Impact of Sex and Pubertal Development on Anxiety in Adolescents After Concussion.

Concussion often results in psychological symptoms, including anxiety. Post-concussion anxiety has been well documented, although much of this research has focused on collegiate athletes. The purpose of this study was to compare (1) anxiety symptoms in concussed and healthy controls over time and (2) to explore sex differences in post-concussion anxiety within the context of pubertal development. Participants (N = 126, mean age = 15.1 years old), including concussed (n = 86) and healthy adolescents (n = 40), completed the Pubertal Development Scale (PDS) and the Screen for Child Anxiety and Related Disorders (SCARED-C). The concussed groups completed SCARED-C at three visits (<10 days, 4 weeks, 3 months). Results of an analysis of covariance (ANCOVA) and multi-variate analysis of covariance (MANCOVA) found concussed adolescents reported higher SCARED-C total, generalized, and panic anxiety scores than healthy controls, after controlling for sex, age, and PDS score (PDSS). A three-way mixed ANCOVA examined the effects of sex, PDSS, time, and their interaction on SCARED-C total score in concussed adolescents while controlling for age. There was a significant three-way interaction between sex, age, and PDSS on SCARED-C total score while controlling for age. Overall, we observed increased anxiety in concussed adolescents, compared with controls, as well as greater post-concussion anxiety reported by females compared with males, including within PDSS groups. Concussion providers should be prepared to receive training to administer well-validated measures of psychopathology and should consider that female adolescents, compared with males, regardless of pubertal development, may be at greater risk for post-concussion anxiety.

A Common Data Element-Based Adjudication Process for mTBI Clinical Profiles: A Targeted Multidomain Clinical Trial Preliminary Study.

INTRODUCTION: The primary purpose of this study was to examine the prevalence and percent agreement of clinician-identified mild traumatic brain injury (mTBI) clinical profiles and cutoff scores for selected Federal Interagency Traumatic Brain Injury Research common data elements (CDEs). A secondary purpose was to investigate the predictive value of established CDE assessments in determining clinical profiles in adults with mTBI. MATERIALS AND METHODS: Seventy-one (23 males; 48 females) participants (M = 29.00, SD = 7.60, range 18-48 years) within 1-5 months (M = 24.20, SD = 25.30, range 8-154 days) of mTBI completed a clinical interview/exam and a multidomain assessment conducted by a licensed clinician with specialized training in concussion, and this information was used to identify mTBI clinical profile(s). A researcher administered CDE assessments to all participants, and scores exceeding CDE cutoffs were used to identify an mTBI clinical profile. The clinician- and CDE-identified clinical profiles were submitted to a multidisciplinary team for adjudication. The prevalence and percent agreement between clinician- and CDE-identified clinical profiles was documented, and a series of logistic regressions with adjusted odds ratios were performed to identify which CDE assessments best predicted clinician-identified mTBI clinical profiles. RESULTS: Migraine/headache, vestibular, and anxiety/mood mTBI clinical profiles exhibited the highest prevalence and overall percent agreement among CDE and clinician approaches. Participants exceeding cutoff scores for the Global Severity Index and Headache Impact Test-6 assessments were 3.90 and 8.81 times more likely to have anxiety/mood and migraine/headache profiles, respectively. The Vestibular/Ocular Motor Screening vestibular items and the Pittsburgh Sleep Quality Index total score were predictive of clinician-identified vestibular and sleep profiles, respectively. CONCLUSIONS: The CDEs from migraine/headache, vestibular, and anxiety/mood domains, and to a lesser extent the sleep modifier, may be clinically useful for identifying patients with these profiles following mTBI. However, CDEs for cognitive and ocular may have more limited clinical value for identifying mTBI profiles.

Targeted multidomain intervention for complex mTBI: protocol for a multisite randomized controlled trial in military-age civilians.

