…If I had a dime for every time someone with concussion said “my doctor doesn’t listen to me”. Nearly every day in clinical practice patients report to me one way or another this very real concern. While this is true across all areas of specialty at our center, it is far more prevalent in those suffering the effects of concussion and post-concussion syndrome.
There are several theories as to why many doctors don’t take the time to listen. These can be explored at length with a simple internet search. Here, I will briefly explore some of these more accepted views and, more importantly, what I have come to see is the real truth behind why so many are being ignored, and in many cases dismissed, by their ‘trusted’ health care providers.
The Usual Suspects
Time. Most primary care physicians are pressured by the demands of heavy patient loads and declining insurance reimbursements. That leaves you as the patient at the mercy of a provider that may only give you one minute or less to voice your concerns; which for those of you with concussion are often too many to list.
Distraction. Electronic records, insurance forms, mobile devices, and excessive patient volume can cause doctors to get caught up in things that are not right in front of them. That is you, the patient. If a doctor is distracted, they will not do a great job at listening.
Bias. It has been established that many doctors will spend less time with individuals based on race, gender, and other factors such as socio-economic status. Also, patients that come in with recurring complaints are more likely to be dismissed or ignored.
While I believe these are accurate (although unacceptable) reasons for many being short-changed when it comes to their health care provider’s attention; there are more specific reasons doctors don’t listen when it comes to the laundry list of life struggles that can accompany concussion and post-concussion syndrome.
The Real Story Doctors Don’t Listen to Those With Concussion
Ignorance. This may seem like a harsh term to many (particularly the doctors), although it simply means that most primary care providers lack the knowledge and information necessary to properly question and screen for these types of conditions.
Invisible. Concussions are not seen on CT scans or found in blood work. They are silent injuries that result in functional problems with balance, vision, cognitive abilities, and more. Conventional medical approaches are not well suited for these conditions; therefore, doctors are less inclined to listen to problems they cannot treat.
Overwhelming. The number of symptoms and conditions that can result from a hit to the head are staggering (we’ve compiled a list of over 50!). Most doctors when presented with 5, 10, or more complaints may focus only on 1 or 2 as this is what they are accustomed to.
Unknown. Even with all the attention given to concussion over the past several years in sports, the media, and movies, this is still uncharted territory for most providers in mainstream medicine. This is also true for many of the doctors those with concussion are being referred to.
So, What’s the Answer?
The internet is full of strategies to get your provider to listen better. This, however, is not the focus of this article. And, it will not serve you well to try and get those that don’t understand concussion to listen to you! What you need to do is seek out the services of a qualified functional neurologist who is well versed in the art of listening. And, who understands the multitude of symptoms those with concussion and post-concussion syndrome experience. Only then will you be able to get answers as to what the best method of treatment will be for you. Concussions are real, and so are the symptoms and solutions!
For more information please call us at 828.708.5274, or visit any of the following resources:
At the time of presentation to APEX Brain centers in Asheville, NC in late 2015, Jackie was a 55-year-old, soon to be retired professional female. Post-concussive symptoms of debilitating headaches, memory loss, learning and behavioral issues, fluctuations in heart rate, and difficulty handling visual stimulation such as driving, busy public places and computer screens were preventing her from leading a normal life. Prior to traveling to APEX from Charlotte, NC, Jackie had sought care from several different doctors in her area. Vestibular therapy and chiropractic care had given her some relief of symptoms, although her other experiences were not so positive. At one point a provider told her that she was mentally ill. Jackie was outraged and, as many with post-concussion syndrome report similarly, she offered this statement: “I’m not crazy. I didn’t have any of these symptoms before I had the injury and I am definitely not making them up”. This is the unfortunate reality of many who suffer with brain injury.
