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Screening for lifetime concussion in athletes: Importance of oculomotor measures

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Hypothesis/objective: The purpose of the present study was to determine the utility of oculomotor-based evaluation protocols in screening for lifetime concussion incidence in elite hockey players. Methods: Forty-two Division I collegiate male and female hockey players were evaluated using the guidelines of an overall oculomotor-based diagnostic clinical test protocol for the mTBI population. The sensitivity of the collected measures to lifetime concussion was then compared with the corresponding sensitivity of measures of neuropsychological functioning (ImPACT) often used with athletes for acute concussion diagnosis. Results: This model showed that a hockey player with a Near Point of Fixation Disparity (NPFD) equal to or greater than 15 cm, Visagraph comprehension rate less than 85% and the total score on part A of an ADHD questionnaire equal to or greater than 11 was on average 10.72-times more likely to have previously suffered a concussion than an athlete with lower values on the NPFD and ADHD questionnaire and a higher comprehension rate on the Visagraph. None of the IMPACT baseline assessment measures were significantly predictive of the individual's concussion history. Conclusion: The study provides a relatively sensitive screening tool to assess the probability of previous concussion(s) in an athlete. This model may allow athletic personnel to address in a timely manner the risks associated with repeat concussions and to develop individualized concussion management protocols.
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... 32À34 Concerning the physical exam, saccadic testing, vergence amplitude/facility testing, accommodative amplitude/facility testing, and fixation disparity (FD) assessment [i.e., associated heterophoria (AH) testing] are all crucial. 35,36 If such tests are not performed, the assumption of normality might not only be incorrect, but can result in limited gains in other rehabilitative areas, such as vestibular rehabilitation therapy or physiotherapy. This is because patients with visual concerns after mTBI are less sure of their own positioning in space 37 and require correct visual cues to promote better balance. ...
... 36 Notably, patients with reduced oculomotor function are far more likely to reveal a history of concussion. 35 A basic saccadic eye movement is a rapid refixation from one point to another. 68 In order to initiate a saccade, the visual system must not only release fixation from the point of regard, but also preplan where the next fixation will take hold, a process which ultimately requires peripheral awareness. ...
... 134,135 Isolated measurements of vergence can be accomplished employing graded prisms through which a subject looks from fixed distances; measuring vergence while changing the target distance simultaneously challenges the accommodation system and, therefore, should be avoided if only vergence measurements are sought. Vergence deficits (of amplitude and/or facility) have been shown to be quite common in mTBI, 20,35,136 with some forms of vergence deficit being reported in approximately 45% of adolescent concussions. 22 CI is the inability to move both eyes inwards without undue strain. ...
... At the same time positive benefits of such training are expected only under the assumption of intact visual "hardware." In many athletes, however, visual hardware (such as accommodation and vergence) may be compromised due to a previous history of concussion (Thiagarajan et al., 2011;Poltavski and Biberdorf, 2014), which may potentially compromise sportsvision training. Further deficits are also observed in visual signal processing. ...
... flippers) phoropter-based near testing including negative relative vergence; positive relative vergence; positive relative accommodation; negative relative accommodation; and phoropter-based associative vergence measures and Nearpoint of Fixation Disparity (NPFD by Vision Assessment Corporation). The full description of oculomotor protocols used in the present study can be found in Poltavski and Biberdorf (2014). ...
