Concussion Health

With a new state concussion law for high-school athletes in place, Eastwood High School athletic trainer Tom Lechtenberg had many questions: Who would set his district’s return-to-play protocol? What is the best method for determining concussions?

 On Saturday, in what some called a ground-breaking event, Lechtenberg began to get answers.

 The Spine and Rehab Specialists sponsored a day-long concussion management seminar at UTEP’s Larry K. Durham Center where Bridget Wallace, a national concussion expert, discussed the new law, which passed in spring, and the best ways to diagnose, treat and respond to concussions with about 65 El Paso health professionals, including area high-school athletic trainers.

 ”With the new bill being passed, I think there’s some uncertainty,” Lechtenberg said. “So this was a great way for us to get some clarity.”

 Adolescents are the most prone to concussions and an estimated 250,000 high-school athletes suffer concussions every year, Wallace said.

 The new law (HB2038) has stricter guidelines on when a high-school athlete can come back from a head trauma – at least one day. The gray area occurs with the new requirement of a concussion management team for each school district.

 The team, which must include a physician, is in charge of developing the return-to-play policy on an individual and district-wide basis.

 ”It’s a good law because it creates oversight,” Wallace said. “But there’s not a clear way for these school districts to implement it. That’s the hard part.”

 Socorro Independent School District has started forming its concussion management team. The district has reached an agreement with a doctor and has drafted letters to parents. But funding and consistency are issues.

 ”It hasn’t been easy,” Montwood athletic trainer Lindsay Moore said. “Tests are expensive for 1,000 athletes … and what if the kid’s primary care physician sees something differently than we do?”

 Some trainers suggested creating one policy for all of El Paso. Wallace said that discussion is a good start and so is raising awareness.

 The seminar also included several ways to identify and recognize concussions. One of Wallace’s biggest messages was a multidiscipline approach – not just focusing on balance, vision or emotion, but combining all three. That makes it more difficult for an athlete to hide the head trauma and easier for the athletic trainer to diagnose.

 Wallace stressed that recovery time should not just be spent off the field. She said the brain needs rest and stimulation – such as skateboards, iPods and computers – should be limited.

 The day concluded with a concussion certification exam.

 ”It definitely enhanced my evaluation skills,” Riverside athletic trainer Jay Hill said. “And that makes us better and the student athlete safer.”

 Evan Mohl may be reached at emohl@elpasotimes.com;546-6381.

Sharing a story from a Play It SAFE app user…

I went to Kansas last week to see my 11 year old grandson play baseball.  On Thursday morning I was telling my son about this app, but it was not available on his phone.  Anyway he coaches the team and that evening we had a game.  The opposing team was at bat and a kid hit a hard ball to center.  As the kid rounded second he tripped and lost his helmet.  He continued on to 3^rd.  Just as he was sliding the catcher tried to throw him out and hit him behind the left ear.  After a couple of minutes the kid is still on the ground and my son ran out to check on him.  He immediately remembered my demoing the app, so he yelled for me to come out.  Unfortunately I left my iPhone in the car, but I had played with the app so knew what to do. 

The kid was responsive, but when asked the day of the week he said Monday.  We then got him on his feet, he looked fine and said he was okay.  I had him stand with his feet together, arms crossed and asked him to close his eyes.  He immediately swayed.  I recommended to the coach that he not play and because of the sway I said “if he was my son, I would probably take him to ER.” 

That coach called my son the next day to thank him for my observations.  The parents did take him to ER and the kid was admitted for the night for observation.  The ER doctor told the parents how critical it is for these things to be diagnosed early and they were fortunate someone was there that knew concussion assessment.  J It was your app! 

My son wants me to come up before the next season starts to talk to all the coaches about this and hopefully by that time the app will be available for all phones.  Fortunately, there is so much emphasis about this on the collegiate and high school level.  Unfortunately, there may never be any emphasis on the recreational league level.  And these are really young kids who could very easily suffer their first concussion at 5 or 6.  I am going to spread the word of this app to everyone I know and hopefully those people will share it with others.  We must get the word out! 

Balance testing as part of a comprehensive concussion management program is becoming increasingly accepted and, in some cases, mandated. There are a number of standardized balance tests although performing a series of tests is preferred. In the sports arena, there is notable recognition of the Balance Error Scoring Scale (BESS). The BESS consists of six balance tests of which all are performed eyes closed. The first 3 are eyes closed on a firm surface (feet together, heel to toe, and standing on one leg), which are repeated on a standardized foam surface. More recently, the BESS also has a modified version that excludes standing on a foam surface.

