The Effect of a Home Exercise Program on Visio-Vestibular Function in Concussed Pediatric Patients

ObjectiveTo explore if a home exercise program (HEP) affects visio-vestibular function in concussed pediatric patients.BackgroundA HEP can provide an equitable and cost-effective method for therapy targeted towards visio-vestibular deficits that are common following concussion. It is unclear if pediatric patients prescribed a HEP demonstrate improved visio-vestibular function.Design/MethodsThis observational study included 1,041 patients (59% female; age = 14.0 ± 2.5 years) reporting to a specialty care concussion center for an initial visit ≤28 days post-injury and follow-up ≤60 days post-injury. All patients completed a Visio-Vestibular Examination (VVE) at both timepoints consisting of 9 subtests: smooth pursuit, horizontal/vertical saccades and gaze stability, binocular convergence, left/right monocular accommodation, and complex tandem gait. Patients were prescribed a HEP (1–2 times/day) at initial visit consisting of exercises addressing visio-vestibular deficits. At follow-up, patients reported their progress: (1) has not done the HEP, (2) is currently doing the HEP, or (3) has completed the HEP. Primary outcomes included HEP progress, VVE subtests (normal/abnormal), and total VVE (abnormal = 2 + abnormal subtests). Chi-square tests with Bonferroni corrections were used to determine if abnormal VVE outcomes were associated with HEP status.ResultsAt initial visit, 81 2(77.6%) patients presented with abnormal total VVE. At follow-up, the proportion of abnormal total VVE did not differ among patients not doing the HEP (101 [62.0%]), patients currently doing the HEP (516 [69.0%]), and patients who had completed the HEP (51 [69.0%]). However among VVE subtests, a lower proportion who completed the HEP presented with abnormal smooth pursuit (7.5%), horizontal (3.8%) and vertical (3.8%) saccades, and complex tandem gait (0%) relative to patients currently doing the HEP (p = 0.003) and patients not doing the HEP (p = 0.01).ConclusionsOur findings indicate that patients who completed the HEP presented with improved elements of visio-vestibular function relative to those who did not start or were currently doing the HEP.

The Effects of a Single Bout of Soccer Heading of Single and Dual-Task Tandem Gait in Collegiate Recreationally Active Individuals

Introduction: The understanding of subconcussive impacts is limited with few assessments to determine effects in a recreationally active population due to existing tests being static and unidimensional. Methods: This study investigated the effects of 10 soccer headers on pre and post-test measurements of patient reported outcome measures and single and dual-task tandem gait of 12 recreationally active college-aged participants. Results: No changes due to the heading session were observed; however, there was a detectable learning effect with participants walking faster and committing more gait errors but less cognitive errors. Conclusion: A bout of soccer heading may not pose an immediate risk to dynamic postural control and cognitive function.

Derivation of the Buffalo Concussion Physical Examination risk of delayed recovery (RDR) score to identify children at risk for persistent postconcussive symptoms

ObjectiveThe Buffalo Concussion Physical Examination (BCPE) is a brief, but pertinent physical examination designed for the subacute, outpatient assessment of concussion. The purpose of this study was to perform the BCPE on a larger sample and derive a scoring system to identify children at risk for Persistent Post-Concussive Symptoms (PPCS, recovery ≥30 days).MethodsThis prospective, observational cohort study from September 2016 to March 2019 was performed at three university-affiliated concussion clinics. Male and female children (n=270, 14.92±1.86 years, range 8–18, 38% female) were diagnosed with a concussion within 14 days of injury and followed-up until recovery. Logistic regression was used with history and physical examination variables to predict PPCS and a weighted scoring metric was derived.ResultsOut of 15 predictor variables, the main effects of 1 preinjury variable (≥3 previous concussions), 2 injury characteristic variables (days-since-injury and type-of-injury), 3 physical examination variables (orthostatic intolerance (OI), vestibulo-ocular reflex (VOR) and tandem gait) and 2 interaction terms (OI/VOR and tandem gait/type-of-injury) produced a score that was 85% accurate for identifying children with low-risk, medium-risk and high-risk for PPCS on cross-validation.ConclusionThe Risk for Delayed Recovery (RDR)-Score allows physicians in an outpatient setting to more accurately predict which children are at greater risk for PPCS early after their injury, and who would benefit most from targeted therapies. The RDR-Score is intended to be used as part of a comprehensive assessment that should include validated symptom checklists, mental health history and adjunct testing (eg, cognitive or physical exertion) where clinically indicated.

Tandem Gait test – kinematics and temporal parameters at normal children and patients survived after posterior fossa tumor

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Diagnostic usefulness of 10-step tandem gait test for the patient with degenerative cervical myelopathy

Tandem gait is considered one of the most useful screening tools for gait impairment. The aim of this study is to evaluate diagnostic usefulness of 10-step tandem gait test for the patients with degenerative cervical myelopathy (DCM). Sixty-two DCM patients were compared to 55 persons without gait abnormalities as control. We counted the number of consecutive steps and graded into five according the number of steps and stability. Five grades of tandem gait were investigated for association with clinical parameters including qualitative Japanese orthopedic association (JOA) sub-score for lower extremities and Nurick scale and quantitative balance and gait assessments. The number of tandem steps were reduced and the grades of tandem gait were differently distributed in the DCM patients compared to controls (steps, 7.1 ± 3.6 versus 9.9 ± 0.4, p < 0.001; grades of 0/1/2/3/4/5, 1/13/14/15/19 versus 0/0/2/15/38, p < 0.001 in patients with DCM and control respectively). Patients with DCM showed more unstable balance and abnormal gait features including slower velocity, shorter strides, wider bases with increased stance phase of a gait cycle compared to the control group. The grades of tandem gait were correlated with JOA sub-score (r = 0.553, p < 0.001) and the Nurick scale (r = − 0.652, p < 0.001) as well as both balance and gait parameters. In DCM patients, tandem gait was impaired and correlated with severity of gait abnormality. The authors believe that 10-step tandem gait test is an objective and useful screening test for evaluating gait disturbance in patients with DCM.

Lambert-Eaton Myasthenic Syndrome Presenting as Cerebellar Symptoms

A 79-year-old man visited neurology clinic due to gait ataxia and vertigo for 10 months. Neurologic examination revealed saccadic pursuit, mild dysmetria, impaired tandem gait, and areflexia that recovers after exercise. The amplitude of compound muscle action potentials recorded on the abductor digiti minimi increased up to 6,639.4% during repetitive nerve stimulation at 50 Hz stimulation. This case demonstrates that clinicians should consider Lambert-Eaton myasthenic syndrome as a differential diagnosis when a patient complains of gait ataxia and vertigo.

DETERMINANTS OF IMMEDIATE AND DELAYED RECALL PERFORMANCE FOLLOWING PEDIATRIC CONCUSSION

Background: The assessment of cognitive functioning, including attention, memory, and concentration is one component of concussion evaluation.1-3 Immediate and delayed recall tasks are clinical assessments of cognitive functioning which evaluate memory performance post-injury.2 These tasks require patients to verbally recall as many items as possible from a word list both immediately after the list is administered and following a 5-minute delay.2 While previous studies have used a 5-word recall list (SCAT3),4 few have investigated the determinants of performance using a 10-word recall list (SCAT5). Purpose: The purpose of the investigation was to identify demographic, injury, and clinical test characteristics associated with immediate and delayed recall performance using the SCAT5 10-word recall test. Methods: We conducted a retrospective chart review collecting demographic (age, sex, history of concussion, relevant medical history), injury [time of clinical presentation, loss of consciousness (LOS), neuroimaging], and clinical (symptom inventory, m-BESS, tandem gait) characteristics, as well as immediate and delayed recall performance on a 10-word list. Results: Patients seen within 14 days of concussion (n=125; 15.2±1.6 years of age; 45% female; evaluated 6.9±3.4 days post-injury) were included in the analysis. Patients 15 years or older performed significantly better on both immediate and delayed recall tasks than those younger than 15 years of age (Table 1). In addition, patients who reported a diagnosis of ADD or ADHD accurately recalled fewer items during the delayed recall task (Table 1). No injury characteristics were associated with better or worse memory performance (Table 2). Patients who performed better on immediate recall reported fewer symptoms, made fewer m-BESS errors, and performed better on cognitive tasks during dual-task tandem gait (Table 3 & 4). Conclusion: Our data indicate immediate and delayed recall performance is associated with age, symptom severity, balance, and cognitive accuracy in tandem gait. Specifically, patients younger than 15 years of age and those reporting higher symptom severities demonstrated worse performance on both immediate and delayed recall tasks. Furthermore, patients reporting ADD/ADHD did not demonstrate a performance difference on immediate recall relative to peers but performed significantly worse during delayed recall testing. Additional patient characteristics of sex, concussion history, timing of clinical presentation, and injury characteristics (LOC or need for neuroimaging) were not associated with immediate and delayed recall performance. As such, clinicians using the SCAT5 word recall test during concussion evaluation should consider these patient characteristics when interpreting memory performance. References: McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51(11):838-847. doi:10.1136/bjsports-2017-097699 Echemendia RJ, Meeuwisse W, McCrory P, et al. The Sport Concussion Assessment Tool 5th Edition (SCAT5): Background and rationale. Br J Sports Med. 2017;51(11):848-850. doi:10.1136/bjsports-2017-097506 McCrea M. Standardized Mental Status Testing on the Sideline After Sport-Related Concussion. J Athl Train. 2001;36(3):274-279. McCrea M, Kelly JP, Randolph C, et al. Standardized assessment of concussion (SAC): on-site mental status evaluation of the athlete. J Head Trauma Rehabil. 1998;13(2):27-35. doi:10.1097/00001199-199804000-00005 Tables/Figures: [Table: see text][Table: see text][Table: see text][Table: see text]

Age is associated with postural control performance following youth concussion

PURPOSE: To examine the effect of age on postural control outcomes among patients being seen during their initial post-concussion clinical visit. METHODS: Youth patients were seen≤14 days post-concussion, and completed a series of postural control evaluations: tandem gait, Romberg, and Balance Error Scoring System (BESS) tests. RESULTS: We included 109 children 8–12 years of age (24%female, evaluated median = 7 [interquartile range = 4–10] days post-injury) and 353 adolescents aged 13–18 years (36%female, evaluated median = 7 [4–10] days post-injury). There was a higher proportion of children who demonstrated abnormal tandem gait relative to adolescents (26%vs. 11%; p < 0.001). They also made more BESS errors in single (median = 5 [2–10] vs. 4 [2–6] errors) and tandem (median = 3 [1–6] vs. 2 [0–4]) firm stances. After covariate adjustment, children demonstrated worse tandem gait (adjusted odds ratio = 3.05, 95%CI = 1.68–5.53) and more firm surface BESS errors (double stance β=0.51, 95%CI = 0.22–0.80; single stance β= 1.18, 95%CI = 0.42–1.95; tandem stance β= 0.98, 95%CI = 0.28–1.68) than adolescents. CONCLUSIONS: Tandem gait and BESS performance following concussion differ in children compared to adolescents who present within 2 weeks of injury. Clinicians assessing and managing concussion should recognize age differences in postural control performance when assessing those with concussion.