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In the present study we combined popular methods of sports vision training (SVT) with traditional oculomotor protocols of Optometric Vision Therapy (OVT) and electrophysiological indexes of EEG and VEP activity to monitor training progress and changes in performance of youth ice hockey players without the history of concussion. We hypothesized that administration of OVT protocols before SVT training may result in larger performance improvements compared to the reverse order due to the initial strengthening of visual hardware capable of handling greater demands during training of visuomotor integration and information processing skills (visual software). In a cross-over design 53 youth ice hockey players (ages 13–18) were randomly assigned to one of the two training groups. Group one (hardware-software group) completed 5 weeks of oculomotor training first followed by 5 weeks of software training. For group 2 (software-hardware) the order of procedures were reversed. After 10 weeks of training both groups significantly improved their performance on all but one measure of the Nike/Senaptec Sensory station measures. Additionally, the software-hardware training order resulted in significantly lower frontal theta-to-gamma amplitude ratios on the Nike/Senaptec test of Near-Far Quickness as well as in faster P100 latencies. Both training orders also resulted in significant decreases in post-treatment P100 amplitude to transient VEP stimuli as well as decreased theta-gamma ratios for perception span, Go/No-Go and Hand Reaction time. The observed changes in the electrophysiological indexes in the present study are thought to reflect greater efficiency in visual information processing and cognitive resource allocation following 10 weeks of visual training. There is also some evidence of the greater effectiveness of the software-hardware training order possibly due to the improved preparedness of the oculomotor system in the youth athletes for administration of targeted protocols of the Optometric Vision Therapy.
... While it is known that visual symptoms present frequently after mTBI and patients are often found to demonstrate disorders listed above, patients might only describe vague complaints such as difficulty reading, or eyes not working together or simply "discomfort around the eyes" (Kontos et al., 2020;Lovell, 2004). The peri-ocular and ocular headache that might be described as a "pressure feeling around the eyes" was seen with more than a 10-fold rate in concussed athletes compared to controls (Poltavski, 2014). ...
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Article
Background: Post-traumatic headache is the most common sequela of brain injury and can last months or years after the damaging event. Many headache types are associated with visual concerns also known to stem from concussion. Objectives: To describe the various headache types seen after head injury and demonstrate how they impact or are impacted by the visual system. Methods: We will mirror the International Classification of Headache Disorders (ICHD) format to demonstrate the variety of headaches following brain injury and relate correlates to the visual pathways. The PubMed database was searched using terms such as headache, head pain, vision, concussion, traumatic brain injury, glare, visuomotor pathways. Results: Every type of headache described in the International Classification of Headache Disorders Edition III can be initiated or worsened after head trauma. Furthermore, there is very often a direct or indirect impact upon the visual system for each of these headaches. Conclusion: Headaches of every described type in the ICHD can be caused by brain injury and all are related in some way to the afferent, efferent or association areas of the visual system.
... Collegiate hockey players with a lifetime history of concussion did not appear to differ in their accommodative amplitude compared to the players with no concussion history; however, the concussion history group did have a significantly larger near point of fixation disparity, a measure of convergence insufficiency. 26 While, in our study, concussion history had no association with BOX score or NPC, we did find a significant association between concussion history and greater BAA distance. ( Figure 2C) Successful accommodation occurs when an individual can maintain focus on an object of interest, and it is frequently impaired in concussion patients due to the number of neural pathways associated with the accommodative system that are disrupted following injury. ...
Article
Significance: Concussions are complex injuries that require a multifaceted testing battery. Vision impairments are common after concussion, but it is unknown exactly how eye tracking may be affected after injury and how it is associated with other clinical concussion assessments. Purpose: This study aimed to (1) examine the relationship between eye tracking performance (BOX score) and other common concussion evaluations, (2) identify if eye tracking adds novel information that augments baseline concussion evaluations, and (3) examine the effect of age, concussion history, and attention-deficit/hyperactivity disorder on eye tracking and other ophthalmological measures. Methods: A total of 102 male high school football athletes (age, 16.0 years; 95% confidence interval, 15.8 to 16.2 years) completed a series of visual and neurocognitive tests during their pre-season baseline assessment. The main outcome measures were BOX score, near point of convergence (NPC) distance, binocular accommodative amplitude (BAA) distance, Standardized Assessment of Concussion score, and Immediate Post-Concussion Assessment and Cognitive Testing composite scores. Results: BOX score was not significantly associated with symptoms, Standardized Assessment of Concussion score, NPC distance, BAA distance, or any Immediate Post-Concussion Assessment and Cognitive Testing composite scores. Age, concussion history, attention-deficit/hyperactivity disorder, and number of prior years playing football were not significantly associated with BOX score or NPC distance, but there was a significant association between concussion history and greater BAA distance (β = 1.60; 95% confidence interval = 0.19 to 3.01; P < .03). The BOX score cutoff of 10 resulted in a 12% false-positive rate. Conclusions: Eye tracking was not significantly associated with the commonly used clinical concussion assessments. These results suggest that an objective eye tracking variable may be a valuable addition to the current concussion battery.
