Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2025 Sep 1.
Published in final edited form as: Phys Ther Sport. 2024 Jul 11;69:33–39. doi: 10.1016/j.ptsp.2024.07.002

Cervical Spine Proprioception and Vestibular/Oculomotor Function: An Observational Study Comparing Young Adults With and Without a Concussion History

Katherine L Smulligan 1,2, Patrick Carry 1,2, Andrew C Smith 3, Carrie Esopenko 4, Christine M Baugh 5, Julie C Wilson 1,2,6, David R Howell 1,2
PMCID: PMC11343652  NIHMSID: NIHMS2010408  PMID: 39013262

Abstract

Objective:

To investigate dizziness, vestibular/oculomotor symptoms, and cervical spine proprioception among adults with/without a concussion history.

Methods:

Adults ages 18–40 years with/without a concussion history completed: dizziness handicap inventory (DHI), visio-vestibular exam (VVE), and head repositioning accuracy (HRA, assesses cervical spine proprioception). Linear regression models were used to assess relationships between (1) concussion/no concussion history group and VVE, HRA, and DHI, and (2) DHI with HRA and VVE for the concussion history group.

Results:

We enrolled 42 participants with concussion history (age=26.5±4.5 years, 79% female, mean=1.4±0.8 years post-concussion) and 46 without (age=27.0±3.8 years, 74% female). Concussion history was associated with worse HRA (β=1.23, 95% confidence interval [CI]: 0.77, 1.68; p<0.001), more positive VVE subtests (β=3.01, 95%CI: 2.32, 3.70; p<0.001), and higher DHI scores (β=9.79, 95%CI: 6.27, 13.32; p<0.001) after covariate adjustment. For the concussion history group, number of positive VVE subtests was significantly associated with DHI score (β=3.78, 95%CI: 2.30, 5.26; p<0.001) after covariate adjustment, while HRA error was not (β=1.10, 95%CI: −2.32, 4.51; p=0.52).

Conclusions:

Vestibular/oculomotor symptom provocation and cervical spine proprioception impairments may persist chronically (i.e., 3 years) after concussion. Assessing dizziness, vestibular/oculomotor and cervical spine function after concussion may inform patient-specific treatments to address ongoing dysfunction.

Keywords: Dizziness, mild traumatic brain injury, neck, assessment

Introduction

Concussions cause a myriad of clinical symptoms which typically resolve within 4 weeks after injury, though some individuals experience persisting symptoms beyond this timeframe.1 One of the most frequently reported symptoms of concussion is dizziness,2 which can also take days to weeks to resolve. The underlying factors contributing to post-concussion dizziness are often not thoroughly evaluated through routine clinical evaluations, which use only a single question on a concussion symptom scale.3,4 However, self-reported dizziness may last 6 months or longer after concussion, after other symptoms have resolved, suggesting that underlying impairments persist beyond accepted clinical recovery.5 Post-concussion dizziness is associated with increased anxiety and depressive symptoms, and reduced quality of life.6,7 Thus, understanding the underlying factors contributing to dizziness is crucial for optimizing recovery following concussion.

While self-reported dizziness suggests underlying impairment, the presence of dizziness is non-specific and does not indicate which systems may be impaired.5,8 Dizziness is a complex and multifactorial symptom, and may be associated with vestibular/oculomotor system and/or cervical spine deficits.9 Vestibular/oculomotor dysfunction is commonly observed within the days to weeks after concussion, can effectively distinguish between those with and without concussion, and is associated with developing persisting concussion symptoms.10–12 Similarly, impaired cervical spine proprioception has been observed within 3 weeks of concussion,13 and a recent systematic review reported that 90% of individuals experiencing persisting symptoms after concussion exhibited cervical spine symptoms (i.e., headache, dizziness, neck pain).14 Given that the cervical spine, vestibular, and oculomotor systems are each associated with dizziness, impairment in any or all of these systems may underpin dizziness.9 The interdependence between these systems highlights the need for an individualized assessment approach addressing each system to identify all potential sources of impairment.8,14

In addition to higher levels of self-reported dizziness, patients who are beyond the acute post-concussion timeframe (1–6 months post-injury) may have more cervical spine, sensorimotor, and vestibular/oculomotor impairments compared to uninjured controls.15,16 These impairments are observed even among those who reported concussion symptom resolution, demonstrating that cervical spine or vestibular/oculomotor impairments may persist beyond clinical recovery.15,16 The integration of accurate sensory information from the cervical spine, vestibular, and oculomotor systems is necessary for postural stability and orientation in space.17,18 It is plausible that lingering dysfunction in one or more of these systems after concussion may impair postural control, thus predisposing individuals to subsequent post-concussion injury. Individuals with concussion have been reported to sustain subsequent injuries at higher rates relative to uninjured controls, and this increased risk has been reported up to 3 years after concussion,19–22 well beyond the timeframe that vestibular, oculomotor, and cervical spine deficits have been observed (i.e., within 6 months post-concussion).15,16 Understanding whether cervical spine and/or vestibular/oculomotor deficits exist during this time frame (i.e., 6 months to 3 years after concussion) is critical to inform effective clinical assessments and to identify feasible treatment approaches to reduce poor outcomes associated with lingering functional deficits.

