Assessment of Saccades and Gaze Stability in the Diagnosis of Pediatric Concussion

BACKGROUND: The crucial role of early vestibular rehabilitation (VR) to recover a dynamic semicircular canal function was recently highlighted in patients with unilateral vestibular hypofunction (UVH). However, wide inter-individual differences were observed, suggesting that parameters other than early rehabilitation are involved. OBJECTIVE: The aim of the study was to determine to what extent the degree of vestibular loss assessed by the angular vestibulo-ocular reflex (aVOR) gain could be an additional parameter interfering with rehabilitation in the recovery process. And to examine whether different VR protocols have the same effectiveness with regard to the aVOR recovery. METHODS: The aVOR gain and the percentage of compensatory saccades were recorded in 81 UVH patients with the passive head impulse test before and after early VR (first two weeks after vertigo onset: N = 43) or late VR (third to sixth week after onset: N = 38) performed twice a week for four weeks. VR was performed either with the unidirectional rotation paradigm or gaze stability exercises. Supplementary outcomes were the dizziness handicap inventory (DHI) score, and the static and dynamic subjective visual vertical. RESULTS: The cluster analysis differentiated two distinct populations of UVH patients with pre-rehab aVOR gain values on the hypofunction side below 0.20 (N = 42) or above 0.20 (N = 39). The mean gain values were respectively 0.07±0.05 and 0.34±0.12 for the lateral canal (p < 0.0001), 0.09±0.06 and 0.44±0.19 for the anterior canal (p < 0.0001). Patients with aVOR gains above 0.20 and early rehab fully recovered dynamic horizontal canal function (0.84±0.14) and showed very few compensatory saccades (18.7% ±20.1%) while those with gains below 0.20 and late rehab did not improve their aVOR gain value (0.16±0.09) and showed compensatory saccades only (82.9% ±23.7%). Similar results were found for the anterior canal function. Recovery of the dynamic function of the lateral canal was found with both VR protocols while it was observed with the gaze stability exercises only for the anterior canal. All the patients reduced their DHI score, normalized their static SVV, and exhibited uncompensated dynamic SVV. CONCLUSIONS: Early rehab is a necessary but not sufficient condition to fully recover dynamic canal function. The degree of vestibular loss plays a crucial role too, and to be effective rehabilitation protocols must be carried out in the plane of the semicircular canals.

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Benign Paroxysmal Positional Vertigo in Children and Adolescents With Concussion

Sports Health A Multidisciplinary Approach ◽

10.1177/1941738120970515 ◽

2021 ◽

pp. 194173812097051

Author(s):

Alicia Wang ◽

Guangwei Zhou ◽

Kosuke Kawai ◽

Michael O’Brien ◽

A. Eliot Shearer ◽

...

Keyword(s):