Background: Mild traumatic brain injury (mTBI) affects ~18,000 military personnel each year, and although most will recover in 3-4 weeks, many experience persisting symptoms and impairment lasting months or longer. Current standard of care for U.S. military personnel with complex mTBI involves initial (<48 h) prescribed rest, followed by behavioral (e.g., physical activity, sleep regulation, stress reduction, hydration, nutrition), and symptom-guided management. There is growing agreement that mTBI involves different clinical profiles or subtypes that require a comprehensive multidomain evaluation and adjudication process, as well as a targeted approach to treatment. However, there is a lack of research examining the effectiveness of this approach to assessing and treating mTBI. This multisite randomized controlled trial (RCT) will determine the effectiveness of a targeted multidomain (T-MD) intervention (anxiety/mood, cognitive, migraine, ocular, vestibular; and sleep, autonomic) compared to usual care (behavioral management) in military-aged civilians with complex mTBI. Methods: This study employs a single-blinded, two-group repeated measures design. The RCT will enroll up to 250 military-aged civilians (18-49 yrs) with a diagnosed complex mTBI within 8 days to 6 months of injury from two concussion specialty clinics. The two study arms are a T-MD intervention and a usual care, behavioral management control group. All participants will complete a comprehensive, multidomain clinical evaluation at their first clinical visit. Information gathered from this evaluation will be used to adjudicate mTBI clinical profiles. Participants will then be randomized to either the 4-week T-MD or control arm. The T-MD group will receive targeted interventions that correspond to the patient's clinical profile (s) and the control group will receive behavioral management strategies. Primary outcomes for this study are changes from enrollment to post-intervention on the Neurobehavioral Symptom Inventory (NSI), Patient Global Impression of Change (PGIC), and functional near-infrared spectroscopy (fNIRS). Time to return to activity (RTA), and healthcare utilization costs will also be assessed. Discussion: Study findings may inform a more effective approach to treat complex mTBI in military personnel and civilians, reduce morbidity, and accelerate safe return-to-duty/activity. Ethics and dissemination: The study is approved by the University of Pittsburgh Institutional Review board and registered at clinicaltrials.gov. Dissemination plans include peer-reviewed publications and presentations at professional meetings. Clinical Trial Registration: www.clinicaltrials.gov, identifier: NCT04549532.

Incidence of concussion and associated risk factors in collegiate soccer: findings from the NCAA-DoD CARE consortium.

This retrospective cohort study aims to examine concussion incidence rates (IR) in collegiate soccer players and compare IRs based on risk factors including sex, competition level, games/practices, history of concussion, and playing position. Collegiate soccer players were recruited (n = 2,471) from 23 institutions from the NCAA-DoD Concussion Assessment, Research, and Education (CARE) Consortium. Incidence rates for concussion per 1000 athlete exposures (AEs) were calculated across the 2015-16/2016-17 seasons. Incidence rates (IR) comparing risk factor groups were also calculated. A total of 162 concussions occurred during the study, for an IR of 0.08/1000 AEs. Females were more likely to have a concussion than males overall (IR = 1.47) and were more likely to have a concussion in games (IR = 1.42) and practices (IR = 2.91). Concussions were more likely during competition compared to practice (IR = 2.53), and less likely in Division III, compared to Divisions I and II, χ2 = 6.5, p > .05. In the concussed group, male sex was associated with 2.47 times higher odds of playing defender and 2.29 times higher odds of a collision mechanism. Results confirm previous findings that females and game exposures have higher concussion IR than males and practice exposures. Findings also supported sex differences in IRs based on exposure type, position, and mechanism.

Serum 25-hydroxyvitamin D concentrations in dogs with coccidioidomycosis and variables associated with extent of clinically evident disease.

BACKGROUND: Clinicopathologic variables predictive of disseminated coccidioidomycosis are known in humans but have not been explored in dogs. Serum 25-hydroxyvitamin (OH)D correlates with severity of disease of various etiologies in dogs but its role in coccidioidomycosis is unknown. OBJECTIVE: Determine whether serum 25(OH)D concentrations are different in dogs with coccidioidomycosis compared with healthy controls and if clinicopathologic variables are associated with extent of disease. ANIMALS: Thirty-five dogs with coccidioidomycosis (pulmonary, n = 13; disseminated, n = 15; uncharacterized, n = 7), and 25 healthy control dogs. METHODS: Prospective cohort study. Serum 25(OH)D and C-reactive protein (CRP) concentrations were measured with modified-HPLC and a commercial ELISA kit, respectively. RESULTS: There was no difference in 25(OH)D concentrations between dogs with coccidioidomycosis (median, interquartile range [IQR]; 31.9 ng/mL, 23.3-49.2) and controls (29.5 ng/mL, 25.6-40.8, P = .73). Serum 25(OH)D concentration was lower in dogs with coccidioidomycosis and IgG titers ≥1:32 than dogs with titers below this cut-off (P = .02). Dogs with IgG titers ≥1:32 were more likely to have disseminated disease (OR, 7.5; 95% CI: 1.1-68; P = .03). Serum CRP concentrations were higher in dogs with IgG titers ≥1:16 (median, IQR; 4474.8 ng/mL, 2885.8-8236.1) than in those below this cut-off (151.2 ng/mL, 30.4-2907.3; P = .02). There was a significant inverse association between serum 25(OH)D and CRP at 25(OH)D concentrations ≤33 ng/mL. CONCLUSION AND CLINICAL IMPORTANCE: Serum 25(OH)D concentration was lower for dogs with IgG titers ≥1:32, indicating a potential association between semi-quantitative titers and 25(OH)D concentrations in dogs with coccidioidomycosis. IgG titers ≥1:32 yielded higher odds of disseminated disease, but was inadequate as a standalone test to determine form of disease.