Therefore, the purpose of our study was to investigate dizziness, cervical spine proprioception, and vestibular/oculomotor symptom provocation among adults who had experienced a concussion 6 months to 3 years prior to evaluation compared to uninjured adults. We hypothesized that individuals with a concussion history would have worse cervical spine proprioception, more vestibular/oculomotor symptom provocation, and higher levels of self-reported dizziness compared to participants without a concussion history. Secondarily, we investigated the relationships between self-reported dizziness and cervical spine and vestibular/oculomotor measures among those with a recent history of concussion. We hypothesized that worse cervical spine proprioception and more vestibular/oculomotor symptom provocation would be moderately correlated with higher self-reported dizziness.

Methods

Participants

We performed a cross-sectional study of young adults with and without a concussion history between August 2021 and September 2023. We recruited participants 18–40 years of age using social media posts, printed/emailed flyers, and word of mouth advertising on a medical research campus and the surrounding community. Participants in the concussion history group were eligible for study inclusion if they had been diagnosed with a concussion by a physician or athletic trainer 6 months to 3 years prior to enrollment and were no longer receiving medical care for their concussion. Concussion definition aligned with the current consensus statement on concussion in sport definition at the time of study enrollment.1,23 Participants without a concussion history were eligible if they had no prior history of diagnosed concussion or traumatic brain injury. Exclusion criteria were any current injuries or pre-existing neurological conditions that limited physical activity or unassisted walking. Prior to study commencement, the protocol was reviewed and approved by the local institutional review board. All participants provided written informed consent prior to study participation.

Outcome Measures

During the study assessment, participants completed an intake form consisting of demographic information (i.e., age, sex, race, ethnicity), prior medical history, and current dizziness ratings. The concussion history group provided information about the most recent and all prior concussions, including the number of previous diagnosed concussions sustained, the symptoms experienced due to the most recent concussion, and concussion symptom duration (number of weeks participants experienced symptoms). Participants also self-reported their physical activity levels by responding to questions about physical activity frequency (number of days per week participating in moderate intensity physical activity for >15 minutes), duration (number of minutes per exercise session), and average intensity of exercise sessions (on a scale of 1–7; 1: low intensity, minimal heart-rate increase; 4: moderate intensity, increased heart rate but some resting; 7: high intensity, significant heart rate increase and minimal rest). Participants rated their current dizziness severity using the Dizziness Handicap Inventory (DHI), consisting of 25 questions about dizziness severity.24 The DHI score range is 0–100 in increments of 2, with higher scores indicating more severe dizziness related impairment.

One rater, a licensed physical therapist, completed all vestibular/oculomotor and cervical spine assessments. Vestibular/oculomotor function was assessed using the visio-vestibular exam (VVE).11,25 Participants completed smooth pursuits, saccades (horizontal and vertical), vestibulo-ocular reflex (horizontal and vertical), and visual motion sensitivity (horizontal and vertical). After performing each VVE subtest, participants reported the onset or worsening of any common concussion or visual symptoms (i.e., dizziness, headache, nausea, eye fatigue, eye pain). Symptom provocation was recorded as a binary (yes/no) response.11 Our primary outcome was the total number of VVE subtests (range= 0–7) that provoked symptoms.

We used head repositioning accuracy (HRA) to assess cervical spine proprioception, assessing the accuracy of returning the head to a neutral starting position with eyes closed after maximal rotation.26,27 Participants were positioned 90 cm from a wall-mounted target (Skill Works, Inc) with the center of the target adjusted to their eye level. Participants wore a laser pointer (SenMoCOR LED Laser Headlamp) on their forehead aimed forward at the target with the laser pointer adjusted to the center of the target. From this starting position, participants were instructed to turn their head to the end of their active range of motion in 4 directions (right rotation, left rotation, flexion, and extension) and return to the center of the target. In each of the 4 directions assessed, participants performed 1 practice trial with their eyes open, followed by 3 trials with their eyes closed. For the 3 eyes closed trials, participants positioned the laser on the center of the target with eyes open, then closed their eyes, turned their head, returned as close as possible to the center of the target, and reported the point which felt like the neutral starting position (i.e., the center of the target). The research team marked the self-reported center point for each of the 12 trials with eyes closed, and we measured the HRA error as the distance from each point to the center of the target in centimeters and converted to degrees (error in degrees = arctangent(error in cm)/90). Our primary outcome for analysis in this investigation was the mean HRA error across the 12 trials, in degrees.28,29

Sample size calculations are based on prior work investigating cervical spine HRA in healthy controls and those with a whiplash history.30 Existing data suggest a difference in HRA between adults with and without a whiplash history with an effect size of 0.63 (controls=2.7 degrees, SD=1.34 degrees; whiplash history mean=3.6 degrees, SD=1.5 degrees). Based on this existing data, we expect those with a concussion history to have worse HRA compared to controls. Given an alpha of 0.05 and power of 0.80, a sample size of 41 participants per group is required to detect a significant difference in HRA across groups.

