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Vision and Vestibular System Dysfunction Predicts Prolonged Concussion Recovery in Children

Master, Christina, L., MD, CAQSM*,†; Master, Stephen, R., MD, PhD; Wiebe, Douglas, J., PhD§; Storey, Eileen, P., AB*; Lockyer, Julia, E., MS*; Podolak, Olivia, E., MD*; Grady, Matthew, F., MD, CAQSM*,†

Clinical Journal of Sport Medicine: March 2018 - Volume 28 - Issue 2 - p 139–145
doi: 10.1097/JSM.0000000000000507
Original Research

Objective: Up to one-third of children with concussion have prolonged symptoms lasting beyond 4 weeks. Vision and vestibular dysfunction is common after concussion. It is unknown whether such dysfunction predicts prolonged recovery. We sought to determine which vision or vestibular problems predict prolonged recovery in children.

Design: A retrospective cohort of pediatric patients with concussion.

Setting: A subspecialty pediatric concussion program.

Patients (or Participants): Four hundred thirty-two patient records were abstracted.

Assessment of Risk Factors: Presence of vision or vestibular dysfunction upon presentation to the subspecialty concussion program.

Main Outcome Measures: The main outcome of interest was time to clinical recovery, defined by discharge from clinical follow-up, including resolution of acute symptoms, resumption of normal physical and cognitive activity, and normalization of physical examination findings to functional levels.

Results: Study subjects were 5 to 18 years (median = 14). A total of 378 of 432 subjects (88%) presented with vision or vestibular problems. A history of motion sickness was associated with vestibular dysfunction. Younger age, public insurance, and presence of headache were associated with later presentation for subspecialty concussion care. Vision and vestibular problems were associated within distinct clusters. Provocable symptoms with vestibulo-ocular reflex (VOR) and smooth pursuits and abnormal balance and accommodative amplitude (AA) predicted prolonged recovery time.

Conclusions: Vision and vestibular problems predict prolonged concussion recovery in children. A history of motion sickness may be an important premorbid factor. Public insurance status may represent problems with disparities in access to concussion care. Vision assessments in concussion must include smooth pursuits, saccades, near point of convergence (NPC), and accommodative amplitude (AA). A comprehensive, multidomain assessment is essential to predict prolonged recovery time and enable active intervention with specific school accommodations and targeted rehabilitation.

*Division of Orthopaedics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;

Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania;

Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York; and

§Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Corresponding Author: Christina L. Master, MD, CAQSM, Division of Orthopaedics, The Children's Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104 (

The authors report no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Received January 24, 2017

Accepted July 22, 2017

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