... Some researchers have even identified an oculomotor sub-type of concussion in which vision problems are the primary factor causing persistent symptoms Ellis et al., 2015). Others have suggested the importance of incorporating oculomotor testing into the physician medical assessment of concussive brain injury (Master et al., 2018a(Master et al., , 2018bZasler et al., 2019;Ventura et al., 2015;Galetta et al., 2015;Mucha et al., 2014;Poltavski and Biberdorf, 2014;Raghuram et al., 2019). Given these multiple reports (Swanson et al., 2017;Pearce et al., 2015) suggesting that vision problems play a role in concussion recovery, it is surprising that there are relatively few prospective studies investigating the frequency of post-concussion vision disorders, particularly in the pediatric population. ...
Article
The purpose of the study was to determine the frequency of vision diagnoses after concussion in adolescents and evaluate the sensitivity and specificity of physician-administered screening for detecting convergence and accommodative disorders post-concussion. We enrolled participants 11 to 17 years old, assessed 4 to 12 weeks following a diagnosed concussion. During the initial concussion examination, a sports medicine physician measured the near point of convergence (NPC), monocular accommodative amplitude (AA), and symptoms using the Convergence Insufficiency Symptom Survey (CISS). A comprehensive oculomotor evaluation was performed by an optometrist. One hundred and thirteen adolescents were enrolled, with a mean age of 15.2 years. Seventy-nine of the 113 (70%) participants had at least one oculomotor diagnosis after concussion, with the most common problems being vergence disorders (60%) and accommodative disorders (57%). The most common vergence disorder was convergence insufficiency (35%). Among accommodative disorders, the most common problem was accommodative insufficiency (35%). In all, 47% of the participants had more than one oculomotor diagnosis following concussion. The sensitivity of physician screening using measures of NPC, AA, and CISS for detecting convergence and accommodative insufficiency was 63%, 43%, 48%, respectively. The results of this study provide additional evidence that vision problems are common in adolescents with persistent concussion symptoms in the sub-acute phase 4 to 12 weeks post-concussion, and current physician screening methods using the NPC, AA, or the CISS underperform. Thus, it is prudent that adolescents with post-concussion symptoms lasting more than 4 weeks post injury receive a comprehensive oculomotor examination.
... 27 A recent study has found that the NFPD break point is a sensitive predictor of past history of concussion, suggesting that this may be an important tool for rinkside diagnosis of concussion. 28 We propose to use the NPFD as a measure of the disruption of the accommodative-vergence system in athletes suspected of having sustained a concussion. Wearing polaroid glasses, the athlete views an E target at the center of a "plus" sign formed by two vertical and two horizontal arrows on the NPFD target. ...
... 1,2 Recent studies show that concussion may also lead to clinically impaired smooth pursuit and saccadic function, increased near point of convergence to receded near point of convergence, and symptom exacerbation with optokinetic stimulation. [3][4][5][6][7] More objective studies including eye movement recordings show that athletes with concussion have difficulty holding gaze stable and in performing saccadic and accommodative tasks, demonstrating the need for more research into the clinical utility of visuo-oculomotor function in concussion. [8][9][10] The pathophysiology of oculomotor dysfunction associated with concussion is not well understood. ...