Statistical Analysis

Data are presented as mean (± standard deviation) for continuous variables and N (corresponding percentage per group) for categorical variables. To compare participant demographics and characteristics between those with and without a concussion history, we used independent samples t-tests for continuous variables and Fisher’s exact tests for categorical variables. We included any participant characteristic that differed significantly between groups (p<0.05) in the multivariable models.

We used independent samples t-tests to compare mean HRA error, number of positive VVE subtests, and DHI scores between groups. To determine the clinical significance of between group differences for these variables, we also calculated Cohen’s d effect size, interpreted as small (0.20–0.49), moderate (0.50–0.79), and large (>0.8). We then constructed separate multivariable linear regression models with HRA mean error, number of positive VVE subtests, and DHI score as the outcomes of interest and concussion/no concussion history group, age, sex, and any variables that differed significantly between groups as predictors. We included sex and age in the multivariable regression model as these variables have been observed to influence outcomes after concussion.31,32 We assessed for collinearity in the regression models using variance inflation factors (VIFs). A VIF between variables of 2.5 was considered collinear, and only one variable was included in the final model.33

To address our second aim, for the concussion history group, we assessed correlations between DHI scores and 1) HRA error and 2) number of positive VVE subtests. We first assessed normality of each variable using a Shapiro-Wilk test and calculated correlation coefficients between DHI and each outcome (Pearson r for normally distributed variables, Spearman rho for non-normally distributed variables). We defined correlation strength as follows: no correlation (0–0.19), low (0.2–0.39), moderate (0.4–0.59), moderately high (0.6–0.79), and high (≥0.8).34 We then constructed separate linear regression models to assess the relationships between DHI scores and each predictor (HRA error, number of positive VVE subtests), adjusting for covariates. Missing data was handled as such, and no imputations were performed. All tests were two-sided, and statistical significance was set a priori as p<0.05. Statistical analyses were performed using R Studio (version 4.2.2, R Core Team 2022, Vienna, Austria).

Results

We enrolled 88 participants in our study: 42 participants with a concussion history (average = 1.4±0.8 years post-concussion) and 46 without a concussion history (Table 1). Participant characteristics were similar between groups including age, proportion of female participants, race, ethnicity, self-reported physical activity levels, and history of migraine and attention deficit disorder. The concussion history group had a higher proportion of participants with anxiety/depression history, and thus this variable was added as a covariate to adjusted (multiple linear regression) comparisons between groups.

Table 1.

Participant characteristics stratified by group.

No Concussion History (N=46) Concussion History (N=42) P-value
Age (years) 27.0 (±3.75) 26.5 (±4.49) 0.55
Sex (female) 34 (74%) 33 (79%) 0.63
Race
 American Indian or Alaska Native 0 (0%) 0 (0%) 0.40
 Asian 4 (9%) 6 (14%)
 Black or African American 2 (4%) 1 (2%)
 Native Hawaiian or other Pacific Islander 0 (0%) 0 (0%)
 White 30 (65%) 30 (71%)
 More than 1 race reported 4 (9%) 4 (10%)
 Unknown or not reported 6 (13%) 1 (2%)
Ethnicity
 Hispanic or Latino 7 (15%) 4 (10%) 0.43
 Not Hispanic or Latino 39 (85%) 37 (88%)
 Unknown or not reported 0 (0%) 1 (2%)
Migraine history 7 (15%) 9 (21%) 0.58
Attention deficit disorder history 3 (7%) 7 (17%) 0.18
Anxiety/Depression history 14 (30%) 26 (62%) 0.003
Self-reported physical activity
 Frequency (sessions/week) 4.4 (±1.6) 4.0 (±1.6) 0.33
 Duration (minutes/session) 54.3 (±24.8) 59.0 (±33.6) 0.47
 Intensity 4.6 (±1.1) 4.6 (±1.5) 0.97
Height (cm) 171 (±9.43) 170 (±8.57) 0.72
Weight (kg) 70.4 (±13.2) 67.9 (±12.9) 0.37
Time since concussion (years) - 1.4 (±0.8) -
Concussion symptom duration (weeks) - 13.0 (±18.2) -
Number of previous concussions
 1 - 14 (33%) -
 2 - 5 (12%) -
 3 - 11 (26%) -
 4+ - 12 (29%) -
Open in a new tab

Those with a concussion history demonstrated significantly worse HRA (Figure 1A), more positive VVE subtests (Figure 1B), and higher DHI scores (Figure 1C) compared to those without a concussion history. Results of the multivariable linear regression models indicate that after adjusting for age, sex, and anxiety/depression history, concussion history was significantly associated with more HRA error, more positive VVE subtests, and higher DHI scores (Table 2).

