Multimodal Assessment of Sport-Related Concussion.

OBJECTIVE: The purpose of this study was to determine which assessments best identify athletes with sport-related concussion (SRC) from healthy controls in the acute/early subacute phase (within 10 days of SRC) of injury. DESIGN: Prospective, cohort study. SETTING: Specialty concussion clinic. PARTICIPANTS: Sixty-four athletes with SRC (52% male) and 59 matched (age and sex), healthy controls (56% male) aged 12 to 20 years (Mean [M] = 15.07, Standard Deviation [SD] = 2.23). ASSESSMENT: Participants completed symptom, cognitive, vestibular/oculomotor, near point of convergence (NPC), and balance assessments. MAIN OUTCOME MEASURES: Univariate analyses were conducted to compare athletes with SRC to healthy controls across all assessments. Assessments that significantly differed between the SRC group and healthy controls were used as predictors in an enter method logistic regression (LR) model and subsequent forward stepwise LR. RESULTS: Results of LR analyses indicated that symptom inventory and symptom provocation on vestibular/oculomotor assessments significantly predicted athletes with SRC versus controls. The forward stepwise LR accurately classified 84.6% of the overall sample (78.3% of athletes with SRC and 91.2% of controls were accurately predicted) and accounted for 60.5% of the variance in predicting athletes with SRC versus controls. Total symptom inventory score (P = 0.003) and vestibular/oculomotor symptom provocation (P < 0.01) were the most sensitive and specific measures in a comprehensive, multimodal assessment for distinguishing athletes with SRC from healthy controls within 10 days of injury. CONCLUSIONS: Elements within a multimodal evaluation that are the most robust at discriminating athletes with SRC from healthy controls in the acute/early subacute phase of injury include symptom report and provocation of symptoms on vestibular/oculomotor assessment. These assessments should be considered in conjunction with other objective assessments (ie, NPC measurement and cognitive testing) as part of a comprehensive evaluation of SRC.

Test Order Does Not Affect Vestibular/Ocular Motor Screening Item Scores in High School Athletes.

OBJECTIVE: To compare VOMS item scores between a fixed and randomized administration order in a sample of nonconcussed high school athletes. DESIGN: Post-test only, quasi-experimental design. SETTING: Local high schools in a mid-west region of the United States. PATIENTS: Fifty nonconcussed high school athletes (M = 15.64; SD = 1.12 years) completed the VOMS in a randomized testing order (RANDOM), and 49 (M = 15.64; SD = 1.12 years) completed the VOMS in the fixed testing order (FIXED). The groups were matched on age, sex, learning disorder, attention-deficit/hyperactivity disorder, concussion history, and baseline concussion symptoms. INTERVENTIONS: The Vestibular/Ocular Motor Screening (VOMS) tool comprises pretest symptoms, smooth pursuit (SP), horizontal/vertical saccade (HSAC/VSAC), average near-point of convergence (NPC) distance, convergence symptoms, horizontal/vertical vestibular ocular reflex (HVOR/VVOR), and visual motion sensitivity (VMS). MAIN OUTCOME MEASURES: Mann-Whitney U tests were performed to examine differences between FIXED and RANDOM groups on VOMS items. RANDOM scores were rearranged in order of administration and combined with the FIXED group scores, and a Freidman test was performed for repeated measures. RESULTS: There were no significant differences between FIXED and RANDOM groups on VOMS pretest symptoms (U = 1171, P = 0.57), SP (U = 1122.5, P = 0.35), HSAC (U = 1128.5, P = 0.44), VSAC (U = 1055.5, P = 0.16), convergence symptoms (U = 1129.0, P = 0.41), average NPC distance (U = 979.0, P = 0.06), HVOR (U = 1085.0, P = 0.25), VVOR (U = 1126.0, P = 0.41), and VMS scores (U = 1101.0, P = 0.32). When VOMS items were rearranged and the sample was combined, there were no differences for repeated measures [χ2 (6) = 9.92, P = 0.13]. CONCLUSIONS: There were no significant differences on VOMS items between FIXED and RANDOM groups for repeated measures. The testing order of VOMS items does not affect VOMS scores in nonconcussed high school athletes.

Preliminary Evidence of a Dose-Response for Continuing to Play on Recovery Time After Concussion.