Benign Paroxysmal Positional Vertigo ◽

Pediatric Patients ◽

Head Injuries ◽

Vestibular Disorder ◽

Symptom Scale ◽

Level Of Evidence ◽

Pediatric Concussion ◽

Positional Vertigo ◽

Level 3 ◽

Paroxysmal Positional Vertigo

Background: Dizziness after concussion is primarily attributed to effects on the brain, but traumatic inner ear disorders can also contribute. Benign paroxysmal positional vertigo (BPPV) is a common vestibular disorder that can result from minor head trauma and can be easily diagnosed and rapidly treated in an office setting. The role of BPPV in pediatric postconcussive dizziness has not been well-studied. Purpose: To evaluate the prevalence and clinical features of BPPV in a group of pediatric patients with concussion and prolonged dizziness after concussion. Study Design: Case-control study. Level of Evidence: Level 3. Methods: Retrospective review of 102 patients seen within the past 3 years in a pediatric multidisciplinary concussion clinic for evaluation of postconcussive dizziness. Results: BPPV was diagnosed in 29.4% (30/102) of patients with postconcussion syndrome and dizziness. All patients with BPPV were treated with repositioning maneuvers, except for 5 patients who had spontaneous resolution of symptoms. Patients were evaluated at an average of 18.8 weeks (SD, 16.4 weeks) after the injury. BPPV was diagnosed at similar rates regardless of gender or age group (children vs adolescents). The mean Post-Concussion Symptom Scale (PCSS) score did not differ significantly between patients with (58.3 [SD, 22.5]) or without BPPV (55.8 [SD, 29.4]; P = 0.39). The PCSS “balance problems or dizziness” subscore also did not differ between patients with (3.3 [SD, 1.7]) or without BPPV (2.8 [SD, 1.6]; P = 0.13). Conclusion: BPPV is fairly common in pediatric concussion, occurring in one-third of the patients studied. BPPV is often not diagnosed and treated until many weeks after the injury. Increased awareness of the evaluation and management of BPPV among pediatric concussion providers may help expedite resolution of dizziness and hasten overall recovery in affected patients. Clinical Relevance: BPPV is a treatable cause of dizziness caused by minor head injuries and is more common than previously reported in pediatric patients with concussion. Improved awareness of BPPV by concussion providers may expedite recovery.

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“What is the actual goal of the pathway?”: examining emergency department physician and nurse perspectives on the implementation of a pediatric concussion pathway using the theoretical domains framework

BMC Health Services Research ◽

10.1186/s12913-021-06110-2 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Anh Ly ◽

Roger Zemek ◽

Bruce Wright ◽

Jennifer Zwicker ◽

Kathryn Schneider ◽

...

Keyword(s):

Emergency Department ◽

Health Care Providers ◽

Clinical Pathways ◽

Theoretical Domains Framework ◽

Local Context ◽

Emergency Department Physician ◽

Evidence Based ◽

Care Providers ◽

Structured Interviews ◽

Pediatric Concussion

Abstract Background Multiple evidence-based clinical practice guidelines (CPGs) exist to guide the management of concussion in children, but few have been translated into clinical pathways (CP), which operationalize guidelines into accessible and actionable algorithms that can be more readily implemented by health care providers. This study aimed to identify the clinical behaviours, attitudinal factors, and environmental contexts that potentially influence the implementation of a clinical pathway for pediatric concussion. Methods Semi-structured interviews were conducted from October 2017 to January 2018 with 42 emergency department clinicians (17 physicians, 25 nurses) at five urban emergency departments in Alberta, Canada. A Theoretical Domains Framework (TDF)-informed interview guide contained open-ended questions intended to gather feedback on the proposed pathway developed for the study, as well as factors that could potentially influence its implementation. Results The original 14 domains of the TDF were collapsed into 6 clusters based on significant overlap between domains in the issues discussed by clinicians: 1) knowledge, skills, and practice; 2) professional roles and identity; 3) attitudes, beliefs, and motivations; 4) goals and priorities; 5) local context and resources; and 6) engagement and collaboration. The 6 clusters identified in the interviews each reflect 2–4 predominant topics that can be condensed into six overarching themes regarding clinicians’ views on the implementation of a concussion CP: 1) standardization in the midst of evolving research; 2) clarifying and communicating goals; 3) knowledge dissemination and alignment of information; 4) a team-oriented approach; 5) site engagement; and 6) streamlining clinical processes. Conclusion Application of a comprehensive, evidence-based, and theory-driven framework in conjunction with an inductive thematic analysis approach enabled six themes to emerge as to how to successfullly implement a concussion CP.

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Variations in Time to Recovery from Pediatric Concussion Based on Differing Outcomes of Interest

Neurology ◽

10.1212/01.wnl.0000801828.94648.3d ◽

2021 ◽

Vol 98 (1 Supplement 1) ◽

pp. S10.2-S11

Author(s):

Christina Master ◽

Kristi Metzger ◽

Mr. Daniel Corwin ◽

Catherine McDonald ◽

Melissa Pfeiffer ◽

...