Figure 1.

Figure 1.

Open in a new tab

Boxplot with individual data points (jittered) demonstrating the median, interquartile range, total range, and distribution of A) head repositioning accuracy, B) number of positive VVE subtests, and C) dizziness handicap inventory scores between those with and without a concussion history.

Table 2.

Linear regression results for the association between each outcome variable and concussion history/no concussion history group.

Variable Parameter Estimate 95% Confidence Interval P-value
Head Repositioning Accuracy
 Group † 1.23 0.77, 1.68 <0.001
 Sex ‡ −0.11 −0.38, 0.15 0.40
 Age −0.06 −0.11, −0.003 0.04
 Anxiety/depression history −0.31 −0.80, 0.17 0.20
Visio-Vestibular Exam
 Group † 3.01 2.32, 3.70 <0.001
 Sex ‡ −0.14 −0.55, 0.26 0.49
 Age 0.03 −0.05, 0.11 0.49
 Anxiety/depression history 0.35 −0.38, 1.07 0.34
Dizziness Handicap Inventory
 Group † 9.79 6.27, 13.32 <0.001
 Sex ‡ 0.60 −1.47, 2.66 0.57
 Age 0.04 −0.37, 0.45 0.84
 Anxiety/depression history 3.89 0.20, 7.58 0.04
Open in a new tab
†

Reference group: No concussion history

‡

Reference group: Male

Bold indicates a statistically significant (p<0.05) association with the outcome variable

In the concussion history group, we observed no correlation between HRA mean error and DHI score (Figure 2A). There was a moderately strong significant correlation between a greater number of positive VVE subtests and worse DHI score for the concussion history group (Figure 2B). After adjusting for age, sex, and anxiety/depression history, mean HRA error was not associated with DHI score, while number of positive VVE subtests was (Table 3).

Figure 2.

Figure 2.

Open in a new tab

Scatterplot and line of best fit (with corresponding 95% confidence interval) describing the relationship between dizziness handicap inventory score with A) head repositioning accuracy mean error and B) number of positive visio-vestibular exam subtests among the concussion history group.

Table 3.

Linear regression results for the concussion history group investigating the association between Dizziness Handicap Inventory score and each predictor variable, adjusted for covariates.

Outcome: Dizziness Handicap Inventory score Parameter Estimate 95% Confidence Interval P-value
Head Repositioning Accuracy 1.10 −2.32, 4.51 0.52
Sex ‡ 1.42 −3.01, 5.85 0.52
Age 0.13 −0.65, 0.90 0.74
Anxiety/depression history 8.59 1.08, 16.11 0.03
Visio-Vestibular Exam 3.78 2.30, 5.26 <0.001
Sex ‡ 2.37 −1.03, 5.77 0.17
Age −0.07 −0.67, 0.52 0.81
Anxiety/depression history 5.13 −0.57, 10.83 0.08
Open in a new tab
‡

Reference group: Male

Bold indicates a statistically significant (p<0.05) association with the outcome variable.

Discussion

Among adults with a recent history of concussion, we observed more severe self-reported dizziness scores, worse cervical spine proprioception, and more vestibular/oculomotor symptom provocation compared to participants without a concussion history. It has previously been suggested that there is a period of time after concussion during which neurobiological or physiological dysfunction exists, even after symptoms have resolved, suggesting that deficits may exist beyond clinical recovery.35 Notably, vestibular, oculomotor, and cervical spine deficits have been observed up to 6 months after concussion, even among those without symptoms.15,16 While our ability to understand the time course of recovery of these specific systems is limited by our cross-sectional study design, our results are consistent with and extend prior work suggesting that persistent impairments in multiple systems may exist for a prolonged period after concussion.

Previous work reported higher dizziness ratings up to 6 months after concussion compared to those without concussion, indicating that deficits may persist after resolution of other concussion symptoms.5 The individuals in our study with a recent history of a concussion, who were well beyond the acute and sub-acute period after concussion (i.e., up to 3 years), also reported more severe dizziness symptoms than those with no concussion history. Post-concussion dizziness is associated with higher overall concussion symptom severity, higher anxiety and depressive symptoms, and worse health-related quality of life.6,7 Additionally, individuals with persisting dizziness may have worse mental health outcomes compared to those with persisting post-concussion symptoms without dizziness, suggesting a unique role of dizziness in overall health.36 Our results indicate that dizziness can persist up to 3 years after injury, which may have implications for mental health and quality of life as previously reported.6,7 Collectively, this evidence highlights the need to evaluate dizziness after concussion with the goal of intervening to mitigate poor outcomes associated with dizziness.6,7,36

