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Emerging Frontiers in Concussion - Session 7: Targeted Evaluation and Active Treatment and Rehabilitation Approaches for Concussion – Part 2
Doctors Cara Troutman-Enseki, Brian Hagen and Nathaniel Steinhafel discuss various topics related to targeted evaluation and active treatment and rehabilitation approaches for concussion.
Upon completion of this activity, participants should be able to:
- Describe evidence supporting exertion therapy
- Recognize normal concussion recovery
- Recognize movement patterns for cervical clearing and red flags
- Recognize cervical strengthening exercise concepts
- Recognize mechanism of injury in relation to anatomy
- Better assess ocular symptomology secondary to concussion
- Identify convergence insufficiency using the near point method
- Recognize vision therapy is a key component to treat ocular disorders following concussion
- Mucha A, Collins MW, Elbin RJ, et al. A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions: Preliminary Findings. Am J Sports Med. 2014.
- Broglio SP, Collins MW, Williams RM, Mucha A, Kontos AP. Current and emerging rehabilitation for concussion: a review of the evidence. Clin Sports Med. 2015;34(2):213-231.
- Lau BC, Kontos AP, Collins MW, Mucha A, Lovell MR. Which On-field Signs/Symptoms Predict Protracted Recovery From Sport-Related Concussion Among High School Football Players? Am J Sports Med. 2011.
- The Convergence Insufficiency Treatment Trial Study Group. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol. 2008 Oct;126(10):1336-49.
- Ciuffreda KJ, Kapoor N, Rutner D, Suchoff IB, Han ME, Craig S. Occurrence of oculomotor dysfunctions in acquired brain injury: a retrospective analysis. Optometry. 2007; Apr;78(4):155-61.
- Ciuffreda KJ, Rutner D, Kapoor N, Suchoff IB, Craig S, Han ME. Vision therapy for oculomotor dysfunction in acquired brain injury: a retrospective analysis. Optometry. 2008; Jan;79(1):18-22
- Alvarez TL, Vicci VR, Alkan Y, Kim EH, Gohel S, Barrett AM, Chiaravalloti N, Biswal BB. Vision therapy in adults with convergence insufficiency: clinical and functional magnetic resonance imaging measures. Optom Vis Sci. 2010 Dec;87(12):E985-1002.
Drs. Troutman-Enseki and Hagen have reported no relevant relationships with proprietary entities producing health care goods or services.
Dr. Steinhafel has financial interests with the following proprietary entity or entities producing health care goods or services as indicated below:
- Consulatant: Speaker for ImPACT Technologies, Inc.
All presenters disclosure of relevant financial relationships with any proprietary entity producing, marketing, re-selling, or distributing health care goods or services, used on, or consumed by, patients is listed above. No other planners, members of the planning committee, speakers, presenters, authors, content reviewers and/or anyone else in a position to control the content of this education activity have relevant financial relationships to disclose.
The University of Pittsburgh School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
The University of Pittsburgh School of Medicine designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credits™. Each physician should only claim credit commensurate with the extent of their participation in the activity. Other health care professionals are awarded (0.125) continuing education units (CEU) which are equivalent to 1.25 contact hour.
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Release Date: 1/17/2017 | Last Modified On: 1/17/2017 | Expires: 1/17/2018
I'm going to try and just talk about a couple of things here in a very short period of time. But you know how many people treat cervical on a regular basis as part of the regular practice? You know when we looked at concussion you know what pops to me right away is cervical injury and I think you have to rule that out. Rule it in, rule it out both from a cervical injury but also how is it relating to the concussion symptoms. And sometimes separating those out becomes a little bit tricky. We will also talk about some of the things that we are doing trying from a preventative mechanism as well.
When we look at you know the history and intake and of a concussion you know one of the first things that I think about when I see a patient who comes in with a concussion is how did they get hit. And that really, the mechanism is important to think about what structures potentially are damaged and critically, critical structures that we really need to rule out to keep ourselves out of hot water. So some of the things that we look at are you know range of motion or upper quarter screen and palpation. And depending on the mechanism of injury we may pull the trigger a little bit faster on imaging versus not. And I want hopefully you walk away with a very quick screening tool to look at you know when do I send this person back for some imaging and when don't I, and I feel comfortable moving forward.
So you know and depending on what they are coming in for and what your discipline is I think focuses on what area you are looking at. So you know I'm always thinking cervical first, concussion second. I know Dr. Collins is probably thinking the other way around. So you know when we look at that we want to look at what is your point of entry? How are they coming in to see you just to make sure that we don't miss anything in those areas. So we want to look at past and present injuries. but I think the big thing we are talking about with cervical as far as an injury component is these couple of points on the left. If they are a traumatic injury whether it's direct contact or noncontact we have to think about ruling out the nasty stuff first. So whether it's an athlete, auto accident, whatever it is those are the things we really want to focus on. So when I look at you know a slide like this I think you know our concussion experts look at the top half , okay what part of the brain was impacted? I'm looking at okay what part of the neck was stressed and hit? And so you know when we look at mechanism of injury you know one of the things that we think about is the forced mechanism of what we call closing or closing pattern. And also rotary.
So when we look at these things, upper cervical versus lower cervical is what sort of comes to my mind, and when we are thinking about the rotary type hits we really have to focus in on that upper cervical section, AO and AA to see what's happening there. Lower cervical we are thinking about extension, side bending kinematics because we are compressing structures, bony structures there. And those are - when we do that we need to be very careful you now to rule out things like fracture and so forth.
