The Utility of Vestibular and Ocular Assessment Tools in Diagnosing a Sports-Related Concussion: A Critically Appraised Topic

Powers C1, Nosker A1, Beidler E2

1 Student, 2 Assistant Professor; Duquesne University, Pittsburgh, PA

• The overall average Sport-related concussion (SRC) incidence rate is 26.1 SRCs per 100,000 athlete-exposures.1

• A multi-faceted evaluative approach to SRC management is recommended that includes assessments of self-reported symptoms, motor control, mental status, and neurocognition.2

• Dizziness and balance problems occur in 50% of concussed athletes and vision problems occur in 30%.3,4

• Many current diagnostic assessments fail to take into consideration vestibular and ocular deficits.

• High sensitivity and internal consistency are important components for determining the clinical utility of sideline SRC assessment tools.

The studies reviewed were identified as the “best evidence” and met all the inclusion criteria (Table 1). There were 5 articles identified; 4 studies4,5,7 demonstrated that vestibular and ocular assessments have a high internal consistency and three studies4,5,7

showed high sensitivities for diagnosing SRCs.Combining near point convergence (NPC), smooth pursuits, and

vestibular-ocular reflex increased the accuracy of vestibular and ocular assessment tools to 87.5%.5 The sensitivity of adding NPC to the diagnostic process is 0.83 and stands out as being a beneficial tool in diagnosing a sports-related concussion.5

METHODS

Do vestibular and ocular assessments have suitable levels of internal consistency and sensitivity for diagnosing sport-related concussions?

INTRODUCTION

CLINICAL QUESTION

RESULTS DISCUSSION

REFERENCES

Balaban et al. (2016)Cohort Study

Kontos et al. (2016) Cohort Study

McDevitt et al. (2016)Cross-Sectional Study

Mucha et al. (2014)Cross-Sectional Study

Pearce et al. (2015)Cross-Sectional Study

Participants 200 athletes (50 concussed) 394 NCAA student-athletes 72 active collegiate student-athletes 142 athletes (mean age = 13.9 y/o ± 2.5 y) 78 athletes (mean age = 14.31 y/o)

Intervention Symptom profile, functional gait index, dizziness handicap inventory, battery of oculomotor, vestibular, and reaction time (OVRT) reflexes

Vestibular and ocular motor screening (VOMS) test

Sensory organization test (SOT), Balanceerror scoring system, VOMS components

5 domains of VOMS: smooth pursuit, horizontal/vertical saccades, near point convergence, horizontal vestibular ocular reflex, vision motion sensitivity

Near point convergence (NPC) testing, neurocognitive and symptom assessments (3 trials)

Outcome Measures Sensitivity Internal consistency Internal consistency Internal consistency & sensitivity Internal consistency

Main Findings 2 cohorts (different time frames) didnot differ in functional test results.

Sensitivity: 88-92%Specificity: 98-99%

High internal consistency (0.97)High Sensitivity

False positive (11%) due to history of motion sickness.

Best exam consists of: sensory organization tests, sensory ratios, NPC, and optokinetic stimulation signs/symptoms score.

High sensitivity and accuracy (98.6%)

61% of patients reported symptoms after 1 VOMS test.

Vestibular ocular reflex & visual motion sensitivity were most predictive.

Internal consistency = 0.95-0.98

Patients in convergence insufficiency group had NPC 12.64±8.97cm compared to 1.53cm of the normal group.

Level of Evidence 2b 2b 2b 2b 3

Conclusions Does not require a baseline, just past medical history.

Sensitivity of saccade testing showed significance during diagnosis.

Efficient test for determining if an athlete is concussed.

False positive rate is acceptable.

Important to have a baseline exam to determine relevant risk factors (e.g. motion sickness, migraines).

Near point convergence-sensitive assessment models should be used to determine if a patient has a concussion.

If patients present with 2 symptoms: increases the chance of correct diagnosis by 50%.

High internal consistency (0.92) High sensitivity

VOMS may serve as a single component of a comprehensive assessment. Scores ≥2 total symptoms and ≥5cm on NPC resulted in high rates on identifying concussions (96% and 84% respectively)

Convergence insufficiency is common in athletes following concussion (45%). Athletes with convergence insufficiency are at risk for greater impairments and higher symptom scores.

Search Strategy

Terms Used to Guide Search Strategy (PIO):- Patient: Athletes- Intervention: Vestibular/Ocular assessment tools- Outcome: Internal Consistency & Sensitivity

Sources of Evidence Searched:- PubMed - Google Scholar- Cinahl- SPORTDiscus- Global Health Library

Inclusion and Exclusion Criteria

Inclusion: Exclusion:- Studies that investigated SRC - Non-athletes - Athletes - Specified outcomes - Outcomes of internal consistency not measuredand/or sensitivity

- Published in the last decade(2006-2016)

- Limited to English Language

Vestibular and ocular deficits following a SRC are contributed to the impact mechanism occurring on the occipital and temporal regions of the brain. With the increasing number of vision and balance problems reported in patients, it is important to take these into consideration during the multi-faceted SRC evaluation process.3,4

Research shows that dizziness and visual problems are becoming more prevalent in concussed athletes.3-8 The 4th International Consensus Statement on Concussion in Sport states that there is a need for a standardized assessment tool for on-field evaluations that takes into consideration the rapidly changing signs and symptoms; such as those affecting the vestibulo-ocular system.2

Clinical Importance:• Vestibular and ocular assessments should be incorporated as a

component of the systematic approach to diagnosing a SRC. • They are cost effective and easily accessible compared to

computerized assessment tools.• They are simple and are an effective use of time during the

acute SRC assessment and management period.