False-Positive Rates and Associated Risk Factors on the Vestibular-Ocular Motor Screening and Modified Balance Error Scoring System in US Military Personnel.

CONTEXT: In 2018, the US military developed the Military Acute Concussion Evaluation-2 (MACE-2) to inform the acute evaluation of mild traumatic brain injury (mTBI). However, researchers have yet to investigate false-positive rates for components of the MACE-2, including the Vestibular-Ocular Motor Screening (VOMS) and modified Balance Error Scoring System (mBESS), in military personnel. OBJECTIVE: To examine factors associated with false-positive results on the VOMS and mBESS in US Army Special Operations Command (USASOC) personnel. DESIGN: Cross-sectional study. SETTING: Military medical clinic. PATIENTS OR OTHER PARTICIPANTS: A total of 416 healthy USASOC personnel completed the medical history, VOMS, and mBESS evaluations. MAIN OUTCOME MEASURE(S): False-positive rates for the VOMS (≥2 on VOMS symptom items, >5 cm for near point of convergence [NPC] distance) and mBESS (total score >4) were determined using χ2 analyses and independent-samples t tests. Multivariable logistic regressions (LRs) with adjusted odds ratios (aORs) were performed to identify risk factors for false-positive results on the VOMS and mBESS. The VOMS item false-positive rates ranged from 10.6% (smooth pursuits) to 17.5% (NPC). The mBESS total score false-positive rate was 36.5%. RESULTS: The multivariable LR model supported 3 significant predictors of VOMS false-positives, age (aOR = 1.07; 95% CI = 1.02, 1.12; P = .007), migraine history (aOR = 2.49; 95% CI = 1.29, 4.81; P = .007), and motion sickness history (aOR = 2.46; 95% CI = 1.34, 4.50; P = .004). Only a history of motion sickness was a significant predictor of mBESS false-positive findings (aOR = 2.34; 95% CI = 1.34, 4.05; P = .002). CONCLUSIONS: False-positive rates across VOMS items were low and associated with age and a history of mTBI, migraine, or motion sickness. False-positive results for the mBESS total score were higher (36.5%) and associated only with a history of motion sickness. These risk factors for false-positive findings should be considered when administering and interpreting VOMS and mBESS components of the MACE-2 in this population.

Average symptom severity and related predictors of prolonged recovery in pediatric patients with concussion.

The purpose of this study is to compare the predictive utility of total number of individual symptoms endorsed, total symptom severity, and average symptom severity on prolonged recovery among children/adolescents with a concussion. Patients (n = 115) completed the Post-Concussion Symptom Scale (PCSS) at their initial clinical visit (7.9 ± 6.6 days) days post-injury. PCSS outcomes were total symptom severity (i.e., total PCSS score), number of symptoms endorsed (i.e., number out of 22-items on the PCSS with a symptom score >0) and average symptom severity (i.e., mean of scores for each of the 22-items on the PCSS, not just endorsed symptoms). Logistic regression was performed with all symptom measures and recovery time >30 days as the binary outcome. Logistic regression indicated that average symptom severity (OR = 1.9; p = 0.01) and later time to first clinical visit (OR = 5.0; p < 0.001) were the only significant predictors of recovery time. Average symptom severity at initial clinic visit and earlier clinical visit may be a better predictor of recovery time than total number of symptoms endorsed or total symptom severity among children and adolescents.

Predictors of poor reading performance in student-athletes following sport-related concussion.