So everybody familiar with ERS, FRS terminology, opening, closing? Seeing a lot of yes, good. So those are the things you want to think about and we do a quick screening exam. We use motion diagrams. But we use a motion diagram which essentially it's a quick look at the patient from front on. And so flexion, extension, lateral rotation, right and left rotation rather and side bending. And it can tell us a lot in a very short period of time if we look at the range of motion and where their pain is and/or if there is radicular components. So mainly with this we are looking at the mid-lower cervical symptoms. So one of the quick areas that we look at, when we see someone with extension radicular symptoms, and ti can be extension, lateral bending and/or rotation with radicular symptoms that's a red flag that goes up, okay, because we are compressing, we are causing foraminal encroachment and we are loading the facet joint in the pars reticularis, so you've got to be thinking they either have a restriction or okay something more serious. Is there a potential fracture here that hasn't been diagnosed at this point? So when we see that those are the ones that we want to say yeah we probably want to see some x-rays on this person before we do a whole lot with their neck too aggressive.
So opening patterns are more when the facet joints are moving away from each other or disassociating with each other. So we are less worried about that from a bony intrusion standpoint, typically so that pattern that you see on the right opening pattern, flexion with radicular symptoms. You know typically that's a classic pattern for a herniated disc that we'd see. So need to treat it, can certainly play into cervical symptoms as far as headaches and things like that; but we are less concerned about you know significant imaging findings on x-ray.
Some of the other ones are if we don't have a radicular component, some of the non-radicular patterns we look at same thing. If we are causing a closing pattern in the cervical spine and they have pain we really have to be thinking about what's happening at the facet joints there and what do we need to do to possibly rule out anything significant. So the one on the right there we see opening patterns without radicular, those are a lot of times what you are going to see post-concussion. So my neck is sore, I got hit, yeah the muscles are tight, I have a little bit of spasm in there. Okay, no big deal, we are not worried about those too much. We are going to treat that and get through that.
When we talk about upper cervical a little different scenario. You know when we look at the upper cervical it's typically an unstable joint and the atlantoaxial joint is a convex on convex surface, it's unstable. These hard rotary hits affect that joint and that's where most of our rotation comes from so you really have to pay attention to that joint. Axial loading as well is problematic.
I put a lot of information in here, we are not going to go through it all but you can take a look at you know when do we order stress films, when are we worried about something significant in the upper cervical and/or playing in because upper cervical symptoms do mimic a lot of the concussion symptoms that you'll see. Lightheadedness, dizziness, suboccipital pain. You'll hear patients describe a heavy head sensation. When you hear that we start to think about upper cervical instability. And not gross instability, it may be very subtle just ligamentous laxity or they were stretched out a little bit. Visual disturbances, blurred vision, you've heard it 3 times probably in the last 4 talks. So those are the things that we do think about with upper cervical and obviously headaches. So ruling out those things with concussion is important. And we do that using tools with our experts to look at concussion, you know impact testing. We compare that with our physical exam and our imaging to rule in or rule out what - how much of that is concussion symptoms versus how much of that is post-cervical injury or post-cervical symptoms.
So we'll kick down through, these are just some of the tests that we look at for stability in the upper cervical spine: shear test, Sharp Purser test, so we are really just trying to rule in, rule out the cervical symptoms.
And I put some information in there on stress films and imaging. So you want to make sure you are friends with your radiologist. If you start to see some of these things on your clinical exam where you are looking at stress films and essentially that arrow is pointing to what we call the ADI, the atlantodental interval and we are looking for movement or gapping in there on our stress films. So when that opens up and they look at about 5 mm or so as being abnormal, this is CT, the distance between the anterior arch of atlas in that area. But I think even when you see a smaller movement pattern there it's still significant, and especially if the other symptoms fall into place. So you need to keep that in mind. So we'll skip through a few of these but this is a very significant, the lateral mass is shifted so this would be a fracture situation that would need surgical intervention quickly. So again looking at the symptoms that play into your differential diagnosis on cervical and upper cervical are very important as we look through these things. So again I put a lot in there.
The other piece I wanted to cover here is neck strength, and you know there is some evolution in the literature coming out but we look at it from a little different perspective, not just the neck but looking at neck strength, core strength. And we are going to talk a little bit about reaction time and how does that fit into post-concussion. You know we all know this is an acceleration type injury, okay we are banging the brain on the inside of the skull and how do we minimize that from happening you know?
And there is some information out there, most of the information in the literature out there is now supporting to say you know that neck strength is a factor and it's an important factor in potentially mitigating concussion. You'll see some out there that say well no, we don't think so. If I put James Harrison on that side of the room and I put these two guys on this side of the room and I ask you which body you want to climb into to take the hit, I think we have to use common sense in some of these things when we look at this. You know if we can decelerate the head, you know we look at force equals mass times acceleration it's pretty straight physics in my book. You know we are trying to control motion at the head, and clearly there are different types of hits and we are going to show you some of the training techniques that we use and strengthening techniques to mitigate some of those things. But you know you have to keep that in mind.
So when we think about neck strength and accentuating neck strength the opportunity is there to essentially control eccentric deceleration. In a lot of these injuries that's what it is, falling backwards, I'm trying to control the acceleration of the head before it hits the ground. But the core comes into play there too, which we'll talk about. Shock attenuation, we have more mass, we can take up more shock on the hit. We talked about the force. Also cervical protection, we are just talking about the neck as well. I know we are talking about concussion today but there is a factor there as well, okay. That guy on the left you don't see him on the football field for a reason, he wouldn't be able to take the forces in the hit.
Reaction time, there is a component to reaction time that seems to play into this, so it's not just strength. The combination of the two is something that we are looking at. So you know when we look at training in certain areas and certain things so you know this is just one of the exercises we do, resistance training for neck strengthening but we are doing an abdominal exercise, core strength while we are doing our neck strengthening. So we are trying to strengthen both together, and if you think about the mechanics, kid backpedaling falls down, hits, what's going to slow him down? It's his abdominals and it's his neck flexors before he hits the ground, it's not one or the other, it's both. And so that timing and reaction to be able to fire those muscles and fire them strong to slow the head before they hit the ground is important. So we are looking at again just some of the strengthening things that we do we are taking those into consideration.