OBJECTIVE: To investigate a dose-response relationship between continuing to play following concussion and outcomes. PARTICIPANTS: A total of 130 athletes (age 11-19 years). DESIGN: Repeated-measures design comparing symptoms, neurocognitive performance, and recovery time between 52 athletes immediately removed from play (Removed), 24 who continued to play for 15 minutes or less (Short-Play), and 32 who continued to play for more than 15 minutes (Long-Play). MAIN MEASURES: Recovery was the number of days from injury to clearance. Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) measured neurocognitive outcomes and the Post-Concussion Symptom Scale (PCSS) measured symptom severity. RESULTS: Long-Play (44.09 ± 27.01 days) took longer to recover than Short-Play (28.42±12.74 days) and Removed (18.98 ± 13.76 days). Short-Play was 5.43 times more likely, and Long-Play 11.76 times more likely, to experience protracted recovery relative to Removed. Both Play groups had worse neurocognitive performance and higher symptom scores than Removed at days 1 to 7, with Long-Play demonstrating worse reaction time than Short-Play. At days 8 to 30, both Play groups performed worse than Removed on visual memory and visual motor speed, while only Long-Play performed worse on verbal memory and reaction time. CONCLUSIONS: Results provide initial evidence of a dose-response effect for continuing to play on recovery from concussion, highlighting the importance of removal from play.

Do Initial Symptom Factor Scores Predict Subsequent Impairment Following Concussion?

OBJECTIVE: Symptom factors present during the first week following concussion may predict subsequent concussion outcomes and recovery duration. We hypothesized that a high loading on cognitive-fatigue-migraine and somatic factors would be predictive of neurocognitive impairment following concussion. We also hypothesized that the affective factor would be related to vestibular symptoms and impairment. DESIGN: Prospective repeated measures. SETTING: Concussion specialty clinic. PARTICIPANTS: Athletes aged 13 to 20 years diagnosed with a concussion within the past 7 days. INDEPENDENT VARIABLE: Symptom factors at the initial visit 1 to 7 days after injury. MAIN OUTCOME MEASURE: Symptom factor score, neurocognitive testing, and vestibular/ocular motor assessment at the second visit (2-4 weeks after injury). RESULTS: The somatic symptom factor from the initial visit was significant (P < 0.05) in all vestibular/ocular screening components (P < 0.05) but not neurocognitive test performance (P > 0.05) at the second visit. The cognitive-migraine-fatigue and affective symptom factors predicted symptom burden at the second visit (P < 0.001) but did not predict recovery time (P = 0.200). CONCLUSIONS: The somatic symptom factor during the first week after injury predicted symptom provocation during vestibular/ocular screening at 2 to 4 weeks after injury. Specifically, higher scores on somatic symptom factor at the initial visit predicted worse symptom reporting for all vestibular/ocular screening components at the second visit. Patients with higher scores on the cognitive-migraine-fatigue and affective symptom factors at the initial visit predicted total symptom burden at the second visit.

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.

Mobile Ecological Momentary Assessment of Postconcussion Symptoms and Recovery Outcomes.

OBJECTIVE: Evaluate mobile ecological momentary assessment (mEMA) as an approach to measure sport-related concussion (SRC) symptoms, explore the relationships between clinical outcomes and mEMA, and determine whether mEMA was advantageous for predicting recovery outcomes compared to traditional symptom report. SETTING: Outpatient concussion clinic. PARTICIPANTS: 20 athletes aged 12 to 19 years with SRC. METHODS: Prospective study of mEMA surveys assessing activity and symptoms delivered via mobile application (3 time blocks daily) and clinical assessment at visit 1 (<72 hours postinjury) and visit 2 (6-18 days postinjury). Linear mixed models examined changes in mEMA symptoms over time and relationships among simultaneous report of activity type (cognitive, physical, sedentary, vestibular) and symptoms. Linear regressions evaluated the association among symptoms for activity types and clinical outcomes. MAIN MEASURES: mEMA symptom scores, Post-Concussion Symptom Scale, neurocognitive testing, vestibular/oculomotor screening (VOMS). RESULTS: mEMA response rate was 52.4% (N = 1155) for prompts and 50.4% per participant. Symptoms were lower in the morning (P < .001) compared with afternoon and evening. Higher mEMA symptoms were reported during vestibular compared with physical (P = .035) and sedentary (P = .001) activities. mEMA symptoms were positively associated with Post-Concussion Symptom Scale (PCSS) (P = .007), VOMS (P = 0.001-0.002), and recovery time (P < .001), but not neurocognitive scores. mEMA symptom score (P = .021) was a better predictor of recovery time than PCSS at either clinic visit. CONCLUSION: mEMA overcomes barriers of traditional symptom scales by eliminating retrospective bias and capturing fluctuations in symptoms by time of day and activity type, ultimately helping clinicians refine symptom management strategies.

