Characteristics of Pediatric Concussion across Different Mechanisms of Injury in 5 through 12-Year-Olds.

OBJECTIVE: To investigate characteristics of sport-related concussion (SRC), recreation-related concussion (RRC), and non-sport or recreation-related concussion (non-SRRC) in patients 5 through 12 years old, an understudied population in youth concussion. STUDY DESIGN: This retrospective, observational study included patients aged 5 through 12 years presenting to a specialty care concussion setting at ≤28 days post-injury form 2018 through 2022. The following characteristics were assessed: demographics, injury mechanism (SRC, RRC, or SRRC), point of healthcare entry, and clinical signs and symptoms. Kruskal-Wallis and chi-square tests were used to assess group differences. Post hoc pairwise comparisons were employed for all analyses (α=0.017). RESULTS: 1,141 patients reported at ≤28 days of injury (female=42.9%, median age=11, IQR=9-12) with the most common mechanism being RRC (37.3%), followed by non-SRRC (31.9%). More non-SRRCs (39.6%) and RRC (35.7%) were first seen in the emergency department (p<0.001) compared with SRC (27.9%). Patients with RRC and non-SRRC were first evaluated at specialists 4 and 6 days later than SRC (p<0.001). Patients with non-SRRC reported with higher symptom burden, more frequent visio-vestibular abnormalities, and more changes to sleep and daily habits (p<0.001) compared with RRC and SRC (p<0.001). CONCLUSIONS: In concussion patients 5 through 12 years, RRCs and non-SRRC were more prevalent than SRC, presenting first more commonly to the emergency department and taking longer to present to specialists. Non-SRRC had more severe clinical features. RRC and non-SRRC are distinct from SRC in potential for less supervision at time of injury and less direct access to established concussion health care following injury.

MRI findings of growth plate fractures of the knee: are there age- and fracture-dependent differences?

OBJECTIVE: To investigate MRI findings in children with physeal fractures of the knee with respect to age, location, and articular involvement. METHODS: Children with physeal fractures who underwent knee MRI between 2008 and 2021 were included. Two radiologists retrospectively reviewed all examinations to determine articular involvement, findings of physeal instability (perichondral disruption, periosteal entrapment), and internal derangement (cruciate ligament injury, meniscal tear, chondromalacia). Independent samples t, Mann-Whitney U, Pearson's chi-square, and Fisher's exact tests were used to compare findings. RESULTS: Fifty-six patients (37 boys, 19 girls; mean age: 12.2 ± 2.5 years; 32 distal femur, 24 proximal tibial fractures) included 24(43%) intraarticular fractures. Fractures were more common in the tibia than the femur (67% versus 25%, p = 0.004) and intraarticular fractures were more common in older than younger children (13.1 ± 2.0 versus 11.5 ± 2.7 years, p = 0.01), to associate with chondromalacia (46% versus 12%, p = 0.02) and undergo surgery (33% versus 10%, p = 0.04) when compared to extraarticular fractures. Perichondral disruption (n = 44, 79%) and periosteal entrapment (n = 13, 23%) did not significantly differ based on location or articular involvement (p > 0.05). At a median follow-up of 17.5 months (interquartile range: 1.25-34), 3 patients (2 intraarticular, 1 extraarticular fractures) developed osteoarthritis, osteochondral lesion, and leg-length discrepancy from growth arrest, which required additional surgery. CONCLUSION: Intraarticular physeal fractures were more common with older children, associate with chondromalacia, and underdo surgical intervention when compared to extraarticular fractures of the knee. While MRI findings of physeal instability were common, no significant differences were found between fractures based on anatomic location or fracture pattern.

Exercise-Induced Vision Dysfunction Early After Sport-Related Concussion Is Associated With Persistent Postconcussive Symptoms.