As we talked about there is growing evidence, you can look through a lot of the research, Dr. Collins and some of these, we have a bunch of other ones in here. You know it's something that we want to look at pretty seriously. We did do a study looking at neck strength, we tested about 400 individuals just to try and get a baseline and I want to just say thank you to the Pittsburgh Penguins Foundation, they've been a huge supporter of our outreach testing and preventative measures program and moving forward and supporting these from a number of different angles.
But I won't go through a lot of these but this was just a test that we did trying to get some normative baseline on patients and kids. And you know essentially what we see is the obvious, okay males are stronger than females. You'll see in this slide there is a little bit of variation as they start going through puberty. These kids grow taller, necks get long, they get thin and they go back, so we see some variation in puberty that changes pretty dramatically as they go through. You can take a look through here by sport, there is some slight variations in sport, age, ratio of flexion and extension by sport. We looked at those things as well trying to look and see if there is a strong deterrent between the two. Soccer and hockey we saw some differences in those also.
But you know I think the overall message here is that stability in any direction is important. And one of the things that we do look at in our strengthening component is you know everyone says okay well strength in flexion and extension. Some people do lateral rotation. We make sure we do rotation, side bending, flexion and extension because you don't know which direction you are going to get hit in, and those muscles that control rotation are very small. They can be strengthened and they should be strengthened but most people negate those and avoid them.
So we look at a 4 phase kind of training program from strengthening. Isometric are typically our post-concussion patients that we are starting slow, progressing forward. The other ones where we are looking more of a preventative we can start in the - that's my time, trying to stay on time, man. So you know we look at starting the isotonic phase but the thing that we use you know and we do functional training and then overspeed and reaction training and I'll touch on this very briefly about that.
So we were able to again through the Penguins Foundation has been a big help, we put together a cervical strengthening kit. We use bands as opposed to weights. And we like bands a lot, there is no axial compression, there is no load on the facet joints, we can do functional movements with them and we can do reaction training with them without worrying about momentum causing overload. So this was just the kit and we've done this with a lot of different patients but we can go through all motions with these, again we are not loading but we can also do core exercises with these in conjunction with cervical. So strengthening in general is important but making sure we are covering all of those aspects where we are working on core, cervical together. There is videos on our website, upmcsportsmedicine.com if anybody wants to watch them, it goes through the whole series of strengthening and functional training with them, that's the other thing that we can do.
So we can go through functional training, torquing the head in the rotation, lateral bending. This is, you can't see this without the video, this is overspeed and reaction training so essentially we are trying to have them eccentrically catch their neck to slow it down as quickly as possible with a load on it. You don't do this with concussion patients early on. So this is patients that are feeling good, or nonsymptomatic or non-concussed.
So just in summary you know I think the big thing is rule out the cervical stuff and hopefully you know a very quick range of motion exam picking up some of those things, whether it's on the sideline or in your office to make sure that these patients get the right direction and get the differential diagnosis because we've seen patients who have come in from different areas and it was a neck and treated as concussion and vice versa. And so you really want to make sure you are addressing the two. And again I think prevention, there is probably a long way to go in that. We know the helmet manufacturers and everyone are looking at this feverishly but you know I think that's a tough road because it's an acceleration injury and so I think we need to control those acceleration factors if we are going to prevent anything moving forward.
So there is further information on all of these areas if anybody so chooses to look further. But we have a lot of videos online and things like that from the training aspect of things and the strengthening aspect.
So as Dr. Collins talked about, today we are going to talk about the role of exertion and exercise in not only evaluating but treating our patients post-concussion. So what do we know about exercise? So we know what happens when you withhold exercise, so these studies showed in subjects that were non-concussed withholding exercise manifested anxiety and depression. So we know that if we take them out of their physical activity, their sport we do kind of have that anxiety depression manifest in our post-concussion patients that can get worse. So imagine holding someone out for 4 weeks, 2 months post-injury and what can happen to their mood. We also know that migraines are associated with limited physical activity so there is a role in migraine suffering patients for exertion for working out and the right doses. A study by Thomas showed that in the Emergency Dept. they had two groups, usual care and strict rest. On follow-up the strict rest group did worse so we know that getting those kids moving was better for them than just shutting them down.
So I'm sure you guys talked about this yesterday but our concussion subtypes in the clinic that we see where we group them into where is the symptoms coming from, what is driving the symptoms? Well exercise has a role in treating most of those subtypes, especially the moods. So a lot of kids won't take medications, a lot of your professional athletes and even your collegiate athletes there is such a stigma about medications so they won't take them. Exercise can help combat some of the mood. We know in our cervical patients exercise helps. In our migraine patients exercise helps in their cognitive fatigue, getting them moving can help combat some of that cognitive fatigue.
Can we influence PCS with exertion therapy? So the role of exertion therapy in our post-concussion patients there has been several studies done that show these patients with these high level of symptoms you get them moving at submaximal activity and you can combat some of that. They showed that at follow-up these groups did better and had shorter recovery and they also had less symptoms at follow-up.
So what do we look for in our exertion evaluation and our treatment of our patient? So when they first come in we are screening them for their vestibular/ocular system. We are looking at the VOMS. So why is it important for me as an exertion therapist to look at the VOMS? Well I can make them worse if I don't know what's going on, so as Anne talked about VMS is probably the most prominent thing that a vestibular therapist is going to treat. Well if they come into the clinic and they have VMS impairments if I do a ton of rotational stuff I'm going to make them worse, so it's important for me to know in the back of my mind what's going on, set this patient up for success so they can get through sone exertion stuff and they can get moving and start to feel better.
And then Brian Hagan will talk about neck in a little bit but we do screen them for cervical involvement. We know that headaches and dizziness can come from the cervical spine so it's my job to kind of screen that out to make sure that's not playing a role. And if there is a role, if it is playing a role I will treat it.
