Visio-vestibular testing may help predict needs after concussion

April 29, 2022

3 minute read


Biography/Disclosures


Biography: Corwin is assistant professor of pediatrics at the University of Pennsylvania, attending physician and associate director of research for the Division of Emergency Medicine, and chief of the emergency department of the Minds Matter Concussion Program at Children’s Hospital of Pennsylvania.


Disclosures: Corwin does not report any relevant financial information.


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Concussion research has grown rapidly over the past decade. The majority of research that has expanded our knowledge of the signs, symptoms, and clinical course of concussions in young people has focused on sports-related injuries.

However, about 30% of all concussions occur through other mechanisms, such as assaults, falls and traffic accidents.

To better assess the trajectory of injuries sustained due to non-sporting mechanisms, my colleagues and I investigated a group of children who suffered injuries from assault and compared them to a group of children who suffered sports injuries. We found that there are disparities in care related to how the concussion was sustained.

Corwin Mug

Daniel Corvin

Those who suffered a concussion as a result of an assault were more likely to present to the emergency department and significantly less likely to receive concussion-specific testing in the form of a visio-vestibular examination (27% received this test compared to 74% of those who had a sports concussion). Victims of assault also had different outcomes, with an increased risk of declining academic performance and prolonged trajectories of recovery.

These findings come from a retrospective chart review of 124 patients ages 8 to 17 who were diagnosed with concussion at Children’s Hospital of Philadelphia (CHOP) over a 2-year period (Means et al.). Half of the children had an assault-related concussion, while the other half had a sports-related concussion. Patients in our study could have entered the CHOP system via the emergency department, a specialty clinic (such as sports medicine or neurology), or a primary care clinic.

There are many reasons why children and adolescents who sustain an assault-related concussion may have disparate outcomes compared to their peers who sustain injuries from a sports-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 injury, the biomechanical forces that induce aggression-related injury may be unique to a sports injury, resulting in a different post-injury physiology.

The diagnosis of concussion may be delayed or overshadowed when a child has multiple trauma or damage to multiple systems. Consider the journey of a child going to the emergency room after being hit in the head during a football game. Most likely, concussion will be at the forefront of the provider’s mind and the only area of ​​focus.

In contrast, when a child presents to the emergency room with nasal trauma, arm deformity, and rib fractures, medical staff have many issues to deal with simultaneously, some of which are immediately life-threatening. Concussion may fall further down the list, both in terms of care provided and advice offered upon discharge. Law enforcement or social workers may be involved, or the family may have priorities that override concussion-related back-to-school protocols.

During their recovery, young concussion victims who have been assaulted may have access to different or fewer support options than those who suffer from sports injuries. For example, young athletes can have access to team staff to observe progress and support their rehabilitation.

We can take several steps to address the systemic and procedural differences that can lead to these disparities in care. At CHOP, we work hard to standardize protocols of care that are consistent with best practices in concussion management. Approximately 75% of our concussion patients now undergo visio-vestibular testing in the emergency department. With just a quick 5 minute exam we can assess eye tracking, gaze stability, near point convergence, gait and balance. We know that concussed young people with significant visio-vestibular deficits are likely to recover longer.

If these tests identify such deficits, we can better advise families on the expected trajectory after a concussion. As the test is also an assessment of a student’s functional ability, we can also anticipate that the child may have difficulty reading or taking notes at school and proactively implement some supports , such as asking the school to provide pre-printed notes, larger fonts, or a later work deadline.

Ultimately, knowing the differences in the recovery of concussion patients who sustain their injuries as a result of an assault can help the diagnostic provider anticipate patient needs in order to expedite recovery times. recovery.

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Daniel J. Corwin, MD, PhD, is assistant professor of pediatrics at the University of Pennsylvania, attending physician and associate director of research for the Division of Emergency Medicine, and chief of the emergency department for the Minds Matter Concussion Program at CHOP. His research focuses on pediatric concussions. He is particularly interested in improving the diagnosis and initial management of pediatric concussions and identifying those most at 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 stated. This blog is for informational purposes only and does not replace professional medical advice from a physician. NORA does not recommend or endorse any specific test, physician, product, or procedure. To learn more about our website and online content, click here.


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