Test-Retest Reliability and Efficacy of Individual Symptoms in Concussion Management.

OBJECTIVE: (1) To determine test-retest reliability of individual Sport Concussion Assessment Tool-Third Edition (SCAT-3) symptom scores and symptom severity scores, (2) to examine the specificity/sensitivity of individual SCAT-3 symptom severity scores acutely (24-48 hours) postconcussion, and (3) to develop a model of symptoms best able to differentiate concussed from nonconcussed student athletes and cadets. DESIGN: Prospective, longitudinal, and cross-sectional. SETTING: Twenty-six civilian schools and 3 US service academies. PARTICIPANTS: Collegiate student athletes (n = 5519) and cadets (n = 5359) from the National Collegiate Athletic Association-Department of Defense Grand Alliance: Concussion Assessment, Research and Education Consortium, including 290 student athletes and 205 cadets, assessed 24 to 48 hours postconcussion. INDEPENDENT VARIABLES: Concussed and nonconcussed student athlete and cadet groups. MAIN OUTCOME MEASURES: Sport Concussion Assessment Tool-Third Edition individual symptom severity scores, total symptom scores, and symptom severity scores. RESULTS: Results indicated poor test-retest reliability across all symptom scores (intraclass correlation coefficient = 0.029-0.331), but several individual symptoms had excellent predictive capability in discriminating concussed from nonconcussed participants (eg, headache, pressure in the head, and don't feel right had area under the curve >0.8, sensitivity >70%, and specificity >85%) regardless of baseline testing. These symptoms were consistent with Chi-square Automatic Interaction Detector classification trees with the highest mean probability. CONCLUSIONS: Findings support the excellent diagnostic accuracy of honest symptom reporting, notwithstanding the known limitations in symptom underreporting, and suggest that there may be added value in examining individual symptoms rather than total symptom scores and symptom severity scores alone. Finally, findings suggest that baseline testing is not necessary for interpreting postconcussion symptom scores.

Minimum detectable change and false positive rates of the vestibular/ocular motor screening (VOMS) tool: an NCAA-DoD care consortium analysis.

OBJECTIVE: To derive minimum detectable change (MDC) across individual Vestibular-Ocular Motor Screening (VOMS) items and VOMS overall score in 17-25 years old collegiate athletes and to examine false positive rates. METHOD: Participants (n = 378) completed VOMS pre-season for two consecutive years. MDC was identified for individual VOMS symptom items and NPC distance (cm). Both total and change methods of VOMS scoring were included in analysis. RESULTS: Regarding total scoring, MDC for ocular VOMS symptom items was 1 and MDC for vestibular VOMS symptoms items was 2. MDC for NPC was 4 cm and for VOMS overall score was 10. Regarding change scoring, MDC for each VOMS symptom item was 1, and for VOMS overall score was 8. False positives ranged from 5.3% to 15.9%. CONCLUSIONS: This study presents MDCs for each VOMS item and overall VOMS score, using total and change scoring. These values can be considered true change outside measurement error with 95% confidence in a 17-25 year old collegiate athlete population.

The gaze stability of 4- to 10-week-old human infants.

The relationship between gaze stability, retinal image quality, and visual perception is complex. Gaze instability related to pathology in adults can cause a reduction in visual acuity (e.g., Chung, LaFrance, & Bedell, 2011). Conversely, poor retinal image quality and spatial vision may be a contributing factor to gaze instability (e.g., Ukwade & Bedell, 1993). Though much is known about the immaturities in spatial vision of human infants, little is currently understood about their gaze stability. To characterize the gaze stability of young infants, adult participants and 4- to 10-week-old infants were shown a dynamic random-noise stimulus for 30-s intervals while their eye positions were recorded binocularly. After removing adultlike saccades, we used 5-s epochs of stable intersaccade gaze to estimate bivariate contour ellipse area and standard deviations of vergence. The geometric means (with standard deviations) for infants' bivariate contour ellipse area were left eye = -0.697 ± 0.534 log(°2), right eye = -0.471 ± 0.367 log(°2). For binocular vergence stability, the infant geometric means (with standard deviations) were horizontal = -1.057 ± 0.743 log(°), vertical = -1.257 ± 0.573 log(°). These values were all not significantly different from those of the adult comparison sample, suggesting that gaze instability is not a significant limiting factor in retinal image quality and spatial vision during early postnatal development.

Retinal tear presenting in a patient with ectrodactyly ectodermal dysplasia.