I also look what they can do from a cardiovascular standpoint, so whether that's the bike, the treadmill or elliptical I'm working to see is there autonomic dysregulation, are they able to tolerate that cardiovascular activity. And then also the dynamic movement. This is kind of the newer area so everything was based off of heart rate, heart rate, heart rate but now we are also looking at dynamic movements because we know that can make them symptomatic.
And then how do we tailor their program? So we look at that evaluation, are they having problems with rotational activity? Are they having problems with vertical activity? And we tailor that program to the individual where the impairments are coming from. And I think that's the biggest change in exertion therapy in the past couple of years because everyone pretty much had that standardized sub-max clinical treadmill (inaudible) to max test and that's what they did and everyone did the same protocol. Now we are looking at impairments, just like I would treat a knee or a hip or an ankle. We are looking at what impairments they have, how as a physical therapist or an athletic trainer can I rehab that patient and tailoring the program to the individual. Some examples might be skater bounds with head turns for a hockey player, transferring weights from bed to chair for a nurse, so it's not just athletes we are looking at, it's also recreational activities and jobs., work comp patients we are looking at. Some of these people are injured in car accidents so they are not all returning to sport so you are going to tailor it to what they are going back to. And backbends and jumps for a cheerleader.
So now I'm going to talk a little bit about the 5 stages of exertion. So as I mentioned the old model was solely based off of heart rate. So you'd start at 20 to 30% heart rate max and each stage would progress at a more and more of the heart rate component. So we've tailored that a little bit and added the dynamic movement component. So each stage now only, not only advances by the heart rate but it advances by the movement as well.
So stage 1. Stage 1 would consist of aerobic conditioning. This is probably your bike patients. These are your patients that are going to have vestibular and ocular impairments so you are not going to put them on the treadmill or the elliptical, but they still can do a half hour of max exertion on the bike without problems. You might be dong balance activities such as single leg stance from eyes open, eyes closed. Simple balance activities that aren't going to progress or that aren't going to exacerbate their symptoms too much. So we are going to limit head movements in this stage, so this is the stage you are not really going to do a lot of dynamic movements.
Some examples you can do weight machines. So this is where it varies from our old model. So old model that 20 to 30% heart rate they are getting shut down pretty fast. This newer model we are allowing them to do more activity as long as it's not exacerbating their symptoms too much. Some core exercises in this stage might be simple planks, they can do a plank, they are not moving their head, they are stationary and they are able to complete activity.
Recommendations in this stage. Quiet areas, they might not be able to tolerate the busy environments. In our facility we have two gyms, we have a big open gym that's loud and obnoxious but we also have a quiet area and we have treatment rooms. So in Stage 1 we are going to be in those treatment rooms or a quieter gym to set these people up for success. Another way that this differs than before you might see someone in exertion therapy and vestibular therapy. Our old model they usually finished vestibular therapy, were completely done before they were even sent to exertion therapy. We've kind of moved away from that model to get people working out a little bit sooner and getting rid of some of those mood and migraine components.
In this stage another thing you have to think about in the back of your head is limiting concentration activities. It might not seem like a big deal to you but it is to the patient if they do have a cognitive fatigue and have trouble with school. You might be counting their reps, I know it sounds simple, but to them that's a challenge and it might progress their symptoms a little bit. These are the people that might be taken out of school or academic accommodations in school.
So Stage 2. Aerobic conditioning, this might be the bike or elliptical. So in this stage I might put them on the elliptical. Balance activities with head movements. So you can see in the picture that the hockey player is now adding stick handling. So we are Stage 2 which is an early stage but we are adding in that sport component to get them feeling like I'm getting back to my sport, I'm in the right direction, giving them that confidence. And this stage you are also adding in the head movements, so now instead of just a simple squat I might do a side lunge, a side lunge with head rotation to kind of challenge their vestibular/ocular system. Where they were doing that simple plank in Stage 1 now I might do a plank with head turns. So you see how you can take the same exercise and make it a little bit more dynamic to challenge the vestibular system.
In this stage I want to get them out of that quiet environment. So now I'm throwing them into our busy gym. I want to challenge them a little bit more. They are going to get a little bit symptomatic, that's okay, we need to start getting them rehabbed so we can get them back to what they are going to. Now in this stage I want to add the concentration challenges so I might have them counting their reps.
Stage 3 is our moderately aggressive cardio. So now I want to add intervals. Stage 3 is where I'll add running, plyometrics in this stage. They might be doing their dynamic warmup now, so this is where we really want to hone in on the dynamic activity and challenge them.
Recommendations, now you have to consider are they playing a sport or do they do a job where they are outside as well. Take them outside. Try some of these activities outside. Outside is a totally different environment than inside. You have the bright lights, you have cars, you have people, you have lots of noise, you have lots of visual stimulation that you can't replicate in the clinic so just step outside and try some of these exercises.
Now you might want to do concentration challenges. So what does that mean? So maybe instead of just saying do 10 reps you might say do 8 plus 2 reps, or 3 X 5 reps or something like that they are having to think. Another thing, they might be going through their workout, you might have them say the months backwards, so something that's challenging the cognitive aspect as well.
Stage 4, this is everything but contact. This is where you can only do so much in the clinic, this where they might have to attend a non-contact practice. And it's your job to communicate with their coach, with the parents, with the athlete themselves or with the athletic trainer. You need to know how they did on that non-contact practice because you can't replicate the teammates being there, you can't replicate all the plays, everything that goes on in a practice. So you need to rely on communication.
And Stage 5 is everything including contact. So try some contact drills and then once they are cleared from the neuro-psych and all parties involved then they return to physical activity.
I'm going to give you quickly an example of taking someone through the 5 stages. Now this is just an example, obviously if they had VOR impairments, VMS impairments I'm going to tailor my program based off of that individual but I'm going to give you an idea of what types of exercises you might see in each stage.