The goal of the current study was to determine which sport/recreation-related concussion (SRC) assessments predict academic reading performance following SRC. The study included 70 concussed students aged 14-22 years (M = 16.21, SD = 1.90) evaluated 2-30 days (M = 8.41, SD = 5.88) post-injury. SRC assessments included: Post-Concussion Symptom Scale, Immediate Post-Concussion Assessment and Cognitive Testing, Vestibular/Ocular Motor Screening, and King-Devick test. The Nelson-Denny Reading Test (NDRT) comprehension subtest measured academic reading accuracy and rate. Pearson correlations examined relationships among SRC assessments and reading accuracy/rate; those assessments that significantly correlated with the NDRT were included in multiple regressions (MRs) predicting reading accuracy and reading rate. Results supported positive correlations between visual motor speed and reading accuracy (r = .31, p = .01), and near point of convergence (NPC) and reading rate (r = .30, p = .01). The MRs for reading accuracy (F = 4.61, p = .01) and reading rate (F = 4.61, p = .01) were significant, and predicted approximately 40% of the variance, with visual motor speed and NPC as the only significant predictors in both models. Symptoms were not predictive of reading accuracy or rate. The present study indicates that visual motor speed and NPC are predictive of academic reading performance after SRC, suggesting clinicians should consider these clinical outcomes to better inform academic accommodations.

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

OBJECTIVE: To determine whether the Vestibular/Ocular Motor Screening (VOMS) tool demonstrates concurrent validity with the Dizziness Handicap Inventory (DHI) in a sample of concussed athletes referred for vestibular therapy and whether DHI items were predictive of VOMS outcomes. DESIGN: Cross-sectional cohort study. SETTING: Concussion specialty/vestibular therapy clinic. METHODS: Adolescents (n = 55; 15.4 ± 1.6 years) with diagnosed sport-related concussion (SRC) with vestibular symptoms and/or impairment between October 2018-February 2020. Patients completed VOMS and DHI at initial visit. Seven individual VOMS and twenty-five DHI items, VOMS and DHI total score and three DHI sub-scales, were compared with Spearman correlations. Three backwards linear regression (LR) models were built to predict 1. VOMS vestibular symptoms, 2. VOMS ocular symptoms, and 3. near-point of convergence-distance (NPC-distance) using individual DHI items as predictors. RESULTS: Spearman correlations (p) identified DHI items with moderate to strong associations for VOMS items. DHI sub-scales demonstrated moderate-to-strong correlations with VOMS items (p = 0.30-0.59). Total DHI score demonstrated a moderate-to-strong association with HSAC (p = 0.30), VSAC (p = 0.32), and SP (p = 0.61). Results from the LRs predicting VOMS ocular symptoms (R (Alsalaheen et al., 2010) = 0.56; p < 0.001), and VOMS vestibular symptoms (R (Alsalaheen et al., 2010) = 0.23; p = 0.01), and NPC-distance (R (Alsalaheen et al., 2010) = 0.56; p < 0.001) included significant DHI predictors. CONCLUSIONS: There was moderate-to-strong associations between VOMS and 56% of DHI items (i.e., p > 0.30).

Fixational eye movements following concussion.

The purpose of this study was to evaluate fixational eye movements (FEMs) with high spatial and temporal resolution following concussion, where oculomotor symptoms and impairments are common. Concussion diagnosis was determined using current consensus guidelines. A retinal eye-tracking device, the tracking scanning laser ophthalmoscope (TSLO), was used to measure FEMs in adolescents and young adults following a concussion and in an unaffected control population. FEMs were quantified in two fixational paradigms: (1) when fixating on the center, or (2) when fixating on the corner of the TSLO imaging raster. Fixational saccade amplitude in recent concussion patients (≤ 21 days) was significantly greater, on average, in the concussion group (mean = 1.03°; SD = 0.36°) compared with the controls (mean = 0.82°; SD = 0.31°), when fixating on the center of the imaging raster (t = 2.87, df = 82, p = 0.005). These fixational saccades followed the main sequence and therefore also had greater peak velocity (t = 2.86, df = 82, p = 0.006) and peak acceleration (t = 2.80, df = 82, p = 0.006). These metrics significantly differentiated concussed from controls (AUC = 0.67-0.68, minimum p = 0.005). No group differences were seen for the drift metrics in either task or for any of the FEMs metrics in the corner-of-raster fixation task. Fixational saccade amplitudes were significantly different in the concussion group, but only when fixating on the center of the raster. This task specificity suggests that task optimization may improve differentiation and warrants further study. FEMs measured in the acute-to-subacute period of concussion recovery may provide a quick (<3 minutes), objective, sensitive, and accurate ocular dysfunction assessment. Future work should assess the impact of age, mechanism of injury, and post-concussion recovery on FEM alterations following concussion.