History of High Motion Sickness Susceptibility Predicts Vestibular Dysfunction Following Sport/Recreation-Related Concussion.

OBJECTIVE: To compare vestibular dysfunction at 1 to 10 and 11 to 20 days following sport/recreation-related concussion (SRC) in athletes with and without history of motion sickness susceptibility. Secondary aims of this study were to investigate differences in neurocognitive performance and affective symptoms in these groups. DESIGN: Cross-sectional. SETTING: Concussion Specialty Clinic. PARTICIPANTS: One hundred twenty-four adolescents and adults (82 males, 42 females) aged 14 to 26 (16.36 ± 2.10) years, diagnosed with SRC in the past 10 (4.56 ± 2.54) days; 47 participants composed the sample for quartile analyses. INDEPENDENT VARIABLE: Motion sickness susceptibility questionnaire short form score. MAIN OUTCOME MEASURES: Computerized neurocognitive test scores, vestibular/oculomotor screening scores (VOMS), and symptom factor scores from a standardized concussion symptom inventory. RESULTS: There was no association between history of motion sickness susceptibility and VOMS scores (above or below clinical cutoff) at 1 to 10 days after injury, although at 11 to 20 days after injury there was an association between high motion sickness susceptibility and symptoms above clinical cutoff on 5 of the 6 VOMS items (P values 0.01-0.04). The high motion sickness group had more affective symptoms on the symptom inventory than the no motion sickness group (P = 0.002) at 1 to 10 days after injury. Groups did not differ on computerized neurocognitive testing (P = 0.11). CONCLUSION: Athletes with a preexisting history of motion sensitivity may exhibit more prolonged vestibular dysfunction following SRC, and may experience more affective symptoms early in recovery.

Sport-related Concussion Clinical Profiles: Clinical Characteristics, Targeted Treatments, and Preliminary Evidence.

Sport-related concussion (SRC) is a heterogeneous injury that involves varied symptoms and impairment that presents a significant clinical challenge to sports medicine professionals. In response to this challenge, clinical researchers have proposed clinical profiles or subtype models for assessing and treating athletes with SRC. One such model emphasizes five concussion clinical profiles including cognitive/fatigue, vestibular, ocular, migraine, and anxiety/mood. Sleep is a common modifier that co-occurs across these clinical profiles. A combination of medical history, risk factors, injury information, clinical characteristics, and assessment outcomes can inform each clinical profile. Preliminary data involving 236 patients from a concussion specialty clinic indicate that the migraine (26%) and anxiety/mood (24%) profiles are the most common, with vestibular and ocular profiles combined representing more than one third (35%) of clinical profiles. Findings also support several relationships among different clinical profiles including vestibular and migraine, suggesting that many athletes present with multiple clinical profiles. Targeted, active treatments for each profile are discussed.

Sleep Problem Risk for Adolescents With Sickle Cell Disease: Sociodemographic, Physical, and Disease-related Correlates.

The aims of the current study were to investigate whether SCD incurs an additional risk for poor sleep over and above the influence of sociodemographic factors (ie, race and sex) during adolescence, and to explore the relationships between sociodemographic, physical (ie, age and pubertal status), and disease-related factors (ie, SCD genotype and hydroxyurea use) on sleep problem risk during adolescence. Black adolescents (age, 12 to 17 y) with SCD (n=53) were recruited from regional pediatric SCD clinics in the southeast and a sample of healthy black adolescents (n=160) were recruited from middle and high schools. Regression analyses indicated that SCD was uniquely related to sleeping more, and worse sleep quality over and above the influence of sociodemographic factors. Having a more severe SCD genotype was related to worse sleep quality and higher pubertal status was related to sleeping longer during the week. Results indicate the need for systematic assessments of sleep problems, with more a focus on youth with more severe genotypes and higher pubertal status. Future research should focus on characterizing trajectories of sleep problems in this population, identifying key risk factors, and elucidating mechanisms linking risk factors to sleep problem risk to aid in tailoring interventions for this population.