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Article
Significance: Oculomotor tests in concussion commonly show impairment in smooth pursuit and saccadic function. Honing in on the systems likely to be affected by concussion will streamline use of oculomotor function as a supplemental diagnostic and prognostic tool, as well as improve our understanding of the pathophysiology of concussion. Purpose: This study investigates oculomotor function between concussed and healthy collegiate athletes and determines measurement test-retest reliability of those tools. Methods: Eighty-seven healthy athletes were recruited from a U.S. Division 1 sports university and completed a 30-minute vestibular ocular testing battery in an enclosed rotary chair system equipped with 100-Hz eye-tracking goggles. Forty-three individuals completed the battery twice. Twenty-eight individuals with a current diagnosis of concussion also completed the battery. All participants were aged 18 to 24 years. Bivariate statistical tests examined differences in scores across groups, and intraclass coefficients were computed to test reliability. Results: Concussed individuals had significantly longer saccadic, visual, and dual-task reaction times and reduced saccadic accuracy. There was no difference in optokinetic reflex gain, but few concussed individuals tolerated the task. Reaction time latencies and optokinetic gain show moderate test-retest reliability. Smooth pursuit tasks and saccadic accuracies showed poor test-retest reliability. Conclusions: Saccadic latency was the most sensitive oculomotor function to change after concussion and was reliable over time. Saccadic accuracy was significantly lower in the concussed group but had poor retest reliability. Optokinetic gain may warrant more investigation because of its high test-retest reliability and symptom provocation in concussion, despite not showing a significant difference between groups.
... [14,15] It is quite possible that the current lab and field testing paradigms have not included the most sensitive and specific balance tests. [16] One of the most interesting and promising areas includes examining oculomotor, vestibular and reaction time (OVRT) reflexes in response to a variety of visual and vestibular challenges. In this paper, we describe the use of a panel of OVRT tests performed with a set of infrared goggles on a rotational chair platform in the diagnosis of mTBI. ...
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Article
Background Despite the prevalence of mild traumatic brain injury (mTBI, concussion) in a wide range of occupational, sport, and military settings, accurate diagnosis and optimal treatment of concussive injuries are delayed by several challenging obstacles. Ability to measure the multisensory functional integrity of numerous neuroanatomical pathways with multiple tasks (oculomotor, vestibular and reaction time) can capture impairments of brain function. Methods 106 mTBI patients and 300 control subjects were tested in the vestibular labs at 2 military hospitals. Patients were tested 3 times at average 2.5, 8.5 and 15.8 days post-injury. All patients completed a health history questionnaire, a dizziness handicap index (DHI), a functional gait index (FGI), and Trail Making Tests (TMTs) and were assessed by a battery of tests with video-oculography (I-Portal VOG) comprised of a head mounted, high speed eye tracking system on a rotary chair device (I-Portal Neuro-Otologic Test Center). The individuals in the study performed multiple tests including saccades, antisaccade, pursuit tracking, nystagmus, optokinetic, vestibular motion, and reaction time. Results No single test was sufficiently predictive to have separation between controls and mTBI subjects but results from a computer controlled rotational head impulse test (crHIT), antisaccade and predictive saccade were highly correlated with mTBI for the first test session. Longitudinally, for example, 74% of patients in session 1, 56% in session 2% and 51% in session 3 had in crHIT gain or absolute asymmetry above 95% of the respective control's distribution. Conclusion These results suggest that vestibular, oculomotor and reaction time tests using can provide an objective and reliable method of capturing and quantifying abnormal response in patients with mTBI. In addition, this type of testing can be used to monitor the recovery process.
Article
Traumatic brain injury (TBI) refers to the alteration of typical brain function that occurs following a blow to the head. Even a mild case of traumatic brain injury (mTBI) can lead to long-term impairment, so accurate and timely detection is vital. Visual symptoms are common following mTBI, so while it may seem to fall outside their typical scope of practice, optometrists are ideally qualified to assess the visual impacts and help with the diagnosis of mTBI. Given that mTBI is challenging to objectively diagnose and has no universally accepted diagnostic criteria, clinicians can lack confidence in diagnosing mTBI, and be hesitant in becoming involved in the management of such patients. The development of easily quantifiable techniques using eye tracking as an objective diagnostic tool provides practitioners with an easier pathway into the field, assigning numerical values to parameters which are difficult to assess using conventional optometric tests. As this evolving technology becomes increasingly integrated into optometric clinical settings, the potential for it to identify deficits accurately and reliably in patients following mTBI, and to monitor both their recovery and the effectiveness of potential treatments will increase. This paper provides an overview of clinical tests, relevant to optometrists, that can uncover oculomotor, attentional, and exteroceptive deficits following a mTBI, so that an optometrist with an interest in eye tracking can play a role in the detection and monitoring of mTBI symptoms.
