Concussions: Part Two – Assessment and Follow-Up

April 17th, 2017

The Assessment

Baseline testing should be a high priority of every athletic department, coach, parent (of a student athlete) and athlete, and should include cognitive, vestibular and visual assessment. Cognitive testing alone – frequently performed without the other components – is insufficient. This holds true in cases of post injury assessment as well.

For athletes who have had the benefit of baseline testing (performed pre-season and prior to injury), the comparison to their normative values – after a concussion occurs – proves very helpful in assessing the degree of dysfunction and determining complete recovery. Since the rest of us may not have this advantage, it is the thorough post-injury assessment alone that is the key to determining the loss of function and in guiding treatment.

One caveat that Dr. Erickson of the Banner Concussion Center stresses is that in a game situation, it is NOT okay to simply ask the athlete who may have suffered a concussion if he or she is okay and trust that the information received is accurate. The athlete should be removed from play and evaluated. Keep this in mind if you are an adult participating in recreational sports – sitting out may be the tough but obvious best option. You may not know until later that what seemed like jarring but manageable contact was, in fact, concussive.

If when consulting a provider for care following concussion, you – or a loved one – does not receive an assessment of all the components of a thorough assessment that are described below, please seek care elsewhere. Whether the center you go to can meet your needs in-house or relies on outside referrals to do so, any piece of the puzzle that is omitted might result in overlooking an element that could influence recovery.

The assessment should include:

  1. A physical exam by a physician specializing in sports medicine/internal medicine to rule out more serious pathology, diagnose concussion and to identify any other injuries (particularly of a musculoskeletal nature) that may have occurred along with the mild head injury.
  2. ImPACT™ 15: ImPACT™ – which stands for Immediate Postconcussion Assessment and Cognitive Testing – is a computerized neurocognitive tool developed in 2000 by a medical team at the University of Pittsburgh Medical Center (UPMC). It is used to assess brain processing speed, verbal and visual memory, reaction time and visual motor skills (in those at least 11 years old). This tool was established after its developers had first utilized paper and pencil testing methods, and prior to professional sports leagues acknowledging that cognitive testing was necessary in the management of concussions. In addition to its vital role in identifying dysfunction, ImPACT™ is utilized to help determine the degree of recovery. In each instance, scores are compared to normative values.

According to Dr. Erickson, the NFL began to require baseline neuropsychological or neurocognitive testing in 2005-2006 and MLB also instituted a program in 2006. The NHL also currently mandates baseline testing, as does NASCAR. The NBA, Formula One and WWE also currently utilize ImPACT™ baseline testing, as do a number of NCAA Division One Programs.

  1. Audiology evaluation: screens for dizziness, hearing, tinnitus and inner ear disorders associated with mild traumatic brain injury.
  2. Neurovestibular and balance testing (ideally using the Banner or University of Pittsburgh Medical Center Protocol):

Many treatment facilities test balance without attention to its integration with the visual and vestibular system. This is a significant omission.

The vestibular system provides important sensory information about motion, equilibrium, and spatial orientation. The utricle, saccule, and three semicircular canals within each ear comprise the vestibular apparatus. The utricle and saccule detect gravity (vertical orientation) and linear movement.

The smallest bones in the body are the three ossicles of the middle ear. They are the link transmitting vibrations from the eardrum to the inner ear. They also serve to amplify sound. A blow to the head can cause displacement of the ossicles resulting in vestibular disturbance and complaints of feeling like the room is spinning or foggy-headedness. Identifying the nature/direction of this displacement is crucial to pinpointing the type of treatment the physical therapist should perform.

The Banner NVP TM protocol was developed in 2013 by Shelly Massingale, MS, PT and Dr. Steven Erickson of the Banner Concussion Center, in conjunction with Bertec® and utilizing Bertec® force plate technology and Computerized Dynamic Posturography. This trademarked protocol was designed to stimulate and assess a person’s ability to integrate feedback from visual, vestibular and somatosensory systems following MTBI. It incorporates functional balance conditions that directly stimulate the vestibular ocular reflex (known as the vestibular ocular reflex suppression test). This reflex reflects the relationship between the visual system and that of the inner ear and is responsible for enabling fixation of the eyes during head movements.

  1. Fine motor skill testing: assesses coordination using timed measures of fine motor dexterity.
  2. Visual motor testing: Functional visual integration testing using static (without movement) and dynamic (with movement) visual acuity screening to assess eye movement and head coordination.

