daily activity) adverse event; there were no differences in adverse events by arm, with only two reported mild adverse events (both gastrointestinal) in the highest (45 g and 54 g) BCAA arms. Although limited by slow enrollment, small sample size, and missing data, this study provides the first demonstration of efficacy, as well as safety and tolerability, of BCAAs in concussed adolescents and young adults; specifically, a dose-response effect in reducing concussion symptoms and a return to baseline physical activity in those treated with higher total doses of BCAAs. These findings provide important preliminary data to inform a larger trial of BCAA therapy to expedite concussion recovery.

The Efficacy of Vestibular Rehabilitation Therapy for Mild Traumatic Brain Injury: A Systematic Review and Meta-analysis

OBJECTIVE

Mild traumatic brain injury (mTBI) or concussion is a common yet undermanaged and underreported condition. This systematic review and meta-analysis aim to determine the efficacy of vestibular rehabilitation therapy (VRT) as a treatment option for mTBI.

METHOD

This review and meta-analysis was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. It included randomized controlled trials and pre-VRT/post-VRT retrospective chart reviews. Records meeting the inclusion criteria were extracted from the following databases: MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL).

RESULTS

Eight articles met the inclusion criteria, from which 6 randomized controlled trials were included in the meta-analysis. VRT demonstrated significant improvement in decreasing perceived dizziness at the end of the intervention program as shown by Dizziness Handicap Inventory (DHI) scores (standardized mean difference [SMD] = -0.33, 95% confidence interval [CI]: -0.62 to -0.03, P = .03, I2 = 0%). However, no significant reduction in DHI was evident after 2 months of follow-up (SMD = 0.15, 95% CI: -0.23 to 0.52, P = .44, I2 = 0%). Quantitative analysis also depicted significant reduction in both Vestibular/Ocular Motor Screening (SMD = -0.40, 95% CI: -0.60 to -0.20, P < .0001, I2 = 0%) and Post-Concussion Symptom Scale (SMD= -0.39, 95% CI: -0.71 to -0.07, P = .02, I2 = 0%) following the intervention. Finally, there was no significant difference between intervention groups on Balance Error Scoring System scores (SMD = -31, 95% CI: -0.71 to 0.10, P = .14, I2 = 0%) and return to sport/function (95% CI: 0.32-30.80, P = .32, I2 = 82%).

CONCLUSIONS

Current evidence on the efficacy of VRT for mTBI is limited. This review and analysis provides evidence that supports the role of VRT in improving perceived symptoms following concussion. Although findings from this analysis suggest positive effects of VRT on included outcomes, the low certainty of evidence limits the conclusions drawn from this study. There is still a need for high-quality trials evaluating the benefit of VRT using a standardized approach.PROSPERO registration number: CRD42022342473.

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

BACKGROUND

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

HYPOTHESIS

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

STUDY DESIGN

Prospective cohort.

LEVEL OF EVIDENCE

Level 3.

METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL RELEVANCE

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

Improving outcome after paediatric concussion: challenges and possibilities

The term concussion has permeated mainstream media and household vocabulary mainly due to awareness regarding the risks of concussion in professional contact sports, yet it occurs across a variety of settings and ages. Concussion is prevalent in infants, preschoolers, children, and adolescents, and is a common presentation or reason for referral to primary care providers, emergency departments, and specialised trauma clinics. Its broad range of symptoms and sequelae vary according to multiple individual, environmental, and clinical factors and can lead to health and economic burden. More than 20 years of research into risk factors and consequences of paediatric concussion has revealed as many questions as answers, and scientific work and clinical cases continue to expose its complexity and heterogeneity. In this Review, we present empirical evidence for improving outcome after paediatric concussion. We consider work pertaining to both sports and other injury mechanisms to provide a perspective that should be viewed as complementary to publications focused specifically on sports concussion. Contemporary challenges in prevention, diagnosis, prognosis, and intervention are discussed alongside pathways and future directions for improving outcome.

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.

Disparities in Adherence to Concussion Clinical Care Recommendations in a Pediatric Population

OBJECTIVE

To characterize the relationship of sociodemographic factors to adherence to provider recommendations for pediatric concussion.

SETTING

Primary care (PC) practices within the Children's Hospital of Philadelphia network.

PARTICIPANTS

Patients aged 5 to 18 years old who presented to any PC site for concussion from September 26, 2019, to December 31, 2019.