PURPOSE: This article aims to report a case of known ectrodactyly ectodermal dysplasia in a young male patient who subsequently was found to have a retinal tear and localized retinal detachment. CASE REPORT: This is a case report of a 22-year-old white male patient with a history of ectrodactyly ectodermal dysplasia. Our patient initially presented with an acute exacerbation of bilateral, red, irritated eyes. No recent changes in vision were reported. The patient's ocular surface disease was consistent with ectrodermal dysplasia syndrome. However, a dilated fundus examination revealed an asymptomatic retinal tear with a surrounding localized retinal detachment. CONCLUSIONS: In this case, the patient presented with longstanding ocular surface disease known to be associated with this patient's inherited ectoderm disorder. In addition, this patient revealed a retinal tear, raising the possibility that patients with inherited congenital ectodermal dysplasia could be at risk for damaged structures originating from the neural ectoderm. In this heterogeneous disease, we are contributing to the existing literature a case of ectodermal dysplasia syndrome with obvious ectodermal complications that also had retinal findings leading us to speculate question if neural ectoderm could also be involved in this inherited disease.

Arterial oxygen desaturation during moderate hypoxia hinders sensorimotor performance.

INTRODUCTION: Moderate hypoxia may impact cognitive and sensorimotor performance prior to self-recognized impairments. Therefore, rapid and objective assessment tools to identify people at risk of impaired function during moderate hypoxia is needed. PURPOSE: Test the hypothesis that reductions in arterial oxygen saturation during moderate normobaric hypoxia (FiO2 = 14%) decreases gamified sensorimotor performance as measured by alterations of motor acuity. METHODS: Following three consecutive days of practice, thirty healthy adults (25 ± 5 y, 10 females) completed three bouts of the tablet-based gamified assessment (Statespace Labs, Inc.) of motor acuity at Baseline and 60 and 90 min after exposure to 13.8 ± 0.2% (hypoxia) and 20.1 ± 0.4% (normoxia) oxygen. The gamified assessment involved moving the tablet to aim and shoot at targets. Both conditions were completed on the same day and were administered in a single-blind, block randomized manner. Performance metrics included shot time and shot variability. Arterial oxyhemoglobin saturation estimated via forehead pulse oximetry (SpO2). Data were analyzed using linear mixed effects models. RESULTS: Compared to normoxia (99±1%), SpO2 was lower (p<0.001) at 60 (89±3%) and 90 (90±2%) min of hypoxia. Shot time was unaffected by decreases in SpO2 (0.012, p = 0.19). Nor was shot time affected by the interaction between SpO2 decrease and baseline performance (0.006, p = 0.46). Shot variability was greater (i.e., less precision, worse performance) with decreases in SpO2 (0.023, p = 0.02) and depended on the interaction between SpO2 decrease and baseline performance (0.029, p< 0.01). CONCLUSION: Decreases in SpO2 during moderate hypoxic exposure hinders sensorimotor performance via decreased motor acuity, i.e., greater variability (less precision) with no change in speed with differing decreases in SpO2. Thus, personnel who are exposed to moderate hypoxia and have greater decreases in SpO2 exhibit lower motor acuity, i.e., less precise movements even though decision time and movement speed are unaffected.

Latent Profiles of Acute Symptoms, Cognitive Performance, and Balance in Sport-Related Concussions.

BACKGROUND: A sport-related concussion (SRC) is a common injury that affects multiple clinical domains such as cognition, balance, and nonspecific neurobehavioral symptoms. Although multidimensional clinical assessments of concussion are widely accepted, there remain limited empirical data on the nature and clinical utility of distinct clinical profiles identified by multimodal assessments. PURPOSE: Our objectives were to (1) identify distinct clinical profiles discernible from acute postinjury scores on the Sport Concussion Assessment Tool (SCAT), composed of a symptom checklist, a cognitive assessment (Standardized Assessment of Concussion), and a balance assessment (Balance Error Scoring System), and (2) evaluate the clinical utility of the identified profiles by examining their association with injury characteristics, neuropsychological outcomes, and clinical management-related outcomes. STUDY DESIGN: Cohort study (Prognosis); Level of evidence, 2. METHODS: Up to 7 latent profiles were modeled for 1885 collegiate athletes and/or military cadets who completed the SCAT at 0 to 12 hours after an injury. Chi-square tests and general linear models were used to compare identified profiles on outcomes at 12 to 72 hours after the injury. Kaplan-Meier analysis was used to investigate associations between clinical profiles and time to return to being asymptomatic and to return to play. RESULTS: There were 5 latent profiles retained: low impairment (65.8%), high cognitive impairment (5.4%), high balance impairment (5.8%), high symptom severity (16.4%), and global impairment (6.5%). The latent profile predicted outcomes at 12 to 72 hours in expectable ways (eg, the high balance impairment profile demonstrated worse balance at 12 to 72 hours after the injury). Time to return to being asymptomatic and to return to play were different across profiles, with the high symptom severity and global impairment profiles experiencing the longest recovery and the high balance impairment profile experiencing an intermediate-length recovery (vs low impairment profile). CONCLUSION: An SRC is a heterogeneous injury that presents in varying ways clinically in the acute injury period and results in different recovery patterns. These data support the clinical prognostic value of diverse profiles of impairment across symptom, cognitive, and balance domains. By identifying distinct profiles of an SRC and connecting them to differing outcomes, the findings support more evidence-based use of accepted multimodal clinical assessment strategies for SRCs.

