ObjectivesTo determine whether individuals who sustained a sports concussion would exhibit persistent impairments in gait and quiet standing compared to non-injured controls during a dual-task assessment .DesignSystematic review and meta-analysis using individual participant data (IPD).Data sourcesThe search strategy was applied across seven electronic bibliographic and grey literature databases: MEDLINE, EMBASE, CINAHL, SportDISCUS, PsycINFO, PsycARTICLES and Web of Science, from database inception until June 2017.Eligibility criteria for study selectionStudies were included if; individuals with a sports concussion and non-injured controls were included as participants; a steady-state walking or static postural balance task was used as the primary motor task; dual-task performance was assessed with the addition of a secondary cognitive task; spatiotemporal, kinematic or kinetic outcome variables were reported, and; included studies comprised an observational study design with case–control matching.Data extraction and synthesisOur review is reported in line with the Preferred Reporting Items for Systematic review and Meta-Analyses-IPD Statement. We implemented the Risk of Bias Assessment tool for Non-randomised Studies to undertake an outcome-level risk of bias assessment using a domain-based tool. Study-level data were synthesised in one of three tiers depending on the availability and quality of data: (1) homogeneous IPD; (2) heterogeneous IPD and (3) aggregate data for inclusion in a descriptive synthesis. IPD were aggregated using a ‘one-stage’, random-effects model.Results26 studies were included. IPD were available for 20 included studies. Consistently high and unclear risk of bias was identified for selection, detection, attrition, and reporting biases across studies. Individuals with a recent sports concussion walked with slower average walking speed (χ2=51.7; df=4; p<0.001; mean difference=0.06 m/s; 95% CI: 0.004 to 0.11) and greater frontal plane centre of mass displacement (χ2=10.3; df=4; p=0.036; mean difference −0.0039 m; 95% CI: −0.0075 to −0.0004) than controls when evaluated using a dual-task assessment up to 2 months following concussion.Summary/conclusionsOur IPD evidence synthesis identifies that, when evaluated using a dual-task assessment, individuals who had incurred a sports concussion exhibited impairments in gait that persisted beyond reported standard clinical recovery timelines of 7–10 days. Dual-task assessment (with motion capture) may be a useful clinical assessment to evaluate recovery after sports concussion.Protocol pre-registrationThis systematic review was prospectively registered in PROSPERO CRD42017064861.
Background:The Balance Error Scoring System (BESS) shows that balance tends to recover within days after a concussion, whereas measures of the movement of the center of pressure (COP) show that balance deficits can persist up to 1 month after concussion. While approximately 30% of adolescents suffering concussion have functional consequences including balance deficits, evidence of the use of different balance assessments for concussion is limited within this population.Purpose:To compare performance on a series of balance assessments between adolescents with a diagnosed concussion at 1 month postinjury and noninjured control participants within the same age distribution.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Thirty-three adolescents 1 month postconcussion and 33 control participants completed the BESS followed by two, 2-minute trials standing on a Nintendo Wii Balance Board (WBB), during which the COP under their feet was recorded using 2 testing protocols: (1) double-leg stance, eyes open (EO) and (2) double-leg stance, eyes closed (EC). Participants then completed a dual-task condition (DT) with eyes open combining a double-leg stance and a Stroop color and word test while standing on the WBB. Three commonly used COP variables, anterior-posterior (A/P) and mediolateral (M/L) velocity and 95% ellipse, were computed for each condition performed on the WBB.Results:Participants postconcussion swayed over a significantly larger ellipse area compared with the control group in the EO (P = .008), EC (P = .002), and DT (P = .003) conditions and also performed the DT condition with faster COP velocity in the M/L direction (P = .007). No significant group difference was identified for BESS total score.Conclusion:At 1 month postconcussion, participants continued to demonstrate balance deficits in COP control despite scoring similar to controls on the BESS. Simple COP measures of balance may identify subtle impairments not captured by the BESS.
Context Deficits in both balance and oculomotor function, including impairments in saccadic eye movements, are observed in approximately 30% of patients postconcussion. Whereas balance and saccadic eye movements are routinely assessed separately, growing evidence suggests that they should be assessed concurrently. Objective To compare balance measures and saccades between adolescents 1 to 3 months postconcussion and healthy uninjured adolescents. Design Case-control study. Setting Concussion clinic and 2 private schools. Patients or Other Participants Twenty-five adolescents (10 boys, 15 girls; median [interquartile range (IQR)] age = 14 years [11.5–16 years]) between 1 and 3 months postconcussion (median [IQR] time since injury = 39.5 days [30–56.75 days]) and 33 uninjured adolescents (18 boys, 15 girls; median [IQR] age = 13 years [11.5–14 years]). Main Outcome Measure(s) The center-of-pressure 95% ellipse area and medial-lateral and anterior-posterior velocity and the number of saccades in the dual-task balance conditions including a high cognitive load (cognitive condition), a low cognitive load and a gaze-shifting component (visual condition) or both a high cognitive load and a gaze-shifting component (combined condition). Results Concussion-group participants swayed over larger center-of-pressure ellipse areas in the visual ( P = .02; effect size = 0.73) and combined ( P = .005; effect size = 0.86) conditions but not in the cognitive condition ( P = .07; effect size = 0.50). No group differences were identified for anterior-posterior ( F1,56 = 2.57, P = .12) or medial-lateral ( F1,56 = 0.157, P = .69) velocity. Concussion-group participants also did not perform more saccades than the control-group participants ( F1,56 = 2.04, P = .16). Conclusions Performing dual-task balance conditions for which the secondary task involved a gaze-shifting component or both a gaze-shifting component and a high cognitive load resulted in greater sway amplitude in adolescents with concussion. However, these larger amounts of postural sway were not associated with increased saccadic eye movements.
Background: Mild traumatic brain injury is a common neurological condition affecting adolescents in North America. In adults, symptoms related to balance are some of the most commonly reported. Methods: The purpose of this study was to investigate the balance in adolescents with mild traumatic brain injury using linear and non-linear centre of pressure (COP) measures in quiet stance and during dual-task. Adolescents aged 13.00 to 17.99 years were tested once at one month following mild traumatic brain injury (n ¼ 25), and healthy adolescents (n ¼ 22) were tested once as controls in four conditions: standing with eyes open, standing with eyes closed, standing on a single leg and standing while performing a visual Stroop task. Results: In general, compared to healthy adolescents, adolescents with mild traumatic brain injury demonstrated more variability (p ¼ 0.007, 95% CI (0.9, 5.4) and p ¼ 0.049, 95% CI (0.009, 4.0), mediolateral and anteroposterior, respectively), showed more cumulative movement (path length, p ¼ 0.016, 95% CI (1.3, 11.9)) and required greater speed of movement (p ¼ 0.012, 95% CI (0.99, 7.4) and p ¼ 0.035, 95% CI (0.28, 7.5), mediolateral and anteroposterior, respectively) in maintaining balance, and in underlying temporal organization showed less local stability (mediolateral largest Lyapunov, p ¼ 0.033, 95% CI (0.001, 0.027)), more short-term complexity anteroposteriorly (p ¼ 0.029, 95% CI (0.005, 0.099)) and less long-term complexity mediolaterally (p ¼ 0.001, 95% CI (0.015, 0.056)). Condition differences are additionally presented. Conclusions: Findings suggest that, for adolescents with mild traumatic brain injury, when maintaining balance visual input is relied on differently, the effectiveness of control may be an issue during dual-task, and consequently, the challenge of dual-task may be on par with single leg stance.
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