OBJECTIVE: The purpose of this study was to determine if exercise-induced vision dysfunction [reduced performance and/or symptom exacerbation on a post-exercise King-Devick (KD) test] in adolescents early after sport-related concussion was associated with increased risk of persistent post-concussive symptoms (PPCS, recovery >28 days). We used exercise as a provocative maneuver before the KD test, hypothesizing that concussed adolescents with exercise-induced vision dysfunction would be more likely to develop PPCS. DESIGN: Secondary analysis of data from a multi-center, randomized clinical trial comparing KD test performance before and after the Buffalo Concussion Treadmill Test in adolescents within 10 days of sport-related concussion who were randomized to aerobic exercise or placebo stretching program. SETTING: Three university-associated sports medicine clinical programs. PARTICIPANTS: Ninety-nine adolescents with sport-related concussion (exercise group: n = 50, 15.3 ± 1 years, 60% M, 22% with PPCS; stretching group: n = 49, 15.9 ± 1 years, 65% M, 35% with PPCS) tested a mean of 6 ± 2 days from injury. INDEPENDENT VARIABLE: King-Devick test performed immediately before and 2 minutes after Buffalo Concussion Treadmill Test. MAIN OUTCOME MEASURE: Persistent post-concussive symptoms. RESULTS: Adolescents who demonstrated exercise-induced vision dysfunction upon initial evaluation developed PPCS at a significantly greater rate when compared with adolescents who did not (71% vs 34%, P < 0.001). Exercise-induced vision dysfunction corresponded to a relative risk of 3.13 for PPCS. CONCLUSIONS: Adolescents with exercise-induced vision dysfunction had a 3-fold greater relative risk of developing PPCS than those without exercise-induced vision dysfunction.

Visio-Vestibular Deficits in Healthy Child and Adolescent Athletes.

OBJECTIVE: To determine the relationship between patient characteristics and performance on the visio-vestibular examination (VVE) in a cohort of healthy youth athletes and explore the potential association between the VVE and other standardized concussion batteries. DESIGN: Cross-sectional. SETTING: Suburban middle and high school. PATIENTS: One hundred ninety subjects age 11 to 18 enrolled before their respective scholastic sport season between August 2017 and March 2020. ASSESSMENT OF INDEPENDENT VARIABLES: Patient age, sex, concussion history, comorbidities, hours of weekly exercise, Sport Concussion Assessment Tool, 5th edition (SCAT-5), King-Devick (K-D), Postconcussion Symptom Inventory (PCSI). MAIN OUTCOME MEASURES: Visio-vestibular examination abnormalities (smooth pursuit, horizontal and vertical saccades, horizontal and vertical gaze stability, convergence, right and left monocular accommodation, complex tandem gait). RESULTS: Overall, 29.5% of subjects had at least one of 9 VVE elements abnormal, 7.9% at least 2, and 3.2% at least 3. None of 72 comparisons of the VVE elements, when stratified by age, sex, concussion history, history of headaches, attention deficit hyperactivity disorder, learning issues, psychiatric problems, motion sickness, or weekly hours of exercise, reached significance using the Benjamini-Hochberg procedure at a false discovery rate of 5%. There were no significant associations between VVE elements and the SCAT-5, K-D, or PCSI. CONCLUSIONS: The VVE is robust across multiple patient characteristics. Although healthy subjects may have one abnormal element, multiple abnormal elements are a less common feature, making multiple abnormal elements more indicative of concussion, highlighting the use of this assessment in the setting of injury. The VVE tests unique domains when compared with the PCSI, SCAT-5, and K-D.

Assessment of Saccades and Gaze Stability in the Diagnosis of Pediatric Concussion.

OBJECTIVE: To evaluate the discriminatory ability of different repetition increments of saccades and gaze stability testing for diagnosing concussion in adolescents. DESIGN: Cross-sectional. SETTING: Suburban high school and academic pediatric tertiary care center. PARTICIPANTS: Sixty-nine adolescent athletes within 28 days of a sports- or recreation-related concussion and 69 adolescent athletes without recent concussion. ASSESSMENT OF INDEPENDENT VARIABLES: Symptom provocation with horizontal and vertical saccades and gaze stability testing performed up to 30 repetitions. MAIN OUTCOME MEASURES: Sensitivity and specificity at 10-repetition increments (≤10, ≤20, ≤30) and area under the receiver operating characteristic curves (AUC) of a visio-vestibular examination (VVE) subscore, scored 0 to 4 based on the number of assessments with symptom provocation, at each repetition increment. RESULTS: Sensitivity improved when increasing from ≤10 to ≤20 to ≤30 repetitions for horizontal (25% to 50% to 69%) and vertical (32% to 52% to 74%) saccades and horizontal (19% to 45% to 71%) and vertical (23% to 45% to 72%) gaze stability. Specificity was comparable at ≤10 and ≤20 repetitions, but decreased at ≤30 repetitions across assessments. For a VVE subscore (0-4) based on the number of symptomatic assessments, the discriminatory ability of the test was highest at ≤20 repetitions (AUC of 0.79) with an optimal subscore of one (sensitivity 59%, specificity 96%). CONCLUSIONS: A VVE including a higher threshold level of repetitions for saccades and gaze stability has improved discriminatory ability for concussion, with an optimized AUC of 0.79 at ≤20 repetitions. CLINICAL RELEVANCE: The findings in this study suggest that a higher threshold level of repetitions of 2 commonly used visio-vestibular assessments enables clinicians to more accurately diagnose youth concussion.