Prospective Changes in Vestibular and Ocular Motor Impairment After Concussion.

BACKGROUND AND PURPOSE: The utility of prospective changes on the Vestibular/Ocular Motor Screening (VOMS) assessment are unknown, and 2 methods of scoring are published in the literature. Total scores are the total symptom scores for each VOMS component, and change scores are the difference between the pretest total symptom score and component total symptom scores. This study documented prospective changes in vestibular and ocular motor impairments and symptoms in high school athletes with concussion using the total and change scoring methods and compared the percentage of scores over clinical cutoffs using the total and change scoring methods for the VOMS. METHODS: Sixty-three athletes (15.53 ± 1.06 years) completed the VOMS at baseline (ie, preinjury), 1 to 7 days, and 8 to 14 days after concussion. A series of repeated-measures multivariate analyses of variance were conducted on total and change scores. A 2-way repeated-measures analysis of variance was performed on the near-point convergence distance. A series of χ analyses compared scores exceeding clinical cutoffs between the total and change scoring methods. RESULTS: Total scoring revealed impairments (Wilks λ = 0.39, F16,47 = 4.54, P < 0.001, η = 0.61) on all VOMS components at 1 to 7 and 8 to 14 days compared to baseline. Change scoring revealed postinjury impairments compared with baseline (Wilks λ = 0.58, F14,49 = 2.52, P = 0.009, η = 0.42) on all components at 1 to 7 days; however, impairments at 8 to 14 days were revealed only for the vertical vestibular oculomotor reflex and vestibular motor sensitivity components. Total scoring identified significantly more scores over cutoffs at 1 to 7 days (χ1,63 = 5.97, P = 0.02) compared with change scores. DISCUSSION AND CONCLUSIONS: Both total and change scoring methods on the VOMS are useful for identifying impairments following concussion.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A230).

Family History of Migraine Associated With Posttraumatic Migraine Symptoms Following Sport-Related Concussion.

OBJECTIVE: To determine whether family history of migraine increased the likelihood of posttraumatic migraine (PTM) symptom presentation in adolescents following concussion, and examine the influence of family history of migraine and PTM on postinjury outcomes. SETTING: Outpatient concussion clinic. PARTICIPANTS: A total of 153 patients with concussion (103 males and 50 females) aged 15.72 ± 1.48 years (range 12-18 years). DESIGN: Cross-sectional, observational study of patients presenting for initial evaluation 4.72 ± 3.05 days (range 1-14) postinjury. MAIN MEASURES: Computerized neurocognitive testing, symptom report, and vestibular/oculomotor screening. RESULTS: Patients with a family history of migraine were 2.6 times (odds ratio = 2.60, confidence interval = 1.35-5.02, P = .003) more likely to present with PTM compared with patients without a family history. Results of multivariate analyses of covariance, controlling for concussion history, revealed significant main effects for PTM on (1) Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)/Post-Concussion Symptom Scale (PCSS) (F = 15.43, P <.001) and (2) Vestibular/Ocular Motor Screening (VOMS) (F = 8.52, P < .001). There was no main effect for family history of migraine on ImPACT/PCSS (P = .22) and VOMS (P = .83) or interaction between family history of migraine and PTM on ImPACT/PCSS (P = .84) and VOMS (P = .52). CONCLUSION: Family history of migraine is associated with PTM symptoms following sport-related concussion, suggesting a genetic predisposition for migraine may serve as a catalyst or trigger for onset of PTM. However, only presence of PTM, rather than family history of migraine, was related to worse neurocognitive and vestibular/oculomotor outcomes.

A Preliminary Investigation of Accelerometer-Derived Sleep and Physical Activity Following Sport-Related Concussion.