In addition to persisting dizziness symptoms, the concussion history group in our study reported more symptom provocation with vestibular/oculomotor testing and demonstrated worse cervical spine proprioception compared to those without a concussion history. Vestibular and oculomotor deficits are commonly observed after concussion,37,38 are associated with persisting symptoms,39,40 and may persist up to 6 months after concussion, even among individuals who no longer report concussion-related symptoms.15 Similarly, impaired cervical spine proprioception has been observed within 3 weeks of concussion.13 Individuals 1 to 6 months post-concussion who were still experiencing symptoms also had greater HRA error compared to uninjured controls.16 While this did not reach statistical significance,16 it suggests that cervical spine proprioceptive deficits may exist beyond the acute phase of concussion, but may not be routinely evaluated as a part of clinical standard-of-care.13 Our observation of worse vestibular, oculomotor, and cervical spine impairments among those with a concussion history relative to those with no history of concussion supports previous recommendations for assessments of each potentially affected system after concussion, even after symptom resolution, to inform comprehensive treatment plans.9,16,41

Among those with a concussion history, we observed a moderately strong correlation between the number of positive VVE subtests and worse DHI score and no correlation between HRA error and DHI score. The association between VVE and DHI was significant after adjusting for age, sex, and anxiety/depression history, indicating that vestibular/oculomotor symptom provocation and dizziness are associated up to 3 years after concussion. Although we observed significantly higher HRA error and worse DHI scores among those with concussion history compared to those without, we observed no correlation between the HRA and DHI, and no significant association after adjusting for age, sex, and anxiety/depression history. The lack of association between HRA and DHI suggests that cervical spine proprioceptive deficits and self-reported dizziness may reflect distinct physiological impairments and should be evaluated in tandem as part of a comprehensive concussion assessment. However, cervical spine proprioception is not routinely assessed after concussion.13 Thus, it is possible that cervical spine proprioceptive deficits may go undetected and untreated and may therefore persist chronically after concussion (i.e., up to 3 years) regardless of dizziness symptoms.

Our results have implications for clinicians managing patients with concussion. Despite the common occurrence of vestibular, oculomotor, and cervical spine impairment after concussion, specific assessments of these systems may not be routinely performed in emergency or outpatient settings.13,42,43 Dizziness can be a vague and poorly defined symptom, thus, individuals may not recognize or report this symptom.9 Accordingly, a functional concussion examination should be performed to identify all potential sources of impairment and create a comprehensive treatment plan. Further, increased injury risk has been observed up to 3 years after concussion.22 Theories exist for why this increased injury risk exists, such as decreased neuromuscular control,44 however, the underlying mechanisms are not fully understood. Given the potential of cervical spine, vestibular, and/or oculomotor impairments to persist chronically after concussion, along with their roles in spatial orientation and postural stability,17,18 a plausible link exists between impairments in these systems and an increased injury risk after concussion. While our study was not designed to answer this question, future work should investigate each of these systems to identify their role in subsequent injury prognosis.

Our study has limitations that should be considered when interpreting the results. We enrolled a convenience sample of participants assessed at a single time point, and it is possible that our results do not generalize to a broader population of individuals with a concussion history. Individuals who still felt symptoms or perceived lingering issues after their concussion may have been more likely to volunteer for study participation compared to people who felt fully recovered from a recent concussion. Due to our cross-sectional study design, we are unable to determine directionality of the observed associations. Concussion may have caused more dizziness and vestibular/oculomotor and cervical spine impairments that we observed, and it is also possible that pre-existing impairments predisposed individuals to sustaining a concussion, and that these pre-existing deficits were worsened by the injury. There may be other factors influencing the study results that were unaccounted for in the analysis including prior history of cervical spine injuries or vestibular diagnoses (i.e., vertigo). Additionally, study participants had both sport related and non-sport related concussions, and outcomes may differ based on injury mechanisms.

Conclusion

Young adults with a recent history of concussion reported more severe dizziness symptoms, more vestibular/oculomotor symptom provocation, and demonstrated worse cervical spine proprioception compared to young adults with no history of concussion. While dizziness and vestibular/oculomotor symptoms were associated among participants with a recent concussion, we did not observe a similar association between dizziness and cervical spine proprioception. Collectively, these findings suggest that examining the cervical spine and vestibular/oculomotor function after concussion may help identify sources of dysfunction and guide patient-specific treatment to prevent and/or address persistent impairments.

Highlights.

  • Cervical spine evaluations after concussion may help identify sources of dysfunction.

  • Vestibular/oculomotor symptom provocation was more severe in those with concussion history.

  • Dizziness and functional impairments may persist chronically after concussion.

Acknowledgements:

Research reported in this work was supported by the Children’s Hospital Colorado Research Institute, the Eunice Kennedy Shriver National Institute of Child Health & Human Development (R01HD108133), and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (T32AR080630).