DESIGN

Retrospective medical record review.

MAIN MEASURES

The primary outcome was adherence to follow-up recommendations as defined by (1) continued follow-up until provider clearance to return to full activity; (2) no more than 2 no-show visits; and (3) for those referred to specialty care (SC), attending at least 1 visit. We compared adherence by race/ethnicity, insurance, age, sex, injury mechanism, and repeat head injury using bivariate and multivariate analyses. A secondary outcome of referral to SC was compared by sociodemographic factors.

RESULTS

A total of 755 patients were included. Overall, 80.5% of the patients met adherence criteria. Following adjustment, non-Hispanic Black patients and publicly insured/self-pay patients were less likely to adhere to recommendations than non-Hispanic White patients (adjusted odds ratio [AOR] = 0.60; 95% CI, 0.37-1.00) and privately insured patients (AOR = 0.48; 95% CI, 0.30-0.75), respectively. When assessing differences in referral to SC, non-Hispanic Black patients and publicly insured/self-pay patients were more likely to receive a referral than their non-Hispanic White peers (OR = 1.56; 95% CI, 1.00-2.45) and privately insured patients (OR = 1.56; 95% CI, 1.05-2.32), respectively.

CONCLUSION

This study highlights disparities in adherence to concussion care recommendations, with non-Hispanic Black and publicly insured/self-pay patients less likely to adhere to follow-up recommendations than non-Hispanic White and privately insured patients, respectively. These disparities may impact recovery trajectories. Future studies should aim to identify specific individual- and system-level barriers preventing adherence to care in order to ultimately inform targeted interventions to achieve equity in care delivery and outcomes.

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Vergence and Accommodation Deficits in Children and Adolescents with Vestibular Disorders

SIGNIFICANCE

The high frequency of vergence and accommodation deficits coexisting in patients with a vestibular diagnosis merits a detailed visual function examination.

PURPOSE

Deficits in vergence and saccades have been reported in patients with vestibular symptomatology. We retrospectively evaluated visual function deficits in adolescents with vestibular diagnoses and concussion.

METHODS

The following inclusion criteria were used: vestibular and optometric evaluations between 2014 and 2020, 6 to 22 years old, and 20/25 best-corrected vision or better. Clinical criteria assigned vestibular diagnoses and concussion diagnoses. Vestibular diagnoses included vestibular migraine, benign paroxysmal positional vertigo, and persistent postural perceptual dizziness. Visual function deficits were compared with a pediatric control group (30). Nonparametric statistics assessed differences in group distribution.

RESULTS

A total of 153 patients were included: 18 had vestibular diagnoses only, 62 had vestibular diagnoses related to concussion, and 73 had concussion only. Vergence deficits were more frequent in patients with vestibular diagnoses and concussion (42%) and concussion only (34%) compared with controls (3%; all P = .02). Accommodation deficits were more frequent in patients with vestibular diagnoses only (67%), vestibular diagnoses and concussion (71%), and concussion (58%) compared with controls (13%; all P = .002). Patients with vestibular migraine and concussion (21) had more vergence deficits (62%) and accommodation insufficiency (52%) than concussion-only patients (47%, P = .02; 29%, P = .04). Patients with benign paroxysmal positional vertigo and concussion (20) had lower positive fusional vergence and failed near vergence facility (35%) more than concussion-only patients (16%; P = .03).

CONCLUSIONS

Visual function deficits were observed at a high frequency in patients with a vestibular diagnosis with or without a concussion and particularly in vestibular migraine or benign paroxysmal positional vertigo. Visual function assessments may be important for patients with vestibular diagnoses.

Evaluation and management of paediatric vertigo

PURPOSE OF REVIEW

This review summarizes the most current information on cause, evaluation and treatment of dizziness in children.

RECENT FINDINGS

There has been an increased understanding of the multifactorial cause of dizziness in the paediatric population. Quantitative vestibular testing is increasingly used and valuable as a diagnostic adjunct. Vestibular rehabilitation, migraine hygiene, psychological therapies, pharmaceuticals and/or surgery can be used as well tolerated and effective treatments for vertigo in children and adolescents when tailored to cause.

SUMMARY

Paediatric vertigo can be effectively evaluated through careful history taking and physical examination along with adjunctive tests, such as vestibular testing and audiometry, when appropriate. Options for treatment of vestibular disorders in children and adolescents have greatly expanded in recent years allowing for the effective management of nearly all cases of paediatric vertigo, though a multimodal and/or multidisciplinary approach is often needed.

