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We examined the association of self-reported sleep problems with clinical measures of postural stability, memory performance, symptom burden, and symptom duration following youth concussion. Patients 6-18 years of age presenting ≤21 days postconcussion underwent a clinical evaluation including modified Balance Error Scoring System, single- and dual-task tandem gait, immediate and delayed recall, and symptom severity. We calculated time from injury until symptom resolution and determined the proportion of patients who developed persistent postconcussion symptoms, defined as a symptom duration >28 days postconcussion. We grouped patients based on whether they reported sleep problems at their postconcussion clinical evaluation and compared symptom-based and functional outcomes between groups. Of the 207 patients included, n = 97 (14.3 ± 2.9 years; 49% female; initial visit 10.2 ± 5.8 days postconcussion) reported sleep problems postconcussion and n = 110 (14.3 ± 2.4 years; 46% female; initial visit 9.3 ± 5.4 days postinjury) did not. Those reporting sleep problems postconcussion had significantly more modified Balance Error Scoring System errors than those without (8.4 ± 5.5 vs 6.7 ± 4.7; P = .01), but similar tandem gait and memory performance. A significantly greater proportion of those who reported sleep problems postconcussion experienced persistent postconcussion symptoms than those who did not (53% vs 31%; P = .004). After adjusting for time from concussion to clinical visit and preconcussion sleep problems, postconcussion sleep problems were associated with a 2 times greater odds of developing persistent postconcussion symptoms (adjusted odds ratio = 2.02, 95% CI = 1.01, 4.06; P = .049). Identifying sleep problems early following concussion may allow clinicians to implement targeted treatment recommendations to improve sleep and provide an optimal recovery environment.

Context: The relationship between physical activity (PA) and fear of pain with movement (ie, kinesiophobia) during concussion recovery is unknown. Kinesiophobia may limit PA, while PA after concussion may reduce kinesiophobia. Our purpose was to examine the correlation between PA and self-reported kinesiophobia during concussion recovery for adolescents with and without persistent symptoms. Design: Prospective cohort study of children ages 10–18 years within 14 days of concussion. Methods: Participants rated kinesiophobia using the Tampa Scale of Kinesiophobia (TSK) at initial (≤14 d postconcussion) and return to play (RTP) assessments, and wore activity monitors between assessments. Our primary outcome was TSK score change from initial to RTP assessments. We grouped participants based on whether they experienced persistent symptoms (symptoms ≥28 days) or not (symptoms r for normally distributed and Spearman rho for nonnormally distributed variables) between PA variables and TSK change scores. Results: Among the 41 participants enrolled, 44% developed persistent symptoms (n = 18; age = 14.5 [2.0] y; 50% female; symptom duration = 57.3 [6.2] d; RTP = 66.8 [6.4] d) and 56% did not (n = 23; age = 14.9 [1.8] y; 48% female; symptom duration = 15.2 [1.5] d; RTP = 21.7 [1.9] d). For the persistent symptoms group, greater TSK change scores (mean = −2.5 [5.7] point change) were significantly and moderately correlated with higher daily step count (r = −.60, P = .008) and exercise frequency (r = −.63, P = .005), but were not correlated with exercise duration (ρ = −.12, P = .65). Among the no persistent symptoms group, TSK change scores (mean = −6.0 [5.0] point change) were not correlated with step count (r = −.18, P = .41) or exercise duration (ρ = .10, P = .67), and the correlation with frequency was low and not significant (r = −.34, P = .12). Conclusions: Regular PA during concussion recovery, regardless of duration or intensity, may help reduce kinesiophobia for those experiencing persistent symptoms.

