Physiological, vestibulo-ocular and cervicogenic post-concussion disorders: An evidence-based classification system with directions for treatment

Ellis, Michael J.; Leddy, John J.; Willer, Barry

doi:10.3109/02699052.2014.965207

Cited by 258 publications

(218 citation statements)

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“…In accordance with our previous study, 13 we defined VOD as those patients with more than 1 subjective complaint of intermittent blurred or double vision; visual disturbance; difficulty concentrating, focusing, or reading; dizziness; or motion sensitivity, and the presence of more than 1 of the following objective physical examination findings: abnormal near-point convergence (NPC), abnormal extraocular movements or smooth pursuits, or abnormal or symptomatic assessment of horizontal saccades, vertical saccades, or vestibulo-ocular reflexes (VORs). 12 The presence of VOD was assessed at initial consultation for all patients with acute SRC and PCS.…”

supporting

confidence: 93%

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

Ellis

Cordingley²,

Vis³

et al. 2017

PED

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OBJECTIVE 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. METHODS 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 < 30 days postinjury, and PCS was defined according to the International Classification of Diseases, 10th Revision 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. RESULTS 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. CONCLUSIONS 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.

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confidence: 93%

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

Ellis

Cordingley²,

Vis³

et al. 2017

PED

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“…27,30 Although these studies have identified several important clinical predictors of PCS among pediatric patients, limited attention has been paid to features of the physical examination that are associated with specific concussion symptoms and which together may provide important insight into the pathophysiological mechanisms mediating persistent symptoms. 13 The present study meets an urgent unmet need by introducing a novel clinical definition that uses a combination of subjective and objective clinical findings that can potentially identify patients at an elevated risk of developing PCS. In this study, 29% of patients with acute SRC and 63% of those with PCS met the clinical criteria for VOD at initial clinical consultation.…”

Section: Discussionmentioning

confidence: 99%

“…Failure to accurately identify the pretreatment physiological mechanisms governing persistent concussion symptoms (i.e., physiological, vestibular, or cervicogenic) will have an important impact on evaluating the effect of therapeutic interventions in future studies, especially given potential differences in natural history and responses to physiotherapy observed among these unique populations. 13,28 Although the focused vestibulo-ocular examination used in the present study may help physicians identify those pediatric patients with acute SRC who are at risk for PCS and who may benefit from physiotherapy interventions, the widespread incorporation of these tests into standardized sideline or office assessment tools to be used by health care providers without clinical training in neurological, neuroophthalmological, and vestibular examination must be approached with caution. Clinicians using these assessment techniques should not only appreciate the neuroanatomy and physiology that govern each test but should also be aware of the myriad neurological conditions that can present with abnormalities of vestibular and oculomotor function.…”

Section: Discussionmentioning

confidence: 99%

“…29,40,45 Consequently, there is an urgent need to identify pediatric patients at risk for developing PCS and to direct these patients toward rehabilitation strategies that target the pathophysiological mechanisms underlying persistent symptom complexes. 13 Among the most common and debilitating symptoms that occur following mild traumatic brain injury (mTBI) in adults are those caused by dysfunction of the vestibular and oculomotor systems. Because of the rich reciprocal connections shared between these 2 neurological subsystems, symptoms of vestibulo-ocular dysfunction (VOD) often overlap and may include dizziness, vertigo, fogginess, motion sensitivity, disequilibrium, postural or gait imbalance, gaze instability, blurred vision, or diplopia.…”

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confidence: 99%

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Vestibulo-ocular dysfunction in pediatric sports-related concussion