Unrelated to this study, Dr. Howell has received research support from the Eunice Kennedy Shriver National Institute of Child Health & Human Development (R03HD094560), the National Institute of Neurological Disorders And Stroke (R01NS100952, R43NS108823), the National Institute of Arthritis and Musculoskeletal and Skin Diseases (R13AR080451), 59th Medical Wing Department of the Air Force, MINDSOURCE Brain Injury Network, the Tai Foundation, the Colorado Clinical and Translational Sciences Institute (UL1 TR002535-05), and the Denver Broncos Foundation.

Funding

Research reported in this publication was supported by the Tai Foundation, Eunice Kennedy Shriver National Institute of Child Health & Human Development under award number R01HD108133, and the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under award number T32AR080630. The funding sources played no role in the research, including study design, data collection, data analysis, or interpretation of results.

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Ethical Statement

The authors affirm that the study was performed in accordance with institutional guidelines. Prior to study commencement, the local Institutional Review Board approved of the study (Colorado Multiple Institutional Review Board Protocol ID: 20–3169).

Declaration of interests

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:

Research reported in this work was supported by the Children’s Hospital Colorado Research Institute, the Eunice Kennedy Shriver National Institute of Child Health & Human Development (R01HD108133), and the National Institute of Health (T32AR080630). Unrelated to this study, Dr. Howell has received research support from the Eunice Kennedy Shriver National Institute of Child Health & Human Development (R03HD094560), the National Institute of Neurological Disorders And Stroke (R01NS100952, R43NS108823), the National Institute of Arthritis and Musculoskeletal and Skin Diseases (1R13AR080451), the Denver Broncos Foundation, and the Colorado Clinical and Translational Sciences Institute (UL1 TR002535 - 05).