Evaluation and Management of Pediatric Concussion in the Acute Setting.

ABSTRACT: Concussion, a type of mild traumatic brain injury, is a common injury encountered by providers caring for pediatric patients in the emergency department (ED) setting. Our understanding of the pathophysiologic basis for symptom and recovery trajectories for pediatric concussion continues to rapidly evolve. As this understanding changes, so do recommendations for optimal management of concussed youth. As more and more children present to EDs across the country for concussion, it is imperative that providers caring for children in these settings remain up-to-date with diagnostic recommendations and management techniques. This article will review the definition, epidemiology, pathophysiology, diagnosis, and management of pediatric concussion in the ED setting.

Reliability of the visio-vestibular examination for concussion among providers in a pediatric emergency department.

BACKGROUND: Visio-vestibular examination (VVE) deficits are common following pediatric concussion. Guidelines recommend assessing these deficits on all potentially concussed youth given their diagnostic and prognostic value, however test psychometrics of the VVE in the emergency department (ED) setting are unknown. Our objective was to determine the inter-rater (IRR) and test-retest reliability (TRR) of the VVE in a pediatric ED. METHODS: We enrolled 155 patients (112 IRR; 43 TRR) age 6-18 years with head injury presenting to the ED of a tertiary care children's hospital. Exams were performed by a group of 65 attending/fellow physicians, pediatricians, and advanced practice providers. The VVE consisted of 9 maneuvers (smooth pursuits, horizontal/vertical saccades and gaze stability, binocular convergence, left/right monocular accommodation, complex tandem gait). Cohen's kappa was calculated for IRR and TRR for each element. RESULTS: For IRR, 5/9 kappas (saccades, gaze stability, monocular accommodation) were in the moderate agreement range (0.40 to 0.60); remaining kappas showed fair agreement. For TRR, 6/9 maneuvers (saccades, horizontal gaze stability, monocular accommodation, tandem gait) showed substantial agreement (0.60 to 0.80). Kappas of 7/9 elements for subjects age 15-18 showed improved IRR and TRR. CONCLUSIONS: The individual elements of the VVE show fair to moderate agreement between providers and moderate to substantial agreement among the same provider in the ED setting. These findings suggest a role in the VVE in evaluating concussion acutely, particularly given its previously demonstrated ability to assist in risk stratification of concussed youth and the importance of early diagnosis for improved outcomes.

The Economic Burden of Pediatric Postconcussive Syndrome.

OBJECTIVE: To estimate the direct costs of pediatric postconcussive syndrome (PCS). DESIGN: Retrospective cohort study. SETTING: Subspecialty sports medicine clinics of a large pediatric tertiary care network in the United States. PATIENTS: One hundred fifty-four patients aged 5 to 18 years with PCS, evaluated between 2010 and 2011. ASSESSMENT OF INDEPENDENT VARIABLES: Direct costs included visits to sports medicine clinic, visio-vestibular therapy, homebound education, subspecialist referral, and prescription-only medications (amantadine and amitriptyline), all measured beginning at 28 days after injury. MAIN OUTCOME MEASURES: Postconcussive syndrome was defined as persistence beyond 28 days from injury. RESULTS: The cost incurred by each PCS patient for sports medicine visits was $1575, for visio-vestibular therapy was $985, for homebound tutoring was $55, for prescription medications was $22, and for subspecialist referral was $120, totaling $3557 per patient, with a 95% confidence interval range of $2886 to $4257. CONCLUSIONS: Given the high economic costs of PCS determined in this study, therapies that mitigate this syndrome may have the potential to be cost-effective and even cost saving.