Intervention for balance and cognitive decline
Jackie underwent comprehensive Brain Training at a frequency of 3 times per day over the course of 15 days (with 2 days off between each week for much needed rest and recovery). Her brain function was carefully monitored throughout the training process with measurement of EEG brainwaves, vital signs, eye movements, balance, mental and physical timing, and more to ensure she was receiving the proper amount of therapy to be effective without exceeding fatigue limits that could potentially promote worsening of her symptoms. Modalities implemented included, but were not limited to: neurofeedback, Interactive Metronome, vestibular rehabilitation, metabolic/nutritional therapies, eye movement and neurological rehabilitation, electrical stimulation, breathing exercises and home care therapies.
Outcomes after Brain Training
Jackie reported prior to brain training that she would have a constant headache of 6 on a 0-10 scale (0 being no pain and 10 being the worst possible pain) that would escalate into an 8-9 of 10 by the end of the day. The week after her program she reported the headaches were finally manageable at a level of 3-4 of 10 and would not escalate. Jackie has had continued success and reported at 3 weeks after her program that she is headache free, unless she spends too much time in front of a screen or in a busy public place. She also reports that when this occurs, her ‘at home’ brain exercises will relieve them. Aside from headaches, Jackie has reported that she no longer feels like she is in a constant brain fog. Her heart rate has also normalized and no longer fluctuates or spikes.
Actual, measurable objective improvements recorded with post-intensive diagnostic testing include, but are not limited to:
Cognitive Testing: Jackie showed an increase in her Neurocognition Index of 11%. This is a standardized overall score of cognitive performance. Significant improvements in specific areas of memory (one of her biggest concerns) are as follows: 65% in composite memory, 33% in verbal memory, and 67% in visual memory.
Interactive Metronome: 56% improvement in motor timing accuracy and normalization of hyper-anticipatory timing tendency with motor tasks (i.e. premature response to a specified reference tone).
Videonystagmography (VNG): Significant improvements in numerous aspects of oculomotor (eye movement) functionality including: gaze holding, slow and fast eye movements, optokinetic responses, and spontaneous/involuntary eye movements.
Implications for others:
Diagnostic and functional tests can be used to direct an effective Brain Training program and improve post-concussion symptoms. Increased sensory and environmental sensitivities are common symptoms of post-concussion syndrome. There are several areas of your brain that process information from your environment and from your body. If these areas are damaged then it becomes difficult for the brain to process sensory input, resulting in fogginess, memory and cognitive issues, impaired processing of pain, and the many other symptoms seen after concussions. The frustration felt by individuals being made to feel they are “crazy”, as Jackie noted, is entirely unnecessary and driven by a health care system that is largely focused on diagnostic testing and lacking significantly in functional treatment options. There is great hope for partial and full recovery in most cases of concussion given a thorough investigation and functional interventions addressing the physical, cognitive, metabolic and lifestyle factors that influence brain health.
If you or someone you care about is experiencing ANY of these symptoms, or anything out of the ordinary related to a head or brain injury, call APEX Brain Centers now at 828.708.5274. You may also email us at [email protected] for more information and to set up a free consultation.
Ali presented to APEX Brain Centers in August of 2015 in search of concussion relief. She was struggling with a host of debilitating complaints due to multiple head injuries and concussions over the years. Headaches, brain fog, memory loss, anxiety, emotional distress, restless legs, tightness in the chest, tingling in her limbs, postural orthostatic tachycardia syndrome (POTS), dizziness, spatial awareness difficulties, loss of muscle mass and hair, gastrointestinal (GI) difficulties and more were all part of her normal daily experience. She was in a constant search for concussion relief. She had been to a host of specialists with limited outcomes; including osteopaths, naturopaths, ENTs, cardiologists, allergists, chiropractors, physical therapists, acupuncturists and massage therapists. She was an exceptional student and athlete prior to her injuries.
Ali traveled from Virginia to seek care at APEX Brain Centers in Asheville, NC in late August, 2015 on referral from a friend who had similar problems with exceptional outcomes at APEX. She underwent an intensive course of Brain Training where she was admitted into in an individualized program directed by extensive diagnostic testing, and led by clinicians highly experienced in functional neurology and functional medicine. What follows is a sampling of some of the cutting-edge clinical interventions and amazing functional gains Ali experienced during her time at APEX.
