Int J Sports Med 2016; 37(09): 738-747
DOI: 10.1055/s-0042-100470
Orthopedics & Biomechanics
© Georg Thieme Verlag KG Stuttgart · New York

Vestibular and Oculomotor Assessments May Increase Accuracy of Subacute Concussion Assessment

J. McDevitt
1   Athletic Training, East Stroudsburg University, East Stroudsburg, United States
,
K. O. Appiah-Kubi
2   Physical Therapy, Temple University, Philadelphia, United States
,
R. Tierney
3   Kinesiology, Temple University, Philadelphia, United States
,
W. G. Wright
2   Physical Therapy, Temple University, Philadelphia, United States
4   Bioengineering, Temple University, Philadelphia, PA, United States
› Author Affiliations
Further Information

Publication History



accepted after revision 03 January 2016

Publication Date:
13 May 2016 (online)

Abstract

In this study, we collected and analyzed preliminary data for the internal consistency of a new condensed model to assess vestibular and oculomotor impairments following a concussion. We also examined this model’s ability to discriminate concussed athletes from healthy controls. Each participant was tested in a concussion assessment protocol that consisted of the Neurocom’s Sensory Organization Test (SOT), Balance Error Scoring System exam, and a series of 8 vestibular and oculomotor assessments. Of these 10 assessments, only the SOT, near point convergence, and the signs and symptoms (S/S) scores collected following optokinetic stimulation, the horizontal eye saccades test, and the gaze stabilization test were significantly correlated with health status, and were used in further analyses. Multivariate logistic regression for binary outcomes was employed and these beta weights were used to calculate the area under the receiver operating characteristic curve ( area under the curve). The best model supported by our findings suggest that an exam consisting of the 4 SOT sensory ratios, near point convergence, and the optokinetic stimulation signs and symptoms score are sensitive in discriminating concussed athletes from healthy controls (accuracy=98.6%, AUC=0.983). However, an even more parsimonious model consisting of only the optokinetic stimulation and gaze stabilization test S/S scores and near point convergence was found to be a sensitive model for discriminating concussed athletes from healthy controls (accuracy=94.4%, AUC=0.951) without the need for expensive equipment. Although more investigation is needed, these findings will be helpful to health professionals potentially providing them with a sensitive and specific battery of simple vestibular and oculomotor assessments for concussion management.