Clinicians rely on objective concussion assessments that may be influenced by patient characteristics, creating difficulties in isolating the effect of concussion on patient function. The purpose of our study was to identify characteristics associated with performance on the Sport Concussion Assessment Tool 5th edition (SCAT5) 10-word recall test following adolescent concussion. We evaluated patients seen for care within 14 days of concussion (n=125; 15.2±1.6 years of age, range=11–18 years; 46% female; 6.9±3.4 days post-concussion). Patient demographic (age, sex, medical and concussion history, etc.), injury (timing of presentation, symptom severity, sport-type, etc.), and clinical test (Modified Balance Error Scoring System [mBESS], tandem gait) characteristics were assessed, in addition to SCAT5 immediate and delayed memory testing using the 10-word recall list. Immediate and delayed recall performance was significantly associated with concussion symptom burden and cognitive accuracy during tandem gait, although effect sizes were notably small. Specific variables such as age, sex, diagnosis of ADD/ADHD, and performance on other clinical assessments were not significantly associated with recall performance after controlling for covariates. Further, the 10-word recall list demonstrates specific advantages over previously used 5-word lists by way of decreased ceiling effects and reduced interference of inherent patient characteristics.

To examine the utility of a multimodal assessment battery of self-reported dizziness, clinician obtained postural stability, and symptom severity ratings within 14 days of concussion to predict symptom resolution time among children and adolescents.Prospective cohort.Patients ages 6-18 years completed evaluation ≤14 days post-concussion, including self-reported symptom severity using the Post-Concussion Symptom Inventory (PCSI) and postural stability assessments. We grouped patients as dizzy or not dizzy based on the difference in current and pre-injury PSCI dizziness ratings: difference between current and pre-injury dizziness ≥3 = dizzy; difference3 = not dizzy. We evaluated postural stability using modified Balance Error Scoring System (mBESS) and tandem gait (TG). Our primary outcome was time from concussion to symptom resolution. Using a univariable Cox proportional hazard model, we examined the association between dizziness and symptom resolution time. We then used a multivariable Cox proportional hazard model to adjust for potential confounding variables.We examined 89 patients and grouped each as dizzy (n = 34; age = 14.7 ± 2.7 years; 7.1 ± 3.4 days post-injury; symptom resolution time = 40.8 ± 5.7 days) or not dizzy (n = 55; age = 14.4 ± 2.3 years; 7.2 ± 3.1 days post-injury; symptom resolution time = 23.3 ± 3.2 days). Upon univariable examination, dizziness was independently associated with increased symptom resolution time (Hazard Ratio [HR] = 0.49; 95%CI: 0.28, 0.83; p = 0.009). After adjusting for potential confounders (total symptom severity, mBESS tandem stance errors, TG time, loss of consciousness), only symptom severity change was associated with symptom resolution time (HR = 0.98; 95%CI: 0.96, 0.997; p = 0.025).Total symptom severity assessed within 14 days of concussion, but not dizziness or postural stability, was significantly associated with symptom resolution time among children and adolescents following concussion.

To determine the proportion of adolescents at moderate/high risk for Persistent Postconcussion Symptoms (PPCS) who develop PPCS when randomized to early aerobic exercise or standard-of-care and examine exercise volume/intensity between groups.Using a randomized clinical trial design, we enrolled patients 10-18 years of age who obtained a "Predicting/Preventing Postconcussive Problems in Pediatrics" (5P) risk score ≥6 and enrolled/tested ≤ one-week post-concussion (mean = 5.5 ± 1.5 days post-concussion). Participants were randomized to "Exercise" (5 days/week, 20 min/day aerobic exercise at individualized intensity [80% HR at exercise test cessation]) or "Standard-of-Care" (no exercise recommendations). They returned for re-testing one-month post-concussion, and we remotely monitored exercise between assessments.Sixteen participants enrolled (intervention: n = 9, 56% female, 14.2 ± 2.1 years; standard-of-care: n = 7, 57% female, 13.6 ± 1.7 years). A smaller proportion of the early aerobic exercise group developed PPCS when compared to the standard-of-care group (44% vs. 86%; relative risk = 0.52; 95% confidence interval = 0.34-1.36; number-needed-to-treat = 2.4).We observed that participants randomized to early aerobic exercise had a lower risk of PPCS compared to standard-of-care. Although not statistically significant, these results suggest early/individualized aerobic exercise among those at moderate/high PPCS risk may be effective at reducing that risk, and early aerobic exercise is not detrimental to recovery outcomes.

