Though a common injury evaluated across many pediatric practice settings, the diagnosis of concussion remains challenging. Most diagnostic consensus statements rely on symptomatology, and the available tools to assist in prognosis rely mainly on symptoms and historical factors. Given the natural evolution of concussion symptoms, and the variability in how symptoms present, these challenges are amplified for providers who evaluate patients shortly after the injury, including emergency department (ED) providers like me, and primary care pediatricians. We at the Minds Matter Concussion Program have been focusing our research efforts on evaluating objective, physiologic markers of injury to assist providers facing these diagnostic challenges.
Two papers recently published by our Minds Matter Concussion Program Team, with a particular focus on our Visio-Vestibular Examination (VVE), highlight these issues. The VVE, advanced by our sports medicine specialists, is a battery of nine tests that examine the visual, oculomotor, and balance systems following head injury. Initially developed in the sports medicine specialty setting, we have been evaluating its usage across practice settings for the past decade.
Reliability of VVE
The first study, published in the American Journal of Emergency Medicine, evaluated the reliability of the VVE among a group of providers practicing in the ED setting, including pediatric emergency medicine physicians, pediatricians, nurse practitioners, and physician assistants. In 155 children ages 6 to 18 presenting following head injury, we found:
- Fair to moderate agreement of the nine exam elements between providers (five out of nine elements in the moderate agreement range)
- Moderate to substantial agreement of the nine exam elements among the same provider (six out of nine elements in the substantial agreement range)
- Higher agreement for nearly all elements among adolescents, with several elements showing near perfect agreement in 15- to 18-year-old patients
- Each additional abnormal examination element increased the odds of a concussion diagnosis by 2.1 times.
- Over 60% of those with a concussion diagnosis had at least three out of nine elements categorized as abnormal, compared to only 9% of those not diagnosed with concussion.
Immediate Versus Delayed Concussion Diagnosis
The second study, published in the Journal of Emergency Medicine, evaluated visit characteristics and outcomes of those patients who received an immediate concussion diagnosis following their head injury compared with those whose diagnosis was delayed. We compared 159 patients ages 6 to 18 who received a diagnosis on their first presentation to either the ED or an urgent care (UC) center, with 85 patients ages 6 to 18 who were seen in the ED/UC, discharged without a concussion diagnosis, and then subsequently returned to care and then diagnosed with a concussion. We found:
- Those with an immediate diagnosis had more significant symptoms inquired about (median five vs. four symptoms) and were more likely to receive a VVE (80% vs. 37%) at their initial visit.
- Among those with a VVE performed, there were more abnormalities on the VVE at the initial visit for those with an immediate diagnosis (83% vs. 26%).
- Those with a delayed diagnosis had a significantly longer time until symptom resolution (21 days vs. 11 days) and prolonged concussion symptoms (odds 4.4 times higher after adjusting for known risk factors).
These findings highlight potential risks associated with a delayed concussion diagnosis and raise the possibility that a distinct concussion phenotype exists with later onset and later resolution of concussion signs and symptoms.
Taken together, these studies show that the VVE is useful in distinguishing concussed from not concussed children following a head injury in the ED setting, that the exam is reliable outside of the specialty setting, and that its standardized usage may ultimately help hasten recovery by improving diagnostic accuracy.
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