Future research should be completed to differentiate between the multiple vestibular and ocular assessments. Research should also be conducted to understand the long-lasting deficits to the vestibulo-ocular system following a SRC to emphasize the importance of considering them in the clinical examination.

1. Marshall SW, Guskiewicz KM, Shankar V, McCrea M, & Cantu RC. Epidemiology of sports-related concussion in seven US high school and collegiate sports. Injury epidemiology, 2015;2(1).

2. McCrory P, Meeuwisse W, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sport Med. 2013;47(5):250–258.

3. Kontos AP, Sufrinko A, Elbin RJ, Puskar A, Collins MW. Reliability and associated risk factors for performance on the vestibular/ocular motor screening (VOMS) tool in healthy collegiate athletes. The American journal of sports medicine. 2016;44(6):1400-1406.

4. Mucha A, Collins MW, Elbin RJ, et al. A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions: preliminary findings. The American Journal of Sports Medicine. 2014;42(10):2479-2486.

5. McDevitt J, Appiah-Kubi KO, Tierney R, Wright WG. Vestibular and oculomotor assessments may increase accuracy of subacuteconcussion assessment. International Journal of Sports Medicine. 2016;37(9):738-747.

6. Pearce KL, Sufrinko A, Lau BC, Henry L, Collins MW, Kontos AP. Near point of convergence after a sport-related concussion: measurement reliability and relationship to neurocognitive impairment and symptoms. The American journal of sports medicine. 2015;43(12):3055-306.

7. Balaban C, Hoffer ME, Szczupak M, et al. Oculomotor, vestibular, and reaction time tests in mild traumatic brain injury. Janigro D, ed. PLoS ONE. 2016;11(9). doi:10.13710162168.

8. Master CL, Scheiman M, Gallaway M, et al. Vision diagnoses are common after concussion in adolescents. Clinical Pediatrics. 2016;55(3):260-267.

Table 1- Characteristics of Included Studies

Figure 1- Demonstrations of vestibular/ocular assessment components

Nea

r Po

int

Co

nver

gen

ce

Ver

tica

l Sa

cca

des

Ho

rizo

nta

l Sa

cca

des

Ho

rizo

nta

l V

esti

bu

lo-O

cula

r R

efle

x

Vis

ua

l Mo

tio

n S

ensi

tivi

ty

The Effects of ADHD and Learning Disabilities on Sport-Related Concussion Computerized Neurocognitive Baseline Assessments in High School Student-Athletes: A Critically Appraised Topic

Starczewski M 1, Daniel J 1, Beidler E 2

1 Student, 2 Assistant Professor; Duquesne University, Pittsburgh, PA

METHODSINTRODUCTION CLINICAL QUESTION RESULTS

DISCUSSION

REFERENCES

One out of every ten injuries sustained in high school athletic programs is a sport-related concussion (SRC).1

Computerized neurocognitive testing (CNT) is one of the multifaceted approaches in managing SRC. A recent consensus statement deemed developmental conditions, may influence the diagnosis, management, and return to play outcomes following SRC.2

• Concussion is a complex pathophysiological process affecting the brain that is induced by traumatic biomechanical forces.3

• The ImPACT assesses verbal memory, visual memory, visual motor, and reaction time. (See Figure 1)

• These tests fail to accommodate to those with neurological impairments such as athletes with attention-deficit disorder (ADHD) and/or a learning disorder (LD).

• Developmental, behavioral, and learning disorders have emerged as disabling health conditions that affect one in six children in the United States.3

How do high school student-athletes with ADHD and/or a LD perform on baseline neurocognitive test used for SRC management compared to high school athletes without ADHD and/or a LD?

SEARCH STRATEGY

Terms used to Guide Search Strategy:-Patient/Client group: High school athletes -Intervention/Assessment: ADHD and/or LDs-Comparison: No ADHD and/or LD-Outcome: Neurocognitive Baseline Test (ImPACT)

Sources of Evidence Searched: -PubMed-SPORTDiscus-MEDLINE-Google Scholar

INCLUSION AND EXCLUSION CRITERIA

Inclusion Criteria: Exclusion Criteria:- High School Athletes - Middle school, collegiate,- Must have self-reported and recreational athletes

history of ADHD, LD, or both - Invalid baseline scores- Subjects between the ages of

13-19- English language - Valid ImPACT baseline test

Each of the four relevant studies investigated the relationship between ADHD and/or LD and their cognitive baseline scores. 1,3,4,5

- Four studies1,3,4,5 showed athletes with ADHD and/or a LD had higher symptom reporting.

