Multidomain Predictors of Protracted Recovery following Concussion Among 5- to 9-Year-Old Patients: A Preliminary Study.

OBJECTIVE: To determine which components from a multidomain assessment best predict protracted recovery in pediatric patients with a concussion. STUDY DESIGN: A prospective cohort of patients aged 5-9 years who presented within 21 days of concussion to a specialty clinic were categorized into normal (≤30 days) and protracted (>30 days) recovery. Participants provided demographic and medical history information, and completed the Child Sport Concussion Assessment Tool-5 symptom report and balance assessment, the Vestibular/Ocular Motor Screen-Child (VOMS-C), and the Pediatric Immediate Post-concussion Assessment and Cognitive Testing. Univariate logistic regressions (LR) were used to inform a follow-up forward stepwise LR to identify the best predictors of protracted recovery. Receiver operating characteristic analysis of the area under the curve (AUC) was used to identify which predictors retained from the LR model best discriminated recovery. RESULTS: The final sample included 68 patients (7.52 ± 2.3 years; 56% male), 36 (52.9%) with normal and 32 (47.1%) with protracted recovery. Results of the LR to identify protracted recovery were significant (P < .001) and accounted for 39% of the variance. The model accurately classified 78% of patients, with days to first clinic visit (OR, 1.2; 95% CI, 1.1-1.4; P = .003) and positive VOMS-C findings (OR, 8.32; 95% CI, 2.4-28.8; P < .001) as significant predictors. A receiver operating characteristic analysis of the AUC of this 2-factor model discriminated protracted from normal recovery (AUC, 0.82; 95% CI, 0.71-0.92; P < .001). CONCLUSIONS: Days to first clinic visit and positive findings on the VOMS-C were the most robust predictors of protracted recovery after concussion in young pediatric patients.

Temporal Changes in Fixational Eye Movements After Concussion in Adolescents and Adults: Preliminary Findings.

Concussions often involve ocular impairment and symptoms such as convergence insufficiency, accommodative insufficiency, blurred vision, diplopia, eye strain, and pain. Current clinical assessments of ocular function and symptoms rely on subjective symptom reporting and/or involve lengthy administration time. More objective, brief assessments of ocular function following concussion are warranted. The purpose of this study was to evaluate changes in fixational eye movements (FEMs) and their association with clinical outcomes including recovery time, symptoms, cognitive and vestibular/ocular motor impairment. Thirty-three athletes (13-27 years of age; 54.5% female) within 21 days of a diagnosed concussion participated in the study. A tracking scanning laser ophthalmoscope (TSLO) evaluated FEMs metrics during fixation on a center and corner target. Participants completed symptom (Post-Concussion Symptom Scale [PCSS]), cognitive (Immediate Post-concussion Assessment and Cognitive Testing [ImPACT], and Vestibular/Ocular Motor Screening (VOMS) evaluations. All measures were administered at the initial visit and following medical clearance, which was defined as clinical recovery. Changes in FEMs were calculated using paired-samples t tests. Linear regression (LR) models were used to evaluate the association of FEMs with clinical recovery. Pearson product-moment correlations were used to evaluate the associations among FEMs and clinical outcomes. On the center task, changes across time were supported for average microsaccade amplitude (p = 0.005; Cohen's d = 0.53), peak velocity of microsaccades (p = 0.01; d = 0.48), peak acceleration of microsaccades (p = 0.02; d = 0.48), duration of microsaccade (p < 0.001; d = 0.72), and drift vertical (p = 0.017; d = -0.154). The LR model for clinical recovery was significant (R2 = 0.37; p = 0.023) and retained average instantaneous drift amplitude (ß = 0.547) and peak acceleration of microsaccade (ß = 0.414). On the corner task, changes across time were supported for drift proportion (p = 0.03; d = 0.43). The LR model to predict clinical recovery was significant (R2 = 0.85; p = 0.004) and retained average amplitude of microsaccades (ß = 2.66), peak velocity of microsaccades (ß = -15.11), peak acceleration of microsaccades (ß = 12.56), drift horizontal (ß = 7.95), drift vertical (ß = 1.29), drift amplitude (ß = -8.34), drift proportion (ß = 0.584), instantaneous drift direction (ß = -0.26), and instantaneous drift amplitude (ß = 0.819). FEMs metrics were also associated with reports of nausea and performance within the domain of visual memory. The FEMs metric were also associated with PCSS, ImPACT, and VOMS clinical concussion outcomes, with the highest magnitude correlations between average saccade amplitude and VOMS symptoms of nausea and average instantaneous drift speed and ImPACT visual memory, respectively. FEMs metrics changed across time following concussion, were useful in predicting clinical recovery, and were correlated with clinical outcomes. FEMs measurements may provide objective data to augment clinical assessments and inform prognosis following this injury.