Mechanisms of Injury Leading to Concussions in Collegiate Soccer Players: A CARE Consortium Study.

BACKGROUND: Few previous studies have investigated how different injury mechanisms leading to sport-related concussion (SRC) in soccer may affect outcomes. PURPOSE: To describe injury mechanisms and evaluate injury mechanisms as predictors of symptom severity, return to play (RTP) initiation, and unrestricted RTP (URTP) in a cohort of collegiate soccer players. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: The Concussion Assessment, Research and Education (CARE) Consortium database was used. The mechanism of injury was categorized into head-to-ball, head-to-head, head-to-body, and head-to-ground/equipment. Baseline/acute injury characteristics-including Sports Concussion Assessment Tool-3 total symptom severity (TSS), loss of consciousness (LOC), and altered mental status (AMS); descriptive data; and recovery (RTP and URTP)-were compared. Multivariable regression and Weibull models were used to assess the predictive value of the mechanism of injury on TSS and RTP/URTP, respectively. RESULTS: Among 391 soccer SRCs, 32.7% were attributed to a head-to-ball mechanism, 27.9% to a head-to-body mechanism, 21.7% to a head-to-head mechanism, and 17.6% to a head-to-ground/equipment mechanism. Event type was significantly associated with injury mechanism [χ2(3) = 63; P < .001), such that more head-to-ball concussions occurred in practice sessions (n = 92 [51.1%] vs n = 36 [17.1%]) and more head-to-head (n = 65 [30.8%] vs n = 20 [11.1]) and head-to-body (n = 76 [36%] vs n = 33 [18.3%]) concussions occurred in competition. The primary position was significantly associated with injury mechanism [χ2(3) = 24; P < .004], with goalkeepers having no SRCs from the head-to-head mechanism (n = 0 [0%]) and forward players having the least head-to-body mechanism (n = 15 [19.2%]). LOC was also associated with injury mechanism (P = .034), with LOC being most prevalent in head-to-ground/equipment. Finally, AMS was most prevalent in head-to-ball (n = 54 [34.2%]) and head-to-body (n = 48 [30.4%]) mechanisms [χ2(3) = 9; P = .029]. In our multivariable models, the mechanism was not a predictor of TSS or RTP; however, it was associated with URTP (P = .044), with head-to-equipment/ground injuries resulting in the shortest mean number of days (14 ± 9.1 days) to URTP and the head-to-ball mechanism the longest (18.6 ± 21.6 days). CONCLUSION: The mechanism of injury differed by event type and primary position, and LOC and AMS were different across mechanisms. Even though the mechanism of injury was not a significant predictor of acute symptom burden or time until RTP initiation, those with head-to-equipment/ground injuries spent the shortest time until URTP, and those with head-to-ball injuries had the longest time until URTP.

The Prevalence and Influence of New or Worsened Neck Pain After a Sport-Related Concussion in Collegiate Athletes: A Study From the CARE Consortium.

BACKGROUND: Neck pain in a concussion population is an emerging area of study that has been shown to have a negative influence on recovery. This effect has not yet been studied in collegiate athletes. HYPOTHESIS: New or worsened neck pain is common after a concussion (>30%), negatively influences recovery, and is associated with patient sex and level of contact in sport. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Varsity-level athletes from 29 National Collegiate Athletic Association member institutions as well as nonvarsity sport athletes at military service academies were eligible for enrollment. Participants completed a preseason baseline assessment and follow-up assessments at 6 and 24 to 48 hours after a concussion, when they were symptom-free, and when they returned to unrestricted play. Data collection occurred between January 2014 and September 2018. RESULTS: A total of 2163 injuries were studied. New or worsened neck pain was reported with 47.0% of injuries. New or worsened neck pain was associated with patient sex (higher in female athletes), an altered mental status after the injury, the mechanism of injury, and what the athlete collided with. The presence of new/worsened neck pain was associated with delayed recovery. Those with new or worsened neck pain had 11.1 days of symptoms versus 8.8 days in those without (P < .001). They were also less likely to have a resolution of self-reported symptoms in ≤7 days (P < .001). However, the mean duration of the return-to-play protocol was not significantly different for those with new or worsened neck pain (7.5 ± 7.7 days) than those without (7.4 ± 8.3 days) (P = .592). CONCLUSION: This novel study shows that neck pain was common in collegiate athletes sustaining a concussion, was influenced by many factors, and negatively affected recovery.

Association of Premorbid Anxiety and Depression Symptoms in Concussion Recovery in Collegiate Student-Athletes.

