Stanford Sports Concussion Summit

I want to thank Dr. Doug Major for emailing about the Stanford Sports Concussion Summit held last year at which he presented a poster, and the fact that its continuing education presentations are now available online. This program was arranged by the Stanford Brain Performance Center of the Department of Neurosurgery and Stanford Athletics at the Stanford University School of Medicine.

The first video in the online presentation is Concussion Subtypes for Targeting Treatments by Jamshid Ghajar, MD, PhD, FACS. It is notable for including Ocular-Motor as one of the subtypes, which Dr. Ghajar introduces at the 9 minute mark.

Dr. Ghajar also references a paper in press in the journal Neurosurgery, which has now been published, Concussion Guidelines Step 2: Evidence of Subtype Classification. Here is the paragraph from that paper, citing the Ocular-Motor Subtype:

The ocular-motor subtype involves dysfunction of the visual system (eyesight, eye focusing, eye teaming, and visual perception skills) following injury. Ocular-motor and visual dysfunction can cause difficulty obtaining, understanding, and processing visual stimuli. Dysfunction can trigger or exacerbate symptoms and impair a patient’s ability to integrate and process information. Ocular-motor and visual impairments may be detected by saccades, smooth pursuit, conjugate gaze, convergence, accommodation, and fixation assessments. Deficits in the ocular-motor system may mimic cognitive impairment functionally and are frequently found in conjunction with the vestibular symptoms. Patients diagnosed with this subtype have the following: difficulty with visual activities (screen time, reading, near work, driving, etc); asthenopia (eye strain) and eye fatigue; problems with visual focus including changing focus from near to far and back (assessed for as convergence distance, accommodation, and reading issues); photophobia; blurred vision or double vision; frontal headaches or eye pain/pressure behind the eyes; vision-derived nausea; difficulty judging distances; difficulty tolerating complex visual environments; and significant exacerbation of premorbid visual impairment. Hence, these symptoms may contribute to problems concentrating or difficulty in completing written work.

Another informative video is the presentation on Physical Therapy for Concussion Recovery, by Erin Isanhart, PT, DPT, NCS. There are many helpful videos embedded within Dr. Isanhart’s presentation.

There is a nice slide that Dr. Isanhart puts up at the 8:32 mark, citing that vision therapy has been shown to alleviate symptoms of concussion, followed by an even nicer statement that she makes as a vestibular therapist.

“So as a vestibular therapist I have some of that in my repertoire, which you’ll see with the Brock String and the Smile Push-Ups here, but reality is if this isn’t working, we need to send them to somebody that only does vision therapy.”

During her superb presentation, Dr. Isanhart also references something they have at Stanford called the BIT (Bioness Integrated Therapy) System which looks intriguing. It is pictured on your left in this slide (at the 16:30 mark), an looks something like the Sanet Vision Integrator.

The BITS has six main therapy categories with a total of 24 Therapy Programs and four Standardized Assessments. Each program has different levels of difficulty. Variables can be customized to each individual’s needs and paced to be progressively challenging. The standardized assessments are 1) Trail Making, 2) Bell Cancellation, 3) Maze, and 4) Visual Scan & Motor Reaction.

Therapy programs include Visual Scanning (single target and complete array), Visual Pursuit (smooth pursuit and rotator), Cognitive (memory and rhythm), Visual Motor (geoboards and drawing), and Charts (central and peripheral).

Visual deficits from concussions (mTBI) explained by a leading neuro-optometric authority – Dr. Barry Tannen

The impact of head trauma, even a mild traumatic brain injury (mTBI), otherwise known as a concussion, can have a serious impact on the visual system of the affected individual. What can be particularly frustrating is that the person who has sustained a concussion may not be able to find a professional who recognizes the post-concussion vision problems. Too often the symptoms from mTBI induced vision related problems can be confused as “other issues” from trauma and for many individuals, symptoms can persist for weeks, months and even years. However, when proper diagnosis of the visual deficit is made and vision rehabilitation treatment is provided a patient can “return to themselves”.

To address this complex topic, one of the leading experts in neuro-optometry, Dr. Barry Tannen, is interviewed by Dr. Leonard Press for Practice Update. This video is one of a series of interviews produced by Practice Update as a free online resource for healthcare professionals.

In addition to this video, at the VisionHelp Concussion Library, you can find research and articles to help provide an advanced understanding of concussion and how the visual system can be affected and what can be done to restore deficits in visual function.

Dan L. Fortenbacher, O.D., FCOVD

 

 

Use your Brain – Finding effective treatment for chronic concussion (mTBI) symptoms

According the the Center for Disease Control and Prevention (CDC), concussions are serious. They state, “Medical providers may describe a concussion as a “mild” brain injury (mTBI) because concussions are usually not life-threatening. Even so, the effects of a concussion can be serious.” In this 30 second video produced by the CDC  a concussion is described.

