Purpose:
Athletes with sport-related concussion (SRC) have blink reflex abnormalities, and can report combinations of physical, cognitive, fatigue or mood-related symptoms after injury. This study compares blink reflex before and after injury and identifies associations with self-reported symptoms.

Methods:
Blink reflex (EyeStat, BlinkCNS) and Post-Concussion Symptom Scale (max=126) were assessed preseason and within 2 days of SRC. Clustering identified High (HS) and Low (LS) symptom groups. Blink reflex parameters: time to ipsilateral blink (latency), contralateral blink (differential latency), initial velocity, time to open, time to close, number of oscillations, and distance traveled (excursion).

Results:
Differential latency increased (baseline: 4.28±1.8 vs post-injury: 5.33±3.0 ms, p=0.047) and time to close decreased (34.30±5.6 vs 32.38±4.3 ms, p=0.022) after injury on paired t-test, and there was a trend for significance for latency (p=0.094) and oscillations (p=0.074). HS (n=15, 87% male, 20.8±1.5 years, symptoms=43.3±11.4) had slower initial velocity (4.23±0.7 vs 5.16±1.0 pixel/s, p=0.002) than LS (n=23, 74% male, 20.1±1.4 years, symptoms=13.0±6.3), and there was a trend for significance for excursions (p=0.081). Physical symptoms correlated with latency (rho=-0.28, p=0.026) and oscillations (rho=0.37,p=0.003); cognitive correlated with initial velocity (rho=-0.36, p=0.003) and exclusions (rho=-0.38,p=0.002); fatigue correlated with initial velocity (rho=-0.48, p<0.001), time to close (rho=-0.26, p=0.034) and excursion (rho=-0.49, p<0.001). Mood correlated with differential latency (rho=0.49, p<0.001) and initial velocity (rho=-0.30, p=0.014).

Conclusion:
The stimulated blink reflex is abnormal acutely after SRC. Increase in differential latency is suggestive that the contralateral blink reflex arch is less efficient. Decreased time to close with a trend that latency is also faster is suggestive that the blink reflex is excited. The strongest correlations were between increasing differential latency and increasing mood symptoms and decreasing excursions and increasing fatigue.

Significance:
The corneal blink reflex is a primitive brainstem response initiated by light, touch or sound. Technology-assisted objective assessment using a portable blink reflexometer has the potential to aid in SRC diagnosis and validate self-reported symptoms.

Objective: Sport-related concussion (SRC), a subtype of mild traumatic brain injury (mTBI), is common in adolescents. A common clinical outcome of SRC is the development of new anxiety and depressive mood symptoms, which can impair SRC recovery. This study assesses the effect of early, targeted aerobic exercise treatment versus a placebo-like stretching program on recovery in adolescent athletes who report high and low initial mood symptom burden after SRC.

Methods: Exploratory secondary analysis using data from two randomized trials collected in four outpatient clinic settings. Male and female adolescents (13-18 years) diagnosed with SRC within ten days of injury were divided into low (< 6/24 points) or high (≥ 6/24 points) burden based on self-reported symptoms of irritability, sadness, nervousness and feeling more emotional on a 0-6 Likert scale. The main outcome measure was recovering during the intervention period and incidence of Persisting Post-Concussive Symptoms (PPCS).

Results: Out of 198 adolescents with SRC, 156 (79%) reported a low burden of mood symptoms (mean = 1.2 ± 1.65) and 42 (21%) reported a high burden (mean = 9.74 ± 3.70) before randomization. The effect of intervention (exercise versus stretching) was not significant in the low mood symptom burden group (hazard ratio = 0.767, p = 0.128) and was significant in the high burden group (hazard ratio = 0.290, p = 0.005). This corresponds to a 71% reduction in risk for PPCS in the high burden group. High burden of mood symptoms had a positive correlation with high physical, cognitive and sleep symptoms, and a higher number of abnormalities on physical exam, but did not correlate with participant sex or level of exercise tolerance.

Conclusions: Early prescribed aerobic exercise treatment facilitates recovery and significantly reduces the incidence of PPCS in adolescents reporting a high burden of new onset mood symptoms after SRC and should be considered as part of a comprehensive treatment plan for these patients.

BACKGROUND: Traumatic brain injury (TBI) is the leading cause of death and disability for the pediatric population worldwide. With concussions comprising the majority of these TBIs, concussions among children and youth are an established public health concern. However, the management of pediatric concussions, particularly the decision to return to school and activity following concussion, is often inconsistent and a one-size-fits-all approach. To (1) individualize concussion management to each patient’s unique recovery, (2) provide guidance and monitoring for optimal rehabilitation, and (3) revolutionize concussion management in the digital age, the Back2Play App was developed based on CanChild’s evidence-based management strategies and the expertise of pediatric, psychology, and rehabilitation clinicians, machine learning engineers, and exercise science specialists. The purpose of this randomized controlled trial was to evaluate whether the App supports safe and symptom-free return to school and activity.

METHODS: Eligible children and youth aged 10-18 were randomized into an App Group and Usual Care Group. Usual Care Group participants completed a symptom survey once daily, and received typical care which usually includes generic guidelines provided by their physicians. App Group participants received an Apple watch with the Back2Play App that provided interactive feedback and monitored real-time biological variables including heart rate and movement; completed a symptom survey thrice daily; and followed CanChild’s evidence-based management strategies. All participants completed two follow-up interviews to assess recovery progress and ascertain if re-injury occurred.