Intervention for Concussion Relief
Ali underwent comprehensive Brain Training at a frequency of 3 times per day over the course of 10 days (with 2 days off between each week for much needed rest and recovery). Her brain function was carefully monitored throughout the training process with measurement of EEG brainwaves, vital signs (particularly important in those with POTS), eye movements, balance, mental and physical timing, and more to ensure she was receiving the proper amount therapy to be effective; but not too much so as to reproduce/amplify symptoms. Laboratory tests were ordered to evaluate for suspected food reactivity, markers of inflammation, altered stress responses and amino acid insufficiencies; among other factors. Modalities implemented included, but were not limited to: neurofeedback (NFB), Interactive Metronome, vestibular rehabilitation, metabolic/nutritional therapies, eye movement and neurological rehabilitation, whole body vibration, electrical stimulation, cognitive training, breathing exercises and home care protocols.
Ali’s Outcomes after Brain Training
Subsequent to her initial Brain Training program, Ali reported subjective improvements in all areas of pre-intensive complaint. What follows are a sampling of Ali’s words describing outcomes in several of these areas:
My heart rate is down significantly and I have fewer palpitations
I rarely feel unbalanced anymore
The tingling in my hands and feet is gone
Brain Training has greatly decreased my widespread pain
Since leaving APEX I have only had a few minor headaches, and none that have turned into a migraine
Now I can really engage with my children for long periods of time
My emotions are on a more even keel
I can recover from a workout and exercise again the next day
My immune function is improved
I expect all of my capabilities to return and even excel beyond what they used to be in light of the new and better lifestyle I’ve adapted!
Cognitive Testing: Increase in her Neurocognition Index of 13%, which is a standardized overall measurement of cognitive performance. Executive function (reasoning) scores were improved by 35%. Increases in various aspects of memory, attention, processing speed and more were as high as 13%.
Interactive Metronome: 43% improvement in task average with motor timing and 15% improvement in hyper-anticipatory timing tendency with motor tasks (i.e. responding prior to a pre-set reference tone).
Computerized Assessment of Postural Stability (CAPS): 8.2% improvement in balance on an unstable surface with eyes closed; which brought her from a moderate to mild reduction in balance compared to her age and gender matched peers.
Videonystagmography (VNG): Significant improvements in numerous aspects of oculomotor (eye movement) functionality including: gaze holding, slow and fast eye movements, optokinetic responses, and spontaneous/involuntary eye movements.
It should be noted that due to the overwhelming success of her first program Ali returned for a second intensive Brain Training program in November of 2015. She experienced further objective and subjective benefit and continues to update us on her progress.
Concussion Relief IS Possible
An alarming number of individuals do not seeking care for head injuries. It is important to recognize the symptoms of these debilitating injuries and that something can be done about them. The ‘wait and see’ approach to concussion and mild traumatic brain injury is no longer acceptable. Early intervention is key! The longer one waits, the more difficult it is to recover and have full engagement with life!
If you or someone you love is experiencing ANY of these symptoms, call APEX now at 828.708.5274. You may also email us at [email protected] for more information, or to set up a free consultation.
As the buzz surrounding the release of the projected Christmas blockbuster movie Concussion grows; the evidence continues to mount in support of the seemingly insurmountable challenges posed by this ‘silent epidemic’.
Continued reporting from one of America’s most trusted public television investigative news sources, PBS’s FRONTLINE, demonstrates the urgency of the matter at hand; and the extremes to which it can lead… Dementia and, in severe cases, death!
The most recent FRONTLINE update from September 18, 2015, based on research from the Department of Veterans Affairs and Boston University, can be viewed in their article entitled New: 87 Deceased NFL Players Test Positive for Brain Disease. The most shocking part of this reporting is that the disease, chronic traumatic encephalopathy (CTE), was found in 87 of 91 player’s brains tested. Let that soak in for a moment… That is 96% of the brains tested in this particular ongoing study showing signs of a potentially avoidable killer disease. We will come back to this in a moment.