Context The abrupt cessation of school and sport participation during the COVID-19 pandemic may have negative implications for adolescent mental health. Objective (1) To compare mental, physical, and social health and behaviors during pandemic-related stay-at-home mandates with the same measures collected 1–2 years prior. (2) To assess the relationship of physical activity and sleep during the pandemic with anxiety, fatigue, and peer relationship changes between assessment timepoints. Design Prospective cohort study, repeated-measures Setting Pediatric sports medicine center Participants High school athletes (n=39; 16.2±0.9 years of age; 64% female) Main Outcome Measures Patient Reported Outcome Measurement System (PROMIS) anxiety, fatigue, and peer relationships short forms and the Pittsburgh Sleep Quality Index (PSQI) were completed at two timepoints (initial assessment: May 2018 or 2019; follow-up assessment: May/June 2020). Physical activity frequency and duration, and frequency of interaction with other individuals (family, peers, sport coaches, etc.), were self-reported at follow-up assessment for the two weeks prior to school/sport closure and the two weeks prior to questionnaire completion. Results Higher levels of anxiety (5.5±4.0 vs. 3.6±3.4; p=0.003) and fatigue (5.4±3.7 vs. 2.3±2.5; p Conclusions Mental and physical health declined during stay-at-home mandates, compared to assessments 1–2 years earlier. Physical activity behaviors and sources of social interaction underwent significant changes following school and sport cessation. Quality sleep may provide some protection against declining adolescent mental health during the pandemic, although this relationship requires further investigation.

Context Reaction time (RT) is a critical element of return to participation (RTP), and impairments have been linked to subsequent injury following a concussion. Current RT assessments have limitations in clinical feasibility, and identification of subtle deficits after concussion symptom resolution. Objective To examine the utility of RT measurements (clinical drop stick, simple stimulus-response, single-task Stroop, and dual-task Stroop) to differentiate between adolescents with concussion and uninjured control at initial assessment and RTP. Design Prospective Cohort Study Setting Pediatric sports medicine center associated with a regional tertiary care hospital. Patients or Other Participants Twenty-seven adolescents with a concussion (mean age=14.8±2.1 years; 52% female; tested 7.0±3.3 days post-concussion) and twenty-one uninjured controls (mean age=15.5±1.6 years; 48% female). Main Outcome Measure(s) Participants completed the Post-Concussion Symptoms Inventory (PCSI) and battery of RT tests: clinical drop stick, simple stimulus-response, single-task Stroop, and dual-task Stroop. Results The concussion group demonstrated significantly slower clinical drop stick (β=58.8; 95% CI= 29.2, 88.3, p Conclusion Adolescents recovering from concussion may have initial RT deficits which persist despite symptom recovery. Clinical drop stick and dual-task Stroop RT demonstrate high clinical utility given high classification accuracy, sensitivity, and specificity to detect post-concussion RT deficits, and may be considered for initial and RTP assessment.

Context Dizziness, poor sleep quality, and postural instability are all commonly reported postconcussion and individually relate to poor outcomes. Objective To examine sleep quality and postural stability among adolescents who did and those who did not report dizziness within 2 weeks of concussion. Design Cross-sectional study. Setting Research laboratory. Patients or Other Participants Participants were individuals 12 to 18 years old and either within 14 days of concussion (n = 58; girls = 29, boys = 29, age = 15.2 ± 1.8 years, time postinjury = 7.1 ± 3.1 days) or uninjured control recruits (n = 73, girls = 31, boys = 42, age = 15.8 ± 1.3 years). Main Outcome Measure(s) Participants rated preinjury and current dizziness using the Post-Concussion Symptom Inventory (PCSI) and current sleep quality using the Pittsburgh Sleep Quality Index. They also completed postural stability assessments (single-task and dual-task tandem gait and modified Balance Error Scoring System[mBESS]). Results We divided patients with concussion into dizzy (n = 21) or not-dizzy (n = 37) groups based on PCSI dizziness ratings (difference between current and preinjury dizziness rating: dizzy = >3, not dizzy = Conclusions Individuals with postconcussion dizziness demonstrated impaired tandem-gait performance, whereas poor sleep quality was associated with total symptom severity. Identifying and treating the underlying dysfunction contributing to dizziness and postural instability may guide customized rehabilitation strategies and facilitate recovery.