BACKGROUND: Mental health disorders are linked to prolonged concussion symptoms. However, the association of premorbid anxiety/depression symptoms with postconcussion return-to-play timelines and total symptom burden is unclear. OBJECTIVE: To examine the association of self-reported premorbid anxiety/depression symptoms in collegiate student-athletes with (1) recovery times until asymptomatic, (2) return-to-play, and (3) postconcussion symptom burden. STUDY DESIGN: Athletes in the Concussion Assessment, Research and Education Consortium completed baseline concussion assessments (Sport Concussion Assessment Tool [SCAT3] and Brief Symptom Inventory-18 [BSI-18]). Athletes were tested postinjury at <6 hours, 24 to 48 hours, time of asymptomatic and start of return-to-play protocol, unrestricted return-to-play, and 6 months after injury. Injured athletes were categorized into 4 groups based on BSI-18 scores: (1) B-ANX, elevated anxiety symptoms only; (2) B-DEP, elevated depression symptoms only; (3) B-ANX&DEP, elevated anxiety and depression symptoms; and (4) B-NEITHER, no elevated anxiety or depression symptoms. Relationship between age, sex, BSI-18 group, SCAT3 total symptom and severity scores, and time to asymptomatic status and return-to-play was assessed with Pearson's chi-squared test and robust analysis of variance. LEVEL OF EVIDENCE: Level 3. RESULTS: Among 1329 athletes with 1352 concussions, no respondents had a self-reported premorbid diagnosis of anxiety/depression. There was no difference in time until asymptomatic or time until return-to-play between BSI-18 groups (P = 0.15 and P = 0.11, respectively). B-ANX, B-DEP, and B-ANX&DEP groups did not have higher total symptom or severity scores postinjury compared with the B-NEITHER group. CONCLUSION: Baseline anxiety/depression symptoms in collegiate student-athletes without a mental health diagnosis are not associated with longer recovery times until asymptomatic, longer time to return-to-play, or higher postconcussion total symptom and severity scores compared with athletes without baseline symptoms. CLINICAL RELEVANCE: Anxiety and depression symptoms without a clear mental health diagnosis should be considered differently from other comorbidities when discussing prolonged recovery in collegiate student-athletes.

Gamified assessment of cognitive performance during moderate hypoxia.

INTRODUCTION: There is a need for rapid and objective assessment tools to identify people at risk of impaired cognitive function during hypoxia. PURPOSE: To test the hypotheses that performance on gamified cognitive tests examining the cognitive domains of executive function (Gridshot), working memory (Capacity) and spatial tracking (Multitracker) will be reduced during normobaric exposure to moderate normobaric hypoxia. METHODS: Following three consecutive days of practice, twenty-one healthy adults (27 ± 5 y, 9 females) completed five 1-min rounds of the tablet-based games Gridshot, Capacity, and Multitracker (Statespace Labs, Inc.) at Baseline and 60 and 90 min after exposure to 14.0 ± 0.2% (hypoxia) and 20.6 ± 0.3% (normoxia) oxygen. Both conditions were completed on the same day and were administered in a single-blind, block randomized manner. Arterial oxyhemoglobin saturation was estimated via forehead pulse oximetry (SpO2). Data were analyzed using ANCOVA with a covariate of Baseline. RESULTS: Compared to normoxia (98 ± 1%), SpO2 was lower (p < 0.001) at 60 (91 ± 3%) and 90 (91 ± 2%) min of hypoxia. No condition x time interaction effects were identified for any gamified cognitive tests (p ≥ 0.32). A main effect of condition was identified for Capacity (p = 0.05) and Multitracker (p = 0.04), but not Gridshot (p = 0.33). Post hoc analyses of the composite scores for both Capacity (p = 0.11) and Multitracker (p = 0.73) demonstrated no difference between conditions. CONCLUSION: Performance on gamified cognitive tests was not consistently affected by acute normobaric moderate hypoxic exposure.

Primary and Secondary Risk Factors Associated With Concussion Symptom Clusters in Collegiate Athletes: Results From the NCAA-DoD Grand Alliance CARE Consortium.

