BLOG: Visio-vestibular testing can help predict post-concussion needs
Click Here to Manage Email Alerts
Research into concussions has been growing rapidly over the past decade. The majority of the research that has expanded our knowledge of the signs, symptoms and clinical course of youth concussion has focused on sport-related injuries.
However, about 30% of all concussions occur by other mechanisms, such as assaults, falls and motor vehicle accidents.
To further assess the trajectory of injuries sustained due to non-sport mechanisms, my colleagues and I investigated a group of children who sustained their injuries due to assaults and compared them with a group of children who sustained injuries due to sport. We found that there are disparities in care related to how the concussion was sustained.
Those who suffered a concussion following an assault were more likely to present to the emergency department and much less likely to receive concussion-specific testing in the form of a visio-vestibular examination (27% received this testing vs. 74% of those with a sports concussion). Assault victims also had different outcomes, with a greater risk of school performance declines and prolonged recovery trajectories.
These findings came from a retrospective chart review of 124 patients 8 to 17 years old who were diagnosed with concussion at Children’s Hospital of Philadelphia (CHOP) over a 2-year period (Means et al.). Half the children had an assault-related concussion, while the other half had a sports-related concussion. The patients in our study could have entered the CHOP system via the ED, a specialty clinic (such as sports medicine or neurology) or a primary care clinic.
There are many reasons why children and adolescents who experience an assault-related concussion may have disparate outcomes compared to their peers who sustain injuries due to a sport-related mechanism. Concussions already involve a wide variety of physical, cognitive and emotional symptoms, which can be compounded by the complex psychosocial dynamics of having been the victim of an assault. At the time of the injury, the biomechanical forces that induce an assault-related injury may be unique from a sport injury, leading to different post-injury physiology.
Concussion diagnosis may be delayed or overshadowed when a child has polytrauma, or injury to multiple systems. Consider the path of a child who goes to the ED because they got hit in the head during a soccer game. Most likely, concussion is going to be at the forefront of the provider’s mind, and the only area of focus.
By contrast, when a child comes to the ED with nasal trauma, an arm deformity and rib fractures, medical personnel have many problems to address simultaneously, some of which are immediately life-threatening. Concussion may fall further down the list, both in terms of the care provided and the guidance offered at discharge. Law enforcement or social workers may be involved, or the family may have priorities that supersede concussion-related return-to-school protocols.
During recovery, concussed youth who have been assaulted may have access to different or fewer support options than those who suffer injuries from sport. For instance, young athletes may have access to team personnel to observe progress and support their rehabilitation.
There are several steps we can take to address the systemic and procedural differences that may lead to these disparities in care. At CHOP, we are working hard to standardize care protocols that are consistent with best practices for concussion management. About 75% of our patients with concussion now get visio-vestibular testing in the ED. With just a quick, 5-minute exam, we can evaluate eye tracking, gaze stability, near-point convergence, and gait and balance. We know that concussed youth with significant visio-vestibular deficits are likely to have a longer recovery.
If this testing identifies such deficits, we can better advise families about the expected trajectory after concussion. As the testing is also an assessment of a student’s functional ability, we can also anticipate that the child may struggle with reading or taking notes in school and proactively implement some supportive measures, such as asking the school to provide pre-printed notes, larger fonts or a later deadline for work.
Ultimately, knowledge of the differences in the recovery of concussion patients who sustain their injuries from an assault can help the diagnosing provider anticipate patient needs to help expedite recovery times.
Reference:
- Means MJ, et al. Pediatr Emerg Care. 2022;doi:10.1097/PEC.0000000000002664.
For more information:
Daniel J. Corwin, MD, MSCE, is assistant professor of Pediatrics at the University of Pennsylvania, attending physician and associate director of research for the Division of Emergency Medicine and emergency department lead of the Minds Matter Concussion Program at CHOP. His research focuses on pediatric concussion. He is particularly interested in improving the diagnosis and initial management of pediatric concussion and in identifying those at highest risk for prolonged recovery.
Disclaimer: The views and opinions expressed in this blog are those of the authors and do not necessarily reflect the official policy or position of the Neuro-Optometric Rehabilitation Association unless otherwise noted. This blog is for informational purposes only and is not a substitute for the professional medical advice of a physician. NORA does not recommend or endorse any specific tests, physicians, products or procedures. For more on our website and online content, click here.
Collapse