A Common Data Element-Based Adjudication Process for mTBI Clinical Profiles: A Targeted Multidomain Clinical Trial Preliminary Study.

INTRODUCTION: The primary purpose of this study was to examine the prevalence and percent agreement of clinician-identified mild traumatic brain injury (mTBI) clinical profiles and cutoff scores for selected Federal Interagency Traumatic Brain Injury Research common data elements (CDEs). A secondary purpose was to investigate the predictive value of established CDE assessments in determining clinical profiles in adults with mTBI. MATERIALS AND METHODS: Seventy-one (23 males; 48 females) participants (M = 29.00, SD = 7.60, range 18-48 years) within 1-5 months (M = 24.20, SD = 25.30, range 8-154 days) of mTBI completed a clinical interview/exam and a multidomain assessment conducted by a licensed clinician with specialized training in concussion, and this information was used to identify mTBI clinical profile(s). A researcher administered CDE assessments to all participants, and scores exceeding CDE cutoffs were used to identify an mTBI clinical profile. The clinician- and CDE-identified clinical profiles were submitted to a multidisciplinary team for adjudication. The prevalence and percent agreement between clinician- and CDE-identified clinical profiles was documented, and a series of logistic regressions with adjusted odds ratios were performed to identify which CDE assessments best predicted clinician-identified mTBI clinical profiles. RESULTS: Migraine/headache, vestibular, and anxiety/mood mTBI clinical profiles exhibited the highest prevalence and overall percent agreement among CDE and clinician approaches. Participants exceeding cutoff scores for the Global Severity Index and Headache Impact Test-6 assessments were 3.90 and 8.81 times more likely to have anxiety/mood and migraine/headache profiles, respectively. The Vestibular/Ocular Motor Screening vestibular items and the Pittsburgh Sleep Quality Index total score were predictive of clinician-identified vestibular and sleep profiles, respectively. CONCLUSIONS: The CDEs from migraine/headache, vestibular, and anxiety/mood domains, and to a lesser extent the sleep modifier, may be clinically useful for identifying patients with these profiles following mTBI. However, CDEs for cognitive and ocular may have more limited clinical value for identifying mTBI profiles.

Comparison of physiological outcomes after dynamic exertion between athletes at return to sport from concussion and controls: Preliminary findings.

OBJECTIVES: Compare physiological (heart rate, heart rate variability, and blood pressure), performance (change-of-direction task completion time and errors), and clinical (symptoms and rating of perceived exertion) outcomes during dynamic exertion between athletes at return to sport after concussion to healthy athlete controls. DESIGN: Case control. METHODS: A sample of 23 (Female = 10; 43.5 %) athletes at medical clearance to play/activity from concussion (CONCUSS) and 23 sex-, age-, and sport-matched healthy athletes (CONTROLS) completed a 5-min seated rest before and after the dynamic exertion test. Independent sample t-tests were used to compare CONCUSS and CONTROLS for completion time, heart rate, and blood pressure; and Mann-Whitney U tests for symptoms, perceived exertion, and errors. A series of ANOVAs were conducted to compare heart rate variability between groups across pre- and post-exercise rest periods. RESULTS: There were no differences in heart rate, blood pressure, symptoms, perceived exertion, and errors. CONCUSS were faster on Zig Zag (p = .048) and Pro Agility (p = .018) tasks, reported lower symptom severity (p = .019), and had lower post-EXiT HRV (p < .049) than CONTROLS. CONCLUSIONS: Performance, symptoms, perceived exertion, and blood pressure outcomes from dynamic exertion were equivocal between athletes at medical clearance from concussion and healthy controls, which provide empirical support for dynamic exercise to inform medical clearance clinical decision making for sport-related concussion. However, differences in autonomic nervous system functioning indicate that additional research is needed to examine temporal changes in heart rate variability and other physiological outcomes following dynamic exertion.

Discriminating Young Children with Concussion in an Outpatient Specialty Clinic from Healthy Controls Using the Child Sports Concussion Assessment Tool-5.

