I have always loved the concept of a meme, which is why the subheading of the journal Neurosurgery (from Wolters Kluwer Health) “The Register Of The Neurosurgical Meme” intrigues me.
Along those lines, concussion guidelines are like nutritional recommendations: If you think you have a handle on best practices, wait a year (in some cases a few months) and the guidelines will change. Case in point, the latest “new” thinking on concussion treatment, as reported in yesterday’s Wall Street Journal, which includes the following statement: “In a white paper summarizing the views of more than three dozen concussion experts, published online Friday in the journal Neurosurgery, the authors aim to clarify the role of rest and physical activity in concussion treatment. The paper says most that concussions are treatable and that active rehabilitation may improve symptoms more than strict rest.”
The white paper they refer to in the article is: “Statements of Agreement From the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015.” If you click on the hyperlink it will give you the option of obtaining the full PDF.
Point 14 of the white paper, found on pages 11 and 12, will be of interest (I added the bold print for vision therapy):
“14. Matching targeted and active treatments to clinical profiles may improve recovery trajectories after concussion.
Although there are no clear evidence-based treatments for concussion, emerging clinical research and observations suggest that recovery after concussion may be facilitated when targeted, active interventions are matched to the patient’s clinical profile on the basis of presentation and history. For example, patients who present with postconcussion vestibular impairment and symptoms (eg, dizziness, vertigo, impaired balance, visual motion sensitivity) may benefit from vestibular rehabilitation exercises that treat benign paroxysmal positional vertigo and improve balance, gaze stability, eye-head coordination, and gait. Similarly, vision therapy was recently reported to be beneficial for patients with concussion and mTBI who exhibited common oculomotor issues such as reading difficulty, vergence, accommodation, saccade, or pursuit impairment. Vision therapy (orthoptics) uses a variety of vision exercises and tools designed to improve oculomotor control, focusing, coordination, and teaming. In addition to vestibular rehabilitation and vision therapy, exercise prescribed as an adjunct to other therapies or medication may reduce symptoms of depression and anxiety. and may prevent or modify the intensity of migraines that often accompany concussion.”
Beautiful to see vision therapy/rehabilitation included. Our experience suggests that rest up to 2 weeks may be warranted in more severe concussions, but you generally want to do rehab asap. The key may be to find out where their tolerance is to rehab therapy and allow them the opportunity to learn to recover. If pushed too hard, they may learn how have symptoms on a more regular basis. So we must also be cognizant of pushing too hard.
Precisely, Curt! We’re working now in therapy with a young woman who had plano lenses with a tint. She has classic visual-vestibular integrative sensitivities. I wrote her a new Rx last week that I was sure would be of benefit, but induced severe motion disturbance despite the fact that I trial framed it, and thought I was being conservative!
Hi, Lenny: I too read with interest the above article in the WSJ last night. Your above quote from the related ‘white paper’ is important to have in the literature for several obvious reasons. While I have only ‘skimmed’ the ‘white paper’, I have some initial comments. First, of the nearly 40 contributors to it, NONE were optometrists. This ‘sends a message”. Second, of the 175 citations, only a couple were derived from either the optometric literature or were conducted by optometrists. Another ‘message”. I guess I was lucky, as 2 papers (out of 60 on the topic) from my brain injury clinical laboratory at SUNY were cited under the area of vision rehabilitation.
On a more positive note, and per Curt’s above comments, it is nice to see that others, especially in medicine, finally believe that, “Vision therapy works, even without a lollipop” (see my recent Perspective in the COVD journal). How could VT NOT work, as the underlying mechanisms are perceptual and motor learning?
Points well taken, Ken. What you’ll notice is that these guidelines come from Mickey Collins, Robert Cantu and colleagues – “The Pittsburgh Group” which promotes the VOMS assessment. They apparently collaborate enough with behavioral/neuro ODs to have put this into the guideline. I agree that it is surprising (and disappointing) that after all this time there would still not be an OD involved as a contributor to that white paper. And I also agree that we need to focus however on the positives!