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.

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

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

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

PRIMARY OBJECTIVE

To review the pathway to care for treatment and management of patients receiving visual and vestibular rehabilitation after mild traumatic brain injury (mTBI).

METHODS & PROCEDURES

English scientific peer-reviewed articles from PubMed, CINAHL, Embase, and PsycINFO between 2000 and 2020 were first screened by title and abstract, then those selected underwent full-text review and analysis.

MAIN OUTCOMES & RESULTS

The database search yielded 1640 results and after title and abstract review, 75 articles were selected for full-text screening, from which 8 were included in the qualitative synthesis. Current evidence includes a limited number of retrospective cohort studies and case studies.

CONCLUSIONS

Many patients with visual and vestibular deficits following mTBI do not receive rehabilitation services until months following their injury as there is no standardized pathway to care for patients for visual and vestibular rehabilitation. Barriers to establishing a standardized pathway are the lack of natural history data for visual and vestibular function following mTBI and the lack of randomized clinical trials establishing the efficacy of rehabilitation in patients following mTBI.

Visio-Vestibular Deficits in Healthy Child and Adolescent Athletes

OBJECTIVE

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

DESIGN

Cross-sectional.

SETTING

Suburban middle and high school.

PATIENTS

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

ASSESSMENT OF INDEPENDENT VARIABLES

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

DESIGN

Retrospective cohort analysis.

SETTING

Specialty pediatric sports concussion clinic.

PARTICIPANTS

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

INDEPENDENT VARIABLES

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Pediatric Sports-Related Concussion: An Approach to Care

Sports-related concussion (SRC) is a common sports injury in children and adolescents. With the vast amount of youth sports participation, an increase in awareness of concussion and evidence that the injury can lead to consequences for school, sports and overall quality of life, it has become increasingly important to properly diagnose and manage concussion. SRC in the student athlete is a unique and complex injury, and it is important to highlight the differences in the management of child and adolescent concussion compared with adults. This review focuses on the importance of developing a multimodal systematic approach to diagnosing and managing pediatric sports-related concussion, from the sidelines through recovery.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03555370.

Does Exercise Increase Vestibular and Ocular Motor Symptom Detection After Sport-Related Concussion?

BACKGROUND AND PURPOSE

Postconcussive vestibular and ocular motor symptoms are common and contribute to longer recovery. The Vestibular/Ocular Motor Screening (VOMS) is used to detect such symptoms, but a VOMS performed at rest may miss symptoms that are only provoked by exertion. Supervised exercise challenges (SECs) have been shown to detect concussion-related symptoms provoked by physical exertion. The purpose of this study was to determine whether athletes undergoing an SEC will exhibit greater symptom provocation with the VOMS compared to a VOMS performed at rest prior to an SEC.

METHODS

Thirty-six athletes (58.3% male) between ages 10 and 18 years and within 30 days of concussion were included. All participants completed VOMS assessments at rest and immediately after an SEC. VOMS total symptom score increases were calculated for both pre- and post-SEC assessments compared using Wilcoxon ranked sum tests. The frequencies of positive assessments for each VOMS item were compared using McNemar's test.

RESULTS

There were significant increases in post-SEC symptom provocation scores compared with pre-SEC scores for all VOMS items. The post-SEC VOMS identified 29 participants (80.6%) as positive in at least 1 VOMS item compared with 21 participants (58.3%) identified as positive pre-SEC (P = 0.008). For all VOMS items, the post-SEC VOMS identified participants who were previously negative on a pre-SEC VOMS but became positive after the SEC.

DISCUSSION AND CONCLUSIONS

An SEC performed prior to a VOMS assessment may increase the detection of vestibular and ocular motor symptoms that may be missed if the VOMS was performed only at rest.Video Abstract available for more insight from the authors (see the Video Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A342).

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.

Vestibular disorders in children: A retrospective analysis of vestibular function test findings

OBJECTIVE

This study was designed to describe the most common vestibular disorders in children and their associated findings on vestibular function testing.

METHOD

Data from 203 children with a mean age of 11.16 ± 3.87 (range, 1-17) years were collected from among 3400 patients who underwent vestibular assessment at a vertigo center in a tertiary hospital over a 3-year period. A retrospective data analysis was performed for 203 children.