Effects of the COVID-19 Pandemic on Patients with Concussion Presenting to a Specialty Clinic.

The purpose of this study is to examine the effects of the COVID-19 pandemic on patients presenting with concussion at a specialty clinic. This study used a retrospective cohort design to compare participants (n = 3021) with a suspected concussion, including a Pandemic cohort (n = 1139; March 2020-February 2021) and a Pre-Pandemic cohort (n = 1882; March 2019-February 2020). Concussions and patient characteristics including age, sex, days since injury, and injury mechanism were extracted from an electronic health record. There were 39.5% (n = 743) fewer concussions in Pandemic. Pandemic presented to the clinic 25.8 days later (p < 0.001) and were 1.9 years older (p < 0.001) than Pre-Pandemic. Sport-related concussions decreased 59.6% overall for Pandemic. Pandemic was associated with proportional increases of concussions involving recreational activities (odds ratio [OR] = 6.11; p < 0.001), motor vehicle collisions (OR = 1.39; p < 0.001), and falls/assaults (OR = 1.33; p < 0.001). A total of 9.4% (107/1139) of all Pandemic concussion initial clinical visits were performed using telehealth (0% in Pre-Pandemic). Concussion visit volume to a sub-specialty clinic decreased by approximately 40% during the COVID-19 pandemic and patients presented to the clinic nearly 1 month later. The increase in telehealth highlights the potential to expand clinical care outreach during the current and future pandemics or similar restrictive time periods.

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.

Targeted Intervention Improves Symptoms and Impairments in Patients With Mild Traumatic Brain Injury With Chronic Symptom: A Prospective, Multiple Interventional Research Trial.

BACKGROUND: Mild traumatic brain injury (mTBI) and its potential long-term consequences is a primary concern for the US military. The purpose of the study is to evaluate if participants improved in anxiety/mood symptoms, sleep quality, and vestibular/ocular symptoms following a 6-month active intervention, and to explore the effect of targeted treatment for those with specific symptoms/impairments (e.g., psychological, sleep, ocular, vestibular). MATERIALS AND METHODS: A multidisciplinary clinical team adjudicated participants (n=72, 35.8±8.6 years old, 19% female) to have one of the following primary clinical trajectories: psychological (PSYCH; n=34), sleep (SLEEP; n=25) and vestibular/ocular (VESTIB/OCULAR; n=18). Participants returned for follow-up assessment 6 months later. Assessments included the Post-Concussion Symptom Scale [PCSS], Generalized Anxiety Disorder-7 [GAD-7], Pittsburgh Sleep Quality Index [PSQI], and Dizziness Handicap Inventory [DHI]. Change in concussion symptoms and primary outcome for the given trajectory (i.e., PSYCH=GAD-7, SLEEP=PSQI, VESTIB/OCULAR=DHI) was assessed. RESULTS: Following the 6-month intervention, participants reduced PCSS Score (-14.5±2.4; p<.001; η2=0.34), GAD-7 (-3.1±0.5; p<.001; η2=0.34), PSQI (-2.7±0.5; p<.001; η2=0.34) and DHI (-9.2±2.0; p<.001; η2=0.23). PSYCH (n=34) reduced PCSS score (-17.9±3.6; p<.001; η2=0.45) and GAD-7 (-3.1±0.7; p<.001; η2=0.38). SLEEP (n=25) reduced PCSS score (-8.8±4.4; p=.06; η2=0.15) and PSQI (-3.6±0.9; p<.001; η2=0.45) scores. VESTIB/OCULAR (n=18) reduced PCSS score (-16.7±4.8; p=.03; η2=0.45), and DHI (-15.7±5.5; p=.012; η2=0.35). CONCLUSIONS: Large effects were observed for concussion, anxiety, sleep, and dizziness symptom reduction over 6-month treatment. Each primary outcome demonstrated a larger treatment effect for the given trajectory than the overall sample, indicating that targeted treatment can reduce symptom burden in patients with mTBI with chronic symptoms.