Keyword(s):

Sports Medicine ◽

Clinical Care ◽

Median Number ◽

Self Report ◽

Return To School ◽

Self Assessment ◽

Concussion Management ◽

Pediatric Concussion ◽

Concussion Recovery ◽

Definition Of

ObjectiveTo quantify variability in pediatric concussion recovery across multiple outcomes of interest.BackgroundPediatric concussion studies are hindered by a common significant limitation: lack of agreement on a standard definition of “recovery.” A variety of clinical outcomes of interest utilized across studies, including symptom self-report, neurocognitive testing results, self-reported return to activity, and physician clearance for activity, leads to challenges for both research, as well as clinical concussion management.Design/MethodsWe enrolled concussed youth, ages 11–18 years, from a specialty sports medicine clinic = 28 days of injury. Patients were followed as part of clinical care for concussion for up to 13 weeks. At each visit, participants completed questionnaires and a battery of clinical measures. From these data, we constructed 10 potential definitions of recovery: 3 based on self-reported symptoms (change from pre-injury, no symptoms, below pre-determined thresholds), 2 based on visio-vestibular examination (VVE) deficits (none, = 1), 2 based on physician clearance (for return to school/sport), and 3 based on self-assessment (“back to normal”, return to school/exercise).ResultsOne hundred seventy-four concussed youth were enrolled (median age: 15 years, 54.6% female) with a median time from injury to initial visit of 12 days (IQR: 7, 20). Median number of visits was 2 (range: 1, 5). We observed a wide variation in the proportion of participants recovered across the 10 definitions. Depending on definition, between 4% and 45% were considered recovered within 4 weeks, and between 10% and 80% were considered recovered at the end of follow-up. The VVE-based definition (=1 deficit) consistently had the highest proportion recovered at all time points, while self-reported return to exercise had the lowest proportion.ConclusionsRecovery from concussion is not a single unitary point in time. These results will provide valuable guidance to clinicians in managing concussion and researchers in designing future observational and interventional trials of pediatric concussion.

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“Torso Rotation”' experiments. 4: the role of vision and the cervico-ocular reflex in compensation for a deficient VOR

Journal of Vestibular Research ◽

10.3233/ves-1999-9203 ◽

1999 ◽

Vol 9 (2) ◽

pp. 89-101

Author(s):

L.J.G. Bouyer ◽

D.G.D. Watt

Keyword(s):

Motion Sickness ◽

Vestibular Function ◽

Repeated Exposure ◽

Head Movements ◽

Upper Body ◽

Calibration Data ◽

En Bloc ◽

Mean Velocity ◽

Gaze Stability ◽

Velocity Gain

Acute, reversible changes in human vestibular function can be produced by exposure to “Torso Rotation” (TR), a method involving the overuse of certain types of simple, self-generated movements. A single session results in multiple, short-lasting aftereffects, including perceptual illusions, VOR gain reduction,gaze and postural instability, and motion sickness. With repeated exposure, motion sickness susceptibility disappears and gaze stability improves. VOR gain continues to be reduced, however. Therefore, another gaze stabilizing system must come into play. Are visual and/or neck inputs involved in this functional compensation? Six subjects participated in this 7-day experiment. Eye and head movements were measured during 2 tests: 1) voluntary “head only” shaking between 0.3 and 3.0 Hz (lights off) and 2) voluntary “head and torso” shaking, moving the upper body en bloc (neck immobilized). Measurements were obtained before and repeatedly after TR. Velocity gain (eye velocity/head velocity) was determined for each of these tests. Each day, mean velocity gain during “head only” shaking in the dark (averaged over 1.0 to 2.0 Hz) dropped significantly after TR ( P < 0.01), with no long-term improvement ( P > 0.9). Similar results, although more noisy, were obtained for “head and torso” shaking. As a control, EOG calibration data confirmed that gaze stability in the light did improve over the 7 days of testing. This experiment demonstrates that the reduction in gaze instability following repeated exposure to TR results from an increased use of vision. It excludes the VOR, the COR, and predictive mechanisms (including efference copy) as contributors. In addition, in the 20 minutes following TR completion, gaze stability recovered less than during previous VOR testing in the dark. These results are compatible with the motion that exposure to TR leads to a change in sensorimotor strategy involving a de-emphasis of vestibular inputs.