OBJECTIVE: To evaluate the clinical utility of the Sports Concussion Assessment Tool-5 Child (Child SCAT5) in an outpatient specialty clinic sample of children aged 5-9 years. STUDY DESIGN: Ninety-six children within 30 days of a concussion (mean = 8.90 ± 5.78 days) and 43 age- and sex-matched healthy controls completed the Child SCAT5, including balance items, cognitive screening, parent and child symptom severity reports, as well as each individual parent- and child-rated symptom severity (0-3). A series of receiver operating characteristic curves with area under the curve (AUC) analysis were performed to evaluate the clinical utility of the Child SCAT5 components to discriminate concussion. RESULTS: The AUC values were nondiscriminate for cognitive screening (0.32) and poor for balance (0.61) items. The AUC values were acceptable for parent-reported symptoms worsening after physical activity (0.73) and mental activity (0.72). The AUCs for symptom severity items were excellent for parent (0.89) and child-reported (0.81) headaches, and were acceptable for parent-reported tired a lot (0.75) and both parent- (0.72) and child-reported (0.72) tired easily. CONCLUSION: With the exception of parent- and child-reported symptoms, the Child SCAT5 provides limited clinical utility for evaluating concussion in children aged 5-9 years seen at an outpatient concussion specialty clinic. The cognitive screening and balance testing items were not useful in discriminating concussion. Parent- and child-reported headache were the only Child SCAT5 items with excellent ability to differentiate concussion from controls in the age group.

Neck Symptoms and Associated Clinical Outcomes in Patients Following Concussion.

OBJECTIVE: To examine the frequency and association of neck pain symptoms in patients with a concussion. STUDY SETTING AND PARTICIPANTS: Three-hundred and thirty-one consecutively enrolled patients aged 9 to 68 years with a diagnosed concussion 1 to 384 days post-injury were enrolled at a concussion clinic from a single integrated healthcare system in Western Pennsylvania between 2019 and 2021. DESIGN: Retrospective cohort analysis of prospectively collected concussion screening tool intake survey responses and clinical outcomes data. The primary outcome was self-reported neck pain or difficulty with neck movement on the Concussion Clinical Profiles Screening (CP Screen) tool, recovery time, and incidence of treatment referral. Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) composite scores, Vestibular/Ocular Motor Screening (VOMS) item scores, type and severity of neck symptoms, mechanism of injury, time from injury to clinic presentation, medical history, and concussion symptom profile were secondary outcomes. RESULTS: Of the 306 consecutively enrolled eligible patients in the registry, 145 (47%) reported neck pain, 68 (22.2%) reported difficulty moving their neck, and 146 (47.7%) reported either symptom. A total of 47 (15.4%) participants reported more severe neck symptoms, and this group took longer to recover (40 ± 27 days) than those not reporting neck symptoms (30 ± 28 days; U = 8316, P < .001). Stepwise logistic regression predicting more severe neck symptoms was significant (Nagelkerke R2 = 0.174, χ 2 = 9.315, P = .316) with older age ( P = .019) and mechanism of injury including motor vehicle collisions (MVCs) ( P = .047) and falls ( P = .044) as risk factors. MVCs and falls were associated with over 4 times and 2 times greater risk, respectively, for reporting more severe neck symptoms. CONCLUSION: Neck pain and stiffness symptoms are common in patients with a concussion following high-energy mechanisms of injury including MVCs or falls from height. These symptoms are associated with prolonged recovery. Providers should evaluate neck symptoms and consider targeted treatment strategies to limit their effects in patients with a concussion.

Comparison of Clinical Outcomes Between Athletes With Immediate and Delayed Onset of Symptoms Following Sport-Related Concussion.

OBJECTIVE: To compare characteristics and clinical outcomes of adolescent athletes with immediate and delayed onset of symptoms following sport-related concussion (SRC). A secondary objective was to describe the symptoms that are delayed and the timing of symptom onset. DESIGN: Prospective, repeated measures study. SETTING: Concussion Specialty Clinic. PARTICIPANTS: One hundred fifty-two participants (63.3% men) aged 11 to 24 (15.78 ± 3.47) evaluated within 7 days (3.47 ± 1.66) of sustaining an SRC. INDEPENDENT VARIABLE: Group classification of immediate (IMMEDIATE) or delayed onset of symptoms (DELAYED; >60 seconds following mechanism of injury) through structured clinical interview. MAIN OUTCOME MEASURES: Group comparisons on demographic and medical history factors, concussion and clinical profile symptom scores, computerized neurocognitive test scores, vestibular/oculomotor screening scores, and days to medical clearance. RESULTS: 24.3% of athletes in the sample were DELAYED. The groups did not differ on demographics and medical history. The DELAYED group had increased likelihood of posttraumatic migraine (PTM) as a primary/secondary clinical profile ( P = 0.03). Groups did not differ on any other clinical profiles ( P > 0.05). Groups did not differ on recovery time ( P = 0.47), the IMMEDIATE group higher dizziness on vestibular/ocular motor screening ( P = 0.016) and increased likelihood of dizziness being the initial symptom experienced ( P < 0 .001). CONCLUSIONS: The results indicated that delayed onset of symptoms in athletes were relatively common following SRC, supporting continued evaluation of athletes for several days following suspected injuries. Delayed onset of symptoms was associated with PTM, whereas immediate onset was associated with more pronounced vestibular dysfunction, suggesting that clinicians should consider the timing of symptom onset when assessing and treating athletes following SRC.