OBJECTIVE: Describe changes in postconcussion activity levels and sleep throughout recovery in a sample of pediatric sport-related concussion (SRC) patients, and examine the predictive value of accelerometer-derived activity and sleep on subsequent clinical outcomes at a follow-up clinic visit. SETTING: Outpatient concussion clinic. PARTICIPANTS: Twenty athletes aged 12 to 19 years with diagnosed SRC. METHODS: Prospective study including visit 1 (<72 hours postinjury) and visit 2 (6-18 days postinjury). Linear regressions used to predict scores (ie, neurocognitive, vestibular/oculomotor) at visit 2 from accelerometer-derived data collected 0 to 6 days postinjury. Linear mixed models evaluated changes in activity and sleep across recovery. MAIN MEASURES: Symptom, neurocognitive, and vestibular/oculomotor scores; sleep and activity data (Actigraph GT3x+) RESULTS:: The maximum intensity of physical activity increased (P = .009) and time in bed decreased throughout recovery (P = .026). Several physical activity metrics from 0 to 6 days postinjury were predictive of worse vestibular/oculomotor scores at visit 2 (P < .05). Metrics indicative of poor sleep 0 to 6 days postinjury were associated with worse reaction time at visit 2 (P < .05). CONCLUSIONS: This exploratory study suggests physical activity and sleep change from the acute to subacute postinjury time period in adolescent SRC patients. In our small sample, excess physical activity and poor sleep the first week postinjury may be associated with worse outcomes at follow-up in the subacute stage of recovery. This study further supported the feasibility of research utilizing wearable technology in concussion patients, and future research in a large, diverse sample of concussion patients examined at concise time intervals postinjury is needed.

The Effectiveness of Prescribed Rest Depends on Initial Presentation After Concussion.

OBJECTIVE: To evaluate if patients with signs of injury respond differently to prescribed rest after concussion compared with patients with symptoms only. STUDY DESIGN: Secondary analysis was completed of a prospective randomized controlled trial (NCT01101724) of pediatric concussion patients aged 11-18 years. Patients completed computerized neurocognitive testing and standardized balance assessment at the emergency department within 24 hours of injury and on follow-up (3 and 10 days). Patients were randomized to rest or usual care and completed activity and symptom diaries for 10 days after injury. A series of 2?×?2 ANOVAs with grouping factors of patient group (symptoms, signs) and treatment arm (prescribed rest, standard of care) were used to examine differences on clinical measures. Univariate nonparametric test (ie, ?2 with ORs and 95% CIs) was used to examine the association between treatment arm and symptom status 1-9 days after injury. RESULTS: A 2?×?2 factorial ANOVA revealed a significant patient group × treatment arm interaction for symptom score at 3 days after injury (F?=?6.31, P?=?.01, ?2?=?0.07). Prescribed rest increased the likelihood of still being symptomatic at days 1-6 and 8 (P?

Comprehensive Headache Experience in Collegiate Student-Athletes: An Initial Report From the NCAA Headache Task Force.

BACKGROUND: The prevalence of primary headache disorders in the general population provides a unique challenge in the evaluation of headache occurring in the context of sport. Despite a wealth of studies exploring the epidemiology of headache in the layperson, little is known about the prevalence and nature of headaches in collegiate student-athletes. These scenarios are challenging in the return to play context, as it is often unclear whether an athlete has an exacerbation of a primary headache disorder, new onset headache unrelated to trauma, or has suffered a concussive injury. PURPOSE: To establish the prevalence and nature of headaches in collegiate student-athletes. STUDY DESIGN: Retrospective cross-sectional survey. METHODS: This cross-sectional survey evaluated the characteristics and prevalence of headache in 834 student-athletes from four NCAA Division-I institutions. Because headache occurrence may vary by sport (collision, contact, non-contact), by sex, and medical history, our sample included male and female athletes in a variety of sports, with differing degrees of contact exposure. The 20 question survey collected data on personal and family history of headache, as well as concussion history. RESULTS: A total of 23.7% (n = 198) of participants reported having a personal history of migraine, 25.2% (n = 210) history of sinus headache, and 12.3% (n = 103) history of tension type headache. Among athletes with a prior history of concussion, 46.3% (n = 25) of females reported a history of migraine, while only 32.2% of males reported history of migraine (χ2 = 3.421, P = .064). CONCLUSIONS: The etiology of increased prevalence of migraine in our study is unclear. Whether this is due to increased awareness of headache disorders, a consequence of contact exposure, or a predisposition for migraine development in this age group remains unclear. Further studies are indicated.

Sex Differences in Vestibular/Ocular and Neurocognitive Outcomes After Sport-Related Concussion.