The American Medical Society for Sports Medicine position statement says, “It is estimated that as many as 3.8 million concussions occur in the USA per year during competitive sports and recreational activities; however, as many as 50% of the concussions may go unreported.” In addition, it goes on to say that “While the majority of concussions resolve within 7–10 days, in some cases symptoms persist for weeks, months or years beyond the initial injury.”

Additional evidence of this was just published, June 3, 2019, in the Journal of the American Medical Association (JAMA) Neurology  Recovery After Mild Traumatic Brain Injury in Patients Presenting to US Level I Trauma Centers A Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Study  This study came to the following conclusion: “Most patients with Mild Traumatic Brain Injury (mTBI) presenting to US level I trauma centers report persistent, injury-related life difficulties at 1 year post-injury, suggesting the need for more systematic follow-up of patients with mTBI to provide treatments and reduce the risk of chronic problems after mTBI.”

Optometry’s role and neuro-optometric vision rehabilitation can be a key in patient recovery after mTBI along with other rehabilitation professionals. Unfortunately, too often patients who are living with the “after effect” of chronic symptoms following a concussion (mTBI) are told, by some doctors, to just “wait it out” and symptoms will go away on their own.

But, along comes Anne Ruh Clauss, graduate from Princeton University with a degree in Aerospace Engineering, MBA from Harvard Business School and Fellow 2018-2019 Swarthmore College Athletic Department and author of the new book: Use your Brain – Concussion Therapy An Active Call to Action.

Throughout her book she uses a story based narrative of concussed individuals and how mTBI affected their lives woven in with facts and available online resources to help the reader find help. She outlines three key questions for those individuals and family members who are dealing with the impact of  chronic symptoms following a mTBI. They are:

  1. What just happened?
  2. What can I do about it?
  3. Who can help? Where do we go?

In chapter 4 entitled: “The eyes have it: Check them out”, she gives a nice overview of neuro-optometry and vision rehabilitation. It was my honor to be cited as a resource in addition to Dr. Kenneth Ciuffreda, Dr. Michael Gallaway, Dr. Mitch Scheiman and sports pediatrician Dr. Christina Master.

She also emphasizes the importance of finding an optometrist dedicated to neuro-optometric vision rehabilitation with the following resources:

The College of Optometrists in Vision Development (COVD) www.covd.org

The Neuro-Optometric Rehabilitation Association (NORA) www.noravisionrehab.org

The VisionHelp Concussion Project www.concussionproject.com

This is an excellent book for the public as well as professionals to share with patients who are dealing with chronic post concussion symptoms.

Dan L. Fortenbacher, O.D., FCOVD

New research in AJO…High frequency of treatable vision problems associated with chronic concussion symptoms.

The American Medical Society for Sports Medicine position statement: concussion in sport states that, “While the majority of concussions resolve within 7–10 days, in some cases symptoms persist for weeks, months or years beyond the initial injury.”

Those who suffer from chronic concussion-based symptoms, at the root of these symptoms are typically visual problems, that left untreated can be tough to deal with.  From the words of one of our patients, “My journey started about 5 years ago when I had a pretty significantly hit to my head. Shortly after that, I began to notice some negative changes in my vision. My eyes would become fatigued after the simplest of visual tasks. They felt like they were being pulled apart when reading anything up close, I had blurry vision, double vision, light sensitivity, and headaches. It got to the point where I would completely avoid using a computer, TV, etc. Even driving made my eyes symptomatic. It was a tough time for me to say the least.”

Indeed, persistent visual problems and related frustration are often found in these individuals with chronic concussion-based symptoms. Therefore, the  first step should begin with a referral to a vision care provider for a comprehensive eye health and vision evaluation including a refraction for glasses. Yet, while this might seem like the solution to the problem; if the doctor limits the evaluation to eye health and refraction for glasses alone, key categories of visual function related to eye coordination involving binocular vision/vergence (eye teaming), accommodation (eye focusing) and oculomotor function (eye tracking) can be overlooked.

An important example of eye coordination involving binocular vision involves testing of the two eyes performing “convergence”. If the doctor does a procedure called the Near Point of Convergence Test, they will often find the patient with post-concussion symptoms to exhibit difficulty with convergence to a normal ability (<7cm). As a result this would typically be diagnosed as Convergence Insufficiency.

But wait…just published, new research by Harvard Medical School, Department of Ophthalmology in the American Journal of Ophthalmology  entitled: Post-Concussion: Receded Near Point of Convergence is Not Diagnostic of Convergence Insufficiency.