- Four 1,3,4,5 showed this special population to have lower verbal memory, visual memory, and visual motor test scores along with higher reaction time and impulse control scores.

Athletes that have ADHD and/or a LD are predisposed to lower baseline scores. This predisposition brings forth numerous problems when using general population normative baseline score comparisons for return to play decision-making.

CLINICAL IMPLICATIONS

- It is imperative that pre-season neurocognitive concussion baseline tests be collected for athletes with ADHD and/or a LD in order to provide an accurate pre-injury cognitive ability measurement for these individuals.

- Without an personalized baseline score for this special population, recovery times may be increased as they would appear to be impaired for longer when compared post-injury to the general population normative values.

- This unintentional increase in time loss from sport could lead to adverse psychological effects, such as anxiety and depression, that accompany prolonged recovery times.6

Future research should focus on tailoring RTP concussion management plans for athletes with ADHD and/or a LD.

Figure 1: An athlete taking the ImPACT test

1. Brooks BL, Iverson GL, Atkins JE, Zafonte R, Berkner P. Sex differences and self-reported attention problems during baseline concussion testing. Applied Neuropsychology. 2015; 0:1-8.

2. McCrory, P., Meeuwisse, W., Johnston, K., Dvorak, J., Aubry., Molly, M., et all. (2009). Consensus statement on concussion in sport-the 3rd International Conference on concussion in sport, held in Zurich, November 2008. Journal of Clinical Neuroscience, 16 (6), 755-763.

3. Zuckerman SL, Lee YM, Odom MJ, Solomon GS, Sills AK. Baseline neurocognitive scores in athletes with attention deficit-spectrum disorders and/or learning disability. J Neurosurg Pediatrics. 2013; 12: 103-109.

4. Elbin R, Kontos A, Kegel N, et al. Individual and combined effects of LD and ADHD on computerized neurocognitive concussion test performance: evidence for separate norms. Archives of Clinical Neuropsychology. 2013; 28: 476-484.

5.Salinas M, Dean P, LoGalbo A, et al. Attention-deficit hyperactivity disorder status and baseline neurocognitive performance in high school athletes. Applied Neuropsychology. 2016; 5: 264-272.

6. DiFazio M, Silverberg ND, Kirkwood MW, Bernier R, Iverson GL. Prolonged activity restriction after concussion: are we worsening outcomes? Clinical pediatrics. 2016;55(5):443-451.

Brooks et al.1

Cohort Study

Elbin et al.4

Cross-sectional Study

Salinas et al.5

Cohort Study

Zuckerman et al.3

Case Control Study

Participants 2,860 boys and 2,290 girls high school athletes 27,016 high school varsity athletes 512 high school athletes 6636 high school athletes

Intervention ADHD and/or LD vs. No ADHD and/or LD ADHD and/or LD vs. No ADHD and/or LD ADHD and/or LD vs. No ADHD and/or LD ADHD and/or LD vs. No ADHD and/or LD

Outcomes Measures ImPACT scores and symptoms reporting Mean and standard deviation of CNT and ImPACT Index scores provided by ImPACT test Mean and S/D of ImPACT scores of each group

Main Findings - Boys with ADHD had worse reaction time (p=.96, d=.01) and more cognitive-sensory (p=.03, d=.41) and sleep-arousal symptoms (20%) compared to control.

- Girls with ADHD had worse visual-motor speed (p=.01, d=.32), more cognitive-sensory (p=.03, d=.41), and affective symptoms than the control (p=.03, d=.41)

- Athletes with a LD had lower verbal memory (SD=10), visual memory (SD=13.5), visual motor (SD=6.64), and higher reaction time (SD=.09) than the control.

- Athletes with ADHD had lower visual memory (SD=13.24), visual motor (SD=7.31), and a higher reaction time (SD=.90) than the control.

- Athletes with LD/ADHD had lower verbal memory (SD=10.34), visual memory (SD=14.9), visual motor (SD=7.95), and higher reaction time than the control (SD=.10).

- Athletes with LD, ADHD, LD/ADHD reported more symptoms at baseline than control (SD=4.45)

- Adolescent athletes with ADHD had reduced verbal memory (p=.06), visual motor (p=.04), and impulse control scores (p>0.001) compared to control.

- Athletes with ADHD were nearly twice as likely to have sustained a prior concussion (ADHD 14%, non-ADHD 7.8%).

- Significant differences between LD only and control were found for all composite scores except impulse control (p>.001).

- Significant differences for all composite scores between ADHD and control (p>.001).

- Significant differences between mean baseline visual motor speed, reaction time, and total symptom scores between those with both LD/ADHD with no LD or ADHD (p>.001).

Level of Evidence IIb IIb IIb IIIb

Conclusions ADHD is associated with lower scores on ImPACTdomains and more symptoms.

Separate normative data for athletes with LD, ADHD, and LD/ADHD should be use when evaluating concussions.

ADHD is linked to lower neurocognitive test scores and higher risk of sustaining a head injury.

ADHD and/or LD athletes have lower baseline ImPACTscores compared with athletes without.

Table 1: Characteristics of Included Studies