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

BACKGROUND: Concussions are common pediatric injuries. Previous studies have found concussed youth may be underdiagnosed in the emergency department (ED), but outcomes for those with delayed diagnosis have yet to be described. OBJECTIVE: Our aim was to compare visit characteristics and outcomes of patients who present to the ED with head injury who receive immediate vs. delayed diagnosis. METHODS: Retrospective chart review of patients aged 6 to 18 years diagnosed with concussion on their first ED or urgent care (UC) visit and patients requiring a second visit for diagnosis between July 1, 2017 and June 20, 2019. We compared demographic information, ED or UC visit features, and recovery outcomes using χ2 tests, Student's t-tests, and Wilcoxon rank-sum tests. RESULTS: Overall, we included 85 patients with delayed concussion diagnosis and 159 with immediate diagnosis. Those with immediate diagnosis had more symptoms inquired at initial visit (5 vs. 4; p = 0.003) and a higher likelihood of receiving concussion-specific physical examinations (80% vs. 36.5%; p < 0.001); 76.5% of delayed diagnosis patients had at least 1 symptom at follow-up visit that was not inquired about at initial visit. Those with delayed diagnosis had more medical visits during recovery (3 vs. 2; p < 0.001), longer average time to symptom resolution (21 vs. 11 days; p = 0.004), and a higher likelihood of having persistent concussion symptoms (odds ratio 2.9; 95% confidence interval 1.4-5.9). CONCLUSIONS: Concussed children evaluated acutely for head injury who do not receive an immediate diagnosis may be at risk for persistent symptoms. Performance of a concussion-specific physical examination and use of a standardized symptom scale may aid in identification of concussed youth acutely.

Concussion.

Concussions are a common injury for which patients often present first to primary care physicians. They can affect the day-to-day function of patients in school and work, as well as in sports and recreational activities. Recognizing common physical signs and symptoms after injury facilitates timely diagnosis and treatment, permitting initiation of an active management approach to recovery while preventing secondary injury. For persons with persistent symptoms, active rehabilitation may be utilized, with the goal of returning patients to full function.

Factors Affecting Recovery Trajectories in Pediatric Female Concussion.

OBJECTIVE: Up to one-third of children with concussion have persistent postconcussion symptoms lasting beyond 4 weeks. Females have been shown to have prolonged concussion recovery compared with males. This study examined characteristics in pediatric athletes with concussion to investigate the underlying factors that may contribute to this difference and their relation to recovery trajectories in females compared with males. DESIGN: A retrospective cohort study of pediatric patients with sports-related concussion (SRC). SETTING: A subspecialty pediatric concussion program. SUBJECTS: One hundred ninety-two records were reviewed, 75 females and 117 males, ages 7 to 18 years old. ASSESSMENT OF RISK FACTORS: Sex of patient, time to presentation to specialty care after injury, presence of vision, and vestibular deficits on initial clinical examination. MAIN OUTCOME MEASURES: The main outcome of interest was time to clinical recovery, defined by resolution of symptoms, recovery of physical examination deficits, including vision and vestibular examination, recovery of neurocognitive function, and return to school, exercise, and sport. RESULTS: Pediatric females, on average, presented later to specialty care for evaluation after SRC than males. Females also took longer to recover on 5 markers of recovery: time to return to school without accommodations, time to return to noncontact exercise, time to return to full sport, time to recovery of neurocognitive function on computerized testing, and time to clinical recovery of vision and vestibular deficits on examination including smooth pursuits, saccades, gaze stability, near point of convergence, and balance. These sex-based differences in recovery disappeared when controlling for time to presentation to specialty care. CONCLUSIONS: In this cohort of pediatric patients, ages 7 to 18 years old with SRC, females took longer to recover than males. Our results indicate, however, that a modifiable extrinsic factor, time to presentation to specialty care, may contribute to this difference in recovery between the sexes.

Vestibular Rehabilitation Is Associated With Visuovestibular Improvement in Pediatric Concussion.