RESULTS

Vestibular disorders were diagnosed in 78.3% (n = 159) of 203 children among 3400 patients, which revealed a 3-year incidence of 4.67% in our study. Benign paroxysmal positional vertigo (BPPV) was the most common diagnosis in our group of children (49%; n = 100), which involved both primary BPPV, and secondary BPPV that was associated with other vestibular pathologies. Vestibular migraine (VM) was the second most common diagnosis (41%; n = 83) followed by benign paroxysmal vertigo of childhood (BPVC; 4.5%, n = 9), vestibular neuritis (VN; 4.5%, n = 9), and psychogenic vertigo (4.5%, n = 9). Our study showed that Meniere's Disease (MD; 1.5%, n = 3) and central vertigo (1.5%, n = 3) were less commonly diagnosed in children. Perilymphatic fistula (PLF) was diagnosed and surgically confirmed in only one child.

CONCLUSION

BPPV and VM were the most common pediatric vestibular disorders in our study. Clinicians should be aware of the prevalence, signs, and symptoms of the most common vestibular disorders in children to enable diagnosis, treatment, and rehabilitation. Vestibular function testing with age-appropriate adaptations results in improved differential diagnosis, which guides medical treatment and rehabilitation.

A Pilot Study Evaluating the Timing of Vestibular Therapy After Sport-Related Concussion: Is Earlier Better?

BACKGROUND

Vestibular dysfunction, characterized by nausea, dizziness, imbalance, and/or gait disturbance, represents an important sport-related concussion (SRC) subtype associated with prolonged recovery. Vestibular physical therapy promotes recovery; however, the benefit of earlier therapy is unclear.

HYPOTHESIS

Earlier vestibular therapy for young athletes with SRC is associated with earlier return to play (RTP), return to learn (RTL), and symptom resolution.

STUDY DESIGN

Retrospective cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Patients aged 5 to 23 years with SRC who initiated vestibular rehabilitation therapy (VRT) from January 2019 to December 2019 were included and patient records were reviewed. Therapy initiation was defined as either early, ≤30 days postinjury, or late (>30 days). Univariate comparisons between groups, Kaplan-Meier plots, and multivariate Cox proportional hazard modeling were performed.

RESULTS

Overall, 23 patients (10 early, 13 late) aged 16.14 ± 2.98 years and 43.5% were male patients. There was no difference between group demographics or medical history. Median initial total and vestibular symptom scores were comparable between groups. The late therapy group required additional time to RTP (110 days [61.3, 150.8] vs 31 days [22.5, 74.5], P = 0.03) and to achieve symptom resolution (121.5 days [71, 222.8] vs 54 days [27, 91], P = 0.02), but not to RTL (12 days [3.5, 26.5] vs 17.5 days [8, 20.75], P = 0.09). Adjusting for age and initial total symptom score, earlier therapy was protective against delayed symptom resolution (P = 0.01).

CONCLUSION

This pilot study suggests that initiating VRT within the first 30 days after SRC is associated with earlier RTP and symptom resolution. Further prospective trials to evaluate if even earlier VRT should be pursued to further improve recovery time.

CLINICAL RELEVANCE

Clinicians should screen for vestibular dysfunction and consider modifying follow-up schedules after SRC to initiate VRT within a month of injury for improved outcomes.

Sports-Related Concussions and the Pediatric Patient

Pediatric patients with concussions have different needs than adults throughout the recovery process. Adolescents, in particular, may take longer to recover from concussion than adults. Initially, relative rest from academic and physical activities is recommended for 24 to 48 hours to allow symptoms to abate. After this time period, physicians should guide the return to activity and return to school process in a staged fashion using published guidelines. Further concussion research in pediatric patients, particularly those younger than high-school age, is needed to advance the management of this special population.

Nutritional interventions to improve neurophysiological impairments following traumatic brain injury: A systematic review

Traumatic brain injury (TBI) accounts for significant global health burden. Effects of TBI can become chronic even following mild injury. There is a need to develop effective therapies to attenuate the damaging effects of TBI and improve recovery outcomes. This literature review using a priori criteria (PROSPERO; CRD42018100623) summarized 43 studies between January 1998 and July 2019 that investigated nutritional interventions (NUT) delivered with the objective of altering neurophysiological (NP) outcomes following TBI. Risk of bias was assessed for included studies, and NP outcomes recorded. The systematic search resulted in 43 of 3,748 identified studies met inclusion criteria. No studies evaluated the effect of a NUT on NP outcomes of TBI in humans. Biomarkers of morphological changes and apoptosis, oxidative stress, and plasticity, neurogenesis, and neurotransmission were the most evaluated NP outcomes across the 43 studies that used 2,897 animals. The risk of bias was unclear in all reviewed studies due to poorly detailed methodology sections. Taking these limitations into account, anti-oxidants, branched chain amino acids, and ω-3 polyunsaturated fatty acids have shown the most promising pre-clinical results for altering NP outcomes following TBI. Refinement of pre-clinical methodologies used to evaluate effects of interventions on secondary damage of TBI would improve the likelihood of translation to clinical populations.