Background: There is a broad and diverse range of symptoms after a concussion, from irritability to nausea. This heterogeneity of symptoms is a challenge for clinicians managing the different presentations among injuries. Prior research has investigated the structure of postconcussive symptoms to determine if they can be grouped into clusters of related symptoms. Purpose/Hypothesis: The purpose of this study was to identify symptom clusters during the acute phase after a sports-related concussion using exploratory factor analysis and to understand the relationship between risk factors for postconcussion symptoms (ie, demographics, injury characteristics, mental health, and sleep qualities) and different symptom clusters. We hypothesized that certain factors would be predictive of specific symptom clusters. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Collegiate athletes (N = 1104) from the Concussion, Assessment, Research, and Education (CARE) Consortium completed the Sport Concussion Assessment Tool-Third Edition symptom assessment tool 24 to 48 hours after concussion. Exploratory factor analysis was conducted on the symptom evaluation to determine symptom clusters 24 to 48 hours after concussion. Regression analysis was used to examine the effects of pre- and postinjury characteristics. Results: Exploratory factor analysis revealed a 4-cluster structure for acute postconcussive symptoms that explained 62% of the variance in symptom reporting: vestibular-cognitive, migrainous, cognitive fatigue, and affective. Delayed reporting, less sleep before assessment, female sex, and being hurt outside of competition (during practice/training) was correlated with increased symptoms for 4 symptom clusters. Depression predicted higher vestibular-cognitive and affective symptoms. Amnesia was correlated with higher vestibular-cognitive and migrainous symptoms, whereas migraine history was associated with more migrainous and affective symptoms. Conclusion: Symptoms can be grouped into 1 of 4 distinct clusters. Certain variables were associated with increased symptoms across multiple clusters and may be indicative of greater injury severity. Other factors (ie, migraine history, depression, amnesia) were associated with a more specific symptom presentation and may be mechanistically related to concussion outcomes and biological markers.

Optimizing Concussion Care Seeking: A Longitudinal Analysis of Recovery.

BACKGROUND: Approximately half of concussions go undisclosed and therefore undiagnosed. Among diagnosed concussions, 51% to 64% receive delayed medical care. Understanding the influence of undiagnosed concussions and delayed medical care would inform medical and education practices. PURPOSE: To compare postconcussion longitudinal clinical outcomes among (1) individuals with no concussion history, all previous concussions diagnosed, and ≥1 previous concussion undiagnosed, as well as (2) those who have delayed versus immediate symptom onset, symptom reporting, and removal from activity after concussion. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Participants included 2758 military academy cadets and intercollegiate athletes diagnosed with concussion in the CARE Consortium. We determined (1) each participant's previous concussion diagnosis status self-reported at baseline (no history, all diagnosed, ≥1 undiagnosed) and (2) whether the participant had delayed or immediate symptom onset, symptom reporting, and removal from activity. We compared symptom severities, cognition, balance, and recovery duration at baseline, 24 to 48 hours, date of asymptomatic status, and date of unrestricted return to activity using tests of parallel profiles. RESULTS: The ≥1 undiagnosed concussion group had higher baseline symptom burdens (P < .001) than the other 2 groups and poorer baseline verbal memory performance (P = .001) than the all diagnosed group; however, they became asymptomatic and returned to activity sooner than those with no history. Cadets/athletes who delayed symptom reporting had higher symptom burdens 24 to 48 hours after injury (mean ± SE; delayed, 28.8 ± 0.8; immediate, 20.6 ± 0.7), took a median difference of 2 days longer to become asymptomatic, and took 3 days longer to return to activity than those who had immediate symptom reporting. For every 30 minutes of continued participation after injury, days to asymptomatic status increased 8.1% (95% CI, 0.3%-16.4%). CONCLUSION: Clinicians should expect that cadets/athletes who delay reporting concussion symptoms will have acutely higher symptom burdens and take 2 days longer to become asymptomatic. Educational messaging should emphasize the clinical benefits of seeking immediate care for concussion-like symptoms.

The inflow of sensory information for the control of standing is graded and bidirectional.

The control of upright standing is accomplished through the integration of different sources of sensory information and by providing an appropriate motor program to control both expected and unexpected perturbations imposed on the system. However, the dynamic characteristics of postural sway and its interplay with the regulation of Ia sensory information within the spinal cord are largely unknown. Here, using a stochastic technique for analyzing the dynamics of upright standing, we demonstrate that the changes in the dynamics of postural sway were accompanied by modulation of the soleus H-reflex during quiet standing. While the causality of this relation was not established, the results showed that these changes were independent of the sway of the center of pressure and were bidirectional and purposeful. With this novel perspective, the appropriate reflex gain, which is important for balance control, can be predicted from the dynamic characteristics of postural sway. Our current findings provide the first human behavioral evidence to suggest the contribution of the spinal cord in fulfilling the desired motor programming of a complex task. This contribution is, by conventional guess, carried out through interneuronal adjustments, which are under the control of different brain areas.

Optimizing VOMS for identifying acute concussion in collegiate athletes: Findings from the NCAA-DoD CARE consortium.