 
  • References

  • 1 Alsalaheen BA, Mucha A, Morris LO, Whitney SL, Furman JM, Camiolo-Reddy CE, Collins MW, Lovell MR, Sparto PJ. Vestibular rehabilitation for dizziness and balance disorders after concussion. J Neurol Phys Ther 2010; 34: 87-93
  • 2 Baker CS, Cinelli ME. Visuomotor deficits during locomotion in previously concussed athletes 30 or more days following return to play. Physiol Rep 2014; 2: 1-7
  • 3 Bell DR, Guskiewicz KM, Clark MA, Padua DA. Systematic review of Balance Error Scoring System. Sports Health 2011; 3: 287-295
  • 4 Broglio SP, Ferrara MS, Macciocchi SN, Baumgartner TA, Elliott R. Test-retest reliability of computerized concussion assessment programs. J Athl Train 2007; 42: 509-514
  • 5 Cavanaugh JT, Guskiewicz KM, Giuliani C, Marshall S, Mercer V, Stergiou N. Detecting altered postural control after cerebral concussion in athletes with normal postural stability. Br J Sports Med 2005; 39: 805-811
  • 6 Christman SP, Rivara FP, Schliff MA, Zhou C, Comstock RD. Risk factors for concussive symptoms 1 week or longer in high school athletes. Brain Injury 2013; 27: 1-9
  • 7 Ciuffreda KJ, Kappor N, Ludlan DP. Clincal occulomotor training in traumatic brain injury. Optom Vis Dev 2009; 40: 16-23
  • 8 Cohen B, Matsuo V, Raphan T. Quantitative analysis of the velocity characteristics of optokinetic nystagmus and optokinetic after-nystagmus. J Physiol 1977; 270: 321-344
  • 9 Collins MW, Kontos AP, Reynolds E, Murawski CD, Fu FH. A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion. Knee Surg Sports Traumatol Arthrosc 2014; 22: 235-246
  • 10 Field A. A bluffer’s guide to sphericity. The British Psychological Society: MSC Section Newsletter 1998; 6: 13-22
  • 11 Ford-Smith CD, Wyman JF, Elswick RK, Fernandez T, Newton RA. Test-retest reliability of the sensory organization test in noninstitutionalized older adults. Arch Phys Med Rehabil 1995; 76: 77-81
  • 12 Galetta KM, Barrett J, Allen M, Madda F, Delicata D, Tennant AT, Balcer LJ. The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters. Neurology 2011; 76: 1456-1462
  • 13 Galetta KM, Brandes LE, Maki K, Dziemianowicz MS, Laudano E, Allen M, Balcer LJ. The King-Devick test and sports-related concussion: Study of a rapid visual screening tool in a collegiate cohort. J Neurol Sci 2011; 309: 34-39
  • 14 Giza CC, Hovda DA. The neurometabolic cascade of concussion. J Athl Train 2001; 36: 228-235
  • 15 Goebel JA, Tungsiripat N, Sinks B, Carmody J. Gaze stabilization test: A new clinical test of unilateral vestibular dysfunction. Otol Neurotol 2006; 28: 68-73
  • 16 Guskiewicz KM, Ross SE, Marshall SW. Postural stability and neuropsychological deficits after concussion in collegiate athletes. J Athl Train 2001; 36: 263-273
  • 17 Guskiewicz KM, Riemann BL, Perrin DH, Nashner LM. Alternative approaches to the assessment of mild head injury in athletes. Med Sci Sports Exerc 1997; 29: S213-S221
  • 18 Harmon KG, Drezner JA, Gammons M, Guskiewicz KM, Halstead M, Kutcher JS, Pana A, Putukian M, Roberts WO. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sport Med 2013; 47: 15-26
  • 19 Harriss DJ, Atkinson G. Ethical standards in sports and exercise science research: 2016 update. Int J Sports Med 2015; 36: 1121-1124
  • 20 Longridge NS, Mallinson AI. A discussion of the dynamic illegible “E” test: a new method of screening for aminoglycoside vestibulotoxicity. Otolaryngol Head Neck Surg 1984; 92: 671-677
  • 21 Hoffer ME, Gottshall KR, Moore R, Balough BJ, Wester D. Characterizing and treating dizziness and mild traumatic head trauma. Otol Neurotol 2004; 25: 135-138
  • 22 Howard IP, Ohmi M. The efficiency of the central and peripheral retina in driving human optokinetic nystagmus. Vision Res 1984; 24: 969-976
  • 23 Howell DR, Osternig LR, Chou LS. Return to activity after concussion affects dual-task gait balance control recovery. Med Sci Sports Exerc 2015; 47: 673-680
  • 24 Kaufman DR, Puckett MJ, Smith MJ, Wilson KS, Cheema R, Landers MR. Test–retest reliability and responsiveness of gaze stability and dynamic visual acuity in high school and college football players. Phys Ther Sport 2014; 15: 181-188
  • 25 Kutcher J, Eckner J. At-risk populations in sports-related concussion. Curr Sports Med Rep 2010; 9: 16-20
  • 26 Lau B, Lovell M, Collins M, Pardini J. Neurocognitive and symptom predictors of recovery in high school athletes. Clin J Sport Med 2009; 19: 216-221
  • 27 Lau BC, Kontos AP, Collins MW, Mucha A, Lovell MR. Which on-field signs/symptoms predict protracted recovery from sport related concussion among high school football players. Am J Sports Med 2011; 39: 2311-2318
