Clinical examination factors that predict delayed recovery in individuals with concussion

Corina Martinez; Zachary Christopherson; Ashley Lake; Heather Myers; Jeffrey R. Bytomski; Robert J. Butler; Chad E. Cook

doi:10.1186/s40945-020-00081-z

Authors

Corina Martinez Department of Physical Therapy and Occupational Therapy, Duke University, DUMC 3965, Durham, NC 27705, USA
Zachary Christopherson Department of Physical Therapy and Occupational Therapy, Duke University, DUMC 3965, Durham, NC 27705, USA
Ashley Lake Department of Physical Therapy and Occupational Therapy, Duke University, DUMC 3965, Durham, NC 27705, USA
Heather Myers Department of Physical Therapy and Occupational Therapy, Duke University, DUMC 3965, Durham, NC 27705, USA
Jeffrey R. Bytomski Department of Orthopedics, Duke University, Durham, NC, USA
Robert J. Butler Division of Physical Therapy, Department of Orthopedics, Duke University, 2200 W. Main Street, Durham, NC 27708, USA
Chad E. Cook Division of Physical Therapy, Department of Orthopedics, Duke University, 2200 W. Main Street, Durham, NC 27708, USA

DOI:

https://doi.org/10.1186/s40945-020-00081-z

Keywords:

Concussion, Post-concussion syndrome, Vestibular

Abstract

Background: Risk factors for prolonged recovery after concussion have been well researched, but specific objective clinical examination findings have not. This study examined whether clinical examination results could predict delayed recovery (DR) in individuals with concussion diagnosis. A secondary aim explored the influence of early examination on individual prognosis. Methods: The study was a retrospective, observational cohort design that included 163 individuals seen at a concussion clinic who were followed longitudinally until cleared for sports activity. Cognitive, visual, balance, vestibular, and cervical clinical testing and symptom assessment were performed at initial evaluation. DR was calculated by taking the median value associated with time to clearance for activity. Bivariate logistic regression analysis was calculated to determine odds ratios (and 95% confidence intervals) for the odds of DR with presence or absence of each clinical finding. Multivariate analyses were used to define the best predictors of DR. Results: 80 of 163 individuals were considered delayed in their clearance to activity. Cognitive impairments (OR = 2.72; 95%CI = 1.40, 5.28), visual exam findings (OR = 2.98; 95%CI = 1.31, 6.80), and vestibular exam findings (OR = 4.28; 95%CI = 2.18, 8.43) all increased the odds of a DR. Multivariate modeling retained cognitive symptoms and clinical examination-vestibular testing as predictors of delayed recovery. Time to examination after injury was a mediator for DR. Conclusions: The clinical examination provides value in identifying individuals who are likely to exhibit a delayed clearance. In particular, vestibular impairments identified clinically at initial evaluation and cognitive symptoms were associated with increased odds of a DR to return to activity. Our data support that early implementation of a standardized clinical examination can help to identify individuals who may be more at risk of prolonged recovery from concussion.