To determine whether sleep behavior (e.g., duration, timing) and/or physical activity (steps/day, or exercise frequency, duration, intensity) in the first month after adolescent sports-related concussion are associated with developing Persisting Post-Concussion Symptoms (PPCS).Case-control SETTING: Outpatient sports medicine clinic PARTICIPANTS: We prospectively enrolled adolescent athletes who sustained a concussion (N=49, age=14.8±1.8 years; 51% female) who were evaluated within 14 days of concussion (mean=6.7±2.7 days) and followed via sleep/physical activity monitoring for the subsequent two weeks.Participants wore a monitor to track sleep (sleep time, wake time, and time spent awake in bed at night) and physical activity (average steps/day, exercise frequency, exercise duration) behavior for two weeks after initial assessment. Participants were followed until symptom resolution, and the main outcome interest was development of PPCS (symptom duration28 days). We then used a multivariable logistic regression model to examine associations between physical activity and sleep behavior with PPCS.Of the 49 participants, 47% (n=23, mean symptom resolution=57±23 days post-injury) developed PPCS and 53% (n=26, mean symptom resolution=15±7 days post-injury) did not. Univariable analysis showed that the PPCS group took fewer steps/day (7526±2975 vs. 9803±3786 steps/day; p=0.02), exercised less frequently (2.5±2.2 vs. 4.4±2.1 days/week; p=0.005), and spent more time in bed awake (1.2±0.3 vs. 0.8±0.3 hours/night; p=0.03) than the no PPCS group. Multivariable results indicated the odds of developing PPCS significantly increased with fewer exercise session/week (adjusted odds ratio=1.96, 95% confidence interval=1.09, 3.51, p=0.024).More exercise sessions that were15 minutes in duration during concussion recovery was associated with a lower risk of developing PPCS, while sleep and other physical activity measures were not. Further studies regarding exercise duration and intensity are needed. Clinicians may consider advising patients to optimize sleep and physical activity during concussion recovery. This article is protected by copyright. All rights reserved.

Our purpose was to investigate the reliability and minimal detectable change characteristics of a smartphone-based assessment of single- and dual-task gait and cognitive performance. Uninjured adolescent athletes (n = 17; mean age = 16.6, SD = 1.3 y; 47% female) completed assessments initially and again 4 weeks later. The authors collected data via an automated smartphone-based application while participants completed a series of tasks under (1) single-task cognitive, (2) single-task gait, and (3) dual-task cognitive-gait conditions. The cognitive task was a series of continuous auditory Stroop cues. Average gait speed was consistent between testing sessions in single-task (0.98, SD = 0.21 vs 0.96, SD = 0.19 m/s;P = .60;r = .89) and dual-task (0.92, SD = 0.22 vs 0.89, SD = 0.22 m/s;P = .37;r = .88) conditions. Response accuracy was moderately consistent between assessments in single-task standing (82.3% accurate, SD = 17.9% vs 84.6% accurate, SD = 20.1%;P = .64;r = .52) and dual-task gait (89.4% accurate, SD = 15.9% vs 85.8% accurate, SD = 20.2%;P = .23;r = .81) conditions. Our results indicate automated motor-cognitive dual-task outcomes obtained within a smartphone-based assessment are consistent across a 1-month period. Further research is required to understand how this assessment performs in the setting of sport-related concussion. Given the relative reliability of values obtained, a smartphone-based evaluation may be considered for use to evaluate changes across time among adolescents, postconcussion.