Neha Amin, O.D., FAAO, the lead optometrist at the Banner Concussion Center shared some of the visual dysfunctions frequently identified on the optometry exam. They include:

  • Blurred vision: It is possible someone might have had mild blurring pre-injury that he or she is able to compensate for, but a concussion may cause it to worsen and for the patient to become symptomatic.
  • Double vision – this is very common. The eyes may be clear individually but have difficulty working together.
  • Tracking Issues – With tracking issues, the eye movements are very inaccurate as it relates to the two eyes working together. Pre-accident, one eye may be stronger and one weaker. Post-injury, a patient may no longer be able to tolerate that imbalance.
  • Focusing –(accommodative dysfunction) the ability to focus and relax that focus for seeing distance to near, and vice versa (i.e., in the classroom – blackboard to desk). A dysfunction in focusing can result in double/unclear/blurry vision, headaches, attention deficits or a seeming loss of visual acuity.
  • Vergence Issues – convergence and divergence

Convergence, when the eyes move inward toward each other, is important for all near vision tasks and must occur automatically when an object approaches you. When insufficient, double vision is a common side effect.

See if you notice… look in the distance across the room. Now hold a pen in front of your head around 12 inches from your nose. Look from across the room to the pen. Do you feel your eyes turning in? Now pull the pen towards your nose… how close can you bring it before it becomes double?

Many times the ability to converge the eyes is overlooked in eye exams. Do you ever get tired and feel difficulty in “focusing” on a book or computer screen? Do you ever feel like you see double? This is likely due to poor eye alignment. Poor alignment can cause headaches due to the strain to keep your eyes aligned. This same near stress can decrease concentration, and reading accuracy. Attention deficit disorder is heavily linked to this ocular stress.

Dr. Amin noted that convergence Insufficiency has a very high success rate in therapy. Most people exhibit marked improvement after two weeks, noticing diminished eyestrain and headaches along with enhanced attention. Most cases can be alleviated in 3-6 months, depending on the motivation of the patients.

Divergence is the opposite of convergence. Divergence means to move the eyes outward and away from each other and usually occurs when looking at an object moving further away.

If you are doing close reading, your eyes will need to diverge to see far away. Divergence excess means the eyes turn out too much when looking in the distance. This creates a problem for the patient, who will either see double when looking far away, or suppress an eye (shut an eye off).

Likewise, divergence insufficiency means the eyes do not spread apart enough to see in the distance. When the patient is looking far away, the eyes may appear crossed, or one eye may appear turned in slightly. Again, either one eye will shut off or the patient may see double.

Post Concussion Treatment:

Treatment should be individualized to address all of the specific dysfunctions determined to be present during the assessment. It is progressed by determining the reactiveness of the symptoms to the exercises that are prescribed and making adjustments as necessary. Visual, balance and vestibular exercises (with the latter’s focus on combining balance with rapid head movements) are patient specific, as are those that gradually restore each client to full physical activity. The idea is to challenge each of the systems sufficiently that symptoms (i.e., nausea, headaches) may be provoked or amplified mildly yet briefly and resolve to pre- treatment levels or better very quickly (within five minutes). If an exercise fails to sufficiently challenge symptoms, it should be advanced.

The brain responds to habituation (accomplished with repetition), and so patients are advised to do their home exercises three times daily. They are also urged to gradually re-introduce functional activities. If instead they avoid those things that reproduce symptoms (like exposure to light, head movements, or being in a car) the brain becomes even more sensitized. It is important to get out, to walk, to socialize and to seek enjoyment. In addition to the inherent value of such activities, they enhance mood and in that way also accelerate recovery.

With treatment, the vestibular piece typically resolves quickly – often with only one or two sessions in the hands of a skilled physical therapist to reposition ossicles that are out of alignment. There is currently more objective data established via research to determine vestibular recovery than that for the visual system.

The visual piece is less clear. There are fewer objective tests and it is more difficult to assess. Not knowing an individual’s pre-injury status also makes it more complicated, as issues may have predated concussion. This can take much longer to improve, and treatment should continue – though on a much less frequent basis – long after a person tests normally.

Repeated assessment throughout the recovery process enables therapists and doctors to effectively monitor patient progress across all systems. Symptom resolution generally correlates to achieving normative values.

The primary role of the neuropsychologist in the Banner treatment model is to evaluate cognition and assess any possible confounding factors. ImPACT™ results and a client’s neuropsych performance are correlated. Cognitive and emotional issues are identified, and appropriate follow-up education is provided.

Dr. DenBoer noted that many clients do not understand why they are having problems such as issues with attention, concentration and processing speed. Repeated neuropsychology assessments determine the degree to which the various therapies are working on a neuropscyh and cognitive basis.

The neuropsychologist on the treatment team also provides intervention regarding sports psych issues for patients dealing with psychological variables/anxieties with return to school, work or play. This may include seeking academic accommodation for students seeking return to full participation in the classroom, or modified duty for those requiring accommodations at work. While the other therapies provide care to restore function, the neuropsychologist on the team  addresses strategies to return to a pre-injury lifestyle and improve coping skills.

Headaches can throw recovery off course:

Chronic intractable headaches, not uncommon after concussion, are a symptom that can get in the way of recovery.

