Vestibular Deficits following Youth Concussion

doi:10.1016/j.jpeds.2015.01.039

The Journal of Pediatrics

Volume 166, Issue 5, May 2015, Pages 1221-1225

https://doi.org/10.1016/j.jpeds.2015.01.039 Get rights and content

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.

Section snippets

Methods

We conducted a retrospective cohort study approved by our institutional review board of patients seen in the subspecialty sports medicine clinics of The Children's Hospital of Philadelphia, of a large pediatric tertiary care network, with the goal of identifying risk factors for prolonged recovery from youth concussion. The dataset used in this study also was used in a previous study by Corwin et al¹¹ in which they described per-injury characteristics associated with prolonged recovery from

Results

A total of 247 patients were included in the analysis. Information on patient demographics are presented in Table I. Overall, 81% of patients showed either abnormal gaze stability (VOR) or abnormal tandem gait on initial physical examination (Table II), with 69% showing abnormal VOR and 80% showing abnormal tandem gait. Those patients with either abnormal VOR or tandem gait took a significantly longer time to return to school (median 59 days vs 6 days, P = .001) or to be fully cleared (median

Discussion

This study describes the prevalence and morbidity of vestibular deficits in youth concussion among patients referred to a specialty sports medicine practice, as well as their correlation with neurocognitive data and recovery trajectories. The authors of previous studies have described vestibular deficits, including vertigo, dizziness, and imbalance in concussion,8, 9 but have neither described the prevalence of such injuries in youth athletes nor their association with recovery outcomes.

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Determine how positive BPPV findings in adolescents and young adults following concussion impacted the total number of treatments required and time until discharge.
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To optimize outcomes, including symptom resolution and return to sport and/or work, early identification of BPPV and subsequent intervention should be prioritized for individuals who have concussion symptoms that suggest vestibular dysfunction.
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Sports related concussions (SRCs) are common in young athletes. A concussion is a traumatic brain injury induced by biomechanical forces. There are specific symptoms and exam findings which can assist in diagnosing a concussion. There is no single exam finding to definitively diagnose a concussion; rather using several modalities provides a better assessment. Treating concussions with a brief period of cognitive and physical rest is recommended. Patients should be encouraged to gradually increase cognitive and physical activity if symptoms do not worsen. Persistent post-concussive symptoms require a multidisciplinary approach. Preventing SRCs has proven elusive while evidence suggests that repeat concussions are preventable.
Influence of concussion history and age of first concussion on visio-vestibular function
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Citation Excerpt :
Additionally, among those with a repeat concussion, age of first concussion was not associated with abnormal visio-vestibular function. Previous studies assessing visual and vestibular impairments separately have found visual deficits in 69 % of patients13 and vestibular deficits in 81 % of patients12 following pediatric concussion. Utilizing an assessment which combines these components, it is unsurprising that our study found a high proportion of at least two abnormal subtests in all of the patients studied, including those with their first concussion (91 %) and those with a repeat concussion (93 %).
To assess if abnormalities on visio-vestibular examination (VVE) are associated with concussion history (first vs. repeat) or age of first concussion in acutely concussed adolescents.
Cross-sectional.
Data were queried from the Children's Hospital of Philadelphia Minds Matter concussion registry. Patients aged 14–18 years old presenting for their initial visit to the specialty care concussion program within 28 days of injury were included. Demographics, including age, sex, concussion history, and age of first concussion, were collected before the exam. The VVE consisted of 9 subtests: smooth pursuit, horizontal/vertical saccades and vestibulo-ocular reflex (VOR), binocular convergence, left/right monocular accommodation, and complex tandem gait. Primary outcomes included VVE subtests (normal/abnormal), and total VVE score (abnormal = 2+ abnormal subtests).
Among 1051 patients included (female = 604(57.5 %); age = 15.6 ± 1.2; median lifetime concussions = 1 [IQR = 1,3]), 518 had repeat concussion. Controlling for age and sex, first vs. repeat concussion was not associated with any VVE subtest or total score (Total VVE Score RR = 1.35, 99.5%CI = 0.70,2.61). Of those with repeat concussion, 190 had valid age of first concussion data. Controlling for age, sex, and number of lifetime concussions, age of first concussion was not significantly associated with any VVE subtest or total score (Total VVE Score RR = 1.11, 99.5%CI = 0.78,1.57).
Adolescents with concussion history present with similar visio-vestibular function to those with no concussion history. Additionally, clinical effects of early age of first concussion may not be evident in children. This study provides foundational data regarding potential cumulative effects of concussion in younger athletes.
Optimizing the Combination of Common Clinical Concussion Batteries to Predict Persistent Postconcussion Symptoms in a Prospective Cohort of Concussed Youth
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The Ability of Vestibular and Oculomotor Screenings to Predict Recovery in Patients After Concussion: A Systematic Review of the Literature
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: Supported by the Children's Hospital of Philadelphia Department of Pediatrics Chair's Initiative, the National Institutes of Health, National Center for Advancing Translational Sciences (UL1TR000003 for the University of Pennsylvania Health System), the Children's Hospital of Philadelphia Clinical Translational Sciences Award, research institute funding for the Comparative Effectiveness Program, and the National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development (K08HD073241 [to M.Z.]). The authors declare no conflicts of interest.

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Original ArticleVestibular Deficits following Youth Concussion

Objective

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

J Pediatr

Curr Probl Pediatr Adolesc Health Care

Phys Med Rehabil Clin N Am

J Pediatr

J Biomed Inform

Phys Med Rehabil Clin N Am

Current issues in pediatric sports concussion

Clin Neuropsychol

The growing public health concern of sports concussion: the new psychology practice frontier

Prof Psychol Res Pract

Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012

Br J Sports Med

Postural stability assessment following concussion: one piece of the puzzle

Clin J Sport Med

Vestibular and balance treatment of the concussed athlete

NeuroRehabilitation

Vestibular rehabilitation following mild traumatic brain injury

NeuroRehabilitation

Vestibular rehabilitation after mild traumatic brain injury with vestibular pathology

NeuroRehabilitation

A brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions: preliminary findings

Am J Sports Med

Visual fatigue and accommodative dynamics in asymptomatic individuals

Optom Vis Sci

Original Article
Vestibular Deficits following Youth Concussion