Test-retest reliability of the Vestibular Ocular Motor Screening (VOMS) tool and modified Balance Error Scoring System (mBESS) in US military personnel.

The Military Acute Concussion Evaluation 2 (MACE 2), which includes the Vestibular-Ocular Motor Screening (VOMS) tool and the single-leg stance component of the modified Balance Error Scoring System (mBESS), was introduced in 2018 as an assessment of acute mTBI in US military personnel. However, the reliability of the VOMS and mBESS in this population has not been established. OBJECTIVES: The primary purpose of this study was to examine the reliability of the VOMS across a 6-month period in healthy, uninjured US Army Special Operations Command (USASOC) personnel. DESIGN: Active duty/heathy military personnel (n=108) completed the VOMS and mBESS at baseline and follow-up 6 months later (±1 month). METHOD: Cronbach's alpha was used to examine the internal consistency of the VOMS and mBESS at both time points. Two-way mixed intra-class correlation coefficients (ICC) with consistency agreement were used to evaluate test-retest reliability. RESULTS: VOMS demonstrated excellent internal consistency (α=0.99), whereas, the mBESS demonstrated poor internal consistency (α=0.29). Test-retest reliability of VOMS items was moderate-to-good with ICCs ranging from 0.60 to 0.81. Test-retest reliability was moderate for mBESS total score (ICC=0.59) and double-leg stance (ICC=0.73), while single-leg (ICC=0.49) and tandem (ICC=0.02) stances were poor. CONCLUSIONS: The findings suggest that VOMS has high internal consistency and moderate-to-good test-retest reliability. mBESS has poor internal consistency and poor-to-moderate test-retest reliability. The results suggest that VOMS is a reliable addition to the MACE-2, whereas, mBESS single-leg stance is less reliable. As such, mBESS double-leg stance may be a more reliable measure of balance in this population.

Association of Time Since Injury to the First Clinic Visit With Recovery Following Concussion.

Importance: Recovery after concussion varies, with adolescents taking longer (approximately 30 days) than adults. Many factors have been reported to influence recovery, including preinjury factors, perceptions about recovery, comorbid conditions, and sex. However, 1 factor that may play a role in recovery but has received little attention from researchers is the timeliness of clinical evaluation and care. Objective: To investigate the association of time since injury with initiation of clinical care on recovery time following concussion. Design, Setting, and Participants: This retrospective, cross-sectional study was conducted in a sports medicine clinic between August 2016 and March 2018. Eligible participants were aged 12 to 22 years and had a diagnosed, symptomatic concussion; patients were excluded if recovery data were incomplete. Participants were divided into 2 groups: those seen within 7 days of the injury (early) vs between 8 and 20 days of the injury (late). Data were analyzed between June 2019 and August 2019. Exposures: Time from injury (concussion) to initiation of clinical care. Main Outcomes and Measures: Recovery time; testing with the Post-Concussion Symptom Scale, Immediate Post-Concussion Assessment and Cognitive Testing, and Vestibular/Ocular Motor Screening instruments; demographic factors, medical history, and injury information. Results: A total of 416 individuals were eligible, and 254 (61.1%) were excluded, leaving 162 (38.9%) in analyses. The early group (98 patients) and late group (64 patients) did not differ in age (mean [SD] age, early, 15.3 [1.6] years; late, 15.4 [1.6] years), number of female patients (early, 51 of 98 [52.0%]; late, 40 of 64 [62.5%]), or other demographic, medical history, or injury information. The groups also were similar on symptom severity, cognitive, ocular, and vestibular outcomes at the first clinic visit. Results from a logistical regression supported being in the late group (adjusted odds ratio, 5.8 [95% CI, 1.9-17.6]; P = .001) and visual motion sensitivity symptoms greater than 2 (adjusted odds ratio, 4.5 [95% CI, 1.1-18.0]; P = .04) as factors significantly associated with recovery time. Conclusions and Relevance: Findings suggest that earlier initiation of clinical care is associated with faster recovery after concussion. Other factors may also influence recovery time. Further research is needed to determine the role of active rehabilitation and treatment strategies, as well as demographic factors, medical history, and injury characteristics on the current findings.

Concussion Clinical Profiles Screening (CP Screen) Tool: Preliminary Evidence to Inform a Multidisciplinary Approach.