Characteristics and Outcomes for Delayed Diagnosis of Concussion in Pediatric Patients Presenting to the Emergency Department

BACKGROUND

Concussions are common pediatric injuries. Previous studies have found concussed youth may be underdiagnosed in the emergency department (ED), but outcomes for those with delayed diagnosis have yet to be described.

OBJECTIVE

Our aim was to compare visit characteristics and outcomes of patients who present to the ED with head injury who receive immediate vs. delayed diagnosis.

METHODS

Retrospective chart review of patients aged 6 to 18 years diagnosed with concussion on their first ED or urgent care (UC) visit and patients requiring a second visit for diagnosis between July 1, 2017 and June 20, 2019. We compared demographic information, ED or UC visit features, and recovery outcomes using χ² tests, Student's t-tests, and Wilcoxon rank-sum tests.

RESULTS

Overall, we included 85 patients with delayed concussion diagnosis and 159 with immediate diagnosis. Those with immediate diagnosis had more symptoms inquired at initial visit (5 vs. 4; p = 0.003) and a higher likelihood of receiving concussion-specific physical examinations (80% vs. 36.5%; p < 0.001); 76.5% of delayed diagnosis patients had at least 1 symptom at follow-up visit that was not inquired about at initial visit. Those with delayed diagnosis had more medical visits during recovery (3 vs. 2; p < 0.001), longer average time to symptom resolution (21 vs. 11 days; p = 0.004), and a higher likelihood of having persistent concussion symptoms (odds ratio 2.9; 95% confidence interval 1.4-5.9).

CONCLUSIONS

Concussed children evaluated acutely for head injury who do not receive an immediate diagnosis may be at risk for persistent symptoms. Performance of a concussion-specific physical examination and use of a standardized symptom scale may aid in identification of concussed youth acutely.

Characteristics of Concussion in Elementary School-Aged Children: Implications for Clinical Management

OBJECTIVE

To comprehensively characterize the clinical presentation and course of care for concussion among 5- to 11-year-old children, identifying preinjury and injury factors potentially influencing clinical outcomes.

STUDY DESIGN

A single-institution retrospective cohort study using electronic health record data from children ages 5- to 11 years with a concussion from July 1, 2014, through June 30, 2015. Electronic health record data were abstracted for a 20% random sample of 292 patients.

RESULTS

Three-fourths of patients (74.3%) presenting for concussion care had a standardized visiovestibular assessment performed. Almost all of those who eventually sought specialty care (92.9%) also had such an assessment, and only 42.9% patients initially seen in the emergency department or urgent care were examined in this manner. Of those assessed, 62.7% (n = 136) demonstrated deficits, with children ages 9-11 years more frequently exhibiting deficits than their younger counterparts (67.9% vs 53.2%; P = .03). Almost all patients (95.9%) reported at least 1 somatic symptom (eg, headache, dizziness), and one-half to two-thirds reported problems with sleep (54.1%) and visiovestibular symptoms (66.1%). Only 11.6% of children were referred for rehabilitation therapies and less than one-half of concussed patients (43.8%) were provided with a letter recommending school accommodations.

CONCLUSIONS

Somatic symptoms, sleep problems, and visiovestibular deficits are common in elementary school-aged children with concussion, but specific visiovestibular clinical assessments are often not performed, particularly in the emergency department setting. Recommendations for school accommodations are often not provided at the time of concussion diagnosis. Incorporating a standardized visiovestibular assessment into practice could facilitate early targeted school accommodations and thereby improve return to learning for elementary school-aged children with concussion.

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.