So I'm going to do a cheerleader. Stage 1 for a cheerleader might consist of the bike or walking for cardio. Balance might be single leg stands on floor or foam. Strengthening might be weight machines, lunges, squats with focusing on an object. And then make sure they are in a quiet environment. Stage 2 for cardio they might do the bike or elliptical. Balance might be foam with heel stretch. So that other picture of the hockey player stick handling, now I have my cheerleader. I want her doing her stunts. So you are replicating what they are going back to, it's just not a cookie cutter balance activity. Strengthening might be planks with head turns, Russian twist, walking lunges with head turns. Bring them into that busy gym, challenge them a little bit. Stage 3 might be running. Balance now we add height, so now not just that heel stretch on foam now we are adding a height component. On the cheerleading a lot of times the way that they sustain a concussion is falling out of their mount or they are tumbling. So if they are a flyer they might be scared to add that height so you have to add it in the clinic otherwise they are going to go back and you never practice it and they might have a fear component. And this stage agility and plyometrics are added. For a cheerleader you are going to have them do all their jumps, so toe touches, herkies, hurdlers, whatever they have to do. And you are going to do them in repetition because they don't just do one. And make sure they don't get symptomatic. Stage 4 I'll make them go through their full routines. They hate mo for it in the clinic but I will make them go, there is turns, there is quick movement changes and I make them tumble. So as I mentioned they might have fell out of their tumbling and sustained a concussion so they might have done a back tuck or a back hand spring and landed wrong and got a concussion. I make them do it in the clinic. Anything they could do prior to the concussion that they have to complete for their job or sport they have to be able to do before I say that they are okay to go back. And then Stage 5 return them to play. I'll give you a fun fact, that's my cheerleading picture from high school and I won't tell you which one I am.
So when is the right time to add exertion, the last thing we'll talk about. So when is the right time? How do we say you are appropriate for exertion? So with everything with concussion there is no cookie cutter management. We really talk amongst ourselves and we say we need to get this patient going. Obviously in patients that are symptom free we are going to put them through an exertion test and see if they are ready to go back. In our patients that have crossed over that normal 21 day time frame of recovery we area going to get them moving a little bit, they are becoming a little bit more chronic just like our chronic ortho patients, you want to get them moving, you don’t want a low back patient sitting around. The same thing with a concussion patient. In our anxious and depressed patients the exercise can help combat some of that anxiety. In our migraine suffering patients we know that the intensity and frequency of migraines decrease with the right amount of physical activity.
So in animal studies they were trying to see when do you initiate exertion. So in rats they found that unrestricted activity in the first 6 days they did have a worsened performance, so they had poor - their cognitive scores were down. But if physical activity was delayed to 14 to 20 days they had enhanced cognitive performance. So there is a role for that exertion, just when is the right time. So not too early but we don't want to do it too late either.
In human studies they found that in the early days following concussion the groups that did worse were the groups that did too much and too little physical activity. So too little physical activity was associated with worsened performance. So that moderate group actually did the best in that study, so there is a role for exertion.
So in conclusion exercise has a role in both the treatment and the evaluation of concussion patients. So I really think that the treatment is key lately in the past couple of years, so everything was just the clearance, clearance, clearance, but in treatment we can do a role of exertion as well.
All right, thanks for having me.
So in the short duration here I wanted to provide kind of a clean, crisp understanding of how we can apply vision therapy or orthoptics or vision rehabilitation. These terms go together synonymously and I get a lot of questions on you know what can't I do in therapy, what can I do in therapy? When should I refer out to ophthalmology or optometry who has a special interest or focuses on sports related concussion or traumatic brain injury? And today I'm kind of going to kind of bring you from where we've been in vision therapy and how that applies to some of the congenital and into the concussion arena and even into the severe traumatic brain injury cases. You know what the vision therapy definitely applies to the trajectory here and I think vision therapy has gained more mainstream from a rehabilitative case here. There has been some very nice randomized controlled studies that look at vision therapy and how it applies to the congenital groups, but we are very new in terms of how it applies to the sports concussion group.
I have no financial interests but I do speak with ImPACT as part of the Speaker's Bureau.
I want to jump into kind of what we've known as common ocular disorders following MTBI and TBI. It's kind of a no brainer that there is an ocular piece here. We know that there is an ocular component, whether that be ocular misalignments, phorias, decompensated strabismuses, oculomotor dysfunctions including pursuits, saccadics, vertical heterophorias and there is - and there is quite a bit of evidence that shows that the lion's share of the oculomotor disorders that you are going to be seeing in practice in the trenches will be convergence insufficiency. Now there is a lot of different types of vergence disorders but the most of them that you are going to be seeing whether it be concussion or TBI is going to be more convergence or accommodative related. And both of these systems are very interrelated. There is an accommodative convergence interaction that is very, very closely related. So most people that will have a convergence issue will have also an accommodative component based on some retrospective analyses.
The Brahm study in 2009 showed that visual dysfunctions including convergence insufficiency. accommodative insufficiency, saccadic and pursuit were the most common in inpatient and outpatient populations who suffered blast and non-blast injuries. So when we get down into the spectrum of more severe traumatic brain injury you are going to see more of those visual field defects, more of the visual field neglects, the hemianopsias, the palsies, the fourth nerve palsies, the sixth nerve palsies and possibly cranial nerve three palsies although we don't see those as much. But you are going to be seeing more of the binocular vision issues aside from strabismus. Not to say that you couldn't see it but you might see just more of the phorias and bilocular vergence problems.
I like to use this next slide just because it shows kind of what we see in concussion versus what's really out there in the general population just sitting in a classroom. A number of these kids have congenital problems and don't even know it. And that's the scary thing. You know the literature suggests that maybe 2 to 10% of children under the age of 15 years of age have convergence insufficiency that might be symptomatic and some might not be symptomatic. And these are sort of the individuals that we get concerned about when they get concussed because there is that higher chance of recidivism or the higher chance of regression. These are harder patients to treat because convergence insufficiency might just be their baseline. Accommodative insufficiency might just be their every day to day struggle. And some of these patients are symptomatic and some aren't.
