The Concussion Crisis: A Silent Epidemic of ABI


We normally think of concussion as related to direct trauma to the head.  Increasingly common in sports injuries at younger ages, concussion with significant sequelae has now been widely recognized in college football, even at the high school level and younger.  I wrote about this earlier in the year, as related to use of the King-Devick Saccade Test as a remove-from-play sideline screening tool, and it has gained more momentum of late. The cumulative effect of  concussions on the brain and the death of neurons on cognitive function has drawn increasing attention.

 

A new book by Carroll and Rosner makes several excellent points regarding the silent epidemic.  The first is that children with mild TBIs often fall through the cracks.  They have subtle impairments in short term memory and eye-hand coordination among other deficits, and teachers are quick to assume these children aren’t trying hard enough.  The second is that even when tests of subjective cognitive function don’t show the child to be appreciably impaired, objective measures of brain function such as the EEG can be insightful.  (Though the book doesn’t address this, there is evidence that the P1 latency of the VEP is delayed in a significant proportion of individuals with cerebral concussion.)  Third, there are concussions that children experience without a direct blow to the head.  Shaken baby syndrome is a classic example. Lastly, the development of the ImPACT test, the Immediate Post-Concussive Assessment and Cognitive Testing by Lovell and colleagues, is described in detail.

Lovell is featured prominently in the case of Angelica Kruth, a teenager who smashed her chin on the floor during cheerleading practice.  Her mother took Angelica to the pediatrician who diagnosed a swollen jaw and whiplash, treating her with ice packs and painkillers.  X-rays and CT scans of her jaw were normal.  A straight-A student, Angelica couldn’t focus in class.  Her vision was so blurry that she couldn’t read.  Her mother waited another two weeks for an appointment with Lovell who, upon learning of her symptoms administered the ImPACT test, and was not surprised to see her struggle with it.  Her scores on mental processing speed and memory were reduced to the 5th percentile for her age level.  He reassured her mother that with a month or so of rests most kids got significantly better.  For those that didn’t there were promising drug treatments and newly developed rehabilitation techniques.  After a month, things were no better.  Lovell began experimenting with medications to improve Angelica’s migraines so that they could go to work on her vision.

At first, her vision was so impaired that if a page contained even a single word, like “cat”, she could tell that there were letters but she couldn’t make out what they spelled no matter how large they were.  The harder she tried to read the word, the harder her head would pound.  To help her relearn to focus her eyes, therapists used moving targets to help her converge and diverge.  In another exercise she was told to look at a word on the wall and turn her head from side to side without taking her eyes off of it.  What the authors of The Concussion Crisis, Carroll and Rosner are describing here, is part of Vestibular Rehabilitation Therapy, in particular gaze stabilization therapy. The focus of these exercises is primarily to address re-integration and restore the gain of the vestibulo-ocular reflex, and the following videos from the University of Michigan are representative.

 

 

 

While I welcome Carroll and Rosner’s book for its inclusion of VRT exercises, this approach can and should have been complemented by a neuro-optometric vision evaluation.  Angelica’s progress as reported was painstakingly slow, and she was left with residual deficits that may have been helped further, or at least a recovery that might have been accelerated through optometric consultation as outlined by our colleague, Dr. Dan Fortenbacher, in his approach to Neuro-Ocular Vestibular Dysfunction, or the See-Sick Syndrome.  Too many patients like Angelica are left with impaired visual functions as described by Dr. Fortenbacher.  Orientation and movement may be affected, as well as abnormalities in which print looks like this, either initially or after just a few minutes of reading:

Whether through lenses, prisms, filters, or other forms of vision therapy, patients like Angelica should be given the opportunity to benefit from optometric consultation.  To overlook this compounds the silent epidemic.

– Leonard J. Press, O.D., FCOVD, FAAO

 

5 thoughts on “The Concussion Crisis: A Silent Epidemic of ABI

  1. Len- Thanks for your always interesting blogs. I’d like to comment on the videos you presented. In the first the instructional set makes no difference of target on the wall vs. target being held. These are two VERY different conditions. The person localizes with the hands and your comfort is generally much better. We usually address proprioceptive localization with saccadic activities, then remove it over time.

    In the second video, no mention is made to the above, but it is usually different. The second video discusses increasing speed as the patient gets better. This is one of at least five easily controlled variables. They are:
    1-change speed- increase as you can
    2-change range of movement-start small range and increase with time
    3-add proprioceptive localization to initially improve performance, decrease over time
    4-modify distance- increase distance from peripersonal to extrapersonal space, often the use of tools are helpful or visualization of using one(dowel to extend space allows you to work outward with your hand/proprioceptive localization extended).
    5-discuss how they are looking-soft/easy, “look at the letter and keep it as clear as possible” vs. “look at the paragraph, be aware of the whole and can you look softly?”

    *Many suggest the activity itself is important. But perhaps another aspect is more important, that is how do you recover from the mild dizziness or blur that may occur? One should learn to recover from any dizziness or blur they develop. This recovery may be from better fixation, use of proprioceptive localization, blinking, spatial awareness like soft/hard focus, etc.. These cues develop many strategies that when combined, provide the best recovery from visual-vestibular disturbances.
    Curt

    • Thanks, Granville. You can subscribe to the blog on the right hand side. That way you’ll get updates automatically. By the way, great first name! Haven’t heard it since one of my boyhood heroes, Granville (aka Granny) Hamner played baseball for the Phillies.

  2. I have a very similar patient right now in my Outpatient clinic (I am an OTR). I made a referral for her to see a Behavioral Optometrist after noticing that her vision was not improving and the tracking in the left eye was very poor. She displays poor convergence and reports blurry vision and headaches with reading. Unfortunately, she can not get in with the Optometrist for a month. In the mean time, a co-worker suggested to the patient to patch her “bad” eye to tolerate reading for longer periods of time and prevent severe headaches. The patient reports that this is working well for her. I am wondering what your thoughts are regarding the patching. I am not sure that I agree with this but would like to do what is best for the patient until she sees the Optometrist. She is wearing the patch about 3 hours a day (only for reading activities) and broken up throughout the day. Any advice would be greatly appreciated. Thanks so much.

    • I see nothing with doing this on a short term basis, Lisa. Patching is an expedient way of resolving the conflict between the two eyes and resultant headaches. All too often we see that patching is the only alternative offered to such patients. There is usually so much more than can be done therapeutically. The key is to get to the optometrist as soon as possible.

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