The Diagnostic Utility of Cervical Spine Proprioception for Adolescent Concussion.

OBJECTIVE: Cervical spine proprioception may be impaired after concussion. Our objective was to determine the diagnostic utility of cervical spine proprioception for adolescent concussion. DESIGN: Cross-sectional. SETTING: Research laboratory. PARTICIPANTS: Adolescents ≤18 days of concussion and uninjured controls. INTERVENTIONS: N/A. MAIN OUTCOMES: Head repositioning accuracy (HRA) testing, a measure of cervical spine proprioception. The HRA test involved patients relocating their head back to a neutral starting position with eyes closed after maximal cervical spine flexion, extension, and right and left rotations. The overall HRA error score was the mean error (distance from the starting point to self-reported return to neutral) across 12 trials: 3 trials in each direction. We used t-tests to compare group means and logistic regression (outcome = group, predictor = HRA, covariates) to calculate odds ratios. We used a receiver operator characteristic curve to evaluate area under the curve (AUC) and calculate the optimal HRA cutpoint to distinguish concussion from controls. RESULTS: We enrolled and tested 46 participants with concussion (age = 15.8 ± 1.3 years, 59% female, mean = 11.3 ± 3.3 days postconcussion) and 83 uninjured controls (age = 16.1 ± 1.4 years, 88% female). The concussion group had significantly worse HRA than controls (4.3 ± 1.6 vs 2.9 ± 0.7 degrees, P < 0.001, Cohen d = 1.19). The univariable HRA model AUC was 0.81 (95% CI = 0.73, 0.90). After adjusting for age, sex, and concussion history, the multivariable model AUC improved to 0.85 (95% CI = 0.77, 0.92). The model correctly classified 80% of participants as concussion/control at a 3.5-degree cutpoint. CONCLUSIONS: Adolescents with concussion demonstrated worse cervical spine proprioception than uninjured controls. Head repositioning accuracy may offer diagnostic utility for subacute concussion.

Cervical spine proprioception and vestibular/oculomotor function: An observational study comparing young adults with and without a concussion history.

OBJECTIVE: To investigate dizziness, vestibular/oculomotor symptoms, and cervical spine proprioception among adults with/without a concussion history. METHODS: Adults ages 18-40 years with/without a concussion history completed: dizziness handicap inventory (DHI), visio-vestibular exam (VVE), and head repositioning accuracy (HRA, assesses cervical spine proprioception). Linear regression models were used to assess relationships between (1) concussion/no concussion history group and VVE, HRA, and DHI, and (2) DHI with HRA and VVE for the concussion history group. RESULTS: We enrolled 42 participants with concussion history (age = 26.5 ± 4.5 years, 79% female, mean = 1.4± 0.8 years post-concussion) and 46 without (age = 27.0± 3.8 years, 74% female). Concussion history was associated with worse HRA (ß = 1.23, 95% confidence interval [CI]: 0.77, 1.68; p < 0.001), more positive VVE subtests (ß = 3.01, 95%CI: 2.32, 3.70; p < 0.001), and higher DHI scores (ß = 9.79, 95%CI: 6.27, 13.32; p < 0.001) after covariate adjustment. For the concussion history group, number of positive VVE subtests was significantly associated with DHI score (ß = 3.78, 95%CI: 2.30, 5.26; p < 0.001) after covariate adjustment, while HRA error was not (ß = 1.10, 95%CI: -2.32, 4.51; p = 0.52). CONCLUSIONS: Vestibular/oculomotor symptom provocation and cervical spine proprioception impairments may persist chronically (i.e., 3 years) after concussion. Assessing dizziness, vestibular/oculomotor and cervical spine function after concussion may inform patient-specific treatments to address ongoing dysfunction.

Concussion symptom presentation and clinical recovery among pediatric athletes: comparing concussions sustained during school and summer months.

OBJECTIVE: We examined post-concussion symptom presentation, exercise, and sleep among pediatric athletes who sustained concussion during the school year vs. summer months. METHODS: We evaluated athletes 6-18 years old within 21-days of concussion. They reported symptoms (Health and Behavior Inventory), with cognitive/somatic domain sub-scores calculated, and indicated if they had exercised or experienced sleep problems since injury. We grouped patients by injury season: summer months (June-August) vs. school year (September-May). RESULTS: 350 patients (14.4 ± 2.4 years old; 37% female; initial visit 8.8 ± 5.3 days post-concussion) were seen for care: 24% sustained a concussion during summer months, 76% during the school year. Lower cognitive (median = 7 [IQR = 1, 15] vs. 9.5 [4, 17]; p = 0.01), but not somatic (7 [2.5, 11] vs. 8 [4, 13]; p = 0.06), HBI scores were observed for patients injured during the summer. Groups were similar in proportion exercising (16% vs 17%) and endorsing sleep problems (29% vs 31%). After adjustments, sustaining a concussion during the summer predicted total (ß=-3.43; 95%CI = -6.50, -0.36; p = 0.029) and cognitive (ß = -2.29; 95%CI = -4.22, -0.36; p = 0.02), but not somatic (ß=-1.46; 95%CI = -2.84, -0.08; p = 0.04), symptom severity. CONCLUSION: Pediatric patients with concussion may present with greater cognitive symptoms during the school year, compared to summer months.