So when we look at this small study, this was a military study actually and Aponte saw that convergence insufficiencies, accommodative insufficiencies were very, very interrelated. Convergence insufficiency we see in the general population and accommodative dysfunction in the general population. And this parallels a lot of the cohort studies that have been put out as well. We see ocular misalignments and notice how I don't say horizontal-tropia or exotropia or hypertropia, most of these issues are going to be phoria movement so their eyes will actually look straight. Sometimes yes you will see a fourth nerve palsy, you might see some head tilt, you might see some head turns but these are really in the more severe spectrum of concussion as it leads toward traumatic brain injury. But in the general population you are not going to see very many saccadic issues or pursuit dysfunctions and a lot of times these people are compensating if it's preexisting.
So let's quickly look at some of the non-concussion prevalence. So I love the fact that the Convergence Insufficiency Treatment Trial study did this because this was in the non-TBI population. And based on their cohort studies they saw that in the general population maybe 2 to 6% of the population had a convergence issue. And there is a mélange of different studies in the past that say well we also see accommodative issues as well. Maybe 18 or 8 to 17% of school age kids under the age of 15 have some accommodative problem. And this is aside from being farsighted or myopic or just having astigmatism or the need for glasses, this is beyond that. This is when they are best corrected when they are seeing people every year to have glasses and contact lenses.
Interestingly 80% of individuals who have convergence issues will also have an accommodative issue. Now how many of us screen for convergence insufficiency? How many of us are looking for those vergence issues? That's great, so a good population of this room. But on the flip side of the fence we should also be looking for accommodative issues as well. Now I don't expect you to go through a battery of binocular tests and cranial nerve testing and vergence testing in office but there are some simple screen tools that you can use to assess for accommodative dysfunction. And you may not be able to or feel confident to treat these in therapy but at least there are some options. These things are treatable.
So where are these vergence issues and accommodative issues really coming from? If we know it's coming from concussion and we know there are preexisting issues where are they coming from? A lot of them are hereditary and it's a sensory and neuromuscular anomaly of the binocular system, accommodative system and oculomotor system. There is a lot of areas centrally that are involved. You know when we treat these issues with vision therapy we are not trying to beef up eye muscles, right? We are not trying to create you know Arnold Schwarzenegger medial rectus muscles or you know who has the biggest lateral rectus muscle in the room? I definitely don’t, I mean I'm a thin guy, I run, I mean I'm not a muscular guy. I mean so in therapy this is not the way we are trying to you know peripherally treat these patients. It's a central issues, it involves caudate nucleus, you know midbrain, superior commasher And there is lot of vestibular interaction, okay. .
But with age we know there is a breakdown of the accommodative system. A lot of us in the room I see have glasses, maybe progressives and so with age naturally the accommodative system will breakdown and so there is that accommodative vergence relationship that if accommodation breaks down accommodation is not driving or helping out that convergence system as much so there is this cross-linking that sort of deteriorates with time. There is a reduction in fusional vergence ranges. So for example if we know if someone has a particular phoria, their eyes may look straight but they may have a tendency for the eyes to wander outward it's like their happy position, it's their tonic eye position. If their eyes are closed their eyes may want to wander out, up, left, down or torsional. But in many, many cases as people have more birthdays in life which is inevitable, we can't change that, these phorias may decompensate. And if concussed they decompensate real fast. And so the goal really is to get them back to their baseline, maybe even better than baseline with vision therapy techniques.
And so recently this has gained some momentum is how involved is anxiety with ocular based issues? And we know there is a definite component, especially when we talk about accommodative spasms, maybe a convergence spasm or even accommodative insufficiency or that inability to see things up close and have a sustained ability to focus on things up close. But we see this a lot in concussion and the symptoms are very, very similar when we compare this to cohort studies and what we've seen congenitally.
The Barnhardt study saw that 20 to 50% in non-TBI in children under thea ge of 13 years of age had very similar symptoms to patients with binocular issues postinjury. Double vision is what you are going to see with vergence disorders, blurred vision perhaps up close, visual induced headaches, frontal, temporal. And I usually ask, you know one of the first questions I ask these kids when I first see them in the room, are you waking up with headaches? If they are waking up with headaches I'm not jumping out of my seat at could this be a visual issue? I mean we are not reading the Huckleberry Finn in our sleep, we are not doing a lot of homework in our sleep. I mean at least I'm not. But there is - you know there is a lot of relationship between frontal and temporal headaches when we talk about ocular dysfunction.
Kids will have a lot of difficulty losing their place when reading, losing concentration, they may be falling asleep in class, they are on I-Pads. This is a computer generated world, they are watching sports on their computers, their tablets and they are just saying you know I can't watch the movement on the screen, I just can't focus as good as I used to. You know maybe I'll start reading something and everything is great, then all of a sudden maybe 30 or 40 minutes later things start to become really, really strenuous. So it may not be apparent at first for these patients, and it may not be apparent to the clinician either so maybe we'll see these patients a day or two after injury, we are screening for them and convergence or accommodative issues they may not be so prevalent right in the very beginning. They get back to their school environment, they start to stress their ocular system, you see them back a week later for maybe for more cognitive testing. And then all of a sudden you start to see convergence issues or accommodative issues because maybe that's a weak point in their system.
