Vision and vestibular problems predict prolonged concussion recovery in children. A history of motion sickness may be an important premorbid factor. Public insurance status may represent problems with disparities in access to concussion care. Vision assessments in concussion must include smooth pursuits, saccades, near point of convergence (NPC), and accommodative amplitude (AA). A comprehensive, multidomain assessment is essential to predict prolonged recovery time and enable active intervention with specific school accommodations and targeted rehabilitation.
Objective: Up to one-third of children with concussion have persistent postconcussion symptoms lasting beyond 4 weeks. Females have been shown to have prolonged concussion recovery compared with males. This study examined characteristics in pediatric athletes with concussion to investigate the underlying factors that may contribute to this difference and their relation to recovery trajectories in females compared with males. Design: A retrospective cohort study of pediatric patients with sports-related concussion (SRC). Setting: A subspecialty pediatric concussion program. Subjects: One hundred ninety-two records were reviewed, 75 females and 117 males, ages 7 to 18 years old. Assessment of Risk Factors: Sex of patient, time to presentation to specialty care after injury, presence of vision, and vestibular deficits on initial clinical examination. Main Outcome Measures: The main outcome of interest was time to clinical recovery, defined by resolution of symptoms, recovery of physical examination deficits, including vision and vestibular examination, recovery of neurocognitive function, and return to school, exercise, and sport. Results: Pediatric females, on average, presented later to specialty care for evaluation after SRC than males. Females also took longer to recover on 5 markers of recovery: time to return to school without accommodations, time to return to noncontact exercise, time to return to full sport, time to recovery of neurocognitive function on computerized testing, and time to clinical recovery of vision and vestibular deficits on examination including smooth pursuits, saccades, gaze stability, near point of convergence, and balance. These sex-based differences in recovery disappeared when controlling for time to presentation to specialty care. Conclusions: In this cohort of pediatric patients, ages 7 to 18 years old with SRC, females took longer to recover than males. Our results indicate, however, that a modifiable extrinsic factor, time to presentation to specialty care, may contribute to this difference in recovery between the sexes.
Eye tracking correlated with concussion symptoms and detected convergence and accommodative abnormalities associated with concussion in the pediatric population. It demonstrates utility as a rapid, objective, noninvasive aid in the diagnosis of concussion.
Assessment for NPC is a diagnostic entity that warrants consideration in children with concussion. Concussion questionnaires may not be sensitive to detect vision symptoms in children, making an accurate assessment for convergence important in the evaluation of concussion. Some children with abnormal NPC will recover without any formal intervention after concussion; however, a subset of patients with persistent abnormal NPC after concussion may benefit from interventions including vestibular and/or vision therapy.
Objective The study aims to validate eye movement tracking performed without a baseline study as a biomarker for concussion in a paediatric population.DesignThis is a cross-sectional case control study of patients diagnosed with concussion in a referral centre compared to non-concussed controls.MethodsEye movements were recorded with an SR Research Eyelink 1000 eye tracker while a 220-second video was played. Eye tracking metrics were compared to Acute Concussion Evaluation (ACE) scores and clinical assessments of convergence and accommodation.Results56 children with concussions (mean age of 13 years), as defined by symptom presence following an impulsive injury to the brain were evaluated at a mean of 22 weeks post-injury. Twelve eye tracking metrics were significantly different between concussed children and 83 uninjured controls. A model built on a balanced sub-sample to classify concussion based on eye tracking achieved an AUC of 0.854 (sensitivity 71.9%; specificity 84.4%). Two metrics were significant predictors of abnormal near point convergence (NPC) and accommodation. The model built to classify concussion based on NPC status achieved a specificity of 95.8% and a sensitivity of 57.1%. Reduced binocular amplitude of accommodation had a spearman correlation of 0.752 (p-value<0.001) with NPC. Seven eye tracking metrics were found to have a strong correlation (R=0.781) with binocular amplitude of accommodation.ConclusionsEye tracking reliably detected concussion and convergence and accommodative abnormalities in the paediatric population. We propose that eye tracking without baseline assessment may serve as an objective measure of concussion in paediatric patients. Competing interestsUzma Samadani has submitted intellectual property describing the technology utilised in this paper.These patents are owned by NYU, the VA and HCMC and licensed to Oculogica Inc., a company in which all of the above parties have an equity interest
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