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Predicting Psychological Distress after Pediatric Concussion

Journal of Neurotrauma ◽

10.1089/neu.2018.5792 ◽

2019 ◽

Vol 36 (5) ◽

pp. 679-685 ◽

Cited By ~ 8

Author(s):

Brian L. Brooks ◽

Vickie Plourde ◽

Miriam H. Beauchamp ◽

Ken Tang ◽

Keith Owen Yeates ◽

...

Keyword(s):

Psychological Distress ◽

Pediatric Concussion

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When in doubt, sit it out! Pediatric concussion—an update

Child s Nervous System ◽

10.1007/s00381-017-3537-4 ◽

2017 ◽

Vol 33 (10) ◽

pp. 1669-1675 ◽

Cited By ~ 8

Author(s):

Julia Morrow Kerrigan ◽

Christopher C. Giza

Keyword(s):

Pediatric Concussion

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325 Variations in Emergency Department Pediatric Concussion Discharge Instruction Practices

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2015.07.361 ◽

2015 ◽

Vol 66 (4) ◽

pp. S117-S118

Author(s):

H. Wang-Flores ◽

A. Rogers ◽

A. Zamarripa ◽

K. Levasseur ◽

C. Benner ◽

...

Keyword(s):

Emergency Department ◽

Discharge Instruction ◽

Pediatric Concussion

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Gaze Stability, Dynamic Balance and Participation Deficits in People with Multiple Sclerosis at Fall-Risk

The Anatomical Record ◽

10.1002/ar.23852 ◽

2018 ◽

Vol 301 (11) ◽

pp. 1852-1860 ◽

Cited By ~ 4

Author(s):

Hina Garg ◽

Leland E. Dibble ◽

Michael C. Schubert ◽

Jim Sibthorp ◽

K. Bo Foreman ◽

...

Keyword(s):

Multiple Sclerosis ◽

Fall Risk ◽

Dynamic Balance ◽

Gaze Stability

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Tai Chi and vestibular rehabilitation effects on gaze and whole-body stability

Journal of Vestibular Research ◽

10.3233/ves-2004-14605 ◽

2004 ◽

Vol 14 (6) ◽

pp. 467-478 ◽

Cited By ~ 3

Author(s):

Chris A. McGibbon ◽

David E. Krebs ◽

Steven L. Wolf ◽

Peter M. Wayne ◽

Donna Moxley Scarborough ◽

...

Keyword(s):

Significant Relationship ◽

Postural Stability ◽

Intervention Program ◽

Tai Chi ◽

Vestibular Rehabilitation ◽

Whole Body ◽

Gaze Control ◽

Gaze Stability ◽

Vestibular Hypofunction ◽

The Relationship

Tai Chi (TC) is a comparatively new intervention for peripheral vestibular hypofunction, which is often treated with vestibular rehabilitation (VR). We compared gaze stability (GZS), whole-body stability (WBS) and footfall stability (FFS) during locomotion among 26 people with vestibulopathy (VSP), randomized into two treatment arms (13 TC and 13 VR). Each intervention program was offered for 10 weeks. GZS improved more for VR than for TC, but WBS (and FFS) improved more for TC than for VR. There was a significant relationship between changes in GZS and WBS for the VR subjects (r = 0.60, p = 0.01), but not for TC subjects. There was a significant relationship between changes in WBS and FFS for both VR (r = 0.65, p < 0.01) and TC (r = 0.58, p = 0.02) groups; the relationship disappeared in the VR but not the TC group when controlling for GZS. These findings suggest that VR and TC both benefit patients with VSP but via differing mechanisms. Moreover, these data are the first to test the assumption that improving gaze control among patients with VSP perforce improves postural stability: it does not. We conclude that GZS is most improved in those who receive VR, but that TC improves WBS and FFS without improving GZS, suggesting patients with VSP can rely on non-gaze related mechanisms to improve postural control.

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