To determine the association between academic time loss postconcussion and vision symptoms/impairments among pediatric patients.Cross-sectional.Sports medicine clinic.Pediatric patients seen for care in a sports medicine clinic between the ages 6 and 18 years (n = 212; mean age = 14.3, SD = 2.4 years; 48% female) were evaluated within 21 days of concussion (mean = 9.8, SD = 5.7 days).Patients were grouped based on academic time loss (missed5 days vs ≤5 days of school) at their initial postconcussion evaluation.Patients rated concussion symptoms using the Health and Behavior Inventory (HBI) and underwent near point of convergence (NPC) testing. We compared groups on specific HBI symptom ratings of dizziness, blurry vision, seeing double, and light sensitivity, as well as NPC break and recovery point distances.Two hundred twelve patients were included; n = 36 (17%) who reported missing5 days of school. After adjusting for time since injury, parental education level, mechanism of injury, and preinjury anxiety, patients who reported missing5 days of school had higher ratings of double vision (β = 0.27; 95% confidence interval [CI], 0.01-0.53; P = 0.04) and light sensitivity (β = 0.506; 95% CI, 0.061-0.951; P = 0.02), but not dizziness (β = 0.390; 95% CI, -0.047 to 0.827; P = 0.08) or blurry vision (β = 0.026; 95% CI, -0.352 to 0.404; P = 0.89).Missing5 days of school was associated with worse double vision and light sensitivity symptoms. Given the importance of vision in learning, assessing postconcussion vision symptoms may facilitate a successful return to school. Clinicians should assess a wide spectrum of vision-specific symptoms to ensure appropriate support during the return-to-school process.

To examine the association between dizziness and neck/shoulder pain after concussion and if differences in postural stability and oculomotor function exist among patients reporting dizziness with or without concurrent neck/shoulder pain.Cross sectional.Sports medicine clinic.Pediatric patients ≤14 days post concussion.N/A.Patients completed the Health and Behavior Inventory (HBI) symptom rating and separately rated neck/shoulder pain (scale 0-3; 0 = no pain). We grouped patients by HBI dizziness rating (0 = not-dizzy; 1-3 = dizzy) and compared neck/shoulder pain ratings between the groups. We then compared oculomotor and postural stability outcomes between dizzy patients with and without neck/shoulder pain.We included 153 patients: dizzy (n = 100; age = 14.6 ± 2.2 years; 48% female) and not-dizzy (n = 53, age = 14.4 ± 3.1 years; 38% female). The dizzy group reported significantly higher neck/shoulder pain (1.4 ± 1.1 vs 0.5 ± 0.9 points, P0.001) and total symptom score (25.7 ± 11.2 vs 11.7 ± 9.3 points, P0.001) than the not-dizzy group. After adjusting for total symptom score and preinjury anxiety, depression, and migraines, dizziness was associated with higher odds of neck/shoulder pain (odds ratio = 1.9, 95% CI, 1.2-3.0; P = 0.004). No differences were observed between dizzy patients with and without neck/shoulder pain for near point of convergence (10.0 ± 7.5 vs 8.5 ± 6.7 cm, P = 0.43), modified Balance Error Scoring System (8.9 ± 5.5 vs 6.8 ± 4.7 errors, P = 0.09), or tandem gait (single-task: 26.0 ± 12.3 vs 24.2 ± 11.9 seconds, P = 0.56; dual-task: 35.1 ± 14.3 vs 35.6 ± 18.6 seconds, P = 0.90).In concussion patients experiencing dizziness, evaluating neck/shoulder pain may help identify individuals who would benefit from cervical spine rehabilitation. However, other potential causes of dizziness should also be evaluated to facilitate timely recovery.

