INTRODUCTION: Research into the dysfunction of the postural control system in humans has been inconclusive as to the rehabilitative role of the oculomotor subsystem. Studies on the relationship between pursuit and saccadic activities in the rehabilitation of postural abnormalities have had conflicting findings regarding the predictable role of oculomotor activities in rehabilitation. Most studies are performed on healthy athletes rather than challenging compromised patients in a clinical setting. The aim of this study was to measure computerized posturography and saccadic latency of a subject population with loss of postural control to include migraine headaches (39.3%), post-concussion syndrome / traumatic brain injury (35.7%), vertigo (17.9%), and other brain disorders (7.1%) as primary diagnoses.

METHODS: A matched pairs design (pre- and post-treatment assessments) was used to assess the efficacy of a course of personalized Cortical Integrative Therapy, as the rehabilitative strategy. Postural control of 28 refractory adult patients, aged 18 to 64, was measured by computerized posturography and saccadic latency by videonystagmography. As head movements challenge the subject by generating a vestibular stimulus in addition to that generated by the subject’s sway, computerized posturography was conducted with the head in neutral position, right and left. Posturography scores in the three testing positions were compared to right and left horizontally directed saccades latency. These measurements were taken over the intervention course (mean = 7.66 weeks, range 0.57 to 20.29 weeks).

RESULTS: Efficacy of the personalized Cortical Integrative Therapy was indicated by a near 25% (P < 0.05) improvement in the posturography value. Post-intervention, the average latency values with the head in the neutral position and the head in left rotation demonstrated a negative linear correlation (P ≤ 0.05) in both directions of saccadic activity. In contrast, right head rotation testing yielded no statistically significant correlation between latency and posturography values. As expected, no correlation was observed between the postural stability and oculomotor function at baseline pretreatment testing.

CONCLUSION: The relationship between saccadic activities in the rehabilitation of postural abnormalities was demonstrated in a heterogeneous subject population with varied brain injuries and brain-based disorders. Moreover, computerized posturography data suggests that head rotation can help direct therapeutic strategy. Altogether these data suggest a rehabilitative role of vestibular postural systems in conjunction with oculomotor systems, which beckons development and implementation of new intervention approaches for broad-based clinical practice.

A subconcussive impact is defined as a bump, blow, or jolt to the head that does not manifest any overt clinical symptoms. Such events carry a latent potential for neurological impairment, and thus should be of particular concern in contact sports. Existing assessments for sports-related concussions (SRC) predominantly focus on explicit, self-reported symptoms and more obvious neurological impairments, leaving subtle neurological signs in athletes largely undetected and inadequately assessed. These subtle neurological findings are termed soft signs and represent non-localizing abnormalities within the central nervous system. Growing research illustrates that repetitive subconcussive impacts can lead to consequential neurological outcomes and may ultimately culminate in chronic traumatic encephalopathy (CTE). One study demonstrated acute vestibular dysfunction in female soccer players following a single heading practice. Another study demonstrated white matter changes on diffusion tensor imaging in the brains of high school football players post-season, despite no formal concussion diagnoses. Moreover, multiple studies have shown that athletes deemed clinically recovered from SRC are at increased risk for further injuries; our prior research revealed soft signs of residual neurologic damage in such post-concussed athletes. These findings indicate that the existing SRC evaluations lack sensitivity in identifying residual neurological impairments. The Spokane mTBI Exam (SME) was previously developed by our group as a tool to identify soft signs following mTBI/concussion. In the present study, we used an abbreviated version of the SME (aSME) to screen 19 male amateur boxers, compared to 9 non-contact male athletes, swimmers. Participants ages 9 to 22 were evaluated pre- and post-activity using the following metrics: near point convergence (NPC), saccades, ocular smooth pursuits, vestibular-ocular reflex, finger-to-nose testing (dysmetria), and hip flexor strength. Findings revealed that 14 of 19 assessed boxers exhibited post-activity deterioration in their aSME evaluations, and 10 of these 14 exhibited worsening in multiple metrics. Loss of hip flexor strength, deterioration of NPC, and dysmetria, in that order, were the most common changes noted in the boxers. Two out of 9 swimmers revealed a post-activity deficit in 2 of these metrics, which normalized on repeat testing. In contrast, boxers who exhibited a post-activity deficit in NPC either stayed the same or worsened on repeat testing. The post-activity decreases in hip flexor strength observed in boxers cannot be attributed solely to fatigue because swimmers, following a comparable duration and intensity of exercise, showed either stable or improved hip flexor strength. Our findings substantiate the aSME as a pivotal tool for bolstering diagnostic sensitivity in detecting and tracking subconcussive trauma. By objectively monitoring neurological soft signs, the aSME fosters a refined and targeted approach to post-traumatic assessments, which may be used to guide informed return-to-play decisions in contact sports and potentially pave the way for tailored rehabilitation strategies.

