Neurosensory Deficits Vary as a Function of Point of Care in Pediatric Mild Traumatic Brain Injury

Abstract

Neurosensory abnormalities are frequently observed following pediatric mild traumatic brain injury (pmTBI) and may underlie the expression of several common concussion symptoms and delay recovery. Importantly, active evaluation of neurosensory functioning more closely approximates real-world (e.g., physical and academic) environments that provoke symptom worsening. The current study determined whether symptom provocation (i.e., during neurosensory examination) improved classification accuracy relative to pre-examination symptom levels and whether symptoms varied as a function of point of care. Eighty-one pmTBI were recruited from the pediatric emergency department (PED; n = 40) or outpatient concussion clinic (n = 41), along with matched (age, sex, and education) healthy controls (HC; n = 40). All participants completed a brief (∼ 12 min) standardized neurosensory examination and clinical questionnaires. The magnitude of symptom provocation upon neurosensory examination was significantly higher for concussion clinic than for PED patients. Symptom provocation significantly improved diagnostic classification accuracy relative to pre-examination symptom levels, although the magnitude of improvement was modest, and was greater in the concussion clinic. In contrast, PED patients exhibited worse performance on measures of balance, vision, and oculomotor functioning than the concussion clinic patients, with no differences observed between both samples and HC. Despite modest sample sizes, current findings suggest that point of care represents a critical but highly under-studied variable that may influence outcomes following pmTBI. Studies that rely on recruitment from a single point of care may not generalize to the entire pmTBI population in terms of how neurosensory deficits affect recovery.

Keywords: neurosensory; ocular motor; pmTBI; recovery; vestibular; vision.

FIG. 1.

(A) Presents scatter box plots representing the total pre-examination symptom (SX) burden for each group (HC, healthy controls; NM, University of New Mexico Hospital Emergency Department patients; CH, The Children's Hospital of Philadelphia Minds Matter Concussion Program patients). The dashed line indicates the 95th percentile for pre-examination symptoms in HC. Symptom provocation (Prov/positive symptom change = Δ Pos SX) and symptom variability (Var/change in symptom = Δ SX; C) following a non-neurosensory task (DDFS, double dorsiflexion foot stretch) are presented in B and C, respectively. D and E present scatter plots depicting the relationship between the number of days post-injury and pre-examination symptoms experienced by the NM and CH groups.

FIG. 2.

Scatter box plots depicting symptom provocation across all tests (sum of the positive change in symptoms following each individual test = ∑ Δ Pos SX; A) and following each individual test (positive symptom change following each of individual test = Δ Pos SX; B–D) for each group (HC, healthy controls; NM, University of New Mexico Hospital Emergency Department patients; CH, The Children's Hospital of Philadelphia Minds Matter Concussion Program patients). Labels for individual tests include: SMP, smooth pursuits; SAH, horizontal saccades; SAV, vertical saccades; VOH, horizontal vestibular-ocular reflex; VOV, vertical vestibular-ocular reflex; VIM, visual motion sensitivity; NPC, near point of convergence; MAC, monocular accommodative amplitude; TG, tandem gait; KD, King–Devick test.

FIG. 3.

Box plots depicting quantifiable data for near point of convergence distance (NPC; A), left (L) and right (R) monocular accommodative amplitude (MAC; B and C), King–Devick (KD) time (D) and errors (E), and tandem gait errors (TG; F) across groups (HC, healthy controls; NM, University of New Mexico Hospital Emergency Department patients; CH, The Children's Hospital of Philadelphia Minds Matter Concussion Program patients). Per convention, statistical tests were conducted on rank-transformed data, whereas untransformed scores are presented in figures.