Physical Therapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury

Over the last decade, numerous concussion evidence-based clinical practice guidelines (CPGs), consensus statements, and clinical guidance documents have been published. These documents have typically focused on the diagnosis of concussion and medical management of individuals post concussion, but provide little specific guidance for physical therapy management of concussion and its associated impairments. Further, many of these guidance documents have targeted specific populations in specific care contexts. The primary purpose of this CPG is to provide a set of evidence-based recommendations for physical therapist management of the wide spectrum of patients who have experienced a concussive event. J Orthop Sports Phys Ther 2020;50(4):CPG1-CPG73. doi:10.2519/jospt.2020.0301.

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

OBJECTIVE

To examine differences between male and female adolescents on measures of balance, vestibular and oculomotor function within 3 weeks of concussion among a group of pediatric patients presenting to a sports medicine clinic.

DESIGN

Medical record review.

SETTING

Sports medicine clinic.

PARTICIPANTS

197 female (median age = 15.2 years) and 381 male (median age = 14.6 years) pediatric patients seen for a concussion, evaluated 9.3 ± 5.2 (mean ± SD) days post-concussion.

MAIN OUTCOME MEASURES

Patients completed Balance Error Scoring System (BESS), tandem gait, gaze stability, and near point of convergence (NPC) tests.

RESULTS

A higher proportion of female patients exhibited abnormal NPC (22% vs. 14%; p = 0.017), gaze stability (53% vs. 43%; p = 0.028), and tandem gait tests (20% vs. 13%; p = 0.026) compared to male patients. Multivariable analysis indicated an independent association between female sex and increased odds of abnormal NPC (adjusted odds ratio [aOR] = 1.79, 95% CI = 1.07-3.00), and tandem gait tests (aOR = 1.96, 95% CI = 1.12-3.41) following concussion.

CONCLUSIONS

Our results indicate that within the first three weeks of a concussion, female pediatric patients demonstrated increased odds of exhibiting abnormal near point of convergence, and tandem gait test performance compared to male patients.

Oculomotor Response to Cumulative Subconcussive Head Impacts in US High School Football Players: A Pilot Longitudinal Study

Importance

Repetitive subconcussive head impacts in sports have emerged as a complex public health issue. Most of these head impacts remain asymptomatic yet have the potential to cause insidious neurological deficit if sustained repetitively. Near point of convergence (NPC) values have shown to reflect subclinical neuronal damage; however, the longitudinal pattern of NPC changes in association with subconcussive head impacts remains unclear.

Objectives

To examine the NPC response to recurring subconcussive head impacts in a single high school football season through a series of repeated measurements.

Design, Setting, and Participants

This prospective case-series study of US varsity high school football players included baseline measurements of NPC, measurements at pregame and postgame points from 6 in-season games, and postseason follow-up measurements (a total of 14 points). An accelerometer-embedded mouthguard measured head impact frequency and magnitude from all practices and games. During the 6 games, players wore chest-strap heart rate monitors to record heart rate and estimate their excess postexercise oxygen consumption, accounting for possible physical exertion effects on NPC values.

Exposures

Players participated in practices and games with no restriction.

Main Outcomes and Measures

Near point of convergence.

Results

The 12 included players were all boys, with a mean (SD) age of 16.4 (0.5) years. A total of 8009 head impacts, 177 907 g of peak linear acceleration, and 16 123 371 rad/s2 of peak rotational acceleration were recorded from the players in a single football season. There was a significant increase in NPC over time until the middle of the season (mean [SD] NPC: baseline, 5.25 [1.49] cm; pregame 3, 6.42 [1.93] cm; P = .01), which was significantly associated with subconcussive head impact frequency and magnitude (0.02 cm per 100 g of peak linear acceleration [SE, 0.0108; 95% CI, 0.0436-0.004]; P = .01; 0.023 cm per 10 000 rad/s2 of peak rotational acceleration [SE, 0.009; 95% CI, 0.041-0.0105]; P = .02). However, NPC values began to normalize toward baseline level from midseason (mean [SD] NPC: baseline, 5.25 [1.49] cm; pregame 6, 5.75 [2.23] cm; P = .32), as supported by a significant quadratic trend (β [SE], -0.002 [0.001] cm/d; P = .003), while participants continued to incur subconcussive head impacts.

Conclusions and Relevance

This longitudinal case series study suggests that NPC can be perturbed over the long term by subconcussive head impacts but may normalize over time. The oculomotor system may have an adaptational capacity to subclinical head impacts, yet the mechanism for such remains an open question and warrants further investigation.