The Vestibular/Ocular-Motor Screening (VOMS), an important component in acute (<72 h) sport-related concussion (SRC) assessment, is increasingly used alongside the Sport Concussion Assessment Tool (SCAT) and as part of the Military Acute Concussion Evaluation 2 (MACE2). VOMS demonstrates clinically useful diagnostic accuracy for acute SRC and improves the overall utility when added to the SCAT3. However, potential overlap among VOMS's vestibular and oculomotor items suggests the possibility of a more efficient version. VOMS and SCAT3 scores were analyzed for 3,958 preseason (47.8% female) and 496 acute-SRC (37.5% female) NCAA-DoD Concussion Assessment, Research, and Education (CARE) consortium collegiate athlete evaluations. Analyses revealed very large effect sizes (d = 2.39-2.45) and high correlations (rho = 0.95-0.99) among all VOMS items except near point of convergence distance (d = 0.79, rho ≤ 0.341). Receiver operating characteristic (ROC) curve analyses showed clinically useful discriminative utility for VOMS Total (AUC = 0.85) and the VOMS Total change score, where pretest symptoms were incorporated (AUC = 0.81). A modified VOMS (mVOMS) consisting of four items (smooth pursuits, horizontal saccades, horizontal vestibulo-ocular reflex, visual motion sensitivity) yielded identical AUCs to VOMS Total. Integer cutoff analyses suggest a score of ≥4 for VOMS Total and ≥4 for mVOMS Total optimizes concussion identification. Incorporating VOMS or mVOMS into SCAT3 (AUC = 0.79) significantly improved the combined tool's acute utility for acute concussion identification by a maximum of 4% (SCAT3+VOMS AUC = 0.84, SCAT3+mVOMS AUC = 0.83). Future versions of SCAT or MACE may want to consider incorporating a more parsimonious VOMS for the purpose of identifying acute concussion.

Utility of VOMS, SCAT3, and ImPACT Baseline Evaluations for Acute Concussion Identification in Collegiate Athletes: Findings From the NCAA-DoD Concussion Assessment, Research and Education (CARE) Consortium.

BACKGROUND: The Vestibular/Ocular-Motor Screening (VOMS) is a valuable component of acute (<72 hours) sports-related concussion (SRC) assessments and is increasingly used with the Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) instrument and the third edition of the Sport Concussion Assessment Tool (SCAT3). Research has suggested that VOMS acute postinjury scores are useful in identifying acute concussion. However, the utility of preseason baseline measurements to improve diagnostic accuracy remains ambiguous. To this end, there is a need to determine how reliable VOMS baseline assessments are across years and whether incorporating individuals' baseline performance improves diagnostic yield for acute concussions. PURPOSE: To analyze VOMS, SCAT3, and ImPACT to evaluate the test-retest reliability of consecutive-year preseason baseline assessments to directly compare the diagnostic utility of these tools when incorporating baseline assessments versus using postinjury data alone to identify acute SRC. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Preseason and postinjury VOMS, SCAT3, ImPACT Post-Concussion Symptom Scale (PCSS), and ImPACT composite scores were analyzed for 3958 preseason (47.7% female) and 496 acute (≤48 hours) SRC (37.5% female) collegiate athlete evaluations in the National Collegiate Athletic Association-Department of Defense Concussion Assessment Research and Education Consortium. Descriptive statistics, Kolmogorov-Smirnov significance, and Cohen d effect size were calculated. Consecutive-year baseline reliability was evaluated for a subset of 447 athlete encounters using Pearson r, Cohen κ, Cohen d, and 2-way mixed intraclass correlation coefficients (ICCs). Wilcoxon signed rank tests were used to determine the statistical significance between population performances, and the 90% reliable change index (RCI) was calculated from the test-retest results. Preseason to postinjury change scores were then calculated from each tool's RCI. Finally, receiver operating characteristic (ROC) curve analyses were conducted, and DeLong method was used to compare the area under the curve (AUC) of raw postinjury scores versus change scores from preseason baseline assessments. Potential effects of sex, medical history (learning disorders or attention-deficit/hyperactivity disorder), and outlier data were also explored. RESULTS: Effect sizes were large, and overall predictive utilities were clinically useful for postinjury VOMS Total (d = 2.44; AUC = 0.85), the SCAT3 Symptom Evaluation total severity score (d = 1.74; AUC = 0.82), and the ImPACT PCSS total severity score (d = 1.67; AUC = 0.80). Comparatively, effect sizes were small and predictive utilities were poor for Standardized Assessment of Concussion (SAC), modified Balance Error Scoring System (mBESS), and all ImPACT composites (d = 0.11-0.46; AUC = 0.48-0.59). Preseason baseline test-retest reliability was poor to moderate (r = 0.23-0.52; κ = 0.32-0.36; ICC = 0.36-0.68) for all assessments except ImPACT Visual Motion Sensitivity (r = 0.73; ICC = 0.85). Incorporating baseline scores for VOMS Total, SCAT3 (Symptom Evaluation, SAC, mBESS), ImPACT PCSS, or ImPACT composites did not significantly improve AUCs. CONCLUSION: VOMS Total and symptom severity (SCAT3, PCSS) total scores had large effect sizes and clinically useful AUCs for identifying acute concussion. However, all tools demonstrated high within-patient test-retest variability, resulting in poor reliability. The findings in this sample of collegiate athletes suggest that incorporating baseline assessments does not significantly increase diagnostic yield for acute concussion.