Occipital nerve blocks are done with some regularity by neurologists for the treatment of migraines. These entail steroid injections to the nerve at the base of the skull. Dr. Erickson opts for this strategy at Banner when he feels the intervention is necessary to eliminate post concussion headaches. This enables patients to effectively perform and respond to the various therapies (visual, balance and vestibular), curtailing factors that may have been causative of the headaches in the first place. By the time the block wears off, the other systems have been normalized and the headaches generally do not return.

Should headache symptoms persist after an initial injection, or if they return, an additional block may be administered or the patient treated with Botox injection. At Banner, these patients are referred for consultation with a neurologist.

My research has led me to believe that multiple injections are not necessarily the answer in the event headaches return some time after the initial trials. Chronic headaches that may be a factor in persistent post concussion syndrome or that result from repeated trauma might best be approached with biofeedback and other alternative strategies along with nutritional guidance and exercise to best modulate symptoms.

Banner’s Care Delivery Model

The best concussion care employs a very specific, methodical and solitary approach to concussion that results in a very individualized rehab plan for every individual. Though everyone is tested the same way, each client’s experience can be unique.

The Banner program, established in 2013, was the first center of its kind offering an integrated and comprehensive program in which all disciplines work together closely under one roof. This profoundly enhances care. The professionals work as a team, providing each client with a comprehensive assessment. They meet regularly to customize the course of treatment, monitor each patient’s progress and determine readiness for discharge. There is little need to refer outside of the practice (other than as needed for orthopedic physical therapy, neurology or medical imaging offered at the medical center’s outpatient facility across the street).

The Banner Center’s medical model is also unusual in that it’s director, Steven Erickson, MD, is a sports medicine specialist, and not a neuropsychologist. He guides and oversees the entire team. That team includes physical therapists whose specialization is in the vestibular system/balance, ocular specialists (a board certified neuro-optometrist specializing in diagnosis and visual therapy, and an occupational therapist/patient care coordinator who also specializes in visual therapy), neuro/sports psychologists and athletic trainers.

Another distinguishing factor that gives Banner a distinct edge is the unique dynamic method of computerized neurovestibular testing that they developed. It provides objective measures of neurologic function by assessing balance (in double leg stance – meaning on two feet) and it’s relationship with the visual system and head movement (the vestibular component). The force plate technology employed enables objective measures that are far more exacting than the subjective assessment utilized by most outside professionals. Many still test balance more traditionally – without movement (statically), and utilizing various standing positions (including single leg stance) that do not account for the presence of an orthopedic condition that would influence the outcome. By testing in this way, others likely miss dysfunctions that should be addressed in treatment.

Shelly Massingale and Steven Erickson will soon publish their methods and data regarding the rational and methods for the type of testing they do. It is their hope that others will incorporate it into their programs. Though force plate technology is state of-the-art, there are ways to improvise and utilize this information even in the absence of these expensive tools.

There are other concussion centers out there that offer pieces of Banner’s model. The closest is at the University of Pittsburgh Medical Center (UPMC), which as previously noted, developed the computerized ImPACT™ program that is considered to be the gold standard in working with brain injuries. UPMC also independently developed a balance-testing format much like Banner’s. If you are based on the east coast, want a great assessment, and are willing to travel, Pittsburgh is the place to go. The Cleveland Clinic is another highly regarded facility that developed an interesting iPad based neurocognitive program that is different than the ImPACT™ program. They, like UPMC and Banner are also advancing the model of care.

Other smaller centers offer components but not the integrated on-site team approach that is so ideal. These providers refer out for patients to receive the full complement of therapies they may need. For emphasis, it can’t be overstated that if you or someone you know seeks post concussion care at a smaller center, each piece of the assessment and treatment puzzle must be a part of the plan of action. It may be left up to the patient – or someone advocating for that individual – to see to it that the appropriate referrals are obtained along with consistent follow-up treatment.

Return to Activity

Once the acute post concussion phase has passed, limiting academic or work hours as well as cognitive and physical demands is recommended. Incorporating periods of rest proves very helpful.

Progression to full performance of academic or employment responsibilities should be stepped up gradually. It is important to avoid fatigue, excessive stress or symptom exacerbation in a quest to return to full function.

Criteria for returning to sports participation include:

  • Complete resolution of symptoms at rest and with cognitive or physical exertion
  • Demonstration of normal function on neurocognitive, visual, vestibular and balance testing
  • The Concussion in Sport Group established a specific return to play protocol20. It begins with rest and then stresses a gradual increase in activity that first incorporates aerobic exercise and then progresses to sport-specific training. The program advances further by adding non-contact drills (such as cutting and other lateral movements) and ultimately includes full contact controlled training. A return to full participation in any sport – contact or otherwise – is predicated on successful completion of all phases without any symptom provocation.

Part Three will conclude the series on concussions with discussion of football and CTE