Ellis

Cordingley

Vis

et al. 2015

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130

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OBJECT The objective of this study was 2-fold: 1) to examine the prevalence of vestibulo-ocular dysfunction (VOD) among children and adolescents with acute sports-related concussion (SRC) and postconcussion syndrome (PCS) who were referred to a multidisciplinary pediatric concussion program; and 2) to determine if VOD is associated with the development of PCS in this cohort. METHODS The authors conducted a retrospective review of all patients with acute SRC (presenting 30 days or less postinjury) and PCS (3 or more symptoms for at least 1 month) referred to a multidisciplinary pediatric concussion program between September 2013 and July 2014. Initial assessment included clinical history, physical examination, and Post-Concussion Symptom Scale assessment. Patients were also assessed for VOD, which was defined as more than one subjective vestibular and oculomotor complaint (dizziness, blurred vision, and so on) and more than one objective physical examination finding (abnormal smooth pursuits, saccades, vestibulo-ocular reflex, and so on). This study was approved by the local institutional ethics review board. RESULTS A total of 101 patients (mean age 14.2 years, SD 2.3 years; 63 male and 38 female patients) participated, including 77 (76.2%) with acute SRC and 24 (23.8%) with PCS. Twenty-two of the 77 patients (28.6%) with acute SRC and 15 of the 24 (62.5%) with PCS met the clinical criteria for VOD. The median duration of symptoms was 40 days (interquartile range [IQR] 28.5–54 days) for patients with acute SRC who had VOD compared with 21 days (IQR 13–32 days) for those without VOD (p = 0.0001). There was a statistically significant increase in the adjusted odds of developing PCS among patients with acute SRC who had VOD compared with those without VOD (adjusted OR 4.10; 95% CI 1.04–16.16). CONCLUSIONS Evidence of VOD was detected in a significant proportion of children and adolescents with acute SRC and PCS who were referred to a multidisciplinary pediatric concussion program. This clinical feature was a significant risk factor for the subsequent development of PCS in this pediatric acute SRC cohort.

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“…Therefore, as a part of the education process, patients and parents should be apprised that persistent postconcussion symptoms warrant additional investigation to determine their underlying causes. [39][40][41] After returning to play, planned, routine follow-up assessments should be conducted to ensure the adolescent's quality of life is not being compromised. Clinicians need to acknowledge the potential for postconcussion emotional sequelae and work with the injured adolescent to identify potential causes, thereby easing the transition to full recovery.…”

Section: Discussionmentioning

confidence: 99%

Qualitative Examination of Adolescent Health-Related Quality of Life at 1 Year Postconcussion

Iadevaia

Roiger

Zwart

2015

Journal of Athletic Training

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Context: Moderate to severe traumatic brain injuries can negatively influence health-related quality of life (HRQOL) in adolescent patients. The effect of sport-related concussion on adolescent HRQOL remains unclear.Objective: To investigate the perceptions of adolescent student-athletes and their parents regarding the adolescents' HRQOL 1 year after sport-related concussion.Design: Qualitative study. Setting: Secondary school.Patients or Other Participants: Seven adolescent studentathletes (age range, 12-16 years) who sustained a sport-related concussion at least 1 year (15.3 6 2.8 months) before the study participated along with their primary care-giving parents (n ¼ 7).Data Collection and Analysis: Fourteen semistructured face-to-face interviews (7 adolescents, 7 parents) were completed. Interviews were transcribed and inductively analyzed by a team of 3 athletic trainers with 32 combined years of professional experience. Themes were negotiated through a consensual review process. Participant checks were completed to ensure trustworthiness of the results.Results: Four major themes emerged from the interviews: (1) significant effect of symptoms, (2) feelings of frustration, (3) influence on school attendance and activities, and (4) nature of interpersonal and team relationships. Participants indicated that the physical symptoms of the concussion substantially affected their emotional and academic function. The influence of the concussion on social interactions seemed to depend on the nature of interpersonal relationships.Conclusions: Sport-related concussion can negatively influence physical and emotional function, academics, and interpersonal interactions as perceived by adolescent studentathletes and their parents. Education of parents and their children, school professionals, coaches, and teammates remains critical to effectively recognize and manage sport-related concussion. Secondary school districts also play a critical role in the concussion-management process by establishing and implementing accommodation policies that alleviate student concerns about falling behind while ensuring a healthy return to normal school routines. Furthermore, adolescent support systems must be considered throughout the recovery process.

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Physiological, vestibulo-ocular and cervicogenic post-concussion disorders: An evidence-based classification system with directions for treatment

Abstract: Future studies incorporating neuro-imaging and exercise science techniques are underway at the author's institutions to validate this novel pathophysiological approach to acute concussion and PCS.

Cited by 258 publications

References 75 publications

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

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

Vestibulo-ocular dysfunction in pediatric sports-related concussion

Qualitative Examination of Adolescent Health-Related Quality of Life at 1 Year Postconcussion

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