  • 28 McCrea M, Guskiewicz KM, Marshall SW, Barr W, Randolph C, Cantu RC, Onate JA, Yang J, Kelly JP. Acute effects and recovery time following concussion in collegiate football players: the NCAA Concussion Study. JAMA 2003; 290: 2556-2563
  • 29 McCrea M, Barr WB, Guskiewicz KM, Randolph C, Marshall SW, Cantu R, Kelly JP. Standard regression-based methods for measuring recovery after sport-related concussion. Int Neuropsychol Soc 2005; 11: 58-69
  • 30 McCrory P, Meeuwisse W, Aubry M, Cantu R, Dvorak J, Echmendia RJ. 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: 250-258
  • 31 Meehan WP, d’Hemecourt P, Comstock RD. High school concussions in the 2008–2009 academic year: Mechanism, symptoms, and management. Am J Sports Med 2010; 38: 2405-2409
  • 32 Mucha A, Collins MW, Elbin RJ, Furman JM, Troutman-Enseki C, DeWolf RM, Marchetti G, Kontos AP. A Brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions: preliminary findings. Am J Sports Med 2014; 42: 2479-2486
  • 33 Murray N, Salvatore A, Powell D, Reed-Jones R. Reliability and validity evidence of multiple balance assessments in athletes with a concussion. J Athl Train 2014; 49: 540-549
  • 34 NeuroCom. A division of Natus. Setting the standard in balance and mobility. Sensory organization test. http://www.resourcesonbalance.com/neurocom/protocols/sensoryImpairment/SOT.aspx Accessed on January 6th, 2015
  • 35 Rábago CA, Wilken JM. Application of a mild traumatic brain injury rehabilitation program in a virtual realty environment: a case study. J Neurol Phys Ther 2011; 35: 185-193
  • 36 Register-Mihalik JK, Mihalik JP, Guskiewicz KM. Balance deficits after sports-related concussion in individuals reporting posttraumatic headache. Neurosurgery 2008; 63: 76-82
  • 37 Riemann BL, Guskiewicz KM, Shields EW. Relationship between clinical and force plate measures of postural stability. J Sport Rehabil 1999; 8: 71-82
  • 38 Rine RM, Schubert MC, Whitney SL, Roberts D, Redfern MS, Musolino MC, Roche JL, Steed DP, Corbin B, Lin CC, Marchetti GF, Beaumont J, Carey JP, Shepard NP, Jacobson GP, Wrisley DM, Hoffman HJ, Furman G, Slotkin J. Vestibular function assessment using the NIH Toolbox. Neurology 2013; 80: S25-S31
  • 39 Schiman M, Fallaway M, Frantz KA, Peters RJ, Hatch S, Cuff M, Mitchell GL. Nearpoint of convergence: Test procedure, target selection, and normative data. Optom Vis Sci 2003; 80: 214-225
  • 40 Schulz M, Marshall S, Mueller F, Yang J, Weaver N, Kalsbeek W, Bowling J. Incidence and risk factors for concussion in high school athletes, North Carolina, 1996–1999. Am J Epidemiol 2004; 160: 937-944
  • 41 Slobounov S, Slobounov E, Sebastianelli W, Cao C, Newell K. Differential rate of recovery in athletes after first and second concussion episodes. Neurosurgery 2007; 61: 338-344
  • 42 Sosnoff JJ, Broglio SP, Shin S, Ferrara MS. Previous mild traumatic brain injury and postural-control dynamics. J Athl Train 2011; 46: 85-91
  • 43 Teel EF, Register-Mihalik JK, Troy Blackburn J, Guskiewicz KM. Balance and cognitive performance during a dual task: preliminary implications for use in concussion assessment. JSAMS 2013; 16: 190-194
  • 44 Thiagarajan P, Ciuffreda KJ, Ludlam DP. Vergence dysfunction in mild traumatic brain injury (MTBI): a review. Ophthalmic Physiol Opt 2011; 31: 456-468
  • 45 Tjarks BJ, Dorman JC, Valentine VD, Munce TA, Thompson PA, Kindt SL, Bergeron MF. Comparison and utility of King-Devick and ImPACT® composite scores in adolescent concussion patients. J Neurol Sci 2013; 334: 148-153
  • 46 Treleavena J, Jull G, Grip H. Head eye co-ordination and gaze stability in subjects with persistent whiplash associated disorders. Man Ther 2011; 16: 252-257
  • 47 Phillips J, Tierney RT. Effect of target type on near point of convergence in a healthy, active, young adult population. JEMR 2015; 8: 1-6
  • 48 Van Die GC, Collewijn H. Control of human optokinetic nystagmus by the central and peripheral retina: effects of partial visual field masking, scotopic vision and central retinal scotomata. Brain Res 1986; 383: 185-194
  • 49 Ward BK, Mohammad MT, Whitney SL, Marchetti JF, Furman JM. The reliability, stability, and concurrent validity of a test of gaze stabilization. J Vestib Res 2010; 20: 363-372
  • 50 West TA, Marion DW. Current recommendations for the diagnosis and treatment of concussion in sport: a comparison of three new guidelines. J Neurotrauma 2013; 31: 159-168
  • 51 Wrisley DM, Stephens MJ, Mosley S, Wojnowski A, Duffy J, Burkard R. Learning effects of repetitive administrations of the sensory organization test in healthy young adults. Arch Phys Med Rehabil 2007; 88: 1049-1054