Some definitions, facts, and stats to ponder:
Concussion is a traumatic brain injury that alters the way your brain functions
Most sport-related concussions (almost 90%) occur with NO loss of consciousness (LOC)
A median 2.7 million TBIs occur in the US each year (think about how many go unreported), at a cost of nearly $50 billion annually
Symptoms of concussion include: headache, dizziness, balance and speech problems, nausea, light and noise sensitivities, memory and concentration difficulties, behavioral and emotional struggles, and anything out of the ordinary observed that was not an issue prior to the event/s
Risk factors for concussion include: prior concussion, vertigo/dizziness, alcohol/drugs, high-risk behaviors and sports (e.g. football, hockey, soccer, etc.), military conflict, abusive relationships, driving, and high-risk occupations (e.g. construction, utility work, etc.)
Mild traumatic brain injury (mTBI) is another word for concussion; even though, in my opinion, there is no such thing as a ‘mild’ brain injury
Chronic traumatic encephalopathy (CTE) is a progressive degenerative disorder of the brain found in those with a history of repetitive brain trauma
Symptoms of CTE include: memory and executive function decline, depression, irritability, impulsivity, aggressiveness, suicidal behavior, eventual progression to dementia
(All facts and figures presented are courtesy of the Centers for Disease Control and Prevention and The Mayo Clinic)
***Did you know??? Those with ADHD are significantly more likely to experience worse outcomes with a concussion than their non-ADHD peers. This is of extremely important note as many children are placed in sports to control problematic behavioral and academic challenges. Read the abstract from a paper on this topic presented in the Journal of Neurosurgery: Pediatrics***
Back to the FRONTLINE reporting of 96% of the NFL players’ brains containing direct indications of CTE. What is being revealed in this ongoing study is one of, if not the most, statistically significant findings of our times. Consider for a moment if you will… If there were an outbreak of any communicable disease in a family, school, small town, cruise ship, or some similar controlled group separate from our general U.S. population; it would take, in most cases, less than 1% of the population being affected to mobilize critical resources to control and eliminate such an outbreak. Why is nothing being done to prevent and treat this largely controllable epidemic that has been unfolding before our very eyes for some time now?
While there is an extraordinary amount of activity and funding being directed towards this catastrophe, we are still largely no further along in the detection, advocacy, and treatment for this ‘silent epidemic’. As a clinician who has been in the trenches working with concussion and TBI for over 15 years, the stark reality is that the vast majority of patients that have walked through the doors of our Center have been given the same advice: “Wait and see”. That is, to go without treatment in hopes of symptoms subsiding; which, in rough estimates from various sources, will not happen in approximately 25% of cases! In other words, at least one in 4 will continue with any or all of the debilitating symptoms listed above long after a blow to the head.
Why “wait and see”? The primary tests utilized after one has sustained a hit to the head and suspected brain injury are structural in nature. What this means is if you have nothing that shows up on a CT scan or MRI, you are structurally ‘OK’ and sent on your own to wait out the symptoms – possibly with the assistance of medications for pain, dizziness, nausea, etc.
What are often overlooked, or not acted upon if they are in fact implemented, are tests of brain function. There are a great number of ‘biomarkers’ of brain function that can be measured with great precision – that is, tests that tell us what’s going on in the body as a result of commands from the brain; and what might not be working well after a particular region of the brain area has been injured. What follows are some examples of these biomarkers that can be measured and improved in most cases of concussion and TBI:
Blood sugar, hormone regulation, and other metabolic functions
Once functional deficits are identified; a host of neurological, cognitive, and metabolic rehabilitative interventions and processes can be employed to normalize these functions as best possible – and, in many cases, entirely! Examples of such would include: eye movement therapies, gait training, neurofeedback, physiotherapeutic modalities such as electrical stimulation and vibration, nutritional therapies, aromatherapy, visual and auditory training, meditation, lifestyle changes, and more.