So how do we apply vision therapy to convergence insufficiency? So I have a hard time talking about vision therapy applying it to convergence insufficiency with concussion without talking about convergence insufficiency in the congenital populations. The CITT Group or the Convergence Insufficiency Treatment Trial Group looked at a lot of kids. So they looked at kids that were very, very normal with no convergence insufficiency and a lot of kids with convergence insufficiency and they had to be symptomatic. They went through 12 weeks of office based vision therapy and so I want to point out one thing here, they only went through 12 weeks okay. So they only went through maybe 3, 4 months of this. If vision therapy is going to work you are going to know within 4 or 5 weeks. There are going to be some changes happening. If I don’t see changes happen after you know 5 or 6 weeks that's a red flag to me, that means I need to start looking at some of the other trajectories and asking more questions in my history because therapy is going to make some quick changes if it's going to happen.
But this group looked at the convergence insufficiency comparing a placebo group that just did pencil pushups. Most of us have heard of pencil pushups and that can be in place of your finger or everyone has a pencil. And they looked at that as the placebo versus patients who did office based vision therapy, who did more high level activities involving oculomotor and convergence exercises. And they found that those who did office based therapy in addition to some home stuff did a lot better. 73% of the office based improved on near point of convergence versus people who just did the home activities, 33% improved. And what's more concerning for me as a clinician is okay great you got them better but what happens after you release them from therapy? Is this going to translate to real life? Are they going to start having these symptoms again?
So CITT did a follow-up study 12 months later and 84% of the office based group remained stable. And there was a lot less regression, a lot less recidivism versus just the pencil pushups group. That's just because one, you are involving a lot more systems. You might be adding some vestibular exercises, you might be adding in accommodative exercises and kind of integrating multiple systems together to do more higher cortical activity exercises.
Scheiman, he's based out of Philadelphia, he's kind of you know the grandfather, you know he's getting up there. He was the one who kind of piloted with Cuiffreda on a lot of these studies. And he systematically looked at all the randomized controlled studies involving convergence insufficiency as an alternative to maybe eye muscle surgery when convergence issue is definitely a treatable condition and found that outpatient vision therapy or orthoptics is significantly more effective than just doing home based vision therapy exercises alone. So there is a part here where you can be a critical player in doing vision therapy with your patients. How many can say that they are doing some sort of visual exercises, some sort of vision therapy with their patients? So okay, so a handful of people, a smattering. And I think you might be doing vision therapy more than you think you are. So for those who are doing Brock string and pencil pushups you know those are visual exercises but normal functioning visual exercises is going to be helpful with a normal and predicated on a normal function vestibular system too. So you may think you may not be doing vision therapy but you probably are doing some gross level of exercises.
So from a screen standpoint you know I realize this is an eclectic group, we've got physical therapists, athletic trainers, physicians, neurology in this group and so I think everybody can kind of put forth a screening tool for looking for oculomotor dysfunctions. One, you know a lot of people are looking for you know the near point of convergence, the obvious issues, the lion's share of oculomotor disorders from concussion. And that's basically looking at the near point of convergence. So a normal near point of convergence is a lot closer than we think we are, or let me rephrase that, an abnormal convergence is a lot closer than we think. Normal convergence is anywhere between 6 cm, or excuse me less than 6 cm and to the nose. You may think well that's pretty close. If someone gets at 10 cm well that sounds pretty normal too, but in fact that is still considered a mild convergence insufficiency.
And so we want to look at the break of convergence but also the recovery of convergence. How many times have you seen these patients and you say yeah, these patients had totally normal convergence ability but they can't bring it back together once it goes double. So once it goes - I mean everybody can do a near point with their finger and I mean we've been blessed, we all have two of them, and so we can bring our finger toward our nose and regardless of it going blurry that's sort of the tongue in cheek here is that when performing this you have to look at double vision regardless of blurry vision because blurry vision is going to come with age. So regardless of age everybody should be able to get to 6 cm.
So if their near point is say 4 cm and now it's double that's normal, but what happens when I bring it away and all of a sudden oh no, it doesn't regain fusion until you hit 15 or 20 cm. That is still an abnormal convergence function because it takes so much effort to bring your eyes in together that once your eyes dissociate and go double it's so hard for them to regain binocular secondary fusion. So recovery is another important tool that you are going to want to look at. And you know you want to be anywhere between 3 and 7 cm behind that convergence. And so if you are 4 cm on your convergence or 6 cm on convergence really check the recovery, it might be 20 cm, you might be missing something.
So a lot of clinicians will ask me well yeah, yeah I've looked at the convergence, that's kind of old hat, we've known about that for a long, long time but what about the accommodative stuff? And so accommodation is measured monocularly, and so it's very similar to convergence but you simply cover an eye, so she's covering the left eye here and you can use the same target. And anybody under the age of 30 years of age should be able to get at least 15 cm. Now in the office I'm measuring everything in diopters, you can measure in cm, this is a monocular test. We do this one eye at a time from the forehead, 15 cm under the age of 30. Under the age of 30 is normal. I'm going to play this again.
So this young lady has an abnormal amplitude of accommodation. So she cannot focus it at all at that point, that is here threshold. So 5 diopters of accommodation means she got about 20 cm there, that is an abnormal amplitude of accommodation and she's wearing contact lenses as well. So keep in mind they have to be best corrective, they have to be looking with their glasses if they have them.
Obviously you can screen with saccades, that can be included in your VOMS testing. It can also be - you can also look at pursuits. When I'm doing these I'm looking for symptoms but I'm also looking for palsies, restrictions, over-action or under-action in oblique muscles. So there is a number of things that we are not just - you know that we are looking for in terms of under-action but you are also asking about symptoms as well. And for those who are doing the VOMS you are already incorporating these provocatives tests.