Receded Near Point of Convergence NOT diagnostic of convergence insufficiency?  Isn’t this a contradiction? When I first read the headline my first thought was, surely this can’t be true. In all my years and clinical experience evaluating those with chronic concussion-based symptoms, a reduced Near Point of Convergence (NPC) and Convergence Insufficiency diagnosis is very common.

However, maybe the authors selected the title for this article as a clever strategy  to grab our attention and suggest that we not get so fast with a quick diagnosis based on a single test. Because when you read the conclusions of the research it is in fact very consistent with clinical experience. Yes, these patients do have a reduced NPC, but it is much more serious than that.  And, quite frankly, that’s the key to understanding these patients with chronic concussion-based symptoms.

Here is what they found:

In their research, patients who had chronic concussion-based symptoms, 89% had a receded Near Point of Convergence! However, what they also found was, the majority of these post concussion patients had an array of oculomotor, accommodative and binocular/vergence dysfunction. Put another way, their reduced NPC was just the “tip of the  iceberg”.

In addition the researcher’s found of the 89% of those patients with a receded NPC:

  • 95% had an oculomotor disorder
  • 84% had deficits in accommodation (solely 41% or in combination with vergence disorders 43%)
  • 54% had vergence disorders (also usually accompanied by an accommodative disorder 78%)
  • Where as, convergence insufficiency “standing alone”, was found in only 6% of the cases

Therefore, their  final conclusion reads: “Because treatment options for the various oculomotor dysfunctions differ, it is prudent that these patients (with concussion-based symptoms) undergo a thorough examination of their vergence and accommodative systems so that an accurate diagnosis can be made and appropriate treatment prescribed.”

As outlined by the American Optometric Association in the Clinical Practice Guideline (CPG-18) for Accommodative and Vergence Dysfunction, the treatment of choice is office-based optometric vision therapy/rehabilitation for those with binocular/vergence, accommodative and oculomotor dysfunction.

For those patients who are experiencing chronic concussion-based symptoms, appropriate and effective treatment for these complex sensorimotor problems, is not a series of take home eye exercises or just a variety of saccadic eye movement routines. It requires a sophisticated office-based approach to integrate binocular/vergence function with accommodation and oculomotor function by a skilled vision therapist applying appropriate lenses, prisms and/or therapeutic tints prescribed and supervised by an experienced Doctor of Optometry who specializes in developmental vision and rehabilitation.

Dan L Fortenbacher, O.D., FCOVD

 

Cross-Pollination Between NORA and the Concussion Legacy Foundation

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Congratulations to NORA and the Concussion Legacy Foundation on teaming up to create a wonderful educational resource on Common Vision Problems & Symptoms Following A Concussion that you can download here.

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If you’re not familiar with the Concussion Legacy Foundation, note which treatment is featured first when you click on resources:

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You can read the full press release from NORA and CLF, including quotes from Drs. Charles Shidlofsky and Robert Cantu, on eyewire news.

Senate Armed Services Hearing on TBI/Concussions

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On December 13, 2017, Thom Tillis (R-NC), chairman of the Senate Armed Services Committee’s Subcommittee on Personnel, held a hearing to receive testimony updating the subcommittee on research, diagnosis, and treatment for traumatic brain injury/concussion in service members.  In introducing the hearing, Senator Tillis noted:  “Since 2000, the Department of Defense diagnosed over 370,000 service members with traumatic brain injury, with the majority of them diagnosed in non-deployment settings. This is not a unique problem within the Department of Defense however– it is a national problem.  Last year alone, there were about 2.5 million emergency room visits related to concussions in the United States, and medical experts believe there were many more concussed individuals who did not seek medical care. Congress must pursue multiple approaches to understand better the chronic effects of traumatic brain injury, including the long-term neurodegenerative problems associated with multiple concussive injuries.”

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The subcommittee members heard testimony from two panels.  The first panel consisted of Dr. David W. Dodick – Sports Neurology And Concussion Program Director, Mayo Clinic; Dr. Steven D. Devick – Chief Executive Officer King-Devick Technologies, Inc; and Dr. Christopher M. Miles – Associate Director, Sports Medicine Fellowship, Wake Forest University.  The second panel was comprised of Dr. Joel D. Scholten – Associate Chief Of Staff For Rehabilitation Services For The Veterans’ Affairs Medical Center, Washington, DC; Dr. David X. Cifu – Principal Investigator, Chronic Effects Of Neurotrauma Consortium, Department Of Veterans’ Affairs; and Captain (Dr.) Michael J. Colston, USN – Director, Military Health Policy And Oversight For The Assistant Secretary Of Defense For Health Affairs.