The Vestibular/Ocular Motor Screening-Child (VOMS-C) tool for concussion evaluation in 5- to 9-year-old pediatric patients: preliminary evidence.

OBJECTIVE: Vestibular and ocular motor dysfunction occurs in an estimated 60%-90% of concussion patients. The Vestibular/Ocular Motor Screening (VOMS) tool is validated for use in concussion patients older than 9 years. The goal of the current study was to adapt the current VOMS tool for a pediatric sample of children aged 5-9 years and establish its clinical utility in this patient population. METHODS: In this case-control study, 80 symptomatic concussion patients (n = 33 [41%] female) aged 5-9 years (mean age 7.40 ± 1.09 years) and 40 (n = 18 [45%] female) age- and sex-matched uninjured controls (mean age 7.10 ± 1.26 years) completed the VOMS-Child (VOMS-C), a version of the VOMS adapted for younger patients. Differences in binary "yes" or "no" symptom provocation for headache, dizziness, and nausea/"tummy ache" across the 7 items of the VOMS-C, and near point of convergence (NPC) distance, were examined. Logistic regression (LR) models were built to classify concussion and controls. Predicted probabilities were generated from the LR model and entered into receiver operating characteristic (ROC) curve models to generate area under the curve (AUC) values. RESULTS: VOMS-C item provocation ranged from 13% to 30% for concussed patients and 3% to 20% for controls. The LR model distinguished concussed participants from controls (R2 = 0.39; p < 0.001), with significant predictors being smooth pursuits, family depression history, and NPC distance. The ROC analysis had an AUC of 0.81 (95% CI 0.73-0.89; p < 0.001) in the good range. CONCLUSIONS: Accurate diagnosis of concussion in the clinic setting requires comprehensive evaluation in multiple domains, including detailed clinical interview, neurocognitive testing, and vestibular/ocular motor assessment, regardless of patient age. Our results provide preliminary support for the VOMS-C as a developmentally appropriate tool for concussion management.

Is Overparenting Associated with Adolescent/Young Adult Emotional Functioning and Clinical Outcomes Following Concussion?

Overparenting (O-P), or "helicopter" parenting, has warranted increased attention across the past decade. It is characterized as being overly involved, protective, and low on granting autonomy, and is associated with deleterious psychosocial outcomes outside of the concussion literature. This study examined the association of overparenting and patient emotional distress and clinical outcomes (i.e., symptoms, neurocognitive test scores, recovery time) post-concussion. Adolescents/young adult concussion patients (injury < 30 days) and parents (N = 101 child-parent dyads) participated. Patient participants completed measures of depression, anxiety, stress, and concussion clinical outcomes while parents concurrently completed an overparenting measure. Results of a general linear model found that overparenting was associated with higher anxiety and stress report of the child. Overparenting had a significant positive correlation with concussion recovery, although of a small magnitude. Emotional distress level, but not overparenting, was moderately associated with worse performance on clinical outcomes, including neurocognitive testing, vestibular/ocular motor dysfunction, and concussion symptom severity.

Clinical predictors of post-injury anxiety in adolescent patients following concussion.

The purpose of the current study was to examine predictors (e.g., pre-injury anxiety and sub-types, concussion symptom severity, neurocognitive performance, and vestibular/ocular-motor impairment) of post-injury anxiety scores following concussion among youth aged 10-18 years. This observational cohort study enrolled patients (n = 129) within 30 days of a diagnosed concussion. Patients completed Screening for Child Anxiety Related Disorders-Child Reports (SCARED-C), Generalized Anxiety Disorder-7 (GAD-7), Post-concussion Symptom Scale, neurocognitive testing, and Vestibular-Ocular Motor Screening. Logistic regression analyses were conducted to evaluate the role of risk factors and clinical outcomes as predictors of mild (GAD-7 > 5) and moderate levels (GAD-7 > 10) of post-injury anxiety. Twenty-two percent (n = 28) of patients reported clinical levels of pre-injury anxiety, and 13% (n = 17) reported clinical levels of post-injury anxiety. The logistic regression model predicting mild or greater anxiety was significant (R2 = 31.7%; p < 0.001) and supported pre-injury panic symptoms (OR = 1.38) and total symptom severity (OR = 1.04) as the most robust predictors. The logistic regression model predicting clinical anxiety was significant (R2 = 47.2%; p < 0.001) and supported non-SRC injury type (OR = 9.48), vestibular dysfunction (OR = 1.74) and pre-injury panic symptoms (OR = 1.57) as the most robust predictors. Results suggest that clinicians should employ measures of pre-injury and post-injury emotional functioning when evaluating and treating concussion among adolescents. Moreover, these results highlight the importance of assessing different types of pre-injury and post-injury anxiety in the context of concussion management.