Optimizing Concussion Care Seeking: The Influence of Previous Concussion Diagnosis Status on Baseline Assessment Outcomes.

BACKGROUND: The prevalence of unreported concussions is high, and undiagnosed concussions can lead to worse postconcussion outcomes. It is not clear how those with a history of undiagnosed concussion perform on subsequent standard concussion baseline assessments. PURPOSE: To determine if previous concussion diagnosis status was associated with outcomes on the standard baseline concussion assessment battery. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Concussion Assessment, Research, and Education (CARE) Consortium participants (N = 29,934) self-reported concussion history with diagnosis status and completed standard baseline concussion assessments, including assessments for symptoms, mental status, balance, and neurocognition. Multiple linear regression models were used to estimate mean differences and 95% CIs among concussion history groups (no concussion history [n = 23,037; 77.0%], all previous concussions diagnosed [n = 5315; 17.8%], ≥1 previous concussions undiagnosed [n = 1582; 5.3%]) at baseline for all outcomes except symptom severity and Brief Symptom Inventory-18 (BSI-18) score, in which negative binomial models were used to calculate incidence rate ratios (IRRs). All models were adjusted for sex, race, ethnicity, sport contact level, and concussion count. Mean differences with 95% CIs excluding 0.00 and at least a small effect size (≥0.20), and those IRRs with 95% CIs excluding 1.00 and at least a small association (IRR, ≥1.10) were considered significant. RESULTS: The ≥1 previous concussions undiagnosed group reported significantly greater symptom severity scores (IRR, ≥1.38) and BSI-18 (IRR, ≥1.31) scores relative to the no concussion history and all previous concussions diagnosed groups. The ≥1 previous concussions undiagnosed group performed significantly worse on 6 neurocognitive assessments while performing better on only 2 compared with the no concussion history and all previous concussions diagnosed groups. There were no between-group differences on mental status or balance assessments. CONCLUSION: An undiagnosed concussion history was associated with worse clinical indicators at future baseline assessments. Individuals reporting ≥1 previous undiagnosed concussions exhibited worse baseline clinical indicators. This may suggest that concussion-related harm may be exacerbated when injuries are not diagnosed.

Collegiate athlete brain data for white matter mapping and network neuroscience.

We describe a dataset of processed data with associated reproducible preprocessing pipeline collected from two collegiate athlete groups and one non-athlete group. The dataset shares minimally processed diffusion-weighted magnetic resonance imaging (dMRI) data, three models of the diffusion signal in the voxel, full-brain tractograms, segmentation of the major white matter tracts as well as structural connectivity matrices. There is currently a paucity of similar datasets openly shared. Furthermore, major challenges are associated with collecting this type of data. The data and derivatives shared here can be used as a reference to study the effects of long-term exposure to collegiate athletics, such as the effects of repetitive head impacts. We use advanced anatomical and dMRI data processing methods publicly available as reproducible web services at brainlife.io.

Predictive Accuracy of the Sport Concussion Assessment Tool 3 and Vestibular/Ocular-Motor Screening, Individually and In Combination: A National Collegiate Athletic Association-Department of Defense Concussion Assessment, Research and Education Consortium Analysis.

BACKGROUND: Vestibular and ocular symptoms in sport-related concussions are common. The Vestibular/Ocular-Motor Screening (VOMS) tool is a rapid, free, pen-and-paper tool that directly assesses these symptoms and shows consistent utility in concussion identification, prognosis, and management. However, a VOMS validation study in the acute concussion period of a large sample is lacking. PURPOSE: To examine VOMS validity among collegiate student-athletes, concussed and nonconcussed, from the multisite National Collegiate Athletic Association-Department of Defense Concussion Assessment, Research and Education (CARE) Consortium. A secondary aim was to utilize multidimensional machine learning pattern classifiers to deduce the additive power of the VOMS in relation to components of the Sport Concussion Assessment Tool 3 (SCAT3). STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Preseason and acute concussion assessments were analyzed for 419 student-athletes. Variables in the analysis included the VOMS, Balance Error Scoring System, Standardized Assessment of Concussion, and SCAT3 symptom evaluation score. Descriptive statistics were calculated for all tools, including Kolmogorov-Smirnov significance and Cohen d effect size. Correlations between tools were analyzed with Spearman r, and predictive accuracy was evaluated through an Ada Boosted Tree machine learning model's generated receiver operating characteristic curves. RESULTS: Total VOMS scores and SCAT3 symptom scores demonstrated significant increases in the acute concussion time frame (Cohen d = 1.23 and 1.06; P < .0001), whereas the Balance Error Scoring System lacked clinical significance (Cohen d = 0.17). Incorporation of VOMS into the full SCAT3 significantly boosted overall diagnostic ability by 4.4% to an area under the curve of 0.848 (P < .0001) and produced a 9% improvement in test sensitivity over the existing SCAT3 battery. CONCLUSION: The results from this study highlight the relevance of the vestibular and oculomotor systems to concussion and the utility of the VOMS tool. Given the 3.8 million sports-related and 45,121 military-related concussions per year, the addition of VOMS to the SCAT3 is poised to identify up to an additional 304,000 athletes and 3610 servicemembers annually who are concussed, thereby improving concussion assessment and diagnostic rates. Health care providers should consider the addition of VOMS to their concussion assessment toolkits, as its use can positively affect assessment and management of concussions, which may ultimately improve outcomes for this complex and common injury.