In the YouTube video below, Dr. Dodick of the Mayo Clinic gives a marvelous introduction pointing out that TBI/Concussion affects a wider segment of the population than is often recognized or reported, such as battered spouses, in addition to athletes and  soldiers.  Dr. Devick, an optometrist who has partnered with the Mayo Clinic to advance the utilization of the King-Devick Test, points out that there is a three-legged stool for rapid assessment of concussion, incorporating eye movement testing, balance testing, and cognitive testing.

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Here is the video presentation in its entirety, with the testimony by Doctors Dodick and Devick comprising the bulk of first half of the proceedings.  It is a very comprehensive presentation of the issues, and should be well worth your time in watching.

Concussion Featured in EyeNet

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The cover story of the December 2016 issue of EyeNet, the magazine of the American Academy of Ophthalmology is entitled: Concussion Care: Moving Vision off the Sidelines, written by Annie Stuart.  She notes: “Although the visual system involves about half of the brain’s circuits—many of which are vulnerable to head injury—vision has long been sidelined in the world of concussion diagnosis and treatment. That is beginning to change.”

There is a section of the article devoted to the King-Devick Test, featuring two neuro-ophthalmologists, Dr. Laura J. Balcer and Dr. Steven L. Galetta.  As nonpaid consultants,

Drs. Balcer and Galetta were asked 7 years ago to explore the usefulness of the K-D test. The article notes parenthetically that this test was developed by a team of optometrists who test kids for dyslexia, gauging the amount of time it takes to read numbers with variable spacing on 3 test cards.

In 2015, a meta-analysis found the K-D test to be a sensitive candidate for a sideline test, effective with athletes of all ages, said Dr. Balcer. In fact, it has been shown to capture concussions that other types of sideline tests miss, in part, because athletes tend to underreport symptoms. “A robust set of data indicates that it can accurately assess concussion on the sidelines, is feasibly administered by parents and coaches in about a minute, and doesn’t require any special equipment,” she said. “We think it is close to prime time use.”

 

At NYU Langone’s Concussion Center, Margaret A. Waskiewicz, MS, OTR/L, specializes in vision rehabilitation, which links concussion treatment to functional performance such as the ability to work or go to the store.  Vision therapy is typically offered by optometrists or other specialists who have a certification in vision therapy.

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A recent addition to the NYU team is Dr. Neera Kapoor, an Associate Clinical Professor at NYU Langone Medical Center’s Department of Rehabilitation Medicine. She was an Associate Clinical Professor at SUNY College of Optometry for 21 years and is the former Chief of Vision Rehabilitation Services at SUNY College of Optometry’s University Eye Center in New York City.

New Guidelines for Concussion Incorporating Vision Therapy

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.

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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.”

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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.

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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.”

Concussion and Your Vision

A succinct piece about mTBI and vision on the Wills Eye site from Debra Lehr, O.D. – a neuro-optometrist with Wills Eye Hospital at the Jefferson Comprehensive Concussion Center in Philadelphia.  A graduate of Lehigh University with a degree in Behavioral and Neural Biology, Dr. Lehr is a graduate of Salus University and a member of NORA as well as COVD.

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How often is vision affected in concussion?

A recent study found that over 90% of outpatients with mTBI had one or more visual impairment, including difficulty with eye movements, focusing, and eye alignment. Basically, the eyes were not working well together during visual tasks, such as tracking a moving target, shifting eyes from target to target, or holding steady gaze on a target.

What are the most common visual symptoms?

The visual symptoms can be subtle and at times, fatigue or brain fog may be blamed. However, one of the most common visual issues in concussion is difficulty keeping the eyes pointed to the same position in space while focusing the eyes to that same point. That is why objects may appear to move, be seen as double, or blur in and out of focus. Sometimes the impairment is noticed when attempting to focus quickly from near to far or far to near. You may feel uncomfortable when making eye contact or you may not be able to tolerate complex visual environments, such as the grocery stores or patterned flooring.

Other visual problems include light sensitivity, headaches, double vision, fatigue, dizziness, difficulty reading, or loss of peripheral awareness. You may feel the need to wear sunglasses when inside, particularly if you are exposed to fluorescent lights. Visual tasks involving the computer or prolonged reading may require more time than usual, and tend to be more confusing and fatiguing. Another common complaint is eye pain and discomfort, which at times is caused by staring to maintain focus, which dries the surface of the eyes.

What tests are needed to detect these visual problems?

A comprehensive vision evaluation must evaluate the health of the eye, as well as the visual processing system. The examination must include oculomotor (eye movement), binocular vision (eye teaming and alignment), and accommodative (focusing) testing. In addition, it is important to evaluate how the brain is processing the visual information through visual perceptual testing.

What can be done to alleviate these issues?

Once the vision evaluation detects the visual problems, a course of treatment can be prescribed. Remediation of the visual system may require specific lenses or prisms in glasses, lubricating drops, training exercises, and/or tinted filters to reduce light sensitivity.