Article
Collision sports are an integral part of Australian culture. The most common collision sports in Australia are Australian rules football, rugby union, and rugby league. Each of these sports often results in participants sustaining mild brain traumas such as concussive and subconcussive injuries. However, the majority of previous studies and reviews pertaining to the neurological implications of sustaining mild brain traumas while engaging in collision sports have focused on those popular in North America and Europe. As part of this 2020 International Neurotrauma Symposium special issue, which highlights Australian neurotrauma research, this paper will therefore review the burden of mild brain traumas in Australian collision sport athletes. Specifically, this review will first provide an overview of the burden of mild brain trauma in Australian collision sports, followed by a summary of the previous studies that have investigated neurocognition, ocular motor function, neuroimaging and fluid biomarkers, as well as neuropathological outcomes in Australian collision sport athletes. A review of the literature indicates that although Australians have contributed to the field, several knowledge gaps and limitations currently exist. These include important questions related to sex differences, the identification and implementation of blood and imaging biomarkers, the need for consistent study designs and common data elements, as well as more multimodal studies. We conclude that while Australia has had an active history of investigating the neurological impact of collision sport participation, further research is clearly needed to better understand these consequences in Australian athletes, and how they can be mitigated.
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OBJECTIVE Cerebral concussion is common in collision sports such as football, yet the chronic neurological effects of recurrent concussion are not well understood. The purpose of our study was to investigate the association between previous head injury and the likelihood of developing mild cognitive impairment (MCI) and Alzheimer's disease in a unique group of retired professional football players with previous head injury exposure. METHODS A general health questionnaire was completed by 2552 retired professional football players with an average age of 53.8 (±13.4) years and an average professional football playing career of 6.6 (± 3.6) years. A second questionnaire focusing on memory and issues related to MCI was then completed by a subset of 758 retired professional football players (≥50 yr of age). Results on MCI were then cross-tabulated with results from the original health questionnaire for this subset of older retirees. RESULTS Of the former players, 61% sustained at least one concussion during their professional football career, and 24% sustained three or more concussions. Statistical analysis of the data identified an association between recurrent concussion and clinically diagnosed MCI (χ² = 7.82, df = 2, P = 0.02) and self-reported significant memory impairments (χ² = 19.75, df = 2, P = 0.001). Retired players with three or more reported concussions had a fivefold prevalence of MCI diagnosis and a threefold prevalence of reported significant memory problems compared with retirees without a history of concussion. Although there was not an association between recurrent concussion and Alzheimer's disease, we observed an earlier onset of Alzheimer's disease in the retirees than in the general American male population CONCLUSION Our findings suggest that the onset of dementia-related syndromes may be initiated by repetitive cerebral concussions in professional football players.
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Visual Diagnosis and Care of the Patient with Special Needsprovides a thorough review of the eye and vision care needs of patients with special needs. This book gives you a better understanding of the most frequently encountered developmental and acquired disabilities seen in the eye care practitioner's office. These disabilities include patients with autism, brain injury, Fragile X syndrome and Down syndrome, as well as those with psychiatric illness, dual diagnosis, and more. The text discusses, in great detail, the visual issues inherent in these populations and their possible treatment. A group of authors with approximately 500 years of experience in the field of eye care and special populations have been brought together to develop this comprehensive reference. It may appear that this book is written primarily for eye care practitioners such as optometrists and ophthalmologists, while vision is the overriding topic, this book serves as an excellent resource for a multitude of professions including those engaged in occupational therapy, physical therapy, speech and language therapy, physiatry, social work, pediatric medicine, and special education. "There is literally no other book that covers this very important subject area. It is structured by common conditions that lead to special needs so that the reader can easily access areas they need more information in. The writing style and tone of the book are very clear and simple. This text could also be easily read by lay person carers of special needs patients. This area of work within eye health in the world is very much neglected. It is a groundbreaking piece of work to help the most disabled of people in our modern society. In addition they have done a great job of a most complex task." - BMA Medical Book Award reviewer, 2013 BMA Medical Book Awards. © 2012 Wolters Kluwer Health, Lippincott Williams & Wilkins.All rights reserved.
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