Postconcussion Moderate to Vigorous Physical Activity Predicts Anxiety Severity among Adolescent Athletes.

PURPOSE: This study aimed to examine how moderate-to-vigorous physical activity (MVPA) during concussion recovery influences self-reported anxiety symptoms at follow-up assessment. We hypothesized that more MVPA after concussion would be associated with lower anxiety rating at follow-up. METHODS: We performed a prospective study of participants aged 13-18 yr initially assessed within 14 d of diagnosed concussion. Participants rated concussion symptoms using the Post-Concussion Symptom Inventory and were provided a wrist-worn actigraphy device to track activity for 1 wk after assessment. At follow-up assessment, participants rated anxiety symptoms using the four-question Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety subscale. Each question ranged from 1 (never) to 5 (almost always), with an overall score range of 4-20. For univariable analysis, we calculated correlation coefficients between MVPA and PROMIS anxiety subscale scores. We then created a multiple linear regression model with follow-up PROMIS anxiety subscale score as the outcome and MVPA, sex, initial symptom severity, and preconcussion anxiety as predictors. RESULTS: We enrolled and initially tested 55 participants, and 48 were included in the final analysis (age, 14.6±2.7 yr; 56% female; initial assessment, 7.3± 3.1 d; follow-up assessment, 42.0±29.7 d). We observed an inverse and low correlation between MVPA and follow-up PROMIS anxiety subscale T-scores ( r = -0.30, P = 0.04). Multivariable regression results indicated that MVPA ( ß = -5.30; 95% confidence interval (CI), -10.58 to -0.01), initial Post-Concussion Symptom Inventory score ( ß = 0.11; 95% CI, 0.03 to 0.19), and preconcussion anxiety ( ß = 5.56; 95% CI, 0.12 to 11.0), but not sex ( ß = -2.60; 95% CI, -7.14, to 1.94), were associated with follow-up PROMIS anxiety subscale T-scores. CONCLUSIONS: After adjusting for covariates, more MVPA early after concussion predicted lower PROMIS anxiety subscale scores at follow-up. Although initial concussion symptom severity and preconcussion anxiety were also associated with follow-up PROMIS anxiety subscale score, MVPA represents a modifiable factor that may contribute to lower anxiety symptoms.

Exercising More Than 150 min/wk After Concussion Is Associated With Sleep Quality Improvements.

OBJECTIVE: To examine whether a high volume of aerobic exercise after concussion (>150 min/wk) is associated with improved sleep quality over a 1-month period. We hypothesized that more than 150 min/wk of exercise would be associated with improved sleep quality across concussion recovery. DESIGN: Prospective cohort observational study. SETTING: Sports medicine clinic. PARTICIPANTS: Adolescents initially tested 8.4 ± 3.5 (range, 2-18) days postconcussion who returned for a follow-up assessment 34.3 ± 7.7 (range: 20-49) days postconcussion. MAIN OUTCOME MEASURES: Participants completed the Pittsburgh Sleep Quality Index and the Post-Concussion Symptom Inventory. No specific exercise or sleep recommendations were given beyond what their treating physician provided. Between study visits, participants recorded exercise performed via wrist-worn actigraphy. We calculated average exercise minutes per week and grouped participants as those who exercised more than 150 min/wk versus those who exercised 150 min/wk or less. RESULTS: Thirty-six adolescents participated. Fifteen (42%) recorded more than 150 min/wk of aerobic exercise (age = 14.0 ± 1.7 years; 47% female; mean = 5.6 ± 1.2 d/wk of exercise; mean = 49.2 ± 17.5 min/session), and 21 recorded 150 min/wk or less of aerobic exercise (age = 15.0 ± 1.9 years; 76% female; mean = 2.7 ± 1.6 d/wk of exercise; mean = 30.2 ± 7.8 min/session). There were no significant group differences in the proportion of those who self-reported beginning physical activity prior to enrollment (47% vs 33%; P = .42) or for initial sleep quality rating (8.0 ± 3.7 vs 8.6 ± 4.1; P = .67) or initial concussion symptom severity rating (34.9 ± 28.0 vs 42.6 ± 25.9; P = .40). The group that exercised more than 150 min/wk between visits demonstrated significantly greater median PSQI rating improvements than those who exercised 150 min/wk or less, with a large effect size noted (median change [interquartile range] = 5 [3, 7] vs 1 [0, 4]; P = .008; Cohen d = 0.96). CONCLUSION: Current recommendations suggest that subsymptom aerobic exercise can be beneficial after concussion. Our findings indicate that an exercise volume of more than 150 min/wk led to greater sleep quality improvements than those who exercised below this level.