BACKGROUND: Current concussion symptom inventories emphasize total number or symptoms and severity and overlap with other conditions, such as mental health disorders, which may limit their specificity and clinical utility. OBJECTIVE: To develop and test the reliability and validity of a new Concussion Clinical Profiles Screening tool (CP Screen) in both healthy controls and concussed. METHODS: CP Screen is a 29-item self-report, clinical profile-based symptom inventory that measures the following 5 concussion clinical profiles: 1) anxiety/mood, 2) cognitive/fatigue, 3) migraine, 4) ocular, and 5) vestibular; and the following 2 modifying factors: 1) sleep and 2) neck. Post-Concussion Symptom Scale (PCSS), vestibular/ocular motor screening (VOMS) tool, and Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) were conducted. CP Screen was administered in community a concussion surveillance program and 2 sports medicine concussion clinics. Responses include 248 athletes, 121 concussed, and 127 controls, enrolled between 2018 and 2019. RESULTS: Internal consistency of the CP Screen in the control (Cronbach's alpha = .87) and concussed (Cronbach's alpha = .93) samples was high. Moderate to high correlations among the CP Screen factors and PCSS factors and VOMS items, supporting concurrent validity. ROC curve analysis for identifying concussed from controls was significant (P < .001) for all CP Screen factor and modifier scores with excellent AUCs for migraine (.93), ocular (.88), vestibular (.85), and cognitive (.81) factors, demonstrating predictive validity. CONCLUSION: The CP Screen demonstrated strong reliability, concurrent validity with commonly used concussion assessment (ie, PCSS, VOMS, and ImPACT), and predictive validity for identifying concussion. The CP Screen extends current symptom inventories by evaluating more specific symptoms that may reflect clinical profiles and inform better clinical care.

Influence of Test Environment, Age, Sex, and Sport on Baseline Computerized Neurocognitive Test Performance.

BACKGROUND: Baseline computerized testing is a common component of concussion assessments, and the testing environment has been suggested to influence test performance and validity. PURPOSE: To compare concussion baseline computerized neurocognitive test performance and validity among adolescent athletes based on testing environment (group, individual), age group (10-12, 13-15, 16-18 years), sex (male, female), and sport type (collision/combat, contact, noncontact). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Through a concussion community outreach program, participants completed baseline computerized neurocognitive testing using Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). A total of 2845 athletes aged 10 to 18 years completed the baseline assessment. A total of 2241 (79%) athletes completed baseline testing in a group environment, and 604 (21%) completed testing in an individual environment. A random subsample of 500 athletes from each group was selected for statistical comparison. RESULTS: No significant differences were supported in baseline computerized neurocognitive test performance between the group and individual administration environments. Test validity was statistically similar across testing environment, age group, and sex. However, patients of older age (16-18 years), female sex, and collision/combat and contact sports performed better on ImPACT. There were differences in total symptom severity scores (t = 2.19, df = 998, P = .03), with participants in the group testing environment reporting lower total symptom severity scores than those in the individual testing environment. The rates of invalid tests were low across all age groups, averaging from 4.0% in the 10- to 12-year age group to 4.8% in the 13- to 15-year age group. CONCLUSION: The findings indicated that concussion baseline neurocognitive test performance is similar when administered in group and individual testing environments. However, differences based on age group, sex, and sport type should be considered when interpreting baseline computerized neurocognitive test scores. The finding of higher symptom scores in older adolescents in the individual testing environment suggests that they may be less forthcoming about symptoms in a group setting.

Recovery Following Sport-Related Concussion: Integrating Pre- and Postinjury Factors Into Multidisciplinary Care.

OBJECTIVE: Update concussion recovery curves by considering pre- and postinjury modifying factors. Determine whether there is a dose-response for modifying factors on recovery. SETTING: Sports medicine concussion clinic. PARTICIPANTS: A total of 314 athletes aged 12-23 years within 7 days of a concussion enrolled between 2015 and 2018. DESIGN: Prospective cohort study. MAIN MEASURES: Categorical recovery time defined as days from injury to full medical clearance for return to play per established criteria. Preinjury factors included age, gender, concussion history, and migraine history. Postinjury factors included loss of consciousness, posttraumatic amnesia, posttraumatic migraine symptoms, and high symptom burden. RESULTS: Average recovery was 27.5 ± 25 days. Five factors were prognostic of recovery: (1) younger than 18 years, (2) female, (3) history of migraine, (4) posttraumatic migraine symptoms, and (5) high symptom burden (P < .05). Recovery percentage at 21 days after injury was 96.7% for participants with 0 factor, 65.3% for those with 1 to 2, and 31.8% for those with 3 to 5-with prognostic separation in low- to high-risk groups of 62%. CONCLUSIONS: Findings support a dose-response for combined pre- and postinjury factors on recovery. Both the type and quantity of modifying factors influence recovery and should be considered in prognosis and approaches to multidisciplinary care.