BACKGROUND AND PURPOSE: Vision and vestibular-related deficits are common after concussion and are associated with prolonged recovery times, substantially impacting the quality of life for children. The utility of targeted vestibular rehabilitation for these deficits in children after concussion is unknown. The purpose of this study was to determine whether active vestibular rehabilitation is associated with an improvement in visuovestibular signs and symptoms in children with concussion. METHODS: A retrospective cohort study of children diagnosed with concussion and referred to vestibular rehabilitation between 2012 and 2014 was conducted. Patient-reported symptoms and visuovestibular performance measures were assessed in the medical practice and physical therapy settings. RESULTS: One hundred nine children were included in the study with a mean age of 11.8 (3.4) years. Among this group, 59 (54%) were male and 48 (44%) had a sports-related concussion. Children presented to a pediatric sports medicine office and physical therapy a median of 24 (interquartile range [IQR], 14-42) and 55 (IQR, 39-94) days after injury, respectively. Concussion symptoms decreased from a median of 9 (IQR, 5-13) symptoms at initial evaluation to a median of 0 (IQR, 0-2) symptoms at final assessment. Performance on all visuovestibular tasks improved significantly over the course of therapy except for near point of convergence. For the 45 children who completed the Balance Error Scoring System at both initial and final therapy visits, there was a significant improvement in mean level of performance (P < 0.0001). Characteristics between those who completed a full versus partial course of physical therapy were similar. DISCUSSION AND CONCLUSIONS: Vestibular rehabilitation in children with concussion is associated with improvement in symptoms as well as visuovestibular performance. This active intervention may benefit children with persistent symptoms after concussion. Future prospective studies are needed to determine the efficacy and optimal postinjury timing of vestibular rehabilitation.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A208).

Vestibular and oculomotor findings in neurologically-normal, non-concussed children.

OBJECTIVE: To determine the proportion of non-concussed, neurologically normal children with failures on a vestibular and oculomotor examination for concussion performed in an acute setting. DESIGN: This was a cross-sectional study of subjects 6-18 years old presenting to a paediatric emergency department with non-neurologic chief complaints. The examination was administered by a paediatric emergency medicine physician, and includes assessments of dysmetria, nystagmus, smooth pursuits, saccades, gaze stability, near-point of convergence, and gait/balance testing. RESULTS: Of the 295 subjects enrolled, 24% failed at least one element of testing. About 13% had >1 failed element and 5% had >2 failed elements. About 29% of females and 19% of males had failed examinations. By age, 15% of subjects 6-8 years old, 32% 9-11 years, 32% 12-14 years, and 26% 15-18 years had failed examinations. Overall, 10% were unable to complete the exam due to developmental age. CONCLUSIONS: The provider should be aware that a proportion of non-concussed children may demonstrate failure on a single element of the vestibular and oculomotor exam. While this testing is of benefit to the acute care provider in diagnosing paediatric concussion, its utility is greatest in the context of an injury history with acute onset of concussion symptoms.

Vision and Vestibular System Dysfunction Predicts Prolonged Concussion Recovery in Children.

OBJECTIVE: Up to one-third of children with concussion have prolonged symptoms lasting beyond 4 weeks. Vision and vestibular dysfunction is common after concussion. It is unknown whether such dysfunction predicts prolonged recovery. We sought to determine which vision or vestibular problems predict prolonged recovery in children. DESIGN: A retrospective cohort of pediatric patients with concussion. SETTING: A subspecialty pediatric concussion program. PATIENTS (OR PARTICIPANTS): Four hundred thirty-two patient records were abstracted. ASSESSMENT OF RISK FACTORS: Presence of vision or vestibular dysfunction upon presentation to the subspecialty concussion program. MAIN OUTCOME MEASURES: The main outcome of interest was time to clinical recovery, defined by discharge from clinical follow-up, including resolution of acute symptoms, resumption of normal physical and cognitive activity, and normalization of physical examination findings to functional levels. RESULTS: Study subjects were 5 to 18 years (median = 14). A total of 378 of 432 subjects (88%) presented with vision or vestibular problems. A history of motion sickness was associated with vestibular dysfunction. Younger age, public insurance, and presence of headache were associated with later presentation for subspecialty concussion care. Vision and vestibular problems were associated within distinct clusters. Provocable symptoms with vestibulo-ocular reflex (VOR) and smooth pursuits and abnormal balance and accommodative amplitude (AA) predicted prolonged recovery time. CONCLUSIONS: Vision and vestibular problems predict prolonged concussion recovery in children. A history of motion sickness may be an important premorbid factor. Public insurance status may represent problems with disparities in access to concussion care. Vision assessments in concussion must include smooth pursuits, saccades, near point of convergence (NPC), and accommodative amplitude (AA). A comprehensive, multidomain assessment is essential to predict prolonged recovery time and enable active intervention with specific school accommodations and targeted rehabilitation.

Near Point of Convergence after Concussion in Children.