Predicting Time to Evaluation After Pediatric Concussion: Factors Affecting Specialty Concussion Care.

Background: The timing of clinical evaluation after pediatric concussion represents an important and potentially modifiable clinical milestone for diagnosis, selection of appropriate treatment pathways, and recovery prognosis. Patient demographics, socioeconomic status, or medical history may affect the time to the initial evaluation and subsequently influence recovery outcomes. Purpose/Hypothesis: The purpose of this investigation was to evaluate the association of patient characteristics with the time to specialty evaluation after a concussion. It was hypothesized that patients with a history of concussion, a preexisting relationship with our specialty concussion program, or a higher ZIP code-based income estimate would present for care more quickly after a concussion than patients without these characteristics. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Included were patients with a concussion between 6 and 18 years old who were seen for care at a single sports medicine center between January 1 and December 31, 2019. Patient demographic, socioeconomic, injury, and clinical characteristics were collected through a retrospective review of the medical records. The primary outcome was the number of days between the date of the concussion and the patient's initial specialty evaluation. Results: Overall, 220 patients (mean age, 14.4 ± 2.5 years; 46% female) were seen for care at a mean of 9.7 ± 5.6 days (range, 1-21 days) after concussion. A shorter time to specialty evaluation was associated with a history of concussion (ß = -1.72 [95% CI, -3.24 to -0.20]; P = .03) and a prior clinical relationship with the treating clinical department (ß = -1.85 [95% CI, -3.52 to -0.19]; P = .03). Referral by a primary care provider was associated with a longer time to evaluation (ß = 3.86 [95% CI, 2.39-5.33]; P < .0001). Conclusion: A history of concussion and having a preexisting clinical relationship with the deparment were associated with a shorter time to evaluation after concussion. Referral from a primary care physician was associated with a longer time to evaluation. Issues may exist in the propensity to access care after an injury, resulting in delays for initiating early treatment.

Early Moderate to Vigorous Physical Activity After Concussion Is Associated With Faster Symptom Resolution Time.

CONTEXT: Early physical activity (PA) after concussion may promote symptom resolution. Prior studies have investigated exercise frequency/duration, yet precise PA intensity or volume required for optimal recovery requires further investigation. moderate to vigorous physical activity (MVPA) is beneficial for physical health. We investigated whether sedentary time, light activity time, MVPA time, or activity frequency in the weeks following concussion are associated with time to symptom resolution among adolescents. DESIGN: Prospective cohort study. METHODS: Adolescents 10-18 years of age were tested ≤14 days of concussion and followed until symptom resolution. At the initial visit, participants rated symptom severity and were provided wrist-worn activity trackers to monitor PA for the following week. PA behavior was categorized each day based on heart rate: sedentary (resting), light PA (50%-69% age-predicted max heart rate), and MVPA (70%-100% age-predicted max heart rate). Symptom resolution was defined as the date when participants reported cessation of concussion-like symptoms. Patients were not given specific PA instructions, though some may have received instructions from their physician. RESULTS: Fifty-four participants were included in the study (54% female; mean age = 15.0 [1.8] y; initially assessed 7.5 [3.2] d after concussion). Female athletes recorded more sedentary time (900 [46] vs 738 [185] min/d; P = .01; Cohen d = 0.72), and less time in light PA (194.7 [64.5] vs 224 [55] min/d; P = .08; Cohen d = 0.48) and MVPA (23 [17] vs 38 [31] min/d; P = .04; Cohen d = 0.58) than male athletes. After adjusting for sedentary time, hours per day with >250 steps, sex, and initial symptom severity, more MVPA time was associated with faster symptom resolution time (hazard ratio = 1.016; 95% confidence interval, 1.001-1.032; P = .04). CONCLUSION: Our findings offer preliminary insight into how varying PA intensities affect concussion recovery, as MVPA may be a higher intensity than what is typically prescribed in concussion care.

Sleep Problems After Concussion Are Associated With Poor Balance and Persistent Postconcussion Symptoms.

