Abstract
Symptom-based methods of concussion diagnosis in contact sports result in underdiagnosis and repeated head injury exposure, increasing the risk of long-term disability. Measures of neuro-ophthalmologic (NO) function have the potential to serve as objective aids, but their diagnostic utility is unknown. To identify NO measures that accurately differentiate athletes with and without concussion. This cohort study was conducted among athletes with and without concussion who were aged 17 to 22 years between 2016 and 2017. Eye movements and cognitive function were measured a median of 19 days after injury among patients who had an injury meeting the study definition of concussion while playing a sport (retrospectively selected from a concussion clinic), then compared with a control group of participants without concussion (enrolled from 104 noncontact collegiate athlete volunteers without prior head injury). Data analysis was conducted from November 2019 through May 2020. Concussion. Classification accuracy of clinically important discriminator eye-tracking (ET) metrics. Participants' eye movements were evaluated with a 12-minute ET procedure, yielding 42 metrics related to smooth pursuit eye movement (SPEM), saccades, dynamic visual acuity, and reaction time. Clinically important discriminator metrics were defined as those with significantly different group differences and area under the receiver operator characteristic curves (AUROCs) of at least 0.70. A total of 34 participants with concussions (mean [SD] age, 19.7 [2.4] years; 20 [63%] men) and 54 participants without concussions (mean [SD] age, 20.8 [2.2] years; 31 [57%] men) completed the study. Six ET metrics (ie, simple reaction time, discriminate reaction time, discriminate visual reaction speed, choice visual reaction speed, and reaction time on 2 measures of dynamic visual acuity 2) were found to be clinically important; all were measures of reaction time, and none were related to SPEM. Combined, these 6 metrics had an AUROC of 0.90 (95% CI, 0.80-0.99), a sensitivity of 77.8%, and a specificity of 92.6%. The 6 metrics remained significant on sensitivity testing. In this study, ET measures of slowed visual reaction time had high classification accuracy for concussion. Accurate, objective measures of NO function have the potential to improve concussion recognition and reduce the disability associated with underdiagnosis.
Highlights
It is estimated that 1.6 to 3.8 million sports-related concussions occur annually in the United States.[1]
Six eye tracking (ET) metrics were found to be clinically important; all were measures of reaction time, and none were related to smooth pursuit eye movement (SPEM)
ET Metrics in Participants With and Without Concussion The distributions of 8 of the 42 ET metrics (19%) were significantly different between participants with and without concussion after Bonferonni correction. Of these 8 ET metrics, 6 (75%) had an area under the receiver operator characteristic curves (AUROCs) of at least 0.70 and were considered clinically important; all were measures of reaction time and none were related to SPEM (Table 2)
Summary
It is estimated that 1.6 to 3.8 million sports-related concussions occur annually in the United States.[1] Accurate diagnosis is important for managing safe return to play (RTP) and academic activities. The current symptom-based method of concussion diagnosis has been criticized for being subjective,[2] allowing injured athletes to downplay symptoms to avoid being removed from play.[3] This can result in exposure to another head injury before recovery is complete, resulting in prolonged recovery.[4,5] An objective diagnostic aid has the potential to improve concussion recognition and reduce or prevent disability associated with premature RTP. Evaluation of NO response has been proposed as a way to detect neurologic injury after a head impact and aid in the diagnosis of concussion.[18,19,20]
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