Olivia Podolak

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 childrens 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.

Objective Eye Tracking Deficits Following Concussion for Youth Seen in a Sports Medicine Setting

Quantification of visual deficits may help to identify dysfunction following concussion. We evaluated eye-tracking measurements among adolescents within 10 days of concussion and healthy control participants. Patients who reported to 2 tertiary care sport concussion clinics within 10 days of concussion completed an objective eye tracking assessment. Seventy-nine participants completed the study, 44 with concussion (mean age = 14.1 ± 2.2 years, 39% female) and 35 controls (mean age = 14.3 ± 2.4 years, 57% female). Right eye skew along the bottom of the screen was significantly higher for the concussion group compared to controls (median = 0.022 [interquartile range = –0.263, 0.482] vs 0.377 [interquartile range = –0.574, –0.031]; P = .002), but not the left eye. Among the variables investigated, right eye skew was altered for adolescents with a concussion. Visual function is an important component in the postconcussion evaluation, and identifying deficits soon after injury may allow for earlier specialist referral and intervention.

Early vestibular and visual dysfunction predicts prolonged symptomatology following paediatricpediatric concussion

Objective Vestibular and visual dysfunction, including accommodation disorder, symptoms with vestibular ocular reflex (VOR) testing, or receded near point of convergence, are common following concussion and have been associated with prolonged concussion symptomatology. The objective of this study was to determine whether vestibular and visual information contributed significantly to a model predicting the likelihood of having persistent concussion symptoms at 28 days after injury. Design Retrospective cohort study Setting Sports medicine concussion program within a large regional paediatric healthcare network. Participants 274 consecutive patients aged 3-18 years with the diagnosis of concussion seen in the concussion program Independent Variables Standard demographic and clinical data, as well as vestibular and visual examination findings at presentation Outcome measures Symptom recovery from concussion, defined as a symptom score=0 on the Post Concussion Symptom Scale at 28 days Main results Study subjects were 3–18 years (median=14), presenting a median of 14 days from injury. Applying a stepwise regression approach using traditional demographic and clinical variables (age, gender, past medical history, symptoms and balance testing) as well as information from vestibular and visual testing, we found that VOR testing is a statistically significant component (p=0.02) of the final predictive model. Furthermore, in the subset of patients presenting within 14 days of injury, positive VOR testing (p=0.02) and vision problems (p=0.01) significantly contribute to predicting ongoing symptoms at 28 days. Conclusions Symptoms with VOR testing and vision problems upon presentation within 14 days of injury contributed significantly to the prediction model for prolonged symptoms following concussion and warrant further study. Competing interests None.