We examined the association of self-reported sleep problems with clinical measures of postural stability, memory performance, symptom burden, and symptom duration following youth concussion. Patients 6-18 years of age presenting ≤21 days postconcussion underwent a clinical evaluation including modified Balance Error Scoring System, single- and dual-task tandem gait, immediate and delayed recall, and symptom severity. We calculated time from injury until symptom resolution and determined the proportion of patients who developed persistent postconcussion symptoms, defined as a symptom duration >28 days postconcussion. We grouped patients based on whether they reported sleep problems at their postconcussion clinical evaluation and compared symptom-based and functional outcomes between groups. Of the 207 patients included, n = 97 (14.3 ± 2.9 years; 49% female; initial visit 10.2 ± 5.8 days postconcussion) reported sleep problems postconcussion and n = 110 (14.3 ± 2.4 years; 46% female; initial visit 9.3 ± 5.4 days postinjury) did not. Those reporting sleep problems postconcussion had significantly more modified Balance Error Scoring System errors than those without (8.4 ± 5.5 vs 6.7 ± 4.7; P = .01), but similar tandem gait and memory performance. A significantly greater proportion of those who reported sleep problems postconcussion experienced persistent postconcussion symptoms than those who did not (53% vs 31%; P = .004). After adjusting for time from concussion to clinical visit and preconcussion sleep problems, postconcussion sleep problems were associated with a 2 times greater odds of developing persistent postconcussion symptoms (adjusted odds ratio = 2.02, 95% CI = 1.01, 4.06; P = .049). Identifying sleep problems early following concussion may allow clinicians to implement targeted treatment recommendations to improve sleep and provide an optimal recovery environment.

Early physical activity after concussion is associated with sleep quality but not dizziness among adolescent athletes.

OBJECTIVES: To assess the association between early physical activity and post-concussion sleep quality, dizziness, and postural stability among adolescents with concussion compared to uninjured controls. DESIGN: Cross-sectional. METHODS: Adolescents ages 13-18 years assessed within 14 days post-concussion and uninjured controls. Those with concussion reported if they participated in physical activity between the concussion and assessment. Participants completed the Dizziness Handicap Inventory, Pittsburgh Sleep Quality Index, and single/dual-task tandem gait. RESULTS: We enrolled 34 participants with concussion (early physical activity: n = 10, age = 15.8 ±â€¯1.6 years, 70% female; no physical activity: n = 24, age = 16.0 ±â€¯1.3 years, 50% female) and 21 uninjured controls (age = 16.0 ±â€¯1.8 years, 48% female). Compared to controls, the no physical activity group reported worse sleep quality (Pittsburgh Sleep Quality Index: 3.8 ±â€¯2.7 vs 8.0 ±â€¯4.9 points, p = 0.002) and single-task tandem gait time (13.7 ±â€¯3.4 vs 21.2 ±â€¯8.1 s, p = 0.0006), while the early physical activity group did not (Pittsburgh Sleep Quality Index: 3.8 ±â€¯2.7 vs 5.8 ±â€¯3.2 points, p = 0.38; single-task tandem gait: 13.7 ±â€¯3.4 vs 19.0 ±â€¯5.7 s, p = 0.08). Compared to controls, early/no physical activity groups reported worse dizziness (Dizziness Handicap Inventory: 2.0 ±â€¯3.4 vs 22.9 ±â€¯23.8 vs 27.4 ±â€¯19.2 points, p < 0.0001). There were no significant between-group differences for dual-task tandem gait (24.1 ±â€¯8.0 vs 24.8 ±â€¯6.2 vs 26.6 ±â€¯7.3 s, p = 0.57). CONCLUSIONS: The no physical activity group reported worse sleep quality and slower single-task tandem gait than controls, while both groups reported similar sleep quality and tandem gait. Early physical activity may promote sleep quality and postural stability, or early physical activity may be a function of improved sleep and postural stability after concussion.

Double Vision and Light Sensitivity Symptoms are Associated With Return-to-School Timing After Pediatric Concussion.