Discriminative Validity of Vestibular Ocular Motor Screening in Identifying Concussion Among Collegiate Athletes: A National Collegiate Athletic Association-Department of Defense Concussion Assessment, Research, and Education Consortium Study.

BACKGROUND: Vestibular and ocular motor screening tools, such as the Vestibular/Ocular Motor Screening (VOMS), are recognized as important components of a multifaceted evaluation of sport-related concussion. Previous research has supported the predictive utility of the VOMS in identifying concussion, but researchers have yet to examine the predictive utility of the VOMS among collegiate athletes in the first few days after injury. PURPOSE: To determine the discriminative validity of individual VOMS item scores and an overall VOMS score for identifying collegiate athletes with an acute sport-related concussion (≤72 hours) from healthy controls matched by age, sex, and concussion history. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Participants (N = 570) aged 17 to 25 years were included from 8 institutions of the National Collegiate Athletic Association-Department of Defense CARE Consortium (Concussion Assessment, Research, and Education): 285 athletes who were concussed (per current consensus guidelines) and 285 healthy controls matched by age, sex, and concussion history. Participants completed the VOMS within 3 days of injury (concussion) or during preseason (ie, baseline; control). Symptoms are totaled for each VOMS item for an item score (maximum, 40) and totaled across items for an overall score (maximum, 280), and distance (centimeters) for near point of convergence (NPC) is averaged across 3 trials. Receiver operating characteristic analysis of the area under the curve (AUC) was performed on cutoff scores using Youden index (J) for each VOMS item, overall VOMS score, and NPC distance average. A logistic regression was conducted to identify which VOMS scores identified concussed status. RESULTS: A symptom score ≥1 on each VOMS item and horizontal vestibular/ocular reflex ≥2 significantly discriminated concussion from control (AUC, 0.89-0.90). NPC distance did not significantly identify concussion from control (AUC, 0.51). The VOMS overall score had the highest accuracy (AUC, 0.91) for identifying sport-related concussion from control. Among the individual items, vertical saccades ≥1 and horizontal vestibular/ocular reflex ≥2 best discriminated concussion from control. CONCLUSION: The findings indicate that individual VOMS items and overall VOMS scores are useful in identifying concussion in collegiate athletes within 3 days of injury. Clinicians can use the cutoffs from this study to help identify concussion in collegiate athletes.

Effect of contact lens wear and a near task on tear film break-up.

PURPOSE: To study the effect of extrinsic controls on blinking by examining blink parameters and tear stability among adapted soft contact lens (CL) wearers performing tasks that require varying amounts of visual concentration. METHODS: The Demographic Questionnaire, Contact Lens Dry Eye Questionnaire, and Current Symptoms Questionnaire were completed by 15 adapted soft CL wearers (nine females). Three 55 s simultaneous measurements of tear film stability via retroillumination and blinking were obtained with a slit-lamp biomicroscope and 200 Hz video camera while subjects listened to music and played a video game with and without their habitual CLs. Interblink interval (IBI) and blink amplitude (BA) were calculated. The area of break-up (AB) was calculated for the retroillumination image before each blink. The Current Symptoms Questionnaire was completed four times throughout testing. RESULTS: With the game compared to music, IBI was significantly longer and BA significantly decreased without CLs (p < or = 0.001). With CLs, the IBI did not significantly change between tasks but the BA significantly decreased (p = 0.100). The AB significantly increased with CL and the game (paired t-test, p < or = 0.001). The BA was significantly correlated with self-reported severity of dry eye for all testing scenarios (Spearman r > or = 0.5579, p < 0.0001) and several symptom measures (Spearman r > or = 0.6262, p < 0.0001). The AB was significantly correlated with symptom measures including bothersome discomfort for the game with and without CLs (Spearman r > or = 0.5064, p < 0.0001). CONCLUSIONS: During tasks requiring concentration, the IBI increased (blink rate decreased) and many blinks were incomplete without CLs. With CLs, tear film instability increased. Blinking frequency also increased, but it remained high when subjects played the game, and symptoms of ocular irritation increased. This suggests that wearing soft CLs, even when fully adapted, provides enough extrinsic ocular surface stimulation to override internal controls and affect blink parameters.