PURPOSE: To determine the incidence of abnormal near point of convergence (NPC) after acute concussion in pediatric patients and to describe the clinical course of such patients. METHODS: A retrospective cohort study of 275 pediatric patients 5 to 18 years of age presenting to a tertiary care children's hospital subspecialty concussion program with a new concussion between July 1, 2014 and June 30, 2015 was conducted. RESULTS: Sixty-seven out of 275 pediatric patients presenting to a subspecialty concussion referral program were found to have abnormal NPC on physical examination as measured by an accommodative rule. Twenty-six (46%) patients recovered with standard clinical care over a median time frame of 4.5 weeks (range 1-18), including a brief period of cognitive and physical rest followed by gradual return to school and physical activities without any formal interventions. An additional 23 (41%) patients recovered a median of 11 weeks post-injury after referral for formal vestibular therapy, including interventions for abnormal convergence, such as Brock string and pencil pushups. Seven (13%) patients with persistent abnormal NPC and concomitant symptoms that necessitated referral for formal office-based vision therapy with developmental optometry recovered a median of 23 weeks post-injury and a median of 16 weeks after referral to vision therapy. CONCLUSIONS: Assessment for NPC is a diagnostic entity that warrants consideration in children with concussion. Concussion questionnaires may not be sensitive to detect vision symptoms in children, making an accurate assessment for convergence important in the evaluation of concussion. Some children with abnormal NPC will recover without any formal intervention after concussion; however, a subset of patients with persistent abnormal NPC after concussion may benefit from interventions including vestibular and/or vision therapy.

Pediatric Mild Traumatic Brain Injury in the Acute Setting.

Pediatric mild traumatic brain injuries, most of which are concussions, are an increasingly common reason for presentation to emergency departments. The diagnosis of concussion has increased dramatically over the past decade, necessitating the acute care provider to have up-to-date knowledge of the definition, pathophysiology, signs and symptoms, physical examination findings, and acute management of pediatric concussion. This article also addresses populations most vulnerable to prolonged recovery from pediatric concussion and referral recommendations.

After-Hours Call Center Triage of Pediatric Head Injury: Outcomes After a Concussion Initiative.

OBJECTIVE: The aim of the study was to characterize referral patterns and medical outcomes of children with head injury triaged by an after-hours call center of a large urban pediatric network, both before and after an institutional concussion initiative. The initiative included a revised call center triage algorithm referring patients with a suspected concussion to see a primary care provider (PCP) within 24 hours, concussion-specific continuing education for medical providers, and a new concussion information Web site. METHODS: Patients aged 5 to 18 years with head injury using the after-hours call center were identified by retrospective review of electronic medical records before (2011) and after (2012) the initiative. A random 50% sample was taken from each year for further analysis. RESULTS: A total of 127 and 159 eligible patient encounters were randomly selected from 2011 to 2012, respectively. From 2011 to 2012, PCP referrals significantly increased from 7% (95% confidence interval [CI], 4%-13%) to 38% (95% CI, 31%-45%), P < 0.001. Concussion diagnoses also significantly increased from 35% (95% CI, 27%-44%) to 58% (95% CI, 50%-66%), P < 0.001. Emergency department referrals and head computed tomography scans decreased but the differences were not statistically significant. No patients had intracranial injury on computed tomography. Most injuries were not sports related. CONCLUSIONS: After an institutional concussion initiative including implementation of a revised head trauma telephone triage algorithm, more head injuries were evaluated by PCPs and more concussions were ultimately diagnosed without an increase in emergency department referrals. Clinicians can benefit from continuing education and infrastructure to aid in initial concussion diagnosis and management.

Vestibular Deficits following Youth Concussion.

OBJECTIVE: To characterize the prevalence and recovery of pediatric patients with concussion who manifest clinical vestibular deficits and to describe the correlation of these deficits with neurocognitive function, based on computerized neurocognitive testing, in a sample of pediatric patients with concussion. METHODS: This was a retrospective cohort study of patients ages 5-18 years with concussion referred to a tertiary pediatric hospital-affiliated sports medicine clinic from July 1, 2010 to December 31, 2011. A random sample of all eligible patient visits was obtained, and all related visits for those patients were reviewed. RESULTS: A total of 247 patients were chosen from 3740 eligible visits for detailed review and abstraction; 81% showed a vestibular abnormality on initial clinical examination. Those patients with vestibular signs on the initial examination took a significantly longer time to return to school (median 59 days vs 6 days, P=.001) or to be fully cleared (median 106 days vs 29 days, P=.001). They additionally scored more poorly on initial computerized neurocognitive testing, and it took longer for them to recover from neurocognitive deficits. Those patients with 3 or more previous concussions had a greater prevalence of vestibular deficits, and it took longer for those deficits to resolve. CONCLUSION: Vestibular deficits in children and adolescents with a history of concussion are highly prevalent. These deficits appear to be associated with extended recovery times and poorer performance on neurocognitive testing. Further studies evaluating the effectiveness of vestibular therapy on improving such deficits are warranted.