While the quest continues to identify the best, evidence-based practices to combat this growing epidemic with little to no therapeutic intervention being rendered in most cases; there are a small number of progressive centers that strive to provide highly effective functional clinical interventions, as opposed to “wait and see” that has failed so many. Given the apparent lack of immediate shifts in the cultural circumstances that are causing brain injuries, and the inability or lack of desire of many to abstain from behaviors that are causing them, it is imperative that intervention with any head injury be focused largely on the therapeutic aspects once adequate healing time has passed.
One parting thought: There remains a sentiment in opposition to studies of the nature of the one referenced in FRONTLINE; dismissing the evidence as an overreaction to, and sensationalizing of, data from a highly specific group of individuals (i.e. football players get head injuries). My question to you is: If just one person in your family, community, etc. were to contract a disease like polio; do you think there would be any discussion of overreaction to the impending action that would be taken to remediate the cause of this potentially crippling disease?
If you knew there was something you could do, then why “wait and see”?
Liz is a 29-year-old female entrepreneur, designer, and athlete who came to APEX Brain Centers with a history of post-concussion syndrome from previous car accidents and sport related head injuries. She reported symptoms that are often seen in cases of mild Traumatic Brain Injury (mTBI) including brain fog, fluctuating and elevated heart rate, fatigue, incoordination, excessive emotionality, sharp head pains, and decreasing ability to think critically and effectively. Liz’s symptoms have been nothing short of debilitating and have taken away her ability to work full time at the career she loves. She was also very concerned that her future plans of having a baby and starting a family would be compromised due to the health risk to both her and a developing fetus.
Liz traveled from Virginia to the APEX Brain Centers office in Asheville, NC to participate in our targeted, high frequency, high intensity Brain Training program. She began a 10-day course of Brain Training in November of 2014 with a goal of alleviating her concussion related symptoms. With her sincere efforts and dedication to recovery, we were able to record significant measurable changes related to her symptomatology.
Intervention for mTBI
Liz underwent Brain Training 3 times per day over the course of the 10-day period. Her brain function was carefully monitored throughout the training process to ensure she was receiving enough treatment to be effective, but not too much so as to be counter-productive. Modalities delivered included, but were not limited to: neurofeedback (NFB) and transcranial magnetic stimulation (rTMS), Interactive Metronome, vestibular rehabilitation, metabolic/nutritional therapies, eye movement and other aspects of neurological rehabilitation, electrical stimulation, breathing exercises and home care recommendations.
Outcomes after Brain Training
Subsequent to her Brain Training program, Liz reported significant subjective improvements in the vast majority of her post-concussion syndrome symptoms including: fogginess and “wandering” of thought, fluctuating heat rate, ability to control emotions, head pain, sleep, intensity at which she was able to exercise, balance, and levels of energy.
Actual, measurable objective improvements recorded with post-intensive diagnostic testing include:
Cognitive Testing: Improvements in 4 aspects of memory, attention, executive and other cognitive functions ranging from 14% – 800%.
Interactive Metronome: 42% improvement and normalization of hyper-anticipatory timing tendency with motor tasks. 68% improvement in task average with motor skills. 30% improvement in overall response accuracy with motor skills.
Computerized Assessment of Postural Stability (CAPS): Elimination of mild reductions in stability with balance and complete normalization of balance abilities in eyes closed scenarios.
Videonystagmography(VNG): Significant improvements in numerous aspects of oculomotor (eye movement) functionality including: gaze holding, slow and fast eye movements, optokinetic responses, and spontaneous/involuntary eye movements.
Autonomic Testing: Stabilization of heart rate from an erratic range of 90-150 bpm, to 60-90 bpm; saving her over 30 million heartbeats per year!
With an ever-increasing number of individuals experiencing mTBI, it is important to recognize the symptoms of these oftentimes debilitating disorders and, more importantly, that something can be done about them. Borrowing a phrase from the Brain Injury Association of America, “Brain injury is the last thing on your mind, until it is the only thing on your mind”!