OBJECTIVE: To examine sex differences in vestibular and oculomotor symptoms and impairment in athletes with sport-related concussion (SRC). The secondary purpose was to replicate previously reported sex differences in total concussion symptoms, and performance on neurocognitive and balance testing. DESIGN: Prospective cross-sectional study of consecutively enrolled clinic patients within 21 days of a SRC. SETTING: Specialty Concussion Clinic. PARTICIPANTS: Included male (n = 36) and female (n = 28) athletes ages 9 to 18 years. INTERVENTIONS: Vestibular symptoms and impairment was measured with the Vestibular/Ocular Motor Screening (VOMS). Participants completed the Immediate Post-concussion Assessment and Cognitive Test (ImPACT), Post-concussion Symptom Scale (PCSS), and Balance Error Scoring System (BESS). MAIN OUTCOMES MEASURES: Sex differences on clinical measures. RESULTS: Females had higher PCSS scores (P = 0.01) and greater VOMS vestibular ocular reflex (VOR) score (P = 0.01) compared with males. There were no sex differences on BESS or ImPACT. Total PCSS scores together with female sex accounted for 45% of the variance in VOR scores. CONCLUSIONS: Findings suggest higher VOR scores after SRC in female compared with male athletes. Findings did not extend to other components of the VOMS tool suggesting that sex differences may be specific to certain types of vestibular impairment after SRC. Additional research on the clinical significance of the current findings is needed.

Neuropsychological Assessment Following Concussion: an Evidence-Based Review of the Role of Neuropsychological Assessment Pre- and Post-Concussion.

Neuropsychological evaluation is one component of a comprehensive and multifaceted assessment following concussion. Although some neuropsychologists use a "hybrid" assessment approach integrating computerized neurocognitive testing batteries with traditional paper and pencil tests, computerized neurocognitive test batteries are the predominant testing modality for assessment of athletes from the youth to professional level. This review summarizes the most recent research supporting the utility of neuropsychological evaluation and highlights the strengths and weaknesses of both computerized and traditional neuropsychological testing approaches. The most up to date research and guidelines on baseline neurocognitive testing is also discussed. This paper addresses concerns regarding reliability of neuropsychological testing while providing an overview of factors that influence test performance, both transient situational factors (e.g., pain level, anxiety) and characteristics of particular subgroups (e.g., age, preexisting learning disabilities), warranting the expertise of an experienced neuropsychologist for interpretation. Currently, research is moving forward by integrating neuropsychological evaluation with emerging assessment approaches for other domains of brain function (e.g., vestibular function) vulnerable to concussion.

Motion Sickness Susceptibility and Baseline Vestibular and Ocular-Motor Performance in Adolescent Athletes.

CONTEXT: High school athletes with a history of motion sickness susceptibility exhibit higher baseline vestibular and ocular-motor scores than those without a history of motion sickness susceptibility. OBJECTIVE: To examine the effects of motion sickness susceptibility on baseline vestibular and ocular-motor functioning, neurocognitive performance, and symptom scores. DESIGN: Cross-sectional study. SETTING: Preseason concussion testing. PATIENTS OR OTHER PARTICIPANTS: A convenience sample of high school athletes (N = 308, age = 15.13 ± 1.21 years) involved in a variety of sports. MAIN OUTCOME MEASURE(S): Vestibular/Ocular Motor Screening, computerized neurocognitive assessment, symptom scale, and Motion Sickness Susceptibility Questionnaire-Short Form (MSSQ-S). RESULTS: Participants were categorized into 3 groups based on a median split of the scores (eg, NONE, LOW, and HIGH). The LOW (n = 95) and HIGH (n = 92) groups (ie, MSSQ-S score > 0) were 2.64 times more likely (χ21,257 = 7.94, P = .01, 95% confidence interval = 1.32, 5.26) to have baseline Vestibular/Ocular Motor Screening scores larger than the clinical cutoffs for the NONE group (n = 70). No between-groups main effects were present for the NONE (n = 52), LOW (n = 89), and HIGH (n = 90) MSSQ-S groups for verbal (F2,230 = .09, P = .91, η2 = .001) and visual (F2,230 = .15, P = .86, η2 = .001) memory, processing speed (F2,230 = .78, P = .46, η2 = .007), or reaction time (F2,230 = 2.21, P = .11, η2 = .002). The HIGH group exhibited higher total baseline symptom scores than the LOW (U = 3325.50, z = -1.99, P = .05, r = .15) and NONE (U = 1647.50, z = -2.83, P = .005, r = .24) groups. CONCLUSIONS: Motion sickness should be considered a preexisting risk factor that might influence specific domains of the baseline concussion assessment and postinjury management.