So let's apply vision therapy now to the concussion realm. So Cuiffreda in 2008 looked at patients with mild TBI with vergence disorders and showed that there was either A, a complete or a marked reduction in their oculomotor based symptoms and improved clinical signs. So in summary it showed that there was an efficacy of optometric vision therapy for a range of oculomotor abnormalities. So vision therapy is not, you know not everybody are vision therapy candidates and so when prescribing various ocular treatments for these patients some may get prism. I love prism when it works, and I despise it when it doesn't work. And I think we have to be very, very careful on asking or prescribing prism or specific types of glasses for these patients because keep in mind you have to look at the other trajectories. We do not want to make their other symptoms worse. We don't want to be causing vision induced dizziness, we don't want to be having - cause any sort of dependency on these glasses. But sometimes you have to prescribe some sort of correction to get them through their therapies or to kind of get them moving quicker. And so some people are like well gosh I just got glasses like 6 months ago at my optometrist. So I say well you might need these reading glasses to get you going a little quicker. My goal is not to keep in them but to quickly wean you off of them. And so do I prescribe vision therapy for everybody? No, absolutely not. Or prescribe glasses or prism for everybody? No, absolutely not. There is just a melange of different treatments and it's all very, very case specific and so we have to be very careful in what we prescribe to some people and not others.
So lastly here this is a 2010 study, this is the Functional MRI Study. I'm not going to go over any of the imaging results here. I apologize to the neurologists in here who are just salivating at this point. But I'm not going to look at the brain image studies with you here but it is actually a very, very unique and interesting study. But this study looked at and quantified convergence measurements in adults with convergence insufficiency with just MTBI. And they didn't look at the near point of convergence measurement but they actually looked at the peak velocity of how quickly they could make a convergence movement. So the velocity of how fast they could take something from 60 cm and bring it toward the nose and measure how quick they actually did it compared to controls. Some of these measurements were done - well excuse me, all of these measurements were done with the near point method. And there is very different methods of measuring near point of convergence.
So I like this slide because it really shows you the difference between controls and convergence insufficiency. These are functional eye movements of controls versus CI subjects. And these are functional positional responses as a measure of time, and so as a function of time. And so we are looking at the velocity of how quickly they can convert or make a convergence movement. The top are the two controls and the bottom are the concussed individuals. And so you can just see that time over time over time we are repeating convergence measurements and look how they start off okay but they quickly trickle off after that with repeated measurements. And so if you are making near point of convergence measurements don't just do it once, do it twice, do it probably three times, right. Three times is kind of for assurance. So as you start pushing that convergence system their convergence actually gets worse and so they become slower and slower.
And so this is the convergence position versus time. And so their velocity pre and post-therapy. So the blue asterisk here on the far right side of each graph shows where their convergence velocity is actually one week post-therapy. The green dot is 12 weeks post-therapy so they actually normalize pretty well after you know roughly 2 to 3 months. And we do know there is some regression and so patients will actually find themselves having a little bit less convergence than when they did when they finished therapy, but we do see this nice change as they course along. And again this is the average amplitude of accommodation - or convergence. We can see that the convergence insufficiency group had a more difficult time with convergence but also hey what about their divergence as another measurement? The divergence didn't really differ too much between the controls and the convergence insufficiency groups.
So okay, so if you are now just kind of tuning in here for those who do not like to watch graphs and slides and things like that, I'm a very visual person so I want to hear the pearls, okay. And so some patients that are being treated with vestibular therapy or exertional therapy it's kind of good to kind of keep a gross measure of are they wearing glasses, are they wearing contact lenses and kind of assess some of their symptoms while they are doing therapy. Bifocal contact lenses for those who wear them, monovision contact lenses for those who wear them don't provide the proper visual acuity necessary to do vestibular and visual exercises. And progressives for those who are vain enough not to have the line in their glasses, who really just want to have that invisible appearance that they don't have trouble with reading anymore, progressives are just not ideal. You know I don't wear progressives, it is around the bend, but for those who wear progressives know that it's a transition. When you move your head back and forth making horizontal head rotation movements it is actually very difficult in a progressive lens versus a single vision lens. And so sometimes we'll have to put people into single vision for distance and single vision for near to get them back quicker. And I say you know what, I realize there is sometimes a cost with this, and you may have already used the vision insurance and how am I supposed to pay for some of these? And so some of that is you know I'm very sensitive to patients who this is their only option and we have to stick with progressives, and that's okay sometimes. But it just makes for sometimes a more difficult recovery. Having progressives will cause some visual induced distortion but it's not the end of the world if they stick with their progressive because this is their real life, this is how they function in real life. So having progressives is something that we can work through in therapy.
And sometimes you know we will get referrals from the vestibular therapists saying we've plateaued in vestibular therapy and I just can't tackle their double vision or their blurred vision at near point task is so bad that I can't make any progress in vestibular therapy. And we see that quite a bit. And so we'll tackle the ocular trajectory and then maybe have to send back to vestibular therapy so it is definitely a two-way street, there is definitely some crosslinking between the therapies and sometimes one is not effective without the other. So that's something to consider and we found very effective with these patients.
But the bottom line goal is that with vision therapy it's to normalize binocular function, get them back to their previous baseline even if it's not a complete normal near point of convergence or a complete normal accommodation but to the point that they are not symptomatic anymore. And sometimes patient will say hey, maybe I feel even better than I did before. And so that's great to hear, but unfortunately that's not what we hear every single day.
For those who are looking for kind of a systematic approach of hey well what sort of activities can I use in therapy? There are easy, moderate and difficult exercises and we don't expect everybody to tackle the moderate and more difficult things. But pencil pushups, stick and straw, Brock string, some of these gross convergence exercises are something that the vestibular therapist can easily incorporate into their current therapies. There is home computerized activities and some of this is very effective but we don't want to stimulate and provoke their symptoms if they have a lot of vestibular system symptoms, a lot of that movement, a lot of that scrolling on a screen, the lighting. A lot of that can be very difficult and so we have to sort of baby step them into some of these computer programs if it's going to be effective for them. And this can be a very nice tool for people who have no access to care within a 3 hour radius. And so we have a number of patients that we are treating that are in the middle of nowhere and they have no options. And so we kind of help them through this and we can monitor their progress online.