Persistent vestibular-ocular impairment following concussion in adolescents.

OBJECTIVES: The current study investigated the role of persistent vestibular-ocular symptoms and impairment following sport-related concussion on recovery time and clinical outcomes among adolescents. DESIGN: Prospective cohort. METHODS: 50 (F-22/M-28) adolescents aged 12-20 years completed a vestibular-ocular motor screening, neurocognitive assessment, and the Post-Concussion Symptom Scale (PCSS) at clinical assessments conducted at 0-10 and 11-21 days after concussion. Participants were assigned to: 1) persistent vestibular-ocular (PERSIST), 2) vestibular-ocular improvement (IMPROVE), or 3) no vestibular-ocular impairment (NONE) groups based on vestibular-ocular motor screening conducted during each assessment. A 3 (GROUP) X 2 (TIME) ANOVA was performed on neurocognitive and symptom scores, and a between-subjects ANOVA was performed for recovery time. RESULTS: 49 subjects were identified among the PERSIST (n=17), IMPROVE (n=12) and NONE (n=20) groups. There were no neurocognitive performance differences between groups at 0-10 days post-concussion, but groups differed on PCSS at 11-21 days (p=.001), with the PERSIST (29.0±24.9) group reporting higher symptoms than the NONE (5.45±10.0; p=.005) group. The PERSIST group took significantly longer to recover (34.9±11.6 days) than the NONE (22.9±14.9 days) group (p=.03). All groups improved on verbal (p<.001) and visual memory (p=.028), visual motor speed (p=.005), and reaction time (p=.004) from 0-10 to 11-20 days following SRC and no significant group by time interactions for cognitive scores identified. CONCLUSIONS: Persistent post-concussion vestibular-ocular symptoms and impairment may influence neurocognitive performance and clinical recovery following sport-related concussion.

Preliminary Evidence for Improvement in Symptoms, Cognitive, Vestibular, and Oculomotor Outcomes Following Targeted Intervention with Chronic mTBI Patients.

Introduction: To determine if targeted, active interventions would improve symptoms and impairment in previously intractable patients with chronic mild traumatic brain injury (mTBI). Materials and Methods: Twenty-six (20 males; 6 females) out of 51 (51%) former military and civilian patients with chronic (1-3 yr) mTBI enrolled in the TEAM traumatic brain injury (TBI) study completed both an initial and 6-mo post-intervention comprehensive mTBI assessment including symptoms (Post-concussion Symptom Scale [PCSS], Dizziness Handicap Inventory [DHI]), cognitive (Immediate Post-concussion Assessment and Cognitive Testing [ImPACT]), vestibular/oculomotor (Vestibular/Ocular Motor Screening [VOMS]), balance (Activities-specific Balance Confidence [ABC] scale, Balance Error Scoring System [BESS]), and cervical (Neck Disability Index [NDI]). Patients were prescribed progressive, targeted interventions and therapies (e.g., behavioral, vestibular, vision, and exertion) that matched their mTBI clinical profile. A series of paired t-tests adjusted for multiple corrections were used to compare pre- and post-intervention assessment scores. Results: Patients demonstrated significant improvement from pre- to post-intervention on total symptoms (t = 2.69, p = 0.01), verbal memory (t = -1.96, p = 0.05), ABC balance score (t = -2.05, p = 0.05), smooth pursuits (t = 2.32, p = 0.04), near-point convergence distance (t = -3.58, p = 0.01), vestibular ocular reflex (t = 2.31, p = 0.03), and visual motion sensitivity (t = 2.43, p = 0.03). Conclusions: Previously recalcitrant patients with chronic complex mTBI demonstrated significant improvement in symptoms, cognitive, vestibular, oculomotor, and balance function following targeted interventions.