References

  • 1.Patricios JS, Schneider KJ, Dvorak J, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport–Amsterdam, October 2022. Br J Sports Med. 2023;57(11):695–711. doi: 10.1136/bjsports-2023-106898 [DOI] [PubMed] [Google Scholar]
  • 2.Gianoli GJ. Post-concussive Dizziness: A Review and Clinical Approach to the Patient. Front Neurol. 2022;12:718318. doi: 10.3389/fneur.2021.718318 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Lempke LB, Schmidt JD, Lynall RC. Athletic Trainers’ Concussion-Assessment and Concussion-Management Practices: An Update. J Athl Train. 2020;55(1):17–26. doi: 10.4085/1062-6050-322-18 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Echemendia RJ, Brett BL, Broglio S, et al. Sport concussion assessment tool™ – 6 (SCAT6). Br J Sports Med. 2023;57(11):622–631. doi: 10.1136/bjsports-2023-107036 [DOI] [PubMed] [Google Scholar]
  • 5.Galea OA, O’Leary SP, Treleaven JM. Persistent impairment based symptoms post mild traumatic brain injury: Does a standard symptom scale detect them? Musculoskeletal Science and Practice. 2019;41:15–22. doi: 10.1016/j.msksp.2019.02.002 [DOI] [PubMed] [Google Scholar]
  • 6.Hunt DL, Oldham J, Aaron SE, Tan CO, Meehan WPI, Howell DR. Dizziness, Psychosocial Function, and Postural Stability Following Sport-Related Concussion. Clinical Journal of Sport Medicine. 2021;Publish Ahead of Print. doi: 10.1097/JSM.0000000000000923 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Büttner F, Howell DR, Doherty C, Blake C, Ryan J, Delahunt E. Headache- and Dizziness-Specific Health-Related Quality-of-Life Impairments Persist for 1 in 4 Amateur Athletes Who Are Cleared to Return to Sporting Activity Following Sport-Related Concussion: A Prospective Matched-Cohort Study. J Orthop Sports Phys Ther. 2020;50(12):692–701. doi: 10.2519/jospt.2020.9485 [DOI] [PubMed] [Google Scholar]
  • 8.Reneker JC, Cheruvu V, Yang J, et al. Differential diagnosis of dizziness after a sports-related concussion based on descriptors and triggers: an observational study. Inj Epidemiol. 2015;2(1):22. doi: 10.1186/s40621-015-0055-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Reneker JC, Cheruvu VK, Yang J, James MA, Cook CE. Physical examination of dizziness in athletes after a concussion: A descriptive study. Musculoskeletal Science and Practice. 2018;34:8–13. doi: 10.1016/j.msksp.2017.11.012 [DOI] [PubMed] [Google Scholar]
  • 10.Ellis MJ, Cordingley DM, Vis S, Reimer KM, Leiter J, Russell K. Clinical predictors of vestibulo-ocular dysfunction in pediatric sports-related concussion. Journal of Neurosurgery: Pediatrics. 2017;19(1):38–45. doi: 10.3171/2016.7.PEDS16310 [DOI] [PubMed] [Google Scholar]
  • 11.Storey EP, Corwin DJ, McDonald CC, et al. Assessment of Saccades and Gaze Stability in the Diagnosis of Pediatric Concussion. Clinical Journal of Sport Medicine. 2022;32(2):108–113. doi: 10.1097/JSM.0000000000000897 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Barnhart M, Curtis Bay R, McLeod TV. The Ability of Vestibular and Oculomotor Screenings to Predict Recovery in Patients Following Concussion: A Systematic Review of the Literature. Journal of Athletic Training. Published online March 14, 2023. doi: 10.4085/1062-6050-0429.22 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Tiwari D, Goldberg A, Yorke A, Marchetti GF, Alsalaheen B. Characterization of cervical spine impairments in children and adolescents post-concussion. Int J Sports Phys Ther. 2019;14(2):282–295. [PMC free article] [PubMed] [Google Scholar]
  • 14.Cheever K, McDevitt J, Phillips J, Kawata K. The Role of Cervical Symptoms in Post-concussion Management: A Systematic Review. Sports Med. Published online April 23, 2021. doi: 10.1007/s40279-021-01469-y [DOI] [PubMed] [Google Scholar]
  • 15.Galea O, O’Leary S, Williams K, Treleaven J. Investigation of Sensorimotor Impairments in Individuals 4 Weeks to 6 Months After Mild Traumatic Brain Injury. Archives of Physical Medicine and Rehabilitation. Published online November 2021:S0003999321016075. doi: 10.1016/j.apmr.2021.10.029 [DOI] [PubMed] [Google Scholar]
  • 16.Galea O, O’Leary S, Treleaven J. Cervical musculoskeletal and sensorimotor impairments 4 weeks to 6 months following mild traumatic brain injury: An observational cohort study. Musculoskeletal Science and Practice. 2022;57:102490. doi: 10.1016/j.msksp.2021.102490 [DOI] [PubMed] [Google Scholar]
  • 17.Treleaven J Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control. Manual Therapy. 2008;13(1):2–11. doi: 10.1016/j.math.2007.06.003 [DOI] [PubMed] [Google Scholar]
  • 18.Schneider KJ, Meeuwisse WH, Nettel-Aguirre A, et al. Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. Br J Sports Med. 2014;48(17):1294–298. doi: 10.1136/bjsports-2013-093267 [DOI] [PubMed] [Google Scholar]
  • 19.McPherson AL, Nagai T, Webster KE, Hewett TE. Musculoskeletal Injury Risk After Sport-Related Concussion: A Systematic Review and Meta-analysis. Am J Sports Med. 2019;47(7):1754–1762. doi: 10.1177/0363546518785901 [DOI] [PubMed] [Google Scholar]
  • 20.Reneker JC, Babl R, Flowers MM. History of concussion and risk of subsequent injury in athletes and service members: A systematic review and meta-analysis. Musculoskeletal Science and Practice. 2019;42:173–185. doi: 10.1016/j.msksp.2019.04.004 [DOI] [PubMed] [Google Scholar]
  • 21.Jildeh TR, Castle JP, Buckley PJ, Abbas MJ, Hegde Y, Okoroha KR. Lower Extremity Injury After Return to Sports From Concussion: A Systematic Review. Orthopaedic Journal of Sports Medicine. 2022;10(1):23259671211068438. doi: 10.1177/23259671211068438 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.McPherson AL, Shirley MB, Schilaty ND, Larson DR, Hewett TE. Effect of a Concussion on Anterior Cruciate Ligament Injury Risk in a General Population. Sports Med. 2020;50(6):1203–1210. doi: 10.1007/s40279-020-01262-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51(11):838–847. doi: 10.1136/bjsports-2017-097699 [DOI] [PubMed] [Google Scholar]