OBJECTIVE: To determine the association between academic time loss postconcussion and vision symptoms/impairments among pediatric patients. DESIGN: Cross-sectional. SETTING: Sports medicine clinic. PATIENTS: Pediatric patients seen for care in a sports medicine clinic between the ages 6 and 18 years (n = 212; mean age = 14.3, SD = 2.4 years; 48% female) were evaluated within 21 days of concussion (mean = 9.8, SD = 5.7 days). INDEPENDENT VARIABLE: Patients were grouped based on academic time loss (missed >5 days vs ≤5 days of school) at their initial postconcussion evaluation. OUTCOME MEASURES: Patients rated concussion symptoms using the Health and Behavior Inventory (HBI) and underwent near point of convergence (NPC) testing. We compared groups on specific HBI symptom ratings of dizziness, blurry vision, seeing double, and light sensitivity, as well as NPC break and recovery point distances. RESULTS: Two hundred twelve patients were included; n = 36 (17%) who reported missing >5 days of school. After adjusting for time since injury, parental education level, mechanism of injury, and preinjury anxiety, patients who reported missing >5 days of school had higher ratings of double vision (ß = 0.27; 95% confidence interval [CI], 0.01-0.53; P = 0.04) and light sensitivity (ß = 0.506; 95% CI, 0.061-0.951; P = 0.02), but not dizziness (ß = 0.390; 95% CI, -0.047 to 0.827; P = 0.08) or blurry vision (ß = 0.026; 95% CI, -0.352 to 0.404; P = 0.89). CONCLUSION: Missing >5 days of school was associated with worse double vision and light sensitivity symptoms. Given the importance of vision in learning, assessing postconcussion vision symptoms may facilitate a successful return to school. Clinicians should assess a wide spectrum of vision-specific symptoms to ensure appropriate support during the return-to-school process.

More Physical Activity Is Correlated With Reduction in Kinesiophobia for Adolescents With Persistent Symptoms After Concussion.

CONTEXT: The relationship between physical activity (PA) and fear of pain with movement (ie, kinesiophobia) during concussion recovery is unknown. Kinesiophobia may limit PA, while PA after concussion may reduce kinesiophobia. Our purpose was to examine the correlation between PA and self-reported kinesiophobia during concussion recovery for adolescents with and without persistent symptoms. DESIGN: Prospective cohort study of children ages 10-18 years within 14 days of concussion. METHODS: Participants rated kinesiophobia using the Tampa Scale of Kinesiophobia (TSK) at initial (≤14 d postconcussion) and return to play (RTP) assessments, and wore activity monitors between assessments. Our primary outcome was TSK score change from initial to RTP assessments. We grouped participants based on whether they experienced persistent symptoms (symptoms ≥28 days) or not (symptoms <28 days) and calculated correlation coefficients (Pearson r for normally distributed and Spearman rho for nonnormally distributed variables) between PA variables and TSK change scores. RESULTS: Among the 41 participants enrolled, 44% developed persistent symptoms (n = 18; age = 14.5 [2.0] y; 50% female; symptom duration = 57.3 [6.2] d; RTP = 66.8 [6.4] d) and 56% did not (n = 23; age = 14.9 [1.8] y; 48% female; symptom duration = 15.2 [1.5] d; RTP = 21.7 [1.9] d). For the persistent symptoms group, greater TSK change scores (mean = -2.5 [5.7] point change) were significantly and moderately correlated with higher daily step count (r = -.60, P = .008) and exercise frequency (r = -.63, P = .005), but were not correlated with exercise duration (ρ = -.12, P = .65). Among the no persistent symptoms group, TSK change scores (mean = -6.0 [5.0] point change) were not correlated with step count (r = -.18, P = .41) or exercise duration (ρ = .10, P = .67), and the correlation with frequency was low and not significant (r = -.34, P = .12). CONCLUSIONS: Regular PA during concussion recovery, regardless of duration or intensity, may help reduce kinesiophobia for those experiencing persistent symptoms.

The association between sleep and physical activity with persisting postconcussion symptoms among adolescent athletes.

BACKGROUND: Both sleep duration and physical activity following concussion may influence subsequent recovery. Objective measurement of sleep and physical activity behavior via wearable technology may provide insights into their association with concussion recovery. OBJECTIVE: To determine whether sleep behavior (eg, duration, timing) and/or physical activity (steps/day, or exercise frequency, duration, intensity) in the first month after adolescent sports-related concussion are associated with developing persisting postconcussion symptoms (PPCS). DESIGN: Case-control. SETTING: Outpatient sports medicine clinic. PARTICIPANTS: The study prospectively enrolled adolescent athletes who sustained a concussion (N = 49, age = 14.8 ± 1.8 years; 51% female) who were evaluated within 14 days of concussion (mean = 6.7 ± 2.7 days) and followed uvia sleep/physical activity monitoring for the subsequent 2 weeks. MAIN OUTCOME MEASURES: Participants wore a monitor to track sleep (sleep time, wake time, and time spent awake in bed at night) and physical activity (average steps/day, exercise frequency, exercise duration) behavior for 2 weeks after initial assessment. Participants were followed until symptom resolution, and the main outcome of interest was development of PPCS (symptom duration >28 days). A multivariable logistic regression model was used to examine associations between physical activity and sleep behavior with PPCS. RESULTS: Of the 49 participants, 47% (n = 23, mean symptom resolution = 57 ± 23 days post injury) developed PPCS and 53% (n = 26, mean symptom resolution = 15 ± 7 days post injury) did not. Univariable analysis showed that the PPCS group took fewer steps/day (7526 ± 2975 vs. 9803 ± 3786 steps/day; p = .02), exercised less frequently (2.5 ± 2.2 vs. 4.4 ± 2.1 days/week; p = .005), and spent more time in bed awake (1.2 ± 0.3 vs. 0.8 ± 0.3 h/night; p = .03) than the no PPCS group. Multivariable results indicated the odds of developing PPCS significantly increased with fewer exercise session/week (adjusted odds ratio = 1.96, 95% confidence interval = 1.09, 3.51, p = .024). CONCLUSIONS: More exercise sessions that were longer than 15 minutes during concussion recovery was associated with a lower risk of developing PPCS, whereas sleep and other physical activity measures were not. Further studies regarding exercise duration and intensity are needed. Clinicians may consider advising patients to optimize sleep and physical activity during concussion recovery.

Dizziness Is Associated With Neck/Shoulder Pain Following Pediatric Concussion.

OBJECTIVE: To examine the association between dizziness and neck/shoulder pain after concussion and if differences in postural stability and oculomotor function exist among patients reporting dizziness with or without concurrent neck/shoulder pain. DESIGN: Cross sectional. SETTING: Sports medicine clinic. PATIENTS: Pediatric patients ≤14 days post concussion. INTERVENTIONS: N/A. OUTCOME MEASURES: Patients completed the Health and Behavior Inventory (HBI) symptom rating and separately rated neck/shoulder pain (scale 0-3; 0 = no pain). We grouped patients by HBI dizziness rating (0 = not-dizzy; 1-3 = dizzy) and compared neck/shoulder pain ratings between the groups. We then compared oculomotor and postural stability outcomes between dizzy patients with and without neck/shoulder pain. RESULTS: We included 153 patients: dizzy (n = 100; age = 14.6 ± 2.2 years; 48% female) and not-dizzy (n = 53, age = 14.4 ± 3.1 years; 38% female). The dizzy group reported significantly higher neck/shoulder pain (1.4 ± 1.1 vs 0.5 ± 0.9 points, P < 0.001) and total symptom score (25.7 ± 11.2 vs 11.7 ± 9.3 points, P < 0.001) than the not-dizzy group. After adjusting for total symptom score and preinjury anxiety, depression, and migraines, dizziness was associated with higher odds of neck/shoulder pain (odds ratio = 1.9, 95% CI, 1.2-3.0; P = 0.004). No differences were observed between dizzy patients with and without neck/shoulder pain for near point of convergence (10.0 ± 7.5 vs 8.5 ± 6.7 cm, P = 0.43), modified Balance Error Scoring System (8.9 ± 5.5 vs 6.8 ± 4.7 errors, P = 0.09), or tandem gait (single-task: 26.0 ± 12.3 vs 24.2 ± 11.9 seconds, P = 0.56; dual-task: 35.1 ± 14.3 vs 35.6 ± 18.6 seconds, P = 0.90). CONCLUSIONS: In concussion patients experiencing dizziness, evaluating neck/shoulder pain may help identify individuals who would benefit from cervical spine rehabilitation. However, other potential causes of dizziness should also be evaluated to facilitate timely recovery.

Examining initial post-concussion dizziness and postural stability as predictors of time to symptom resolution.

OBJECTIVES: To examine the utility of a multimodal assessment battery of self-reported dizziness, clinician obtained postural stability, and symptom severity ratings within 14 days of concussion to predict symptom resolution time among children and adolescents. DESIGN: Prospective cohort. METHODS: Patients ages 6-18 years completed evaluation ≤14 days post-concussion, including self-reported symptom severity using the Post-Concussion Symptom Inventory (PCSI) and postural stability assessments. We grouped patients as dizzy or not dizzy based on the difference in current and pre-injury PSCI dizziness ratings: difference between current and pre-injury dizziness ≥3 = dizzy; difference <3 = not dizzy. We evaluated postural stability using modified Balance Error Scoring System (mBESS) and tandem gait (TG). Our primary outcome was time from concussion to symptom resolution. Using a univariable Cox proportional hazard model, we examined the association between dizziness and symptom resolution time. We then used a multivariable Cox proportional hazard model to adjust for potential confounding variables. RESULTS: We examined 89 patients and grouped each as dizzy (n = 34; age = 14.7 ±â€¯2.7 years; 7.1 ±â€¯3.4 days post-injury; symptom resolution time = 40.8 ±â€¯5.7 days) or not dizzy (n = 55; age = 14.4 ±â€¯2.3 years; 7.2 ±â€¯3.1 days post-injury; symptom resolution time = 23.3 ±â€¯3.2 days). Upon univariable examination, dizziness was independently associated with increased symptom resolution time (Hazard Ratio [HR] = 0.49; 95%CI: 0.28, 0.83; p = 0.009). After adjusting for potential confounders (total symptom severity, mBESS tandem stance errors, TG time, loss of consciousness), only symptom severity change was associated with symptom resolution time (HR = 0.98; 95%CI: 0.96, 0.997; p = 0.025). CONCLUSIONS: Total symptom severity assessed within 14 days of concussion, but not dizziness or postural stability, was significantly associated with symptom resolution time among children and adolescents following concussion.

Postconcussion Dizziness Severity Predicts Daily Step Count during Recovery among Adolescent Athletes.

PURPOSE: Physical activity (PA) after concussion is an important aspect of appropriate clinical management. However, symptoms or functional deficits may reduce patient propensity toward PA, thereby negatively affecting recovery. Our purpose was to examine whether postconcussion dizziness, total symptom severity, or postural stability predicts PA level in the 2 wk after initial evaluation. METHODS: We evaluated adolescent athletes within 14 d of concussion on assessments of symptoms, dizziness, and postural stability. Athletes were provided an activity monitor to track PA for 2 wk after the evaluation. Our primary outcome was step count (mean steps per day). Potential predictor variables included sex, Post-Concussion Symptom Inventory (PCSI) total symptom severity, individual PCSI ratings of dizziness and balance impairment, and postural stability assessments (single- and dual-task tandem gait, modified Balance Error Scoring System). To examine predictors of PA, we calculated correlation coefficients between steps per day and each potential predictor and included significantly correlated variables in a multivariable regression model. RESULTS: Participants were ages 12-18 yr (n = 35, 15.2 ± 1.7 yr, 49% female) and initially evaluated 7.3 ± 3.0 d after concussion. Upon univariable evaluation, PCSI dizziness rating (Pearson R = -0.49, P = 0.003) and sex (mean difference, 2449 steps per day; P = 0.05) were associated with steps per day. Within the multivariable regression analysis, PCSI dizziness rating (ß = -1035; 95% confidence interval, -191 to -1880; P = 0.018), but not sex, predicted average steps per day in the 2 wk after initial evaluation. CONCLUSIONS: Self-reported dizziness, but not overall symptom severity or postural stability, assessed within 14 d of concussion predicted daily step count in the subsequent 2 wk. Given the importance of PA for concussion recovery, treating acute postconcussion dizziness can potentially reduce a barrier to PA and improve recovery trajectories.

Post-Concussion Dizziness, Sleep Quality, and Postural Instability: A Cross-Sectional Investigation.

CONTEXT: Dizziness, postural instability, and poor sleep quality are all commonly reported post-concussion and individually relate to poor outcomes. OBJECTIVE: To examine sleep quality and postural stability among adolescents who did and did not report dizziness within two weeks of concussion. DESIGN: Cross-sectional study. SETTING: Research laboratory. PATIENTS OR OTHER PARTICIPANTS: Participants ages 12-18 years within 14 days of concussion (n=58, 15.2±1.8 years; 50% female; 7.1±3.1 days post-injury) and uninjured controls (n=73; 15.8±1.3 years; 42% female). MAIN OUTCOME MEASURES: Participants completed pre-injury and current dizziness ratings on the Post-Concussion Symptom Inventory (PCSI) and current sleep quality on the Pittsburgh Sleep Quality Index (PSQI). Participants also completed postural stability assessments (single/dual-task tandem gait and modified Balance Error Scoring System [mBESS]). RESULTS: We grouped concussion patients into dizzy (n=21) or not dizzy (n=37) groups based on PCSI dizziness ratings: difference between current and pre-injury dizziness rating >3=dizzy; difference <3=not dizzy. The dizzy and not dizzy groups both reported significantly worse sleep quality than the control group (PSQI score: mean=9.6±3.7 vs 7.2±3.5 vs 4.3±2.6; p<0.001) upon univariable comparison. Similarly, the dizzy group performed slowest on single and dual-task tandem gait, followed by the not dizzy group, then the control group (single-task TG: mean= 27.2±11.7 sec vs 21.2±6.3 vs 14.7±3.6; p<0.001); (dual-task TG: mean=38.4±16.2 sec vs 29.9±7.2 vs 21.6±7.5; p<0.001). Both concussion groups demonstrated significantly more errors than the control group on the mBESS (mean=9.8±5.1 vs 6.9±5.8 vs 3.8±3.5; p<0.001). After controlling for total symptom severity in the multivariable model, tandem gait, but not mBESS or sleep quality, was associated with dizziness. CONCLUSION: Individuals with post-concussion dizziness also demonstrated impaired tandem gait performance, while poor sleep quality was associated with total symptom severity. Identifying and treating the underlying dysfunction contributing to dizziness and postural instability may guide individualized rehabilitation strategies and facilitate recovery.

Patient perception of dizziness and imbalance does not correlate with gait measures in adolescent athletes post-concussion.

BACKGROUND: Dizziness and gait impairments are commonly observed following a concussion, and both are associated with prolonged concussion recovery. RESEARCH QUESTION: Is there a correlation between combined self-reported dizziness and balance impairment severity with objective gait impairments after concussion? METHODS: Participants (n = 51; 15.4 ± 1.6 years; 51 % female; 7.3 ± 3.2 days post-injury) age 12-18 years self-reported ratings of dizziness and balance impairment using the Post-Concussion Symptom Inventory (PCSI) within 14 days of injury. Individual ratings of dizziness, balance impairment, and moving clumsily on the PCSI were combined to create a comprehensive dizziness and imbalance score. Participants also completed a smartphone-based gait evaluation under single-task and dual-task conditions. Correlation coefficients (Pearson r for normally distributed and Spearman rho for non-normally distributed variables) were calculated between self-reported symptoms and single and dual-task spatiotemporal gait parameters, specifically step velocity, step time, and step length. RESULTS: Correlation coefficients indicated that there was low to no correlation between self-reported dizziness and imbalance impairment severity and smartphone-obtained gait parameters under single- or dual-task conditions, including step velocity (single-task: r=-0.22, p = 0.13; dual-task: r=-0.05, p = 0.72), step time (single-task: rho = 0.16, p = 0.27; dual-task: rho = 0.14, p = 0.33), and step length (single-task: r=-0.15, p = 0.30; dual-task: r = 0.03, p = 0.84). SIGNIFICANCE: Self-reported dizziness and balance impairment severity within the first two weeks of concussion may not reflect objectively measured gait performance, given the lack of association between subjective symptom ratings and functional measures. Further, smartphone collected gait parameters may not provide the necessary sensitivity to detect an association with dizziness. The lack of significant correlation between self-reported symptoms and objective gait performance highlights the importance of using both objective and subjective measures to obtain a more complete picture of concussion deficits.

Symptom and clinical recovery outcomes for pediatric concussion following early physical activity.

OBJECTIVE: Recent research supports initiating physical activity as soon as 24 to 48 hours after concussion to reduce persistent postconcussive symptoms. However, this practice has not been widely adopted. The objective of this study was to evaluate the association of early physical activity with patient-reported and functional outcomes for pediatric patients following a concussion. METHODS: A retrospective cohort of patients who presented to a pediatric sports medicine clinic (48% female, mean age14.3 ± 2.6 years, and mean 9.8 ± 5.7 days postconcussion) were evaluated. Patients were grouped based on whether they reported engaging in physical activity prior to presenting to the clinic. Patient- and parent-reported symptom frequency (Health and Behavior Inventory), 11 different clinical outcomes (including missed school, memory recall, and balance assessments), the presence of symptoms persisting beyond 28 days, and a subgroup analysis of those patients receiving exercise versus symptom-limiting activity prescriptions were examined. Outcomes were compared between physical activity groups using the Mann-Whitney U-test and the chi-square test. To adjust for the effect of potential confounders, a logistic binary regression model was constructed. RESULTS: In total, 211 pediatric patients were included, 35 (17%) of whom reported early physical activity. A greater proportion of the no physical activity group reported a headache (85% vs 60%, p = 0.001). The no physical activity group also reported higher patient-reported (23.1 ± 13.4 vs 15.0 ± 13.4, p < 0.001) and parent-reported (19.4 ± 12.7 vs 11.2 ± 10.3, p = 0.001) symptom frequency at the initial visit. The early physical activity group had a lower proportion of patients with persistent symptoms (44% vs 22%, p = 0.02) and a shorter time to symptom resolution (15.6 ± 12.4 days vs 27.2 ± 24.2 days, p = 0.02). After adjusting for potential confounders, early physical activity was associated with 5.8 lower odds of experiencing persistent symptoms (adjusted OR 5.83, 95% CI 2.05-16.61; p = 0.001). CONCLUSIONS: A significant association between early physical activity and decreased symptom burden was observed. A lower proportion of those patients who engaged in early physical activity experienced persistent symptoms 28 days postinjury. However, low rates of early physical activity prior to the initial clinic visit were also observed, indicating that this approach may not be well known by acute care or primary care providers, or is not widely adopted by patients and families.