Characteristics of prolonged concussion recovery in a pediatric subspecialty referral population.

OBJECTIVE: To identify pre-existing characteristics associated with prolonged recovery from concussion in a sample of patients referred to a pediatric sports medicine clinic. STUDY DESIGN: This was a retrospective, exploratory cohort study of 247 patients age 5-18 years with concussion referred to a tertiary pediatric hospital-affiliated sports medicine clinic from July 1, 2010, through December 31, 2011. A random sample of all eligible patient visits (3740) was chosen for further review and abstraction. Statistical comparisons between subsets of patients were conducted using exact χ(2) tests, logistic regression, quantile regression, and Kaplan-Meier survival curves. RESULTS: The median time until returning to school part-time was 12 days (IQR 6-21); until returning to school full-time without accommodations was 35 days (IQR 11-105); until becoming symptom-free was 64 days (IQR 18-119); and until being fully cleared to return to sports was 75 days (IQR 30-153). Furthermore, 73% of all patients were symptomatic for >4 weeks, 73% were prescribed some form of school accommodation, and 61% reported a decline in grades. Characteristics associated with a prolonged recovery included a history of depression or anxiety; an initial complaint of dizziness; abnormal convergence or symptom provocation following oculomotor examination on physical examination; and history of prior concussion. CONCLUSIONS: Pediatric and adolescent patients with concussion may experience cognitive and emotional morbidity that can last for several months following injury. Clinicians should consider specific pre-existing characteristics and presenting symptoms that may be associated with a more complicated recovery for concussion patients.

Neurovascular Coupling in Acutely Concussed Adolescent Patients.

Neurovascular coupling (NVC) uniquely describes cerebrovascular response to neural activation and has demonstrated impairments following concussion in adult patients. It is currently unclear how adolescent patients experience impaired NVC acutely following concussion during this dynamic phase of physiological development. The purpose of this study was to investigate NVC in acutely concussed adolescent patients relative to controls. We recruited patients presenting to a sports medicine practice within 28 days of a concussion or a musculoskeletal injury (controls). Transcranial Doppler ultrasound was used to measure changes in patients' posterior cerebral artery (PCA) velocity in response to two progressively challenging visual tasks: (1) reading and (2) visual search. Each task was presented in five 1-min trials (20 sec eyes closed/40 sec eyes open). Resting PCA velocity data were derived by averaging PCA velocity across a 2-min baseline period that preceded the visual tasks. Filtered task data were converted to time-series curves representing 40 consecutive 1-sec averages for each trial. Curves were then averaged across the five trials and time-aligned to stimulus onset (eyes open) to generate a single ensemble-averaged 40-sec curve representing NVC response for each participant for each task. Independent t tests were used to assess group differences (concussion vs. control) in resting PCA velocity. Separate linear mixed-effects models were used to evaluate group differences (concussion vs. control) in NVC response profiles for both visual tasks and group-by-task interaction. Twenty-one concussion patients (female = 8 [38.1%]; age = 14.4 ± 1.9 years) and 20 controls (female = 7 [35.0%]; age = 14.4 ± 1.9 years) were included in our analysis. Average resting PCA velocity did not significantly differ between concussion patients (36.6 ± 8.0 cm/sec) and controls (39.3 ± 8.5 cm/sec) (t39 = 1.06; p = 0.30). There were no significant group differences in relative NVC response curves during the reading task (F1,1560 = 2.23; p = 0.14) or the visual search task (F1,1521 = 2.04; p = 0.15). In contrast, the differential response to task (e.g., increase from reading task to visual search task) was significantly greater in concussion patients than in controls (p < 0.0001). The NVC response to the visual search task was 7.1% higher than the response to reading in concussion patients relative to being 5.5% higher in controls. Our data indicate that concussed patients present with a significantly greater response to more difficult tasks than do controls, suggesting that concussed adolescents require increased neural resource allocation as task difficulty increases. The study provides insight into the neurophysiological consequences of concussion in adolescent patients.