A young soccer player, a third grade girl I’ll call Annabelle, came to see me seeking relief from disabling eye pain, lack of visual focus, depression, and anxiety. Annabelle had been living with these symptoms for quite some time, ever since she suffered a mild blow to her head during a game. After the injury her family took her for treatment immediately, and she was diagnosed with a concussion. The physician who saw her told her family to “wait out” the symptoms. So they waited. And waited. The longer Annabelle waited, the worse her symptoms seemed to get. Annabelle had to give up soccer, and started missing an extraordinary amount of school. In my practice I see head injury victims like Annabelle, and the long-term effects of the “wait and see” approach to concussions all too often.
Concussions are one of the greatest concerns for young athletes in this country today. One quarter of a million young people visit emergency rooms every year to seek treatment for sport or recreation related brain injuries, according to the Center for Disease Control. It is thought that many more concussions go untreated because of lack of awareness about the dangers of head injuries. Research into the problem suggests other reasons why concussions go unreported. A study conducted by The Institute of Medicine and the National Research Council concluded that there is a “culture of resistance” among athletes to report concussion symptoms. Many young sports players, their coaches, and families take the wait and see approach. Annabelle’s story demonstrates that many health care practitioners do the same.
The White House Concussion Summit
Recently, President Obama hosted the first ever White House Healthy Kids and Safe Sports Concussion Summit to spread awareness of brain injury prevention and offer resources to recognize and appropriately respond to concussions in young people. After the event, the White House released a fact sheet on sports related concussions aimed at young athletes and their families. What is most striking to me in this release is the continued realization that there are significant gaps in concussion research knowledge, and the statement of, “The truth is we still do not know enough about the consequences of traumatic brain injuries, (whether) it’s a hard knock on the playing field or head injury sustained by one of our troops serving abroad.”
I have personally observed the consequences of mild to severe traumatic brain injury (TBI) in clinical practice for nearly 15 years now, and this perceived lack of understanding of the consequences, in my humble opinion, is the primary reason for the general apathy and “sit and wait” approach most follow when it comes to dealing with mild brain injury or concussion. The greater issue, which is suggested in the White House release from the summit, is the need for better education for and coordination between athletes, parents, coaches, educators, providers, and other stakeholders.
The White House concussion summit offered a lot of reasons for hope, including new research that is being funded by the NCAA, the NFL, and many educational, governmental and non-profit institutions. While it’s encouraging that communication barriers are being broken down and much needed research and guidelines are being assembled, the truth is that today’s young athletes could be receiving much better and swifter care for concussion injuries. There are already effective methods for dealing with brain injuries that deserve more attention. The symptoms, objective markers and testing, treatment options, and long term dangers of concussion are in fact well understood by those clinicians dealing with brain injury on a regular basis.
A Different Approach to Concussion Injuries for Today’s Young Athletes
Functional neurologists are very likely the best equipped clinicians to deal with the ramifications of brain injury in youth, as they are well-versed in function of motor, balance, eye movement, cognitive and emotional, autonomic, and other systems often impacted by blows to the head. They also have at their disposal diagnostic testing procedures to assess function in all of these areas and, most importantly, an exhaustive list of rehabilitative tools to effectively treat these potentially devastating injuries.
As a Functional Neurologist, I have a different approach to concussion. When Annabelle came into my office I did not tell her to “wait and see.” I gave her a full neurological evaluation and ran many other test regimens, including eye movement testing with videonystagmography. Her results revealed that the parts of her brain responsible for visual focus, object tracking, and balance were not performing functionally. Other problems were uncovered as well, including measurable challenges with sequencing and planning in the front part of her brain. After an intensive 5 day course of brain training specific for her measured deficits she returned to school, and was able to finish the rest of her school year without any further problems. She told me, “I am normal again.”