Measuring cognitive difficulties post-concussion is challenging. ‘Baseline’ testing paradigms have individuals complete neurocognitive tests before a concussion occurs (e.g., pre-season for an athlete), followed by post-injury testing for comparative purposes. Evidence suggests that this is effective, but is not always feasible. The second, ostensibly more common method, is to compare an individual’s post-concussion neurocognitive test scores to published norms. The purpose of this project was to examine the utility of neurocognitive testing to screen for cognitive impairment following concussion in a general adult population, using two study designs. Study 1 involved 343 adults (17-85 years of age) seen within seven days of concussion. Subjective cognitive difficulties were characterized by the Sport Concussion Assessment Tool (SCAT) scores for the four cognitive items. Objective neurocognitive measures included Trails A & B and Symbol Search & Coding (administered at Weeks 1, 2, and 12 post-injury), and a measure of verbal learning and recall and Digit Span (Weeks 2 and 12). Scores placing at or below the 3rd percentile on any measure were classified as ‘impaired’. 174 (50.7%) participants reported ‘mild’ cognitive SCAT symptoms; 124 (36.2%) as ‘moderate’; 45 (13.1%) as ‘severe’. Between 1-26 participants (0.3-7.6%) were classified as ‘impaired’, depending on the neurocognitive measure used. Those with severe subjective cognitive difficulties had lower neurocognitive test scores compared to the other groups, however they were still within the ‘average’ range using normative data. Determining an objective indicator of cognitive impairment related to subjective difficulties using a norms-based approach was not established. Study 2 employed a case-control design using 30 adults with acute concussion and 30, non-concussed control participants. A preliminary analysis of 29 non-concussed controls (median age: 24 [IQR 23-28] years, 20 females (67%), average years of education: 16.4 [SD: 1.4]) and 12 age, sex, and education-matched individuals with concussion (median age: 26 [IQR 24-30] years, 11 (92%) females, average years of education: 16.0 [SD: 2.8]), completed the same neurocognitive measures at Weeks 1, 2, and 8 post-injury. Preliminary analyses showed there were few measures with significant differences between cohorts at any single assessment (Coding Week 1, p=0.047; Delayed Recall Week 8, p=0.028). However, the non-concussed cohort improved significantly on several tests over time where the concussed cohort did not (i.e., Learning Week 1 to 8, non-concussed p=0.002, concussed p=0.134), suggesting an absence of learning effect in the concussed cohort. Full dataset to be presented at the conference. Without a baseline approach, using test norms to qualify and quantify a person’s subjective cognitive symptoms may yield false negative results. Therefore, more specific normative data (i.e., adjusting for learning effects) is needed to accurately evaluate cognitive performance post-concussion. Without this, the clinical focus should be to provide treatment and education for any specific self-reported symptoms.

BACKGROUND: A growing body of literature has demonstrated that aerobic exercise (AE) can be beneficial in improving outcomes from concussion. This evidence resulted in an update to recent consensus guidelines for the treatment of sport-related concussion, which recommend initiating light AE within two days of injury. Most research has focused on athletes recovering from sport-related concussion. Less is known about the principles of AE following non-sport-related concussion. The goal of this pilot study was to examine the efficacy of various methods to inform AE recommendations post-concussion in a general adult population.