Background: The benefits of sport participation and physical activity within adolescent populations has been well established, including improved physical and psychological health, social functioning, and sleep quality.1-3 However, mandated stay-at-home orders during the COVID-19 pandemic resulted in an abrupt cessation of school and sport participation for many adolescent athletes. This sudden suspension of sports, physical activity and peer/social interaction may have negative implications on adolescent anxiety and fatigue, as well as peer relationships and sleep quality. Purpose: (1) Compare quality of life and sleep quality measures in adolescent athletes during the COVID-19 pandemic to measures obtained 1-2 years earlier. (2) Assess physical activity and social interaction behavior during the two weeks prior to school closure compared to a two-week period during school closure. Methods: Participants first completed Patient Reported Outcome Measurement System (PROMIS) anxiety, fatigue, and peer relationship short forms, and the Pittsburg Sleep Quality Inventory (PSQI) during pre-participation sport physical evaluations (May 2018 or 2019), and again during May or June (2020). Physical activity and social interaction were assessed at the second timepoint by asking participants to retrospectively report behaviors during the two weeks prior to school closure, and during the two weeks preceding questionnaire completion. We compared outcomes using paired samples t-tests (continuous outcome variables) and McNemar’s test (categorical outcome variables). All statistical tests were two-sided and evaluated at a significance level of α = 0.05. Results: A significant portion (92%) of participants (n=39; 16.2±0.9 years of age; 64% female; 499±177 days between assessments) reported sport cessation due to COVID-19 (Table 1). Compared to pre-COVID assessments, participants reported significantly higher anxiety and fatigue scores, and significantly worse sleep quality after school and sport cessation (Figure 1). Physical activity frequency and duration were significantly reduced in the two weeks prior to questionnaire completion compared to the two weeks before sport and school closure (Table 2). No significant difference was found for quality of peer relationships (Figure 1), although characteristics of peer/social interactions differed significantly between timepoints. Conclusion: Following recent stay-at-home orders, high school athletes reported more anxiety and fatigue, worse sleep quality, and less physical activity compared to assessments obtained in the Spring of 2018 or 2019. The abrupt cessation of school and sport participation due to COVID-19, in combination with other life factors, likely contributed to reductions in physical activity, worse sleep quality, changes in social interaction, elevated levels of anxiety, and increased fatigue among high school athletes. References: Snyder AR, Martinez JC, Bay RC, Parsons JT, Sauers EL, Valovich McLeod TC. Health-related quality of life differs between adolescent athletes and adolescent nonathletes. J Sport Rehabil. 2010;19(3):237-248. doi:10.1123/jsr.19.3.237 Eime RM, Young JA, Harvey JT, Charity MJ, Payne WR. A systematic review of the psychological and social benefits of participation in sport for children and adolescents: informing development of a conceptual model of health through sport. Int J Behav Nutr Phys Act. 2013;10:98. Published 2013 Aug 15. doi:10.1186/1479-5868-10-98 Kredlow MA, Capozzoli MC, Hearon BA, Calkins AW, Otto MW. The effects of physical activity on sleep: a meta-analytic review. J Behav Med. 2015;38(3):427-449. doi:10.1007/s10865-015-9617-6 Tables/Figures: [Table: see text][Figure: see text][Table: see text]

Background: Impairments in postural stability are common following concussion. However, subjectively-scored assessments of postural control, such as the Balance Error Scoring System, may not accurately reflect postural instability. Objective measures, such as gait performance, can more accurately identify ongoing impairments in postural control throughout concussion recovery. Recent technological advances make gait evaluations more feasible across different clinical settings. Purpose: To compare performance on smartphone measured single- and dual-task gait evaluations among adolescent concussion participants and healthy controls across two timepoints. Methods: We evaluated concussed participants at initial (n=13; 14.6±1.3 years; 54% female; 5.5±1.6 days post-concussion) and follow-up visits (33.2±3.3 days post-concussion), and healthy control participants (n=21; 15.5±1.6 years; 48% female) at two timepoints 27.3±0.7 days apart on single- and dual-task gait performance. Single-task gait trials consisted of walking at a self-selected pace for 20 meters. Single-task cognitive trials involved responding to a cognitive task while standing in place. For dual-task trials, participants completed gait and cognitive tasks simultaneously. During each trial a smartphone affixed to the lumbar spine measured gait velocity and cognitive response accuracy and response time. We conducted a 2x2 mixed effects ANOVA to examine changes between groups across the testing timeline. Results: Concussion participants reported significantly greater symptom severity than control participants at the initial timepoint (23.1±13.5 vs 7.4±8.5; p=0.001); however, this difference did not persist to the second timepoint (p=0.99). The concussion group demonstrated significant improvements in single-task gait velocity between timepoints; although, between-group differences in gait velocity were not observed at either timepoint (Figure 1). No differences in cognitive accuracy between groups were identified. However, concussed participants performed worse than healthy controls on cognitive response time at both time points in single- and dual-task testing (Figure 2). Further, response time improved between testing periods for single-task, but not dual-task, conditions. Conclusion: Smartphone gait evaluations indicate improvement in single-task gait velocity during concussion recovery. However, no significant differences in gait velocity were found between concussed and control participants at either time point in single- or dual-task gait conditions. Interestingly, concussion patients had slower cognitive responses than healthy controls at both time points, despite no differences in cognitive accuracy or symptom severity at time 2. Our preliminary findings suggest that smartphone gait evaluations are effective in measuring changes in gait velocity and cognitive performance following adolescent concussion, as well as detecting subtle differences in gait and cognitive performance between concussed and control patients throughout recovery. [Figure: see text][Figure: see text]