  • 24.Jacobson GP, Newman CW. The Development of the Dizziness Handicap Inventory. Arch Otolaryngol Head Neck Surg. 1990;116(4):424–427. doi: 10.1001/archotol.1990.01870040046011 [DOI] [PubMed] [Google Scholar]
  • 25.Corwin DJ, Arbogast KB, Swann C, Haber R, Grady MF, Master CL. Reliability of the visio-vestibular examination for concussion among providers in a pediatric emergency department. The American Journal of Emergency Medicine. 2020;38(9):1847–1853. doi: 10.1016/j.ajem.2020.06.020 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Hill R, Jensen P, Baardsen T, Kulvik K, Jull G, Treleaven J. Head repositioning accuracy to neutral: A comparative study of error calculation. Manual Therapy. 2009;14(1):110–114. doi: 10.1016/j.math.2008.02.008 [DOI] [PubMed] [Google Scholar]
  • 27.Treleaven J, Jull G, Sterling M. Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error. J Rehabil Med. 2003;35(1):36–43. doi: 10.1080/16501970306109 [DOI] [PubMed] [Google Scholar]
  • 28.Roren A, Mayoux-Benhamou MA, Fayad F, Poiraudeau S, Lantz D, Revel M. Comparison of visual and ultrasound based techniques to measure head repositioning in healthy and neck-pain subjects. Manual Therapy. 2009;14(3):270–277. doi: 10.1016/j.math.2008.03.002 [DOI] [PubMed] [Google Scholar]
  • 29.Hides JA, Franettovich Smith MM, Mendis MD, et al. A prospective investigation of changes in the sensorimotor system following sports concussion. An exploratory study. Musculoskeletal Science and Practice. 2017;29:7–19. doi: 10.1016/j.msksp.2017.02.003 [DOI] [PubMed] [Google Scholar]
  • 30.Sterling M, Jull G, Vicenzino B, Kenardy J, Darnell R. Development of motor system dysfunction following whiplash injury. PAIN®. 2003;103(1):65–73. doi: 10.1016/S0304-3959(02)00420-7 [DOI] [PubMed] [Google Scholar]
  • 31.Iverson GL, Gardner AJ, Terry DP, et al. Predictors of clinical recovery from concussion: a systematic review. Br J Sports Med. 2017;51(12):941–948. doi: 10.1136/bjsports-2017-097729 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Kontos AP, Eagle SR, Chrisman SPD, et al. Incidence of concussion and associated risk factors in collegiate soccer: findings from the NCAA-DoD CARE consortium. Science and Medicine in Football. Published online June 23, 2023:1–7. doi: 10.1080/24733938.2023.2227134 [DOI] [PubMed] [Google Scholar]
  • 33.Meehan WP, Mannix R, Monuteaux MC, Stein CJ, Bachur RG. Early symptom burden predicts recovery after sport-related concussion. Neurology. 2014;83(24):2204–2210. doi: 10.1212/WNL.0000000000001073 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Zhu W Sadly, the earth is still round (p < 0.05). Journal of sport and health science. 2012;1(1):9–11. doi: 10.1016/j.jshs.2012.02.002 [DOI] [Google Scholar]
  • 35.Kamins J, Bigler E, Covassin T, et al. What is the physiological time to recovery after concussion? A systematic review. Br J Sports Med. 2017;51(12):935–940. doi: 10.1136/bjsports-2016-097464 [DOI] [PubMed] [Google Scholar]
  • 36.Denby E, Dempster T, White T, et al. Dizziness Directly Influences Postconcussion Symptoms and Is Predictive of Poorer Mental Health in UK Military Personnel: A Retrospective Analysis. Journal of Head Trauma Rehabilitation. Published online September 29, 2023. doi: 10.1097/HTR.0000000000000895 [DOI] [PubMed] [Google Scholar]
  • 37.Ellis MJ, Cordingley D, Vis S, Reimer K, Leiter J, Russell K. Vestibulo-ocular dysfunction in pediatric sports-related concussion. Journal of Neurosurgery: Pediatrics. 2015;16(3):248–255. doi: 10.3171/2015.1.PEDS14524 [DOI] [PubMed] [Google Scholar]
  • 38.Tomczyk CP, Anderson M, Petit KM, Savage JL, Covassin T. Vestibular/Ocular Motor Screening Assessment Outcomes After Sport-Related Concussion in High School and Collegiate Athletes. Journal of Athletic Training. 2021;56(12):1285–1291. doi: 10.4085/1062-6050-0588.20 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Master CL, Master SR, Wiebe DJ, et al. Vision and Vestibular System Dysfunction Predicts Prolonged Concussion Recovery in Children: Clinical Journal of Sport Medicine. 2018;28(2):139–145. doi: 10.1097/JSM.0000000000000507 [DOI] [PubMed] [Google Scholar]
  • 40.Anzalone AJ, Blueitt D, Case T, et al. A Positive Vestibular/Ocular Motor Screening (VOMS) Is Associated With Increased Recovery Time After Sports-Related Concussion in Youth and Adolescent Athletes. Am J Sports Med. 2017;45(2):474–479. doi: 10.1177/0363546516668624 [DOI] [PubMed] [Google Scholar]
  • 41.Ellis MJ, McDonald PJ, Olson A, Koenig J, Russell K. Cervical Spine Dysfunction Following Pediatric Sports-Related Head Trauma: Journal of Head Trauma Rehabilitation. 2019;34(2):103–110. doi: 10.1097/HTR.0000000000000411 [DOI] [PubMed] [Google Scholar]
  • 42.Smith RM, Burgess C, Tahtis V, Marsden J, Seemungal BM. Why are patients with acute traumatic brain injury not routinely assessed or treated for vestibular dysfunction in the UK? A qualitative study. BMJ Open. 2023;13(1):e067967. doi: 10.1136/bmjopen-2022-067967 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Master CL, Curry AE, Pfeiffer MR, et al. Characteristics of Concussion in Elementary School-Aged Children: Implications for Clinical Management. The Journal of Pediatrics. 2020;223:128–135. doi: 10.1016/j.jpeds.2020.04.001 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Howell DR, Lynall RC, Buckley TA, Herman DC. Neuromuscular Control Deficits and the Risk of Subsequent Injury after a Concussion: A Scoping Review. Sports Med. 2018;48(5):1097–1115. doi: 10.1007/s40279-018-0871-y [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES