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Context In 2018, the US military developed the Military Acute Concussion Evaluation-2 (MACE-2) to inform the acute evaluation of mild traumatic brain injury (mTBI). However, researchers have yet to investigate false-positive rates for components of the MACE-2, including the Vestibular-Ocular Motor Screening (VOMS) and modified Balance Error Scoring System (mBESS), in military personnel. Objective To examine factors associated with false-positive results on the VOMS and mBESS in US Army Special Operations Command (USASOC) personnel. Design Cross-sectional study. Setting Military medical clinic. Patients or Other Participants A total of 416 healthy USASOC personnel completed the medical history, VOMS, and mBESS evaluations. Main Outcome Measure(s) False-positive rates for the VOMS (≥2 on VOMS symptom items, >5 cm for near point of convergence [NPC] distance) and mBESS (total score >4) were determined using χ2 analyses and independent-samples t tests. Multivariable logistic regressions (LRs) with adjusted odds ratios (aORs) were performed to identify risk factors for false-positive results on the VOMS and mBESS. The VOMS item false-positive rates ranged from 10.6% (smooth pursuits) to 17.5% (NPC). The mBESS total score false-positive rate was 36.5%. Results The multivariable LR model supported 3 significant predictors of VOMS false-positives, age (aOR = 1.07; 95% CI = 1.02, 1.12; P = .007), migraine history (aOR = 2.49; 95% CI = 1.29, 4.81; P = .007), and motion sickness history (aOR = 2.46; 95% CI = 1.34, 4.50; P = .004). Only a history of motion sickness was a significant predictor of mBESS false-positive findings (aOR = 2.34; 95% CI = 1.34, 4.05; P = .002). Conclusions False-positive rates across VOMS items were low and associated with age and a history of mTBI, migraine, or motion sickness. False-positive results for the mBESS total score were higher (36.5%) and associated only with a history of motion sickness. These risk factors for false-positive findings should be considered when administering and interpreting VOMS and mBESS components of the MACE-2 in this population.

To determine whether the Vestibular/Ocular Motor Screening (VOMS) tool demonstrates concurrent validity with the Dizziness Handicap Inventory (DHI) in a sample of concussed athletes referred for vestibular therapy and whether DHI items were predictive of VOMS outcomes.Cross-sectional cohort study.Concussion specialty/vestibular therapy clinic.Adolescents (n = 55; 15.4 ± 1.6 years) with diagnosed sport-related concussion (SRC) with vestibular symptoms and/or impairment between October 2018-February 2020. Patients completed VOMS and DHI at initial visit. Seven individual VOMS and twenty-five DHI items, VOMS and DHI total score and three DHI sub-scales, were compared with Spearman correlations. Three backwards linear regression (LR) models were built to predict 1. VOMS vestibular symptoms, 2. VOMS ocular symptoms, and 3. near-point of convergence-distance (NPC-distance) using individual DHI items as predictors.Spearman correlations (p) identified DHI items with moderate to strong associations for VOMS items. DHI sub-scales demonstrated moderate-to-strong correlations with VOMS items (p = 0.30-0.59). Total DHI score demonstrated a moderate-to-strong association with HSAC (p = 0.30), VSAC (p = 0.32), and SP (p = 0.61). Results from the LRs predicting VOMS ocular symptoms (R (Alsalaheen et al., 2010) = 0.56; p 0.001), and VOMS vestibular symptoms (R (Alsalaheen et al., 2010) = 0.23; p = 0.01), and NPC-distance (R (Alsalaheen et al., 2010) = 0.56; p 0.001) included significant DHI predictors.There was moderate-to-strong associations between VOMS and 56% of DHI items (i.e., p 0.30).

Objective To compare the effectiveness of a 4-week precision vestibular rehabilitation intervention compared with a behavioral management control intervention for adolescents with vestibular symptoms/impairment within 21 days of a concussion. Study design This study used double-blind, randomized controlled trial design involving adolescent (12-18 years) patients with a diagnosed sport/recreation-related concussion with vestibular symptoms/impairment from a concussion-specialty clinic between October 2018 and February 2020. Eligible participants were randomized in a 1:1 to either a 4-week vestibular intervention group (VESTIB) or a behavioral management control group (CONTROL). CONTROLS (n = 25) were prescribed behavioral management strategies (eg, physical activity, sleep, hydration, nutrition, stress management) and instructed to perform stretching/physical activity (eg, walking, stationary cycle) 30 minutes/day. VESTIB (n = 25) were prescribed precision vestibular rehabilitation exercises and instructed to perform at-home exercises for 30 minutes/day. Primary outcomes were improvement in Vestibular/Ocular Motor Screening vestibular items (ie, horizontal/vertical vestibular-ocular reflex, visual motion sensitivity) at 4 weeks postenrollment. Results We screened 310 and enrolled a total of 55 (18%) adolescent patients who were randomized to one of the interventions. Fifty of fifty-five (91%) participants completed all aspects of the study protocol. Participants in VESTIB improved significantly across the intervention period in horizontal (mean difference-1.628; 95% CI [-3.20, −0.06]; P = .04) and vertical (mean difference-2.24; 95% CI [-4.01, −0.48]; P = .01) vestibular-ocular reflex, but not visual motion sensitivity (mean difference-2.03; 95% CI [-4.26, 0.19]) of the Vestibular/Ocular Motor Screening score compared with CONTROLS. Conclusions Overall, the vestibular intervention group experienced greater clinical improvements in vestibular symptoms/impairment than controls across the 4-week intervention. Trial Registration ClinicalTrials.gov : NCT03555370.

Context: Research in the area of dual-task paradigms to assess sport-related concussion (SRC) status is growing, but additional assessment of this paradigm in adolescents is warranted. Design: This case-control study compared 49 adolescent athletes aged 12–20 years with diagnosed SRC to 49 age- and sex-matched controls on visual–spatial discrimination and perceptual inhibition (PIT) reaction time tasks performed while balancing on floor/foam pad conditions. Methods: The SRC group completed measures at a single time point between 1 and 10 days postinjury. Primary outcomes were dual-task reaction time, accuracy, and sway. General linear models evaluated differences between groups (P Results: Results supported significantly higher anterior–posterior (AP) sway values in concussed participants for visual–spatial discrimination and PIT when balancing on the floor (P = .03) and foam pad (P = .03), as well as mediolateral sway values on the floor during visual–spatial discrimination (P = .01). Logistic regression analysis (R2 = .15; P = .001) of all dual-task outcomes identified AP postural sway during the PIT foam dual task as the only significant predictor of concussed status (ß = −2.4; P = .004). Total symptoms (area under the curve = 0.87; P P = .001) differentiated concussed from controls. Conclusion: The AP postural sway on foam during a postural stability/PIT dual task can identify concussion in adolescents between 1 and 10 days from injury.

To derive minimum detectable change (MDC) across individual Vestibular-Ocular Motor Screening (VOMS) items and VOMS overall score in 17-25 years old collegiate athletes and to examine false positive rates.Participants (n = 378) completed VOMS pre-season for two consecutive years. MDC was identified for individual VOMS symptom items and NPC distance (cm). Both total and change methods of VOMS scoring were included in analysis.Regarding total scoring, MDC for ocular VOMS symptom items was 1 and MDC for vestibular VOMS symptoms items was 2. MDC for NPC was 4 cm and for VOMS overall score was 10. Regarding change scoring, MDC for each VOMS symptom item was 1, and for VOMS overall score was 8. False positives ranged from 5.3% to 15.9%.This study presents MDCs for each VOMS item and overall VOMS score, using total and change scoring. These values can be considered true change outside measurement error with 95% confidence in a 17-25 year old collegiate athlete population.

Research examining sleep and concussion symptoms following sport-related concussion (SRC) is limited by retrospective self-report rather than objective data from wearable technology and real-time symptom report. The purpose of this study is to use actigraphy and ecological momentary assessment (EMA) to examine the relationship between sleep parameters and next day symptoms.Seventeen athletes (47.1%F) aged 12-19 (15.35+/-2.09) years (72 hours post-SRC) wore Actigraph GT3x+ to measure nighttime sleep and completed post-concussion symptom scales (PCSS) three times via mobile EMA, resulting in a range of 91-177 observations for each outcome. Generalized linear mixed models, utilizing independent variables of sleep efficiency (SE%: ratio of awake time to sleep time) and total sleep time (TST) examined the associations between nightly sleep and symptoms next-day and throughout recovery.SE% (IRR .97, 95%CI: .95, .99, P= .009) and TST (IRR .91, 95%CI: .84, .999, P = .047) were negatively associated with next day night symptoms. The negative relationship between SE% and the cognitive-migraine-fatigue (CMF) factor was significant for next day/night symptoms (P = .01), while TST was associated with symptom severity for the affective symptom factor (P = .015). Sleep was negatively associated with total symptoms and afternoon symptoms in Week 1 and total, morning, afternoon, and night symptoms in Week 2 (ps=.001-.021) of recovery.Sleep was negatively associated with symptoms the next day, especially late in the day and among CMF and emotional symptoms. The relationship between sleep and symptom burden was strongest in the subacute stage of concussion recovery, highlighting the potential importance of sleep intervention post-injury.

The coronavirus disease 2019 (COVID-19) pandemic has substantially altered the delivery of healthcare for providers and their patients. Patients have been reticent to seek care for many diseases and injuries including concussion due to fears of potential exposure to COVID-19. Moreover, because of social distancing recommendations and stay-at-home orders, patient screening, evaluation, and delivery of care have become less efficient or impossible to perform via in-person clinic visits. Consequently, there was a sudden need to shift healthcare delivery from primarily in-person visits to telehealth. This sudden shift in healthcare delivery brings with it both challenges and opportunities for clinical concussion care. This article is designed to discuss these challenges and opportunities and provide an experiential-based framework for providing concussion care via telehealth. We first provide an overview of a clinical concussion model utilized at concussion specialty clinics from 3 geographically disparate healthcare systems for in-person service delivery prior to COVID-19. We then discuss the creation of new clinical workflows to facilitate the continued provision of concussion specialty care using telehealth. Finally, we examine lessons learned during this healthcare delivery shift including limitations and potential barriers for telehealth for concussion care, as well as opportunities for expansion of concussion care in rural and underserved areas. We also discuss the need to empirically evaluate the comparative efficacy of telehealth and in-person concussion care moving forward.

Objective To conduct a pilot study of caregiver ratings of therapeutic alliance and patient satisfaction outcomes between telehealth and in-person concussion clinical care in male and female adolescent athletes. Setting Outpatient neuropsychology concussion clinic. Participants Fifteen patients (aged 15.40 ± 1.35 years; 33% female) with a concussion and their accompanying caregivers (n = 15; 87% female) were randomly assigned to an in-person clinic visit and 15 patients (aged 15.13 ± 1.25 years; 40% female) with a concussion and their accompanying caregivers (n = 15; 73% female) were randomly assigned to a telehealth clinic visit. Design A prospective, randomized design. Main measures Therapeutic alliance and patient satisfaction scores. Results Therapeutic alliance scores were not significantly different for patients in the in-person or telehealth setting, and caregiver therapeutic alliance scores were significantly higher for the in-person condition than for the telehealth condition. There were no significant differences between in-person and telehealth session satisfaction scores for patients on depth, smoothness, positivity, arousal, and bad-good outcomes. Patient and caregiver satisfaction with the clinical setting was high (ie, General Endorsement). Conclusion Telehealth is feasible for assessing and interpreting clinical concussion examination, interview, and neurocognitive findings, which are perceived by patients and their caregivers to be comparable with in-person care. Positive satisfaction scores also serve to reinforce the need for healthcare providers to seek ways to actively engage with patients and their caregivers through elements of communicative skills such as active listening, building patient rapport, encouraging patient autonomy, and providing an adequate amount of time for interaction and questions. Telehealth for concussion care is increasing in implementation across health systems, and demand is likely to grow in light of the current COVID-19 pandemic and advances in telehealth delivery.

OBJECTIVE: To investigate the association between risk factors and vestibular-oculomotor outcomes following sport-related concussion (SRC). STUDY DESIGN: Cross-sectional study of patients seen 5.7 +/− 5.4 days (range, 0–30 days) post-injury. SETTING: Specialty clinic PARTICIPANTS: Eighty-five athletes (50 males, 35 females) aged 14.1 +/− 2.8 years (range, 9–24 years) seeking clinical care for SRC. INTERVENTIONS: Participants completed a clinical interview, history questionnaire, symptom inventory, and vestibular/ocular-motor screening (VOMS). Chi-square with odds ratios (OR) and diagnostic accuracy were used to examine the association between risk factors and VOMS outcomes. MAIN OUTCOME MEASURES: Vestibular and ocular-motor screening (VOMS) RESULTS: Female sex [χ(2) = 4.9, p = .03], on-field dizziness [χ(2) = 7.1, p = .008], fogginess [χ(2) = 10.3, p = .001], and post-traumatic migraine (PTM) symptoms including headache [χ(2) = 16.7, p = .001], nausea [χ(2) = 10.9, p = .001], light sensitivity [χ(2) = 14.9, p = .001] and noise sensitivity [χ(2) = 8.7, p = .003] were associated with presence of one or more post-concussion VOMS score above clinical cut-off. On-field dizziness [χ(2) = 3.8, p = .05], fogginess [χ(2) = 7.9, p = .005], and PTM-like symptoms including nausea [χ(2) = 9.0, p = .003] and noise sensitivity [χ(2) = 7.2, p = .007] were associated with obtaining a post-concussion near point convergence (NPC) distance cut-off ≥ 5cm. The likelihood ratios were 5.93 and 5.14 for VOMS symptoms and NPC distance, respectively. CONCLUSIONS: Female sex, on-field dizziness, fogginess, and PTM symptoms were predictive of experiencing vestibular-oculomotor symptoms/impairment following SRC.

The purpose of this study was to describe the mechanism of injury (MOI) and examine factors associated with greater risk for specific MOIs involving concussions in collegiate soccer players.Participants included 3,288 collegiate soccer players from 28 institutions across four competitive seasons, 2014-17. MOIs were documented for 262 soccer-related concussions during the study and placed into one of four categories: collisions, unintentional contact, aerial challenges, and others.70% of the concussions occurred in DI soccer players. Collisions and unintentional contact were the MOIs that resulted in 66.5% of all concussions. DI and DIII soccer players sustained more concussions by unintentional contact versus collisions and aerial challenges when compared to their DII counterparts. Defenders were more likely than midfielders to sustain concussions by aerial challenges than collisions. As expected, the field players experienced more concussions as a result of collisions, unintentional contact, and aerial challenges when compared to goalkeepers.Future research should explore preventive strategies for decreasing collisions, especially during aerial challenges while heading the soccer ball, and unintentional contacts from errant balls in soccer in order to decrease concussion risk.

OBJECTIVE To evaluate predictors of performance validity testing (PVT) and clinical outcome in patients presenting to a specialty clinic with a mild traumatic brain injury (mTBI). SETTING An outpatient mTBI specialty clinic. PARTICIPANTS Seventy-six (47% female) patients aged 16 to 66 (mean = 40.58, SD = 14.18) years within 3 to 433 days (mean = 30.63, SD = 54.88, median = 17.00) of a suspected mTBI between 2018 and 2019. DESIGN A cross-sectional, observational study comparing patients who passed PVT (n = 43) with those who failed (n = 33). A logistic regression (LR) was conducted to evaluate factors that predicted failed PVT. Independent-samples t tests and general linear model were used to evaluate PVT groups on clinical outcomes. The LR with a receiver operating characteristic (ROC) curve was conducted to evaluate embedded validity indicators. MAIN MEASURES Performance validity testing, computerized neurocognitive testing, vestibular/oculomotor screening, symptom reports. RESULTS At their initial clinic visit 43% of patients failed PVT. PVT failure was predicted by presence of secondary gain (odds ratio [OR] = 8.11, P = .02), while a history of mental health predicted passing of PVT (OR = 0.29, P = .08). Those who failed PVT performed significantly worse on computerized neurocognitive testing (P < .05) and took an average of 33 days longer to return to work (P = .02). There was no significant difference (P = .20) in recovery time between failed/passed PVT groups when covarying for those who sustained a work injury. Word memory learning percentage less than 69% and design memory learning percentage less than 50% accurately classified patients who failed PVT (area under the ROC curve = 0.74; P < .001). CONCLUSION Secondary gain was the best predictor of failed PVT. Patients presenting for mTBI evaluation and rehabilitation who fail PVT demonstrate worse performance on cognitive testing and take longer to return to work post-injury, but recover in a similar time frame compared with those who pass PVT. Clinicians should be cautious in discounting patients who yield invalid test results, as these patients appear to be able to achieve recovery in a treatment setting.

Objectives To examine the difference between an individual's first and second concussion using a comprehensive, multidomain assessment including symptoms, neurocognitive, vestibular, ocular, and individual demographic and medical history risk factors associated with protracted recovery. Setting Concussion Specialty Clinic. Participants Seventy-three patients (aged 13-21 years; 57% female) diagnosed with 2 separate concussions (380.5 ± 278.7 days between injuries) from August 2016 to August 2018. Design Retrospective within-subjects cohort study. Main measures ImPACT, PCSS, and Vestibular-Ocular Motor Screen (VOMS) at each visit. Patients were divided into "normal" (≤30 days) and "protracted" recovery (>30 days) for χ analyses. Results There were no differences between the first and second injuries in recovery time, VOMS, visual and verbal memory, or reaction time. Visual motor speed scores were higher at the second injury time point and reported sleep symptoms were higher at the first injury time point. In addition, participants reported to the clinic on average 3 days earlier for an evaluation for their second injury. Results from χ analyses indicated that female sex predicted protracted recovery (>30 days) from concussion at the first injury time point (OR = 4.1; 95% CI, 1.5-11.6; P = .006). Conclusions The findings provide preliminary evidence that there is no clinical difference between patients' first and second concussions when both injuries were treated through a concussion specialty clinic.

ObjectiveTo examine the association between estimated age at first exposure (eAFE) to American football and clinical measures throughout recovery following concussion.MethodsParticipants were recruited across 30 colleges and universities as part of the National Collegiate Athletic Association (NCAA)–Department of Defense Concussion Assessment, Research and Education Consortium. There were 294 NCAA American football players (age 19 ± 1 years) evaluated 24–48 hours following concussion with valid baseline data and 327 (age 19 ± 1 years) evaluated at the time they were asymptomatic with valid baseline data. Participants sustained a medically diagnosed concussion between baseline testing and postconcussion assessments. Outcome measures included the number of days until asymptomatic, Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) composite scores, Balance Error Scoring System (BESS) total score, and Brief Symptom Inventory 18 (BSI-18) subscores. The eAFE was defined as participant's age at the time of assessment minus self-reported number of years playing football.ResultsIn unadjusted regression models, younger eAFE was associated with lower (worse) ImPACT Visual Motor Speed (R2 = 0.031, p = 0.012) at 24–48 hours following injury and lower (better) BSI-18 Somatization subscores (R2 = 0.014, p = 0.038) when the athletes were asymptomatic. The effect sizes were very small. The eAFE was not associated with the number of days until asymptomatic, other ImPACT composite scores, BESS total score, or other BSI-18 subscores.ConclusionEarlier eAFE to American football was not associated with longer symptom recovery, worse balance, worse cognitive performance, or greater psychological distress following concussion. In these NCAA football players, longer duration of exposure to football during childhood and adolescence appears to be unrelated to clinical recovery following concussion.

Introduction Researchers have yet to explore the association of acute (i.e., within 3 days) post-injury VOMS scores and length of time until clearance to return to play in collegiate athletes. Objective The purpose was to determine if individual Vestibular/Ocular Motor Screening (VOMS) component symptom scores (e.g., smooth pursuits, convergence, vestibular-ocular reflex) can predict clearance to return to activity from a sport-related concussion. Methods Pre-season demographic and medical history and post-injury VOMS testing were collected (n = 79) on collegiate student-athletes following concussion. Impaired vestibulo-ocular function post-injury scores (≥2) were compared to normal scores using survival analysis, with days to clearance to return to sport as the outcome. Results Abnormal scores on smooth pursuits (p =.026), horizontal saccades (p =.025), vertical saccades (p =.028), and convergence (p =.031) were associated with lower probability of clearance in comparison with normal scores. Any score ≥2 predicted significantly greater days to clearance for return to play (13.1 days; 95% CI: 11.9-14.3; p = .025) compared with athletes with no abnormal test scores (9.6 days; 95% CI: 7.2-12.1, P =.014). Discussion Post-injury symptoms with VOMS smooth pursuit, saccades, and convergence is associated with increased time-to-clearance for return to sport in collegiate athletes.

Introduction Treatment approaches for mild traumatic brain injury (mTBI) have evolved to focus on active and targeted therapies, but the effect of compliance with therapy has not been investigated. The purpose of this study was to examine the role of patient compliance with prescribed therapies on clinical outcomes following mTBI. Materials and Methods Participants were aged 18-60 years with chronic (ie, 6+ months) mTBI symptoms who were previously recalcitrant (n = 66). Participants were diagnosed with a vestibular disorder and were prescribed vestibular and exertion therapies. Participants were instructed to continue the exercise regimen during the 6-month treatment phase at home. Participant compliance was evaluated by clinicians at patients’ follow up visit as: (1) high, (2) moderate, or (3) low compliance based on patient report and clinician interview. High-compliance was compared to a combined low- and moderate-compliance group on the outcomes using a 2 (group) × 2 (time) analysis of variance. Results 39 of the 66 (59%) participants with vestibular disorder returned for a 6-month evaluation and were included in the analyses. Of these 39 participants, 16 (41%) were high-compliance (36.7 ± 10.9 years, 18.8% female), 17 (44%) were moderate-compliance (32.5 ± 5.5 years, 23.5% female), and 6 (15%) were low-compliance (32.7 ± 3.3 years, 0% female). Conclusion High compliance significantly reduced total Vestibular/Ocular Motor Screening scores compared to low/middle compliance (P = .005). Post-Concussion Symptom Scale was reduced by 48% and dizziness symptoms reduced by 31% in the high-compliance cohort. High compliance with prescribed exertion/vestibular rehabilitation therapies enhanced clinical outcomes for previously recalcitrant patients with chronic mTBI-related vestibular disorders.

Objective Determine whether preinjury concussion symptom factors predict postinjury concussion symptom factors. Setting Community concussion surveillance program between 2008 and 2017. Participants A total of 290 high school and collegiate-aged athletes (n = 168, aged 14-17 years; n = 122, aged 18-21 years, respectively). Design Retrospective analysis. Main measures Post-Concussion Symptom Scale scores prior to and within 7 days of sustaining a sport-related concussion. Methods Post-Concussion Symptom Scale scores were aggregated into cognitive-sensory, sleep-arousal, vestibular-somatic, and affective preinjury symptom factors. These preinjury symptom factors, in conjunction with sex and previous concussion history, underwent linear regressions to predict cognitive-migraine-fatigue, somatic, sleep, and affective postinjury symptom factors. Results The cognitive-sensory factor (P = .002) and female sex (P = .002) predicted the postinjury cognitive-migraine-fatigue factor in combined age group but not stratified age group models. Among the 14 to 17 years age group, and not the 18 to 21 years age group, the preinjury sleep-arousal symptom factor predicted postinjury somatic (P = .003) and sleep factors (P = .005). The affective preinjury factor predicted the affective factor (P = .001) and somatic factor (P = .008) in the 18 to 21 years age group. A history of previous concussions also predicted the postinjury somatic symptom factor (P = .005). Conclusion Preinjury symptom factors predicted postinjury symptom factors and age-associated differences in symptom factors may provide clinical value in prognostic models for subsequent postinjury clinical outcomes.

BACKGROUND Current concussion symptom inventories emphasize total number or symptoms and severity and overlap with other conditions, such as mental health disorders, which may limit their specificity and clinical utility. OBJECTIVE To develop and test the reliability and validity of a new Concussion Clinical Profiles Screening tool (CP Screen) in both healthy controls and concussed. METHODS CP Screen is a 29-item self-report, clinical profile-based symptom inventory that measures the following 5 concussion clinical profiles: 1) anxiety/mood, 2) cognitive/fatigue, 3) migraine, 4) ocular, and 5) vestibular; and the following 2 modifying factors: 1) sleep and 2) neck. Post-Concussion Symptom Scale (PCSS), vestibular/ocular motor screening (VOMS) tool, and Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) were conducted. CP Screen was administered in community a concussion surveillance program and 2 sports medicine concussion clinics. Responses include 248 athletes, 121 concussed, and 127 controls, enrolled between 2018 and 2019. RESULTS Internal consistency of the CP Screen in the control (Cronbach's alpha = .87) and concussed (Cronbach's alpha = .93) samples was high. Moderate to high correlations among the CP Screen factors and PCSS factors and VOMS items, supporting concurrent validity. ROC curve analysis for identifying concussed from controls was significant (P

Context Comprehensive assessments are recommended to evaluate sport-related concussion (SRC). The degree to which the King-Devick (KD) test adds novel information to an SRC evaluation is unknown. Objective To describe relationships at baseline among the KD and other SRC assessments and explore whether the KD provides unique information to a multimodal baseline concussion assessment. Design Cross-sectional study. Setting Five National Collegiate Athletic Association institutions participating in the Concussion Assessment, Research and Education (CARE) Consortium. Patients or Other Participants National Collegiate Athletic Association student-athletes (N = 2258, age = 20 ± 1.5 years, 53.0% male, 68.9% white) in 11 men's and 13 women's sports. Main Outcome Measure(s) Participants completed baseline assessments on the KD and (1) the Symptom Inventory of the Sport Concussion Assessment Tool–3rd edition, (2) the Brief Symptom Inventory-18, (3) the Balance Error Scoring System, (4) the Standardized Assessment of Concussion (SAC), (5) the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) test battery, and (6) the Vestibular/Ocular Motor Screening tool during their first year in CARE. Correlation coefficients between the KD and the 6 other concussion assessments in isolation were determined. Assessments with ρ magnitude >0.1 were included in a multivariate linear regression analysis to evaluate their relative association with the KD. Results Scores for SAC concentration, ImPACT visual motor speed, and ImPACT reaction time were correlated with the KD (ρ = −0.216, −0.276, and 0.164, respectively) and were thus included in the regression model, which explained 16.8% of the variance in baseline KD time (P < .001, Cohen f2 = 0.20). Better SAC concentration score (β = −.174, P < .001), ImPACT visual motor speed (β = −.205, P < .001), and ImPACT reaction time (β = .056, P = .020) were associated with faster baseline KD performance, but the effect sizes were small. Conclusions Better performance on cognitive measures involving concentration, visual motor speed, and reaction time was weakly associated with better baseline KD performance. Symptoms, psychological distress, balance, and vestibular-oculomotor provocation were unrelated to KD performance at baseline. The findings indicate limited overlap at baseline among the CARE SRC assessments and the KD.

OBJECTIVE: Despite increases in education and awareness, many athletes continue to play with signs and symptoms of a sport-related concussion (SRC). The impact that continuing to play has on recovery is unknown. This study compared recovery time and related outcomes between athletes who were immediately removed from play and athletes who continued to play with an SRC. METHODS: A prospective, repeated measures design was used to compare neurocognitive performance, symptoms, and recovery time between 35 athletes (mean ± SD age, 15.61 ± 1.65 years) immediately removed after an SRC (REMOVED group) compared with 34 athletes (mean ± SD age, 15.35 ± 1.73 years) who continued to play (PLAYED group) with SRC. Neurocognitive and symptom data were obtained at baseline and at 1 to 7 days and 8 to 30 days after an SRC. RESULTS: The PLAYED group took longer to recover than the REMOVED group (44.4 ± 36.0 vs 22.0 ± 18.7 days; P = .003) and were 8.80 times more likely to demonstrate protracted recovery (≥21 days) (P < .001). Removal from play status was associated with the greatest risk of protracted recovery (adjusted odds ratio, 14.27; P = .001) compared with other predictors (eg, sex). The PLAYED group exhibited significantly worse neurocognitive and greater symptoms than the REMOVED group. CONCLUSIONS: SRC recovery time may be reduced if athletes are removed from participation. Immediate removal from play is the first step in mitigating prolonged SRC recovery, and these data support current consensus statements and management guidelines.

The purpose of this study is to examine the effects of the COVID-19 pandemic on patients presenting with concussion at a specialty clinic. This study used a retrospective cohort design to compare participants (n = 3021) with a suspected concussion, including a Pandemic cohort (n = 1139; March 2020-February 2021) and a Pre-Pandemic cohort (n = 1882; March 2019-February 2020). Concussions and patient characteristics including age, sex, days since injury, and injury mechanism were extracted from an electronic health record. There were 39.5% (n = 743) fewer concussions in Pandemic. Pandemic presented to the clinic 25.8 days later (p < 0.001) and were 1.9 years older (p < 0.001) than Pre-Pandemic. Sport-related concussions decreased 59.6% overall for Pandemic. Pandemic was associated with proportional increases of concussions involving recreational activities (odds ratio [OR] = 6.11; p < 0.001), motor vehicle collisions (OR = 1.39; p < 0.001), and falls/assaults (OR = 1.33; p < 0.001). A total of 9.4% (107/1139) of all Pandemic concussion initial clinical visits were performed using telehealth (0% in Pre-Pandemic). Concussion visit volume to a sub-specialty clinic decreased by approximately 40% during the COVID-19 pandemic and patients presented to the clinic nearly 1 month later. The increase in telehealth highlights the potential to expand clinical care outreach during the current and future pandemics or similar restrictive time periods.

OBJECTIVE To establish test-retest reliability in nonconcussed high school athletes and compare absolute change, reliable change indices (RCIs), and minimal detectable change (MDC) methods for classifying impairment after sport-related concussion. DESIGN Prospective, repeated measures. SETTING High schools from the Midwest and Central regions of the United States. PARTICIPANTS A convenience sample of 772 nonconcussed high school athletes (n = 546 men) completed preseason K-D testing. In addition, 69 athletes completed a second postseason K-D test, and 54 athletes sustained a concussion and completed postconcussion K-D tests. INTERVENTION K-D test. MAIN OUTCOME MEASURES Data for age, sex, and concussion history were determined using preseason K-D test outcomes. Test-retest reliability, RCIs, and MDCs were calculated using postseason K-D tests (M = 98.9, SD = 9.1 days). Postinjury K-D assessments within 5 days of injury (M = 1.5, SD = 1.5 days) were used to classify impairment on K-D using absolute change, RCI, and MDC methods. RESULTS Significant effects for age (P < 0.001) and history of concussion (P = 0.001) were supported on baseline K-D time, with no sex differences (P = 0.21). Preseason to postseason reliability for K-D times was 0.60 (intraclass correlation coefficient, 95% CI, 0.43-0.73), although 38% of athletes exhibited slower postseason K-D times compared with baseline. Impairment on K-D exhibited for 72% of the concussed sample using absolute change, 48% using MDC, and 44% using RCI methods. CONCLUSIONS K-D exhibited moderate test-retest reliability across 1 season. Absolute change yielded the highest sensitivity for preinjury to postinjury impairment on the K-D compared with RCI and MDC methods.

OBJECTIVE Update concussion recovery curves by considering pre- and postinjury modifying factors. Determine whether there is a dose-response for modifying factors on recovery. SETTING Sports medicine concussion clinic. PARTICIPANTS A total of 314 athletes aged 12-23 years within 7 days of a concussion enrolled between 2015 and 2018. DESIGN Prospective cohort study. MAIN MEASURES Categorical recovery time defined as days from injury to full medical clearance for return to play per established criteria. Preinjury factors included age, gender, concussion history, and migraine history. Postinjury factors included loss of consciousness, posttraumatic amnesia, posttraumatic migraine symptoms, and high symptom burden. RESULTS Average recovery was 27.5 ± 25 days. Five factors were prognostic of recovery: (1) younger than 18 years, (2) female, (3) history of migraine, (4) posttraumatic migraine symptoms, and (5) high symptom burden (P < .05). Recovery percentage at 21 days after injury was 96.7% for participants with 0 factor, 65.3% for those with 1 to 2, and 31.8% for those with 3 to 5-with prognostic separation in low- to high-risk groups of 62%. CONCLUSIONS Findings support a dose-response for combined pre- and postinjury factors on recovery. Both the type and quantity of modifying factors influence recovery and should be considered in prognosis and approaches to multidisciplinary care.

OBJECTIVE Evaluate mobile ecological momentary assessment (mEMA) as an approach to measure sport-related concussion (SRC) symptoms, explore the relationships between clinical outcomes and mEMA, and determine whether mEMA was advantageous for predicting recovery outcomes compared to traditional symptom report. SETTING Outpatient concussion clinic. PARTICIPANTS 20 athletes aged 12 to 19 years with SRC. METHODS Prospective study of mEMA surveys assessing activity and symptoms delivered via mobile application (3 time blocks daily) and clinical assessment at visit 1 (

Background: Baseline computerized testing is a common component of concussion assessments, and the testing environment has been suggested to influence test performance and validity. Purpose: To compare concussion baseline computerized neurocognitive test performance and validity among adolescent athletes based on testing environment (group, individual), age group (10-12, 13-15, 16-18 years), sex (male, female), and sport type (collision/combat, contact, noncontact). Study Design: Cohort study; Level of evidence, 3. Methods: Through a concussion community outreach program, participants completed baseline computerized neurocognitive testing using Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). A total of 2845 athletes aged 10 to 18 years completed the baseline assessment. A total of 2241 (79%) athletes completed baseline testing in a group environment, and 604 (21%) completed testing in an individual environment. A random subsample of 500 athletes from each group was selected for statistical comparison. Results: No significant differences were supported in baseline computerized neurocognitive test performance between the group and individual administration environments. Test validity was statistically similar across testing environment, age group, and sex. However, patients of older age (16-18 years), female sex, and collision/combat and contact sports performed better on ImPACT. There were differences in total symptom severity scores ( t = 2.19, df = 998, P = .03), with participants in the group testing environment reporting lower total symptom severity scores than those in the individual testing environment. The rates of invalid tests were low across all age groups, averaging from 4.0% in the 10- to 12-year age group to 4.8% in the 13- to 15-year age group. Conclusion: The findings indicated that concussion baseline neurocognitive test performance is similar when administered in group and individual testing environments. However, differences based on age group, sex, and sport type should be considered when interpreting baseline computerized neurocognitive test scores. The finding of higher symptom scores in older adolescents in the individual testing environment suggests that they may be less forthcoming about symptoms in a group setting.

Primary Objective: To assess a rapid concussion screening tool in Service members participating in combatives (mixed martial arts; MMA) training school.Research Design: This prospective study included baseline and either post-training or post-injury assessments.Methods and Procedures: Baseline (N = 152) and post-assessments (n = 129) of Service members included symptom reporting and the King-Devick (KD) oculomotor test.Outcomes and Results: Headache, balance problems, and dizziness were the most severe concussive symptoms. KD scores for those who sustained a concussion (n = 31) were significantly worse compared to baseline, but not for participants who finished the course with no concussion (n = 98). For concussed, 74.2% had scores that were worse from baseline (slower) compared to 39.8% of the post-training group. KD scores were worse 34.4% more in individuals who sustained a concussion compared to those who did not. However, there was poor discriminant ability of the KD test (AUC = .60, sensitivity/specificity) to distinguish between concussed and non-concussed participants.Conclusions: The KD test should not be used in isolation as a sideline or field concussion assessment during training scenarios. Rather, it has potential utility for evaluating individual cases to supplement decision making when an established baseline is available.

Background: The Convergence Insufficiency Symptom Survey (CISS) is being utilized as an assessment measure following concussion despite minimal research. This study explored the sensitivity and specificity of the CISS in identifying receded near point of convergence (NPC) post-concussion. Methods: Prospective study of 130 patients post-concussion aged 11-25, classified into normal NPC (n = 94) and CI (n = 36) groups (i.e., NPC >5 cm), completed the CISS, VOMS, and PCSS. Sensitivity and specificity identifying receded NPC were explored with published CISS cutoff score (>16). ROC with AUC analysis was conducted to determine an alternate CISS cutoff score to yield optimal sensitivity and specificity in patients with concussion. Results: Utilizing the published cutoff score, the CISS demonstrated adequate sensitivity (.78 [95% CI = .60-.89]) but poor specificity (.35 [95%CI = .26-.46]). ROC curve demonstrated that CISS score was significant (P = .01) in predicting a positive test result (i.e., NPC >5) with AUC of .65 (95%CI .54-.76). An alternative cutoff score (CISS>23) maximized sensitivity (.70) and specificity (.53) for identifying receded NPC. Conclusions: Both the previously published CISS cutoff and our sample-based cutoff score yielded a high rate of false positives for receded NPC. CISS scores post-concussion may help the clinician understand difficulties with visual tasks but is not a suitable diagnostic tool in this patient population.

Sport-related concussion (SRC) is a common injury in recreational and organized sport. Over the past 30 years, there has been significant progress in our scientific understanding of SRC, which in turn has driven the development of clinical guidelines for diagnosis, assessment, and management of SRC. In addition to a growing need for knowledgeable health care professionals to provide evidence-based care for athletes with SRC, media attention and legislation have created awareness and, in some cases, fear about many issues and unknowns surrounding SRC. The American Medical Society for Sports Medicine formed a writing group to review the existing literature on SRC, update its previous position statement, and address current evidence and knowledge gaps regarding SRC. The absence of definitive outcomes-based data is challenging and requires relying on the best available evidence integrated with clinical experience and patient values. This statement reviews the definition, pathophysiology, and epidemiology of SRC, the diagnosis and management of both acute and persistent concussion symptoms, the short- and long-term risks of SRC and repetitive head impact exposure, SRC prevention strategies, and potential future directions for SRC research. The American Medical Society for Sports Medicine is committed to best clinical practices, evidence-based research, and educational initiatives that positively impact the health and safety of athletes.

Background: Vestibular and ocular motor screening tools, such as the Vestibular/Ocular Motor Screening (VOMS), are recognized as important components of a multifaceted evaluation of sport-related concussion. Previous research has supported the predictive utility of the VOMS in identifying concussion, but researchers have yet to examine the predictive utility of the VOMS among collegiate athletes in the first few days after injury. Purpose: To determine the discriminative validity of individual VOMS item scores and an overall VOMS score for identifying collegiate athletes with an acute sport-related concussion (≤72 hours) from healthy controls matched by age, sex, and concussion history. Study Design: Case-control study; Level of evidence, 3. Methods: Participants (N = 570) aged 17 to 25 years were included from 8 institutions of the National Collegiate Athletic Association–Department of Defense CARE Consortium (Concussion Assessment, Research, and Education): 285 athletes who were concussed (per current consensus guidelines) and 285 healthy controls matched by age, sex, and concussion history. Participants completed the VOMS within 3 days of injury (concussion) or during preseason (ie, baseline; control). Symptoms are totaled for each VOMS item for an item score (maximum, 40) and totaled across items for an overall score (maximum, 280), and distance (centimeters) for near point of convergence (NPC) is averaged across 3 trials. Receiver operating characteristic analysis of the area under the curve (AUC) was performed on cutoff scores using Youden index ( J) for each VOMS item, overall VOMS score, and NPC distance average. A logistic regression was conducted to identify which VOMS scores identified concussed status. Results: A symptom score ≥1 on each VOMS item and horizontal vestibular/ocular reflex ≥2 significantly discriminated concussion from control (AUC, 0.89-0.90). NPC distance did not significantly identify concussion from control (AUC, 0.51). The VOMS overall score had the highest accuracy (AUC, 0.91) for identifying sport-related concussion from control. Among the individual items, vertical saccades ≥1 and horizontal vestibular/ocular reflex ≥2 best discriminated concussion from control. Conclusion: The findings indicate that individual VOMS items and overall VOMS scores are useful in identifying concussion in collegiate athletes within 3 days of injury. Clinicians can use the cutoffs from this study to help identify concussion in collegiate athletes.

Neuroelectric measures derived from human magnetoencephalographic (MEG) recordings hold promise as aides to diagnosis and treatment monitoring and targeting for chronic sequelae of traumatic brain injury (TBI). This study tests novel MEG-derived regional brain measures of tonic neuroelectric activation for long-term test-retest reliability and sensitivity to symptoms. Resting state MEG recordings were obtained from a normative cohort, Cambridge Centre for Ageing and Neuroscience (CamCAN), baseline: n = 619; mean 16-month follow-up: n = 253) and a chronic symptomatic TBI cohort, Targeted Evaluation, Action and Monitoring of Traumatic Brain Injury (TEAM-TBI), baseline: n = 64; mean 6-month follow-up: n = 39). For the CamCAN cohort, MEG-derived neuroelectric measures showed good long-term test-retest reliability for most of the 103 automatically identified stereotypic regions. The TEAM-TBI cohort was screened for depression, somatization, and anxiety with the Brief Symptom Inventory and for insomnia with the Insomnia Severity Index. Linear classifiers constructed from the 103 regional measures from each TEAM-TBI cohort member distinguished those with and without each symptom, with p < 0.01 for each—i.e., the tonic regional neuroelectric measures of activation are sensitive to the presence/absence of these symptoms. The novel regional MEG-derived neuroelectric measures obtained and tested in this study demonstrate the necessary and sufficient properties to be clinically useful—i.e., good test-retest reliability, sensitivity to symptoms in each individual, and obtainable using automatic processing without human judgement or intervention.

Objective: (1) To compare patient- and clinician-administered measurements of near point of convergence (NPC) distance including the percentage of patients exceeding clinical cutoffs among concussed adolescents and (2) to assess the reliability of patient- and clinician-measured NPC distances. Methods: A total of 762 patients (mean = 15.51, SD = 3.09 y) within 30 days of concussion participated. The NPC distance was measured consecutively with the patient and clinician controlling the fixation target. The differences between patient (PT) and clinician (CLIN) measurements and cases exceeding cutoffs (ie, ≥5 cm) were examined with a series of t tests and chi-square tests, respectively. Intraclass correlation coefficients and unbiased estimate of reliability were performed. Results: The NPC measurements were similar, t(761) = −.26, P = .79, between the PT (mean = 3.52, SD = 3.77 cm) and CLIN (mean = 3.54, SD = 3.97 cm) conditions. The number of measurements that exceeded cutoffs was similar among the PT (2.5%; 19/762) and CLIN conditions (3%; 23/762) (P = .10), and the number of measurements classified as abnormal/invalid was also similar among the PT (2.5%; 19/762) and CLIN conditions (3%; 23/762) (P = .10). There was excellent reliability between the methods (intraclass correlation coefficients = .85, unbiased estimate of reliability = .92). Conclusion: The findings support the application of this assessment in clinical settings where the clinician may not have direct contact with their patient and rely on the patient (eg, telehealth).

Objectives The purpose of this study was to identify collegiate athletes' anxiety-related concussion perceptions and examine factors that may be related to increased anxiety injury beliefs. Design Cross-sectional study. Methods Male and female Division I, II and III NCAA collegiate athletes (n = 482) completed a 10- to 15-minute survey examining their demographics, diagnosed concussion history, concussion knowledge, and public media sources they have previously acquired concussion information from. The survey also included the Perceptions of Concussion Inventory for Athletes (PCI-A) which results in six outcome variables (anxiety, effects, control, clarity, treatment, and symptom variability). Univariable and a backward stepwise multivariable logistic regression model were utilized to identify variables that were associated with greater (above median) negative anxiety-related concussion perception scores. Results Collegiate athletes displayed moderate anxiety-related concussion perceptions (12.8 ± 3.2; scores ranged from 4 — low anxiety to 20 — high anxiety). The majority of participants reported that concussions are upsetting to them (60.7%), with a sizable proportion being worried (46.7%), fearful (40.7%), or anxious (25.0%) about sustaining a concussion. In the multivariable regression, higher perception that concussions have long-term effects (OR = 2.72; 95% CI: 1.79–4.12), greater beliefs of internal control to influence concussion outcomes (OR = 1.78; 95% CI: 1.15–2.75), and female sex (OR = 1.77; 95% CI: 1.15–2.71) were associated with higher anxiety beliefs. Conclusions This study for the first time establishes that negative, anxiety-related perceptions about concussions are prevalent in a collegiate athlete population. Addressing these perceptions through evidence-based, educational and management initiatives, such as highlighting that concussions are treatable and most do not result in long-term negative consequences with early diagnosis and proper management, are critical to improve emotions surrounding concussion. This may be particularly important for female athletes in this population.

Background: Identifying separate dimensions of concussion symptoms may inform a precision medicine approach to treatment. It was previously reported that a bifactor model identified distinct acute postconcussion symptom dimensions. Purpose: To replicate previous findings of a bifactor structure of concussion symptoms in the Concussion Assessment Research and Education (CARE) Consortium sample, examine measurement invariance from pre- to postinjury, and evaluate whether factors are associated with other clinical and biomarker measures. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: Collegiate athletes were prospectively evaluated using the Sport Concussion Assessment Tool–3 (SCAT-3) during preseason (N = 31,557); 2789 were followed at Results: The optimal structure for each time point was a 7-factor bifactor model: a General factor, on which all items loaded, and 6 specific factors—Vestibulo-ocular, Headache, Sensory, Fatigue, Cognitive, and Emotional. The model manifested strict invariance across the 2 postinjury time points but only configural invariance from baseline to postinjury. From Conclusion: Bifactor modeling supported the predominant unidimensionality of concussion symptoms while revealing multidimensional properties, including a large dominant General factor and 6 independent factors: Headache, Vestibulo-ocular, Sensory, Cognitive, Fatigue, and Emotional. Unlike the widely used SCAT-3 symptom severity score, which declines gradually after injury, the bifactor model revealed separable symptom dimensions that have distinct trajectories in the acute postinjury period and different patterns of association with other markers of injury severity and outcome. Clinical Relevance: The SCAT-3 total score remains a valuable, robust index of overall concussion symptom severity, and the specific factors identified may inform management strategies. Because some symptom dimensions continue to worsen in the first 24 to 48 hours after injury (ie, Sensory, Fatigue, Emotional), routine follow-up in this time frame may be valuable to ensure that symptoms are managed effectively.

Background: Symptom reporting with scales such as the Post-Concussion Symptom Scale (PCSS) is one of the most sensitive markers of concussed status and/or recovery time, It is known that time from injury until initial clinic visit affects symptom presentation and recovery outcomes, but no study to date has evaluated changes in clinical cutoff scores for the PCSS based on earlier versus later clinical presentation postconcussion. Purpose: To evaluate if time since injury after sports-related concussion (SRC) affects clinical cutoff scores for total PCSS and PCSS factors in differentiating athletes with SRC from healthy controls and predicting prolonged recovery (>30 days) after SRC. Study Design: Cohort study; Level of evidence, 3. Methods: A chart review was conducted of clinical data from patients with SRC (age, 13-25 years; n = 588; female, n = 299) who presented to concussion specialty clinics. Participants were categorized on the basis of time from injury: early (≤7 days; n = 348) and late (8-21 days; n = 240). Outcomes were total symptom severity (ie, total PCSS score) and total score for each of 4 symptom factors (cognitive/migraine/fatigue [CMF], affective, sleep, and somatic). Area under the curve (AUC) analyses were conducted using the Youden index to optimize sensitivity and specificity cutoffs. Results: In the early group, the CMF factor (cutoff, ≥7; AUC = 0.944), affective factor (cutoff, ≥1; AUC = 0.614), and total PCSS (cutoff, ≥7; AUC = 0.889) differentiated athletes with SRC from controls. In the late group, the CMF factor cutoff was reduced (cutoff, ≥4; AUC = 0.945), while the total PCSS score (cutoff, ≥7; AUC = 0.892), affective factor (cutoff, ≥1; AUC = 0.603), and sleep factor (cutoff, ≥1; AUC = 0.609) remained the same. In the early cohort, the CMF factor was the strongest predictor of protracted recovery (cutoff, ≥23; AUC = 0.717), followed by the total PCSS (cutoff, ≥39; AUC = 0.695) and affective factor (cutoff, ≥2; AUC = 0.614). The affective factor (cutoff, ≥1; AUC = 0.642) and total PCSS (cutoff, ≥35; AUC = 0.592) were significant predictors in the late cohort, but the cutoff threshold was reduced. Conclusion: The findings indicate that PCSS symptom clinical cutoffs for identifying injury and recovery prognosis change on the basis of time since injury. Specifically, the combination of CMF, affective, and sleep factors is the best differentiator of athletes with SRC from controls regardless of time since injury. Furthermore, the CMF factor is the most robust predictor of prolonged recovery if the patient is within 1 week of SRC, whereas the affective factor is the most robust predictor of prolonged recovery if the patient is within 2 to 3 weeks of SRC.

The Military Acute Concussion Evaluation 2 (MACE 2), which includes the Vestibular-Ocular Motor Screening (VOMS) tool and the single-leg stance component of the modified Balance Error Scoring System (mBESS), was introduced in 2018 as an assessment of acute mTBI in US military personnel. However, the reliability of the VOMS and mBESS in this population has not been established. Objectives The primary purpose of this study was to examine the reliability of the VOMS across a 6-month period in healthy, uninjured US Army Special Operations Command (USASOC) personnel. Design Active duty/heathy military personnel (n = 108) completed the VOMS and mBESS at baseline and follow-up 6 months later (±1 month). Method Cronbach's alpha was used to examine the internal consistency of the VOMS and mBESS at both time points. Two-way mixed intra-class correlation coefficients (ICC) with consistency agreement were used to evaluate test–retest reliability. Results VOMS demonstrated excellent internal consistency (α = 0.99), whereas, the mBESS demonstrated poor internal consistency (α = 0.29). Test–retest reliability of VOMS items was moderate-to-good with ICCs ranging from 0.60 to 0.81. Test–retest reliability was moderate for mBESS total score (ICC = 0.59) and double-leg stance (ICC = 0.73), while single-leg (ICC = 0.49) and tandem (ICC = 0.02) stances were poor. Conclusions The findings suggest that VOMS has high internal consistency and moderate-to-good test–retest reliability. mBESS has poor internal consistency and poor-to-moderate test–retest reliability. The results suggest that VOMS is a reliable addition to the MACE-2, whereas, mBESS single-leg stance is less reliable. As such, mBESS double-leg stance may be a more reliable measure of balance in this population.

Context Increased near point of convergence (NPC) distance is a common finding after concussion and is associated with physical symptoms and worsened neurocognitive performance. Vestibular/Ocular Motor Screening measures NPC distance across 3 trials and uses the average measurement to inform clinical care. However, whether 3 trials are necessary, are consistent, or add clinical utility is unknown. Objective To investigate the consistency across 3 trials of NPC and establish the classification accuracy (ie, clinical utility) of 1 or 2 trials compared with the standardized average of 3 trials. Design Retrospective cohort study. Setting Sports medicine clinic and research laboratory. Patients or Other Participants Consecutively enrolled patients aged 10 to 22 years with diagnosed concussions (74% sport related; n = 380). Main Outcome Measure(s) The previously reported clinical cutoff value of ≥5 cm across 3 trials was used. Pearson correlation and intraclass correlation coefficients were used to evaluate agreement between trials and average scores. Reliable change indices (RCIs) using 95% confidence intervals were also calculated. Results The Pearson correlation (r = .98) and intraclass correlation (0.98) coefficients revealed excellent agreement between the first measurement and average NPC distance across 3 measurements. The RCI across all trials was 2 cm. When the first NPC measurement was ≤3 cm or ≥7 cm, agreement existed within the RCI between the first measurement and the average of 3 measurements in 99.6% of cases. When we averaged the first and second measurements, 379/380 (99.7%) participants had the same classification (ie, Conclusions Our findings suggest limited utility of multiple or average NPC distance measurements when the initial NPC distance is outside of RCI clinical cutoffs (ie, ≤3 cm or ≥7 cm). Given the high consistency between the first measurement and average NPC distance across 3 trials, only 1 measurement of NPC distance is warranted unless the first measurement is between 3 and 7 cm.

Background: Organizations recommend that athletes should be asymptomatic or symptom-limited before initiating a graduated return-to-play (GRTP) protocol after sports-related concussion, although asymptomatic or symptom-limited is not well-defined. Hypotheses: (1) There will be a range (ie, beyond zero as indicator of “symptom-free”) in symptom severity endorsement when athletes are deemed ready to initiate a GRTP protocol. (2) Baseline symptom severity scores and demographic/preinjury medical history factors influence symptom severity scores at the commencement of the GRTP protocol. (3) Greater symptom severity scores at GRTP protocol initiation will result in longer protocol duration. (4) Symptom severity scores will not differ between those who did and did not sustain a repeat injury within 90 days of their initial injury. Study Design: Cohort study; Level of evidence, 2. Methods: Across 30 universities, athletes (N = 1531) completed assessments at baseline and before beginning the GRTP protocol, as determined by local medical staff. Symptom severity scores were recorded with the symptom checklist of the Sport Concussion Assessment Tool–3rd Edition. Nonparametric comparisons were used to examine the effect of medical, demographic, and injury factors on symptom endorsement at GRTP protocol initiation, as well as differences in symptom severity scores between those who did and did not sustain a repeat injury within 90 days. A Cox regression was used to examine the association between symptom severity scores at GRTP protocol initiation and protocol duration. Results: Symptom severity scores at the time when the GRTP protocol was initiated were as follows: 0 to 5 (n = 1378; 90.0%), 6 to 10 (n = 76; 5.0%), 11 to 20 (n = 42; 3.0%), and ≥21 (n = 35; 2.0%). Demographic (sex and age), medical (psychiatric disorders, attention-deficit/hyperactivity disorder, learning disorder), and other factors (baseline symptom endorsement and sleep) were significantly associated with higher symptom severity scores at the GRTP initiation ( P < .05). The 4 GRTP initiation time point symptom severity score groups did not significantly differ in total time to unrestricted RTP, χ2(3) = 1.4; P = .73. When days until the initiation of the GRTP protocol was included as a covariate, symptom severity scores between 11 and 20 ( P = .02; hazard ratio = 1.44; 95% CI, 1.06-1.96) and ≥21 ( P < .001; hazard ratio = 1.88; 95% CI, 1.34-2.63) were significantly associated with a longer GRTP protocol duration as compared with symptom severity scores between 0 and 5. Symptom severity scores at GRTP initiation did not significantly differ between those who sustained a repeat injury within 90 days and those who did not ( U = 29,893.5; P = .75). Conclusion: A range of symptom severity endorsement was observed at GRTP protocol initiation, with higher endorsement among those with higher baseline symptom endorsement and select demographic and medical history factors. Findings suggest that initiation of a GRTP protocol before an absolute absence of all symptoms is not associated with longer progression of the GRTP protocol, although symptom severity scores >10 were associated with longer duration of a GRTP protocol. Results can be utilized to guide clinicians toward optimal GRTP initiation (ie, balancing active recovery with avoidance of premature return to activity).

Background: Symptoms, cognition, balance, and other domains are commonly assessed at baseline testing as part of comprehensive preseason evaluations among collegiate student-athletes. Although approximately 27% of college students have at least 1 sleep disorder, researchers have yet to examine the role of a preexisting sleep disorder on preinjury baseline performance. Purpose: To compare athletes with and without a reported history of diagnosed sleep disorders on commonly used baseline concussion assessments. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 666 National Collegiate Athletic Association student-athletes completed baseline measures including the Balance Error Scoring System (BESS), Brief Symptom Inventory–18 (BSI-18), Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), Post-Concussion Symptom Scale (PCSS), Sport Concussion Assessment Tool–5th Edition (SCAT5), and Standardized Assessment of Concussion (SAC). There were 333 athletes with a history of diagnosed sleep disorders who were matched on age, sex, sport, and concussion history to 333 athletes with no history of diagnosed sleep disorders. Participants in both groups had a mean age of 19.89 ± 1.36 years and included 182 (54.7%) male athletes, and 126 (37.8%) reported a history of ≥1 concussions. Results: A series of 1-way analyses of covariance with Bonferroni corrections revealed significant group differences on the BESS (F1,559 = 8.88; P < .01); BSI-18 somatization (F1,640 = 18.48; P < .01), depression (F1,640 = 18.78; P < .01), anxiety (F1,640 = 19.42; P < .01), and global severity index (F1,640 = 27.18; P < .01); PCSS (F1,424 = 29.42; P < .01); SCAT5 symptom number (F1,634 = 28.79; P < .01) and symptom severity (F1,634 = 31.74; P < .01); and SAC (F1,578 = 4.36; P = .037). Specifically, while the sleep disorder group did perform better on the BESS, they also reported higher symptoms on the BSI-18, PCSS, and SCAT5 and performed worse on the SAC. There were no group differences on ImPACT performance. Conclusion: Collegiate student-athletes with diagnosed sleep disorders reported elevated affective and concussion symptoms at baseline that could affect the interpretation of postinjury impairments and symptoms. Based on the small effect sizes of our findings, however, the magnitude of these differences is of questionable clinical significance. Still, clinicians should consider diagnosed sleep disorders as reported during preparticipation sports physical examinations when interpreting baseline and postinjury concussion assessments.

Background Sleep dysfunction (SD) is associated with a high symptom burden and lower neurocognitive performance after concussion and on baseline testing without injury. However, few studies have compared concussed athletes and controls with and without SD on clinical outcomes. Objective To evaluate differences in clinical outcomes among both concussed athletes and matched controls with and without SD. Design Retrospective cross-sectional study. Participants Participants aged 12 to 20 years were recruited from a concussion clinic (n = 50 patients) and research registry/flyers (n = 50 healthy age-/sex-matched controls). Participants were categorized by self-reported SD into one of 4 groups: sport-related concussion (SRC) + SD, SRC only, SD only, and controls. Main outcome measures Post-Concussion Symptom Scale (PCSS), Vestibular/Oculomotor Screening (VOMS), and neurocognitive testing (Immediate Postconcussion Assessment Cognitive Test). Results Compared with the SRC only group, the SRC + SD group performed worse on all neurocognitive domains, had a higher total symptom score, and endorsed more symptoms on most VOMS items. In addition, the SRC + SD group was at an increased likelihood of having at least 1 abnormal VOMS item compared with SRC only group. The SRC only group had neurocognitive test scores and symptom reports statistically similar to the SD only group. Conclusion Sleep dysfunction after concussion is related to worse neurocognitive performance and higher concussion symptom reporting. This study extended findings to suggest vestibular symptomology is worse among athletes with SD after injury compared to injured athletes without SD. Similar performances on concussion assessments for the SRC only and SD only groups suggest SD may appear similar to clinical presentation of concussion, even at baseline in the absence of SRC.

OBJECTIVENo studies to date have investigated the role of early clinical care in time to recovery from concussion in a pediatric population. The purpose of this study was to investigate the role of clinic presentation timing (≤ 7 days [early] compared to 8–20 days [late] from injury) in concussion assessment performance and risk for prolonged recovery (> 30 days) in pediatric concussion.METHODSThis study is a retrospective cross-sectional study from a concussion clinic between April 2016 and January 2019, including 218 children and adolescents with diagnosed concussion, separated based on clinic presentation timing following injury: early (≤ 7 days) and late (8–20 days). Outcomes were recovery time, Postconcussion Symptom Scale (PCSS), Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), Vestibular/Ocular Motor Screen (VOMS), and demographics, medical history, and injury information. A general linear model and chi-square analyses were used to assess differences between early and late presentation, along with logistic regression, to predict prolonged recovery (> 30 days).RESULTSThose with early presentation reported higher symptoms on VOMS subtests (79%–85%) compared to those with late presentation (61%–78%), with the exception of near-point of convergence distance and visual motion sensitivity (VMS). The strongest predictor of prolonged recovery was number of days to first clinic visit (OR 9.8). Positive VMS (OR 5.18), history of headache/migraine (OR 4.02), and PCSS score (OR 1.04) were also predictive of prolonged recovery.CONCLUSIONSDespite patients in the early presentation group presenting with more positive VOMS scores, the early presentation group recovered sooner than patients in the late presentation group. Even after controlling for vestibular dysfunction, history of headache or migraine, and total symptom severity, days to first visit remained the most robust predictor of recovery > 30 days. These findings suggest that early, specialized medical care and intervention for children and adolescents with recent concussion is associated with normal recovery time. Clinicians should educate children and parents on the potential importance of early treatment to improve the odds of positive outcomes following concussion.

Mental health-related symptoms are common following concussion with approximately 30% of athletes reporting symptoms such as anxiety and mood disturbance. There is growing agreement that anxiety/mood issues represent a distinct clinical profile or subtype of concussion. Both anxiety and depressed mood have been associated with poor outcomes and longer recovery time following this injury. Depression and anxiety following concussion typically occur at subclinical levels. However, sometimes these issues may become clinical and evolve into more complex phenomena such as functional neurological and somatic symptom disorders, malingering, or suicide in rare cases. Determining the etiology of these symptoms can be challenging, as concussion often serves as a “door opener” for athletes to discuss or address other mental health conditions under the guise of concussion treatment. Fear and anxiety associated with perceived though not empirically based long-term effects of concussion may also exacerbate anxiety and mood issues for many athletes following their injury. The purpose of this chapter is to review key mental health issues that athletes may face following concussion within the context of a conceptual framework that emphasizes targeted behavioral management and treatment for these issues. The chapter also explores the etiology of mental health issues and analyzes how they often overlap with other concussion profiles or subtypes, and includes a case illustration that demonstrates common mental health issues following concussion.

BACKGROUND AND PURPOSE The utility of prospective changes on the Vestibular/Ocular Motor Screening (VOMS) assessment are unknown, and 2 methods of scoring are published in the literature. Total scores are the total symptom scores for each VOMS component, and change scores are the difference between the pretest total symptom score and component total symptom scores. This study documented prospective changes in vestibular and ocular motor impairments and symptoms in high school athletes with concussion using the total and change scoring methods and compared the percentage of scores over clinical cutoffs using the total and change scoring methods for the VOMS. METHODS Sixty-three athletes (15.53 ± 1.06 years) completed the VOMS at baseline (ie, preinjury), 1 to 7 days, and 8 to 14 days after concussion. A series of repeated-measures multivariate analyses of variance were conducted on total and change scores. A 2-way repeated-measures analysis of variance was performed on the near-point convergence distance. A series of χ analyses compared scores exceeding clinical cutoffs between the total and change scoring methods. RESULTS Total scoring revealed impairments (Wilks λ = 0.39, F16,47 = 4.54, P < 0.001, η = 0.61) on all VOMS components at 1 to 7 and 8 to 14 days compared to baseline. Change scoring revealed postinjury impairments compared with baseline (Wilks λ = 0.58, F14,49 = 2.52, P = 0.009, η = 0.42) on all components at 1 to 7 days; however, impairments at 8 to 14 days were revealed only for the vertical vestibular oculomotor reflex and vestibular motor sensitivity components. Total scoring identified significantly more scores over cutoffs at 1 to 7 days (χ1,63 = 5.97, P = 0.02) compared with change scores. DISCUSSION AND CONCLUSIONS Both total and change scoring methods on the VOMS are useful for identifying impairments following concussion.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A230).

Background Individuals who sustain their first concussion during childhood may be at greater risk of sustaining multiple concussions throughout their lifetime because of a longer window of vulnerability. This article aims to estimate the association between age at first concussion and number of subsequent concussions. Patients and Methods A total of 23,582 collegiate athletes from 26 universities and military cadets from three military academies completed a concussion history questionnaire (65% males, age 19.9 ± 1.4 years). Participants self-reported concussions and age at time of each injury. Participants with a history of concussion (n = 3,647, 15.5%) were categorized as having sustained their first concussion during childhood (less than ten years old) or adolescence (≥10 and ≤18 years old). Poisson regression was used to model age group (childhood, adolescence) predicting the number of subsequent concussions (0, 1, 2+). A second Poisson regression was developed to determine whether age at first concussion predicted the number of subsequent concussions. Results Participants self-reporting their first concussion during childhood had an increased risk of subsequent concussions (rate ratio = 2.19, 95% confidence interval: 1.82, 2.64) compared with participants self-reporting their first concussion during adolescence. For every one-year increase in age at first concussion, we observed a 16% reduction in the risk of subsequent concussion (rate ratio = 0.84, 95% confidence interval: 0.82, 0.86). Conclusions Individuals self-reporting a concussion at a young age sustained a higher number of concussions before age 18. Concussion prevention, recognition, and reporting strategies are of particular need at the youth level.

Background: Timely removal from activity after concussion symptoms remains problematic despite heightened awareness. Previous studies indicated potential adverse effects of continuing to participate in physical activity immediately after sustaining a concussion. Hypothesis/Purpose: The purpose was to determine the effect of timing of removal from play after concussion on clinical outcomes. It was hypothesized that immediate removal from activity after sport-related concussion (SRC) would be associated with less time missed from sport, a shorter symptomatic period, and better outcomes on acute clinical measures. Study Design: Cohort study; Level of evidence, 3. Methods: Data were reported from the National Collegiate Athletic Association and Department of Defense Grand Alliance: Concussion Awareness, Research, and Education (CARE) Consortium. Participants with 506 diagnosed SRCs from 18 sports and 25 institutions and military service academies were analyzed and classified as either immediate removal from activity (I-RFA) or delayed removal from activity (D-RFA). Outcomes of interest included time missed from sport attributed to their SRC, symptom duration, and clinical assessment scores. Results: There were 322 participants (63.6%) characterized as D-RFA. I-RFA status was associated with significantly less time missed from sport ( R2 change = .022-.024, P < .001 to P = .001) and shorter symptom duration ( R2 change = .044-.046, P < .001 [all imputations]) while controlling for other SRC recovery modifiers. These athletes missed approximately 3 fewer days from sport participation. I-RFA athletes had significantly less severe acute SRC symptoms and were at lower risk of recovery taking ≥14 days (relative risk = .614, P < .001, small-medium effect size) and ≥21 days (relative risk = .534, P = .010, small effect size). Conclusion: I-RFA is a protective factor associated with less severe acute symptoms and shorter recovery after SRC. Conveying this message to athletes, coaches, and others involved in the care of athletes may promote timely injury reporting.

OBJECTIVE To determine whether family history of migraine increased the likelihood of posttraumatic migraine (PTM) symptom presentation in adolescents following concussion, and examine the influence of family history of migraine and PTM on postinjury outcomes. SETTING Outpatient concussion clinic. PARTICIPANTS A total of 153 patients with concussion (103 males and 50 females) aged 15.72 ± 1.48 years (range 12-18 years). DESIGN Cross-sectional, observational study of patients presenting for initial evaluation 4.72 ± 3.05 days (range 1-14) postinjury. MAIN MEASURES Computerized neurocognitive testing, symptom report, and vestibular/oculomotor screening. RESULTS Patients with a family history of migraine were 2.6 times (odds ratio = 2.60, confidence interval = 1.35-5.02, P = .003) more likely to present with PTM compared with patients without a family history. Results of multivariate analyses of covariance, controlling for concussion history, revealed significant main effects for PTM on (1) Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)/Post-Concussion Symptom Scale (PCSS) (F = 15.43, P

Context: Comprehensive, multidomain assessment is the standard of care after sport-related concussion. However, the relationship between performance on sideline concussion-assessment tools and in-office computerized neurocognitive testing has received little attention, and the prognostic utility of sideline measures is unknown. Objective: To evaluate concurrent impairment on commonly used concussion measures 24 to 48 hours postinjury while also determining the predictive utility of sideline measures on computerized neurocognitive testing in the acute to subacute recovery periods postinjury. Design: Case-control study. Setting: High school and collegiate athletics. Patients or Other Participants: A total of 125 high school and college-aged athletes (85 males, 40 females) 14 to 23 (16.8 ± 2.21) years old. Main Outcome Measure(s): Participants were administered sideline concussion-assessment measures (ie, Immediate Post-Concussion Assessment and Cognitive Testing [ImPACT], Standardized Assessment of Concussion [SAC], and Balance Error Scoring System [BESS]) 24 to 48 hours postinjury and completed ImPACT and the Post-Concussion Symptom Scale 5 to 7 and 10 to 14 days postinjury. Outcome measures were the ImPACT composite (verbal memory, visual memory, reaction time, visual-motor speed), SAC, and BESS scores and total symptom score on the Post-Concussion Symptom Scale. Results: Participants demonstrated heterogeneous patterns of impairment on measures 24 to 48 hours postinjury, with the most common pattern being impairment on ImPACT and the SAC. Performance on the SAC and BESS at 24 to 48 hours after injury did not distinguish between those with and those without impairment on ImPACT at 5 to 7 days postinjury (χ2 = 5.076, P = .079) or 10 to 14 days postinjury (χ2 = 2.04, P = .361). Conclusions: More than 90% of athletes were impaired on at least 1 sideline or neurocognitive measure 24 to 48 hours after sport-related concussion. Although sideline measures are useful for concussion diagnosis, they are not suitable for prognostication of impairment or the presence of symptoms 1 to 2 weeks postinjury.

Background The prevalence of primary headache disorders in the general population provides a unique challenge in the evaluation of headache occurring in the context of sport. Despite a wealth of studies exploring the epidemiology of headache in the layperson, little is known about the prevalence and nature of headaches in collegiate student-athletes. These scenarios are challenging in the return to play context, as it is often unclear whether an athlete has an exacerbation of a primary headache disorder, new onset headache unrelated to trauma, or has suffered a concussive injury. Purpose To establish the prevalence and nature of headaches in collegiate student-athletes. Study design Retrospective cross-sectional survey. Methods This cross-sectional survey evaluated the characteristics and prevalence of headache in 834 student-athletes from four NCAA Division-I institutions. Because headache occurrence may vary by sport (collision, contact, non-contact), by sex, and medical history, our sample included male and female athletes in a variety of sports, with differing degrees of contact exposure. The 20 question survey collected data on personal and family history of headache, as well as concussion history. Results A total of 23.7% (n = 198) of participants reported having a personal history of migraine, 25.2% (n = 210) history of sinus headache, and 12.3% (n = 103) history of tension type headache. Among athletes with a prior history of concussion, 46.3% (n = 25) of females reported a history of migraine, while only 32.2% of males reported history of migraine (χ2 = 3.421, P = .064). Conclusions The etiology of increased prevalence of migraine in our study is unclear. Whether this is due to increased awareness of headache disorders, a consequence of contact exposure, or a predisposition for migraine development in this age group remains unclear. Further studies are indicated.