Do Sideline Concussion Assessments Predict Subsequent Neurocognitive Impairment After Sport-Related Concussion?

CONTEXT: Comprehensive, multidomain assessment is the standard of care after sport-related concussion. However, the relationship between performance on sideline concussion-assessment tools and in-office computerized neurocognitive testing has received little attention, and the prognostic utility of sideline measures is unknown. OBJECTIVE: To evaluate concurrent impairment on commonly used concussion measures 24 to 48 hours postinjury while also determining the predictive utility of sideline measures on computerized neurocognitive testing in the acute to subacute recovery periods postinjury. DESIGN: Case-control study. SETTING: High school and collegiate athletics. PATIENTS OR OTHER PARTICIPANTS: A total of 125 high school and college-aged athletes (85 males, 40 females) 14 to 23 (16.8 ± 2.21) years old. MAIN OUTCOME MEASURE(S): Participants were administered sideline concussion-assessment measures (ie, Immediate Post-Concussion Assessment and Cognitive Testing [ImPACT], Standardized Assessment of Concussion [SAC], and Balance Error Scoring System [BESS]) 24 to 48 hours postinjury and completed ImPACT and the Post-Concussion Symptom Scale 5 to 7 and 10 to 14 days postinjury. Outcome measures were the ImPACT composite (verbal memory, visual memory, reaction time, visual-motor speed), SAC, and BESS scores and total symptom score on the Post-Concussion Symptom Scale. RESULTS: Participants demonstrated heterogeneous patterns of impairment on measures 24 to 48 hours postinjury, with the most common pattern being impairment on ImPACT and the SAC. Performance on the SAC and BESS at 24 to 48 hours after injury did not distinguish between those with and those without impairment on ImPACT at 5 to 7 days postinjury (χ2 = 5.076, P = .079) or 10 to 14 days postinjury (χ2 = 2.04, P = .361). CONCLUSIONS: More than 90% of athletes were impaired on at least 1 sideline or neurocognitive measure 24 to 48 hours after sport-related concussion. Although sideline measures are useful for concussion diagnosis, they are not suitable for prognostication of impairment or the presence of symptoms 1 to 2 weeks postinjury.

Using Acute Performance on a Comprehensive Neurocognitive, Vestibular, and Ocular Motor Assessment Battery to Predict Recovery Duration After Sport-Related Concussions.

BACKGROUND: A sport-related concussion (SRC) is a heterogeneous injury that requires a multifaceted and comprehensive approach for diagnosis and management, including symptom reports, vestibular/ocular motor assessments, and neurocognitive testing. PURPOSE: To determine which acute (eg, within 7 days) vestibular, ocular motor, neurocognitive, and symptom impairments predict the duration of recovery after an SRC. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 2. METHODS: Sixty-nine patients with a mean age of 15.3 ± 1.9 years completed a neurocognitive, vestibular/ocular motor, and symptom assessment within 7 days of a diagnosed concussion. Patients were grouped by recovery time: ≤14 days (n = 27, 39.1%), 15-29 days (n = 25, 36.2%), and 30-90 days (n = 17, 24.6%). Multinomial regression was used to identify the best subset of predictors associated with prolonged recovery relative to ≤14 days. RESULTS: Acute visual motor speed and cognitive-migraine-fatigue symptoms were associated with an increased likelihood of recovery times of 30-90 days and 15-29 days relative to a recovery time of ≤14 days. A model with visual motor speed and cognitive-migraine-fatigue symptoms within the first 7 days of an SRC was 87% accurate at identifying patients with a recovery time of 30-90 days. CONCLUSION: The current study identified cognitive-migraine-fatigue symptoms and visual motor speed as the most robust predictors of protracted recovery after an SRC according to the Post-concussion Symptom Scale, Immediate Post-concussion Assessment and Cognitive Testing, and Vestibular/Ocular Motor Screening (VOMS). While VOMS components were sensitive in identifying a concussion, they were not robust predictors for recovery. Clinicians may consider particular patterns of performance on clinical measures when providing treatment recommendations and discussing anticipated recovery with patients.

Predicting Post-Concussion Symptom Risk in the ED.

Investigators from The Pediatric Emergency Research Canada (PERC) Concussion Team developed a clinical risk score for predicting persistent post-concussion symptoms (PPCS) at 28 days post injury in a large cohort of children initially evaluated at the emergency department (ED) within 48 hours of injury.