RESULTS: Preliminary results indicate that at follow-up, 78.7% (37/47) of App Group participants had returned to sports, compared to 59.6% (28/47) of Usual Care Group participants (p = 0.074). At the early stages of the Return to School protocol (RTS Stage 1), the mean self-assessed cognitive scale score that measures cognitive activity was greater in the App Group than in the Usual Care Group (2.70 +/- 0.27 [N=53] vs. 2.01 +/- 0.21 [N=45], p < 0.01; error = 95% CI).

DISCUSSION: Recruitment for Phase 3 of this study is nearing completion, with 130 participants of the 160 target recruited. Although not statistically significant, the number of participants having returned to sports at follow-up was greater in the App Group than in the Usual Care Group, potentially indicating a higher likelihood of returning to normal activities. The mean cognitive scale score was also higher in the App Group compared to the Usual Care Group at the earliest RTS stage, suggesting higher cognitive activity at the early stages of recovery in line with CanChild’s management strategies.

CONCLUSION: Results from this study can inform clinicians of the efficacy of app-based interventions within this population and address the dearth of consistency and personalization in concussion management, ultimately enabling children and youth who have experienced a concussion to return to school and activity safer and sooner.

BACKGROUND: Concussions occur inside and outside of the sports realm – including those resulting from falls, motor vehicle crashes, and violence – yet the emerging concussion response and management evidence is predominantly from the sports perspective. The 6th International Conference on Concussion in Sport, held in October 2022, prompted wide-spread updating of concussion training and resources. Notably, assessments for concussion, and the roles of rest and aerobic physical activity supporting recovery, have been considerably refined.

TRAINING: The Concussion Awareness Training Tool (CATT) provides free evidence-based concussion training tailored to diverse audiences, extending beyond medical professionals, coaches, youth, athletes, and their caregivers, to include educators, workers and their employers, and those supporting survivors of intimate partner violence. Recently launched on its new online platform, the CATT offers up-to-date educational eLearning modules and downloadable resources, each created using an integrated knowledge translation approach. CATT resources include the Concussion Pathway (also adapted for the Motion Picture, Film, and Live Performance industry, and for neurodiverse students); questions to ask your doctor; strategies for return to activity, school, school, and work; accommodations during concussion recovery; and considerations for managing mental health symptoms.

REACH: To date, over 175,000 people worldwide have completed CATT training. The cattonline.com website receives over 17,000 visits per month from over 50 countries: primarily Canada and the United States, as well as the United Kingdom, Australia, China, New Zealand, Ireland, India, South Africa, France and elsewhere. This wide-reaching approach to online concussion education, originally launched in 2013, provides information in both English and French. ELearning modules for medical professionals, coaches, and school professionals are also available Arabic. CATT training has been mandated by over 100 sporting associations, universities, schools, and other organizations in Canada and the United States. This includes 32 universities/colleges across Canada, and BC School Sports representing 450 schools in British Columbia. Furthermore, the University of British Columbia is the first medical school in Canada to incorporate concussion education into its curriculum, using the CATT resources.

EXPANSION: Global education efforts using CATT have focused on East Africa (Uganda, Kenya, Tanzania), Pakistan, Japan, Lebanon, and South Africa. CATT is currently seeking engagement with Indigenous partners within Canada to create culturally appropriate concussion resources.

INTRODUCTION: Patients who suffer from traumatic head injury are at risk of developing traumatic brain injury, traumatic whiplash injury, or both. The majority of these patients present to multiple disciplines of providers including pediatricians, internal medicine, sports medicine, and emergency medicine with nonspecific complaints including headache, dizziness, nausea, brain fog, and anxiety. The majority of these patients self-resolve within 4-6 weeks however approximately 10% will have persistent symptoms for months, years, or indefinitely. Tools like the VOMS (Vestibular Oculomotor Screening Assessment) have been instrumental in screening for visual-vestibular disorders to allow for referral to vestibular physical therapy. However, not all patients fully resolve with standard vestibular physical therapy and may worsen if the etiology is cervical or oculomotor.

METHODS: We present a case series of 15 patients who presented to a transdisciplinary brain injury clinic to be evaluated by neuro-optometry and orthopedic physical therapy after failing vestibular physical therapy post-concussion. The cases have been reviewed with a distinguished national cohort of concussion experts including neuro-optometry, neurosurgery, orthopedic and vestibular physical therapy to propose a novel clinical assessment. Cervical-Oculomotor-Vestibular Assessment (COVA) that could help all providers differentiate cervical, vestibular, and oculomotor dysfunctions to provide more appropriate referrals to rehabilitation specialists and specialty providers.

RESULTS: The subset of patients with refractory or worsening post concussive symptoms following vestibular physical therapy benefit from a clinical assessment based on simple, subjective and objective testing which can be done chairside or bedside based on the nuances of neuro-anatomy and pathophysiology of whiplash vs traumatic brain injury vs traumatic brainstem injury.

CONCLUSION: The cervical, oculomotor, and vestibular systems are intimately connected neuro-anatomically and are often underlying causes of common post-traumatic symptoms like headaches, nausea, dizziness, and brain fog. By varying the methodology of oculomotor testing from current clinical screening assessments, clinicians may be better able to identify the underlying trigger for symptoms, and triage to the appropriate provider and rehabilitation type.