Clinical predictors of vestibulo-ocular dysfunction in pediatric sports-related concussion

Abstract

<jats:sec> <jats:title>OBJECTIVE</jats:title> <jats:p>There were 2 objectives of this study. The first objective was to identify clinical variables associated with vestibulo-ocular dysfunction (VOD) detected at initial consultation among pediatric patients with acute sports-related concussion (SRC) and postconcussion syndrome (PCS). The second objective was to reexamine the prevalence of VOD in this clinical cohort and evaluate the effect of VOD on length of recovery and the development of PCS.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>A retrospective review was conducted for all patients with acute SRC and PCS who were evaluated at a pediatric multidisciplinary concussion program from September 2013 to May 2015. Acute SRS was defined as presenting &lt; 30 days postinjury, and PCS was defined according to the <jats:italic>International Classification of Diseases, 10th Revision</jats:italic> criteria and included being symptomatic 30 days or longer postinjury. The initial assessment included clinical history and physical examination performed by 1 neurosurgeon. Patients were assessed for VOD, defined as the presence of more than 1 subjective vestibular and oculomotor complaint (dizziness, diplopia, blurred vision, etc.) and more than 1 objective physical examination finding (abnormal near point of convergence, smooth pursuits, saccades, or vestibulo-ocular reflex testing). Poisson regression analysis was used to identify factors that increased the risk of VOD at initial presentation and the development of PCS.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>Three hundred ninety-nine children, including 306 patients with acute SRC and 93 with PCS, were included. Of these patients, 30.1% of those with acute SRC (65.0% male, mean age 13.9 years) and 43.0% of those with PCS (41.9% male, mean age 15.4 years) met the criteria for VOD at initial consultation. Independent predictors of VOD at initial consultation included female sex, preinjury history of depression, posttraumatic amnesia, and presence of dizziness, blurred vision, or difficulty focusing at the time of injury. Independent predictors of PCS among patients with acute SRC included the presence of VOD at initial consultation, preinjury history of depression, and posttraumatic amnesia at the time of injury.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>This study identified important potential risk factors for the development of VOD following pediatric SRC. These results provide confirmatory evidence that VOD at initial consultation is associated with prolonged recovery and is an independent predictor for the development of PCS. Future studies examining clinical prediction rules in pediatric concussion should include VOD. Additional research is needed to elucidate the natural history of VOD following SRC and establish evidence-based indications for targeted vestibular rehabilitation.</jats:p></jats:sec>

Symptom Presentation After Concussion and Pre-existing Anxiety Among Youth Athletes

“…Motion sickness arises when there is a neural mismatch between an internal model of how a dynamic environment should respond and the actual behavior of the environment [34]. The neural mismatch leading to motion sickness and subsequent nausea may be amplified post injury due to vestibular dysfunction associated with concussion [25]. This mismatch may be further exacerbated in a cohort with pre-existing vestibular deficits, which may explain the higher incidence of post-concussive nausea that we observed in the pre-injury anxiety group.…”

“…Evidence suggests that anxiety disorders cause the vestibular system to rely more heavily on visual inputs for balance than those without anxiety -leading to Vestibular-Ocular Dysfunction (VOD) [22]. VOD following concussion has been independently associated with a 4x greater risk of prolonged recovery [25]. Therefore, pre-existing VOD may be associated with pre-injury anxiety disorders.…”

Vestibular Rehabilitation for Children

“…This is of concern due to reports that as many as 50% of those with sports-related concussion have vestibular-ocular dysfunction, which is predictive of prolonged recovery. 17,64 Alsalaheen and colleagues 7 completed a retrospective study examining the efficacy of VR for individuals with concussion. Of the 114 patients, 67 (59%) were children (median age: 16 years, range: 8-18 years).…”

Symptom Burden and Profiles in Concussed Children with and without Prolonged Recovery

“…Previous research has shown that demographic and injury characteristics such as adolescent age [4,[9][10][11], female sex [9,10,[12][13][14], history of prior concussion [15,16], and amnesia [5,12,17] are associated with prolonged recovery from concussion. Additional research shows that symptom burden, defined by a patient's total symptom score (TSS), is the most consistent predictor of prolonged recovery among concussed youth [5,[18][19][20][21][22].…”