Exploring the effect of napping on sleep quality and duration in collegiate athletes.

Purpose: The purpose of this study was to extend research on napping and sleep behaviors in collegiate athletes, and to compare nappers and non-nappers on sleep quality and duration. Methods: Current varsity, club, and intramural athletes between 18-29 years completed the Short Napping Behavior Scale, Pittsburgh Quality Sleep Index, Generalized Anxiety Disorder-7, and the Patient Health Questionnaire-9. Results: Approximately 72% (129/179) reported napping. There were no significant differences in outcomes between nap frequency groups on sleep quality (Χ2(3)=4.97, p=.17) or duration (Χ2(3)=1.20, p=.75). Moreover, there was no significant differences for nap length groups on sleep quality (Χ2(3)=7.03, p=.07) or duration (Χ2(3)=1.32, p=.72). Furthermore, there were no significant differences for nap timing groups on sleep quality (Χ2(3)=1.54, p=.67) or duration (Χ2(3)=2.43, p=.49). Conclusion: In a sample of collegiate athletes, nap frequency, length, and timing were not associated with worse sleep quality or duration.

The relationship between accelerometer-measured sleep and next day ecological momentary assessment symptom report during sport-related concussion recovery.

OBJECTIVES: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Utility of 1 Measurement Versus Multiple Measurements of Near Point of Convergence After Concussion.

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, <5 cm = normal, ≥5 cm = abnormal) as the average NPC distance across 3 measurements. 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.

Effect of Diagnosed Sleep Disorders on Baseline Concussion Symptom, Cognitive, and Balance Assessments in Collegiate Athletes.

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.

Association of Time Since Injury to the First Clinic Visit With Recovery Following Concussion.

Importance: Recovery after concussion varies, with adolescents taking longer (approximately 30 days) than adults. Many factors have been reported to influence recovery, including preinjury factors, perceptions about recovery, comorbid conditions, and sex. However, 1 factor that may play a role in recovery but has received little attention from researchers is the timeliness of clinical evaluation and care. Objective: To investigate the association of time since injury with initiation of clinical care on recovery time following concussion. Design, Setting, and Participants: This retrospective, cross-sectional study was conducted in a sports medicine clinic between August 2016 and March 2018. Eligible participants were aged 12 to 22 years and had a diagnosed, symptomatic concussion; patients were excluded if recovery data were incomplete. Participants were divided into 2 groups: those seen within 7 days of the injury (early) vs between 8 and 20 days of the injury (late). Data were analyzed between June 2019 and August 2019. Exposures: Time from injury (concussion) to initiation of clinical care. Main Outcomes and Measures: Recovery time; testing with the Post-Concussion Symptom Scale, Immediate Post-Concussion Assessment and Cognitive Testing, and Vestibular/Ocular Motor Screening instruments; demographic factors, medical history, and injury information. Results: A total of 416 individuals were eligible, and 254 (61.1%) were excluded, leaving 162 (38.9%) in analyses. The early group (98 patients) and late group (64 patients) did not differ in age (mean [SD] age, early, 15.3 [1.6] years; late, 15.4 [1.6] years), number of female patients (early, 51 of 98 [52.0%]; late, 40 of 64 [62.5%]), or other demographic, medical history, or injury information. The groups also were similar on symptom severity, cognitive, ocular, and vestibular outcomes at the first clinic visit. Results from a logistical regression supported being in the late group (adjusted odds ratio, 5.8 [95% CI, 1.9-17.6]; P = .001) and visual motion sensitivity symptoms greater than 2 (adjusted odds ratio, 4.5 [95% CI, 1.1-18.0]; P = .04) as factors significantly associated with recovery time. Conclusions and Relevance: Findings suggest that earlier initiation of clinical care is associated with faster recovery after concussion. Other factors may also influence recovery time. Further research is needed to determine the role of active rehabilitation and treatment strategies, as well as demographic factors, medical history, and injury characteristics on the current findings.

The utility of the Convergence Insufficiency Symptom Survey (CISS) post-concussion.

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.