Background: Sleep disturbances are common following concussion and may affect symptom severity and recovery timing. Whether post-concussion sleep problems are associated with functional outcomes, such as postural stability, remains unexplored. Hypothesis/Purpose: We examined the association of self-reported sleep problems with clinical measures of postural stability, persistent post-concussion symptoms (PPCS), and symptom severity following pediatric concussion. We hypothesized that patients reporting post-concussion sleep problems would demonstrate worse postural stability, more severe symptoms at their initial clinical visit, and slower symptom recovery times than those without sleep problems. Methods: We retrospectively examined data from patients (6-18 years) evaluated by a sports medicine physician ≤21 days post-concussion. Patients performed the modified Balance Error Scoring System (mBESS) and single- and dual-task tandem gait (TG). They also reported initial concussion symptom severity they recalled within the first 24 hours post-injury and current symptoms at the first clinical visit using the Health and Behavior Inventory (HBI). Symptom duration was the number of days post-injury until the patient reported a return to baseline status. PPCS was defined as a symptom duration >28 days post-injury. We stratified patients based on those that self-reported sleep problems since injury (n=97, 14.32.9 years; 49% female; initial visit 10.25.8 days post-injury) compared to those who did not (n=110, 14.32.4 years; 46% female; initial visit 9.35.4 days post-injury) assessed with a yes/no question. Groups were compared using independent sample t-tests, Mann Whitney U tests, or Chi square analyses evaluated at a significance level of p=0.05. We examined PPCS development between groups using a logistic regression analysis adjusted for time of initial visit. Symptom severity was analyzed using a 2x2 repeated measures ANOVA with pairwise follow-up using an adjusted significance level of p=0.025. Results: Patients reporting sleep problems post-concussion had significantly more mBESS errors than those without (Table 1). We observed no between-group differences for single- or dual-task TG time or dual-task cognitive performance. Sleep problems post-concussion were associated with more severe symptoms during the first clinical visit despite similar day-of-injury symptoms (Figure 1), and a 2x greater odds of developing PPCS (adjusted odds ratio=2.02, 95% confidence interval = 1.01, 4.06; p=0.049). Conclusion: Youth athletes who reported sleep problems post-concussion demonstrated worse balance on the mBESS, increased likelihood of developing PPCS, and more severe symptoms than those who did not. Identifying sleep problems early in concussion recovery may allow clinicians to implement targeted treatment recommendations to improve sleep, and potentially reduce incidence of PPCS. [Table: see text][Figure: see text]