With greater education and awareness of treatment options available today, we can help young athletes like Annabelle get back on their feet, and back to enjoying the quality of life they deserve, without waiting a second longer!
No one is immune to the possibility of concussion; although athletes, children, senior citizens, and those with ‘high-risk’ jobs are much more likely to suffer head and brain injuries. No blow to the head should be taken lightly. The long-term effects of untreated concussions, under-treated concussions, or mistreated concussions can be wide ranging. The dysfunction caused by post-concussion syndrome can show up in many areas of life, including some areas you may not suspect. Here are 5 areas of life where a person with untreated concussion symptoms may struggle long after the injury has occurred:
Student athletes who suffer concussions may be sidelined; not only from sports activities, but also from classes. It is not uncommon for students to miss weeks or even months of school while dealing with symptoms of concussion. Symptoms such as eye pain, blurred vision, memory loss, attention disorders, reading comprehension problems, and fatigue can make it nearly impossible for children and adolescents to focus and concentrate on schoolwork with any degree of success.
It can be difficult to cultivate or nurture meaningful relationships when you are dealing with long-term challenges caused by brain injury. Symptoms such as ‘brain fog’, chronic pain, and emotional dysregulation can damage relationships with family members, friends, and colleagues.
Focus, attention, coordination, and mental timing are significantly impaired with most head injuries. These problems can have a profound negative impact on job performance. Left untreated, or inappropriately treated, the effects of these injuries can be long lasting and often lead to decreased hours on the job, extended leaves of absence, demotions, further injury, and even termination of employment.
Balance issues, vertigo, dizziness, headaches and other pain syndromes, heart rate irregularities, digestive issues, and even seizures are just some of the physical problems experienced by those with one or more concussions.
Mental illness and behavioral disorders including ADHD, anxiety, depression, phobias, PTSD, and addiction are often the end result for many with untreated head injuries. Stress and emotional turmoil, as well as long-term inflammatory responses and altered neurotransmitter function caused by head injury will very likely cause mental health challenges left untreated.
The bottom line is – you should always seek a thorough examination by a qualified practitioner after any head injury. There absolutely is hope for those suffering from the after-effects of concussions and post-concussion syndrome. Proper assessments and intervention strategies specific for your injury are the keys to improvement. For instance: quantitative EEG (qEEG) and neurofeedback, vestibular and balance therapy, assessment and treatment of eye movement, and physical training modalities such as the Interactive Metronome, are just some of the strategies that, if applied appropriately, can help you reduce and even eliminate many of the challenges and symptoms listed above. At APEX Brain Centers we offer this hope through specific, comprehensive Brain Training for these treatable injuries.
Call us now at 828.708.5274 if you or a loved one has, or thinks they may have, suffered a concussion.
While a thorough neurological history and examination with a qualified professional should be performed for any suspected head injury, particular emphasis should be placed on the cranial nerves – the nerves that exit your brain and brainstem. Of these cranial nerves, the most telling findings will likely come from the ones involved in vision and eye movement (cranial nerves 2, 3, 4 and 6). It is also critical to assess higher brain centers that control various eye reflexes, which will be discussed later in this article, during the eye examination as well.
There are many types and causes of head injury, but, by far, the most common are concussions related to motor vehicle accidents and contact sports. Concussion comes from the Latin ‘Concutere’, which means to shake violently. Most experts would agree that these are the least serious type of brain injury; yet left untreated many can suffer devastating and debilitating consequences such as vertigo/dizziness, balance problems, cognitive dysfunction, emotional disorders, headaches, and many others.
Given concussions are ascribed this ‘low severity’ status, timely evaluation and treatment is often poor or non-existent at best. Patients are often treated with a ‘sit-and-wait’ approach; meaning it is only after signs and symptoms have manifested and worsened that people often seek care of their own accord. This is entirely unacceptable as early intervention is critical with concussion, as is the case with most disorders of humankind, and it may significantly decrease the likelihood of more serious consequences. The longer one’s brain is adapting to negative changes incurred as a result of a head injury (referred to as maladaptive plasticity), the longer it will take to rehabilitate their way out of them!