Adapting the Dynamic, Recursive Model of Sport Injury to Concussion: An Individualized Approach to Concussion Prevention, Detection, Assessment, and Treatment

The risk factors of concussion may be categorized as intrinsic (internal factors specific to the individual) or extrinsic (external factors related to the environment or sport). Identifying these factors is part of an individualized, patient-centered approach to prevention, assessment, and management of concussion. In most cases, the symptoms of concussion resolve in the initial few days following the injury, and a strategy involving a gradual return to sport and school is recommended. When symptoms persist for longer than 7 to 10 days, a multifaceted interdisciplinary assessment to guide treatment is recommended. This article applies the dynamic, recursive model of sport injury to sport-related concussion and summarizes the process of individualized assessment and management following concussion in athletes of all ages, with a focus on physical rehabilitation. J Orthop Sports Phys Ther 2019;49(11):799-810. doi:10.2519/jospt.2019.8926.

Review of the Management of Pediatric Post-Concussion Syndrome-a Multi-Disciplinary, Individualized Approach

PURPOSE OF REVIEW

Post-concussion syndrome (PCS), when the patient's concussion symptoms last longer than 4-6 weeks, affects 10-30% of concussion patients. PCS presents a significant source of morbidity to patients and a management challenge to providers. In this review, we present the current evidence and best management approaches for pediatric PCS.

RECENT FINDINGS

There is limited high-quality evidence in pediatric PCS. There is some evidence supporting pharmaceutical management of post-traumatic headaches, cognitive symptoms, and emotional symptoms. Vestibular-ocular dysfunction should be evaluated and managed appropriately. Neuropsychological recovery is expected, but requires appropriate attention to Return to Learn. Emotional symptoms are common in PCS and the evidence supports treatment with cognitive behavioral therapy. PCS presents a unique therapeutic challenge affecting multiple domains for patients-physical, sleep, cognitive, and emotional. Successful management of PCS requires a multi-disciplinary and individualized approach. There remains a significant need for further research, specifically looking into the outcomes and effective interventions in pediatric PCS.

A Multidimensional Approach to Post-concussion Symptoms in Mild Traumatic Brain Injury

Mild traumatic brain injury (mTBI) presents a substantial burden to patients, families, and health care systems. Whereas, recovery can be expected in the majority of patients, a subset continues to report persisting somatic, cognitive, emotional, and/or behavioral problems, generally referred to as post-concussion syndrome (PCS). However, this term has been the subject of debate since the mechanisms underlying post-concussion symptoms and the role of pre- and post-injury-related factors are still poorly understood. We review current evidence and controversies concerning the use of the terms post-concussion symptoms vs. syndrome, its diagnosis, etiology, prevalence, assessment, and treatment in both adults and children. Prevalence rates of post-concussion symptoms vary between 11 and 82%, depending on diagnostic criteria, population and timing of assessment. Post-concussion symptoms are dependent on complex interactions between somatic, psychological, and social factors. Progress in understanding has been hampered by inconsistent classification and variable assessment procedures. There are substantial limitations in research to date, resulting in gaps in our understanding, leading to uncertainty regarding epidemiology, etiology, prognosis, and treatment. Future directions including the identification of potential mechanisms, new imaging techniques, comprehensive, multidisciplinary assessment and treatment options are discussed. Treatment of post-concussion symptoms is highly variable, and primarily directed at symptom relief, rather than at modifying the underlying pathology. Longitudinal studies applying standardized assessment strategies, diagnoses, and evidence-based interventions are required in adult and pediatric mTBI populations to optimize recovery and reduce the substantial socio-economic burden of post-concussion symptoms.

Prognostic Factors in Pediatric Sport-Related Concussion

PURPOSE OF REVIEW

Sport-related concussion (SRC) and mild traumatic brain injury (mTBI) have been thrust into the national spotlight, with youth athletes bearing the burden of this public health problem. The current review aims to provide a practical summary of pediatric SRC, including key terminology, return to play/school, and risk factors for post-concussion syndrome (PCS).

RECENT FINDINGS

While the majority of youth athletes recover within 2 to 4 weeks, approximately 10% of athletes experience a protracted recovery with symptoms lasting months, impacting social, scholastic, and sporting activities. In the pediatric population, the strongest predictors of PCS are initial symptom burden and prior concussion, with mixed results behind the factors of gender, headaches, and learning disability. The role of psychiatric, family history, sports, and socioeconomic factors remain in their infancy.