METHODS: This pilot study represents a subset of the Toronto Concussion Study population. Participants were eligible for pilot study inclusion if they were 18-45 years of age and at low-risk for underlying cardiac disease (determined by the treating physician). Participants who were either uninterested or ineligible were followed regularly by the clinic physician (“Usual Care” cohort). Eligible participants were randomly assigned to either the “Exercise Testing (ET) plus Usual Care” cohort, or the “Exercise Testing (ET) plus Individualized Prescription” cohort. All randomized participants completed a Buffalo Concussion Treadmill Test (BCTT) within seven days of injury. The “ET plus Usual Care” cohort received usual care AE recommendations, while the “ET plus Individualized Prescription” cohort received an individualized prescription based on their BCTT performance. Participants enrolled in both “ET” cohorts were provided with a heart rate (HR) monitor to wear during all waking hours, until they were deemed to be recovered from their concussion by a clinic physician. Kaplan-Meier survival analyses were conducted to evaluate for differences in time to recovery between each of the study cohorts. Log rank tests were used to compare the survival curves for all analyses.

RESULTS: 75 participants were included in this analysis (average age: 31.2 years [SD 11.4], 65.7% female). 20 participants were eligible and randomized to either the “ET plus Usual Care” cohort, or the “ET plus Individualized Prescription” cohort (10 per arm). There was an observed longer time (restricted mean survival time [RMST]) to recovery of the “Usual Care” cohort (n=55, 7.2 weeks) compared to the combined “ET” cohorts (n=20, 5.7 weeks, p=0.046). However, there was no significant difference in time to recovery between the “ET plus Usual Care” cohort (n=10, 6.2 weeks) and the “ET plus Individualized Prescription” cohort (n=10, 5.0 weeks, p=0.350). There was no significant difference in minutes spent above certain HR thresholds (50-90% of age-predicted max HR) between the two “ET” cohorts (p=0.295-0.968).

CONCLUSION: Normalization of AE early post-concussion, under supervision, appears to improve recovery time post-concussion. Individualized AE prescription did not improve outcomes nor did it alter activity levels in our sample. Future rigorous studies should further examine the role of supervised AE in the acute phase post-concussion.

PURPOSE: To evaluate the effectiveness of the Vision Quality of Life with Time (VisQuaL-T) survey in assessing the visual quality of life in concussed adults.

METHODS: Participants between the ages of 18 to 65 years old were recruited from the Virginia Neuro-Optometry and were referred to the clinic after a concussion diagnosis. Data was collected on the first visit, where the participants responded to the 10 questions in the survey. The survey consisted of a list of the following activities: 1) reading for pleasure, 2) studying for a test/exam, 3) completing homework, 4) completing work in an office setting, 5) being in a crowded location, 6) tolerating habitual lighting, 7) using a smartphone/tablet, 8) playing a computer/console video game, 9) using a computer for general purposes, 10) watching a show on a large screen. Participants were asked to indicate how long it took them to experience any of the following symptoms: headache, dizziness, eye strain, double vision, floating words, blurry vision, inability to pay attention, easily distracted, or sleepy/drowsy. The possible time ratings, a novel feature of VisQuaL-T, were 0-15 min, 15-30 min, 30-45min, 60+ min, and N/A (for activities a participant does not participate in). A composite score between 0 and 3 was derived utilizing the methods in the VisQuaL-T normative manuscript by Dungan Et al. 2023.

RESULTS: Presented data was collected on 40 participants (6 males) with an average age of 39.2 ± 12.4 years and an average of 21.8 ± 33.3 months since injury (4 participants were seen 98, 109, 123, and 126 months after injury). Participants had an average composite score of 1.56 ± 0.57.

CONCLUSIONS: An average composite score of 1.56 is equivalent to approximately 20 minutes. Prior studies have shown that the general population scores an average composite score of 2.4. The utilization of time as a measurement factor has the potential to illicit more concise and quantitative data from a concussed individual. The presented instrument can potentially be more clinically relevant as questions examine how long a patient can perform a task before the onset of symptoms rather than simply reporting whether symptoms are present. This non-generalized symptom scale may potentially be a better indication of their quality of life. The VisQuaL-T can potentially indicate quality of life problems in patients after a concussive event and potentially guide clinical intervention. The survey also has the potential to be used as a recovery tracking tool.