Shifting our focus back to the eyes (pun intended); most individuals that have suffered a concussion will complain of some type of symptom related to eye function (e.g. blurry vision, light sensitivity-photophobia, eye fatigue, double vision-diplopia, reading difficulties, etc.). I cannot honestly recall a single case of concussion presenting to my office in the recent years that did not have some type of visual or oculomotor (eye movement) consequence.
We have all seen at some point on TV or the ‘Big Screen’ a doctor shining a light in someone’s eyes to look for lack of pupil constriction as the one and only diagnostic factor for concussion. Well I’m here to tell you that they need to be looking at a great deal more than that! Some basic tests to look for when you or a loved one is being examined for suspected concussion are as follows:
1) Observation for eye malpostion
2) Direct and indirect pupil response to light (as noted above)
3) Cardinal fields of gaze (eye movements in all directions)
4) Observation of slow and fast eye movements, and termination of said movements
5) Eye convergence (crossing of the eyes – as your mother told you to never do!)
6) Ophthalmoscopic examination (looking inside the eyes)
7) Visual acuity/Snellen chart (how well you see)
8) Eye cover/uncover testing (more sensitive test for eye deviation)
9) Eye dominance and/or suppression testing
While not an exhaustive list, these tests can be done in a very short period of time (5 minutes or less) with very little equipment and can reveal a great deal about the integrity of these cranial nerves, as well as the higher brain centers that regulate these functions.
That said, there are a host of other very sensitive tests that can offer clinicians incredibly valuable insight into the workings of the ocular (eye) system and its connections with most parts of the brain.
1) Vestibulo-ocular reflex (VOR) testing – often performed with the patient focusing on an object while the examiner moves the head, or while the patient is rotated in a chair
2) Testing for eye saccades (fast movements between targets) – movements are typically over or under compensated with concussion
3) Cortical blind spot mapping – mapping of the visual defect created by the optic nerve attaching into your retina where there are no receptors for light (rods/cones)
4) Testing for optokinetic nystagmus (OKN) – reflexive eye movement caused by tracking of movement within a visual field (i.e. similar to looking out a car’s side window while moving)
5) Electronystagmography (ENG)– advanced electrical testing of various ocular capabilities
Once again, this is by no means an exhaustive list of assessment tools available to the practitioner for evaluation of the eyes and associated brain systems after a head injury, and evaluation options will vary depending on the type of practitioner utilized for assessment (e.g. DC, DO, MD, PT, PhD, etc).
In my humble opinion, given their astute focus on ‘functional’ abnormalities of the nervous system, functional neurologists such as Chiropractic Neurologists are best equipped to deal with these types of conditions; meaning those injuries where there is no observable ‘structural’ damage to the brain. It is no secret that our modern health care system fails to acknowledge and treat these ‘functional’ brain injuries effectively and the long term ramifications of this ‘sit-and-wait’ behavior can be absolutely devastating.
In closing, while I agree there is a greater awareness of brain injury given the publicity provided to it primarily from the great men and women that have been injured serving our country in the past decade or so, along with all the attention more recently in professional sports; I still feel the attention and treatment given to those with ‘milder’ brain injuries like concussion is poor at best within our current system. And this opinion is validated and reinforced daily in my clinic when I see the changes in folks and their families that have been advised to ‘sit-and-wait’. While many sports programs at all levels are implementing strategies such as sideline visual tests like the King-Devick test that are remarkable for evaluating concussion within minutes of the injury, the passive after-care approaches have not changed a whole lot. I am here, along with my colleagues, to ensure that those suffering concussions do not ‘sit-and-wait’, and that they get the appropriate evaluation and intervention necessary to return them to their pre-injury (or better) status. Please help us in this mission and pass this on to everyone you know as no one is immune to the possibility of head injury!
~Please check back soon for a follow-up article discussing successful non-pharmaceutical treatment interventions for concussion and TBI~