Background: Physical activity after concussion is an important aspect of appropriate management and may help to improve recovery time. However, symptom burden or functional deficits may be self-limiting and reduce activity level in the first weeks following a concussion. Purpose/Hypothesis: To examine dizziness and postural stability as potential predictors of physical activity level after concussion. We hypothesized that increased dizziness severity and more postural instability would predict lower step count acutely post-concussion. Methods: We initially evaluated athletes ages 12-18 years within 14 days of concussion using questionnaires and clinical tests to assess overall symptom burden, dizziness, and postural stability. Athletes were provided with an activity monitor that tracked daily step count for the subsequent two weeks after their initial care visit. Our primary outcome variable was daily step count (mean steps/day) during this two-week period. Potential predictor variables included participant characteristics (sex, age, time since injury, and history of: concussion, musculoskeletal injury, migraine, ADD, anxiety, depression), Post-Concussion Symptom Inventory (PCSI) total symptom burden, specific PCSI ratings of dizziness and balance impairment, and postural stability assessments [single and dual-task tandem gait (TG) and modified balance error scoring system (mBESS)]. To examine clinical predictors of activity we calculated Pearson correlation coefficients between mean steps/day and each potential predictor, and then included significantly correlated variables in a multiple linear regression model. Results: Athletes who participated in the study (n=35, mean 15.2±1.7 years of age, 49% female, mean steps/day=9195±3779) were initially evaluated a mean of 7.3±3.0 days post-concussion. PCSI dizziness rating (Pearson R=-0.49, p=0.003; Figure 1) and sex (mean difference=2449 steps/day, p=0.05) were associated with daily step count upon univariable evaluation and included in the multiple linear regression model. No other participant characteristics, symptom ratings, or objective balance or postural stability measures were significantly associated with steps/day (Table 1). In the multivariable model, PCSI dizziness rating (β=-1035; 95% CI: -191, -1880; p=0.018), but not sex, predicted average steps/day in the two weeks after initial clinical care visits. Conclusion: Self-reported dizziness severity assessed within 14 days of concussion predicted daily step count in the subsequent two weeks, while other measures of overall symptom severity and postural stability did not. Given the importance of physical activity for concussion recovery, identifying individuals with acute post-concussion dizziness may facilitate timely treatment of dizziness, potentially reducing a barrier to physical activity to improve recovery trajectories. [Figure: see text][Table: see text]

Background: Concussed individuals demonstrate significantly slower reaction time than that of healthy controls, particularly in the acute post-injury timeframe. In addition, post-injury reaction time may predict concussion recovery timing. Given that multiple measurement methods exist to assess reaction time post-injury, clinicians treating concussion may desire more information regarding the clinical utility of these methods. Purpose: To determine the clinical utility of two reaction time assessments and identify the ability of each to predict persistent post-concussion symptoms (PPCS), defined as symptoms lasting >28 days post-concussion. Methods: Concussed participants, within 14 days of injury, and healthy controls aged 12 to 18 years completed measures of clinical and smartphone-recorded reaction time. For clinical reaction time testing, participants completed 8 trials of a drop-stick protocol in which participants caught a weighted measuring stick dropped from a standard height between the thumb and palm of the dominant hand. Reaction time was calculated as the distance the stick fell before being caught. Three clinical reaction time outcomes were calculated: mean time, fastest trial, and coefficient of variance among all 8 trials. Smartphone reaction time was assessed through a smartphone application (Reaction Test Pro), which measured the speed at which patients responded to a simple on-screen stimulus. Participants were instructed to tap the phone as quickly as possible when an on-screen button changed color for 30 trials, an approximate test time of 2-3 minutes. Smartphone reaction time was output automatically by the application as the mean of all completed trials. Results: Concussion participants (n=54; 15.1±1.68 years of age; 50% female) assessed 7.0±3.05 days post-injury demonstrated worse performance than healthy controls (n=17; 16.3±1.13 years of age, 47% female) on all measures of reaction time (Table 1). Smartphone-recorded reaction time provided the largest mean difference between groups to distinguish concussed vs control participants. After controlling for age and concussion history, measures of mean clinical and smartphone reaction time were significant predictors of developing PPCS (Table 2). Conclusion: Smartphone-recorded reaction time within 2 weeks of concussion provide the greatest mean difference between concussed and control participants and predicted PPCS development in adolescents. Given the simplicity of smartphone-based measurements in comparison to other options for assessing reaction time, as well as the ubiquity and accessibility of smartphone technology, this technique may be preferred by physicians looking for direct measures of post-concussion reaction time. These assessments may also be used for early identification of patients at increased risk of developing PPCS. [Table: see text][Table: see text]