In the clinical setting, however, the modified Clinical Test of Sensory Interaction on Balance (mCTSIB) is typically performed for balance testing and can be performed with or without technology. The mCTSIB is four sensory balance conditions, which is performed with feet together (non-computerized version) or feet apart (computerized version). The first condition is eyes open on a firm surface while the second condition is performed eyes closed. The last two conditions are a repeat of 1-2 while standing on a standardized foam surface. Both the BESS and the mCTSIB are to observe how well the individual can maintain balance. The BESS was developed specifically as a “higher level” balance test for many do not consider the mCTSIB to be sensitive enough to detect balance impairments in the athletic population. However, many will argue that the BESS test produces unreliable data due to the majority of individuals that cannot perform single leg stance (SLS) and/or heel to toe (tandem) with eyes closed, especially on the foam surface. Certainly, the tandem and SLS stance positions result in more variables than feet together (e.g., hip weakness, orthopaedic injuries, etc). A viable option is adding 2 conditions to the mCTSIB, which would include head movements with eyes closed on firm and foam surface. This would result in higher demand on the vestibular (inner ear) system while decreasing the variabilities associated with tandem and SLS. Such testing has also been shown to increase the sensitivity of detecting balance impairments, especially following head trauma.

I utilize a variety of tools to assess balance in my clinic. During the clinical exam, I perform SLS with eyes open, tandem with eyes open (20 seconds) and eyes closed (10 seconds), and the mCTSIB. I repeat the mCTSIB with computerized balance testing. If the findings are within acceptable limits then I repeat the eyes closed tests (firm and foam) of the mCTSIB with head shakes (1 rotation per second or at 1 Hz). These tests are performed as part of a more comprehensive neurological examination as well as additional vestibular tests. Although I prefer the mCTSIB, we should all be in agreement that no tool should be used in isolation especially when faced with difficult return to play decisions.

Thank you for stopping by our booth at the NATA Annual Meeting & Clinical Symposia in New Orleans!  We were delighted to meet you and welcomed the opportunity to explain what Concussion Health is all about.    The response we received for the introduction of our services was exceptional!  We also want to thank everyone for their enthusiasm and ideas about our new PLAY IT SAFE® app. 

We will be contacting you in the near future to provide more information on Concussion Health.  Please feel free to contact us at any time with feedback and questions.  Stay tuned…

We are excited about the launch of our new i-phone app, PLAY IT SAFE^® Concussion Assessment, and new website: www.concussionhealth.com. Come by our booth (#1659) at NATA to receive a free eye chart as part of your sideline concussion assessment and to sign up for a 1 year free licensure to become a Certified Concussion Health Center™. We look forward to meeting you and answering any questions you may have about our services and/or our associated partners in concussion management.

I am often asked how I came to treat concussions. My initial reaction usually fluctuates between 2 thoughts: (1) Do I tell them the long version of how it started, or (2) do I just state I specialize in dizziness and balance disorders and a concussion is just one of many causes?  My response is typically the latter for I suspect most people are not too interested in my story.  Recently, however, I was asked to do just this – share my story. It goes something like this…

It was 1996 and I was working in an outpatient ”Day Program,” which is a multi-disciplinary outpatient program dedicated to re-entry into home, school/work and community for individuals who have suffered a neurological injury (e.g., head trauma, stroke, etc.). It was truly one of the greatest experiences of my life. It was there that I met a teenage girl who had just undergone surgery for brain cancer. She had dizziness and notable balance difficulties but that is not what defined her. It was her joy, her commitment, and her hope. She also wouldn’t accept her symptoms being explained by the repeated response of “you’re doing well, considering you just underwent major brain surgery for a large tumor.” It was always followed by a sigh, maybe a slight rolling of her eyes and, an under the breath, “but I want to know why.” I found myself being driven by the same question in an effort to better understand her signs and symptoms.

One Friday after our session, I was talking on the phone and noticed a brochure in the trash can about a course for dizziness and balance disorders. It was being held in Houston that very weekend. I decided to go. For 2 days I was overwhelmed. What I came home with was a manual and more questions than I had before the course. Despite the fear of it all, I had a tool…not just a means to start treating dizziness and balance disorders but the framework to seek more knowledge and understanding. Although I became increasingly interested in dizziness and balance disorders and the implementation of vestibular rehabilitation, the medical community was somewhat skeptical. A year later, however, I met a neurotologist who wanted to work together and specialize in this patient population. I was given an opportunity to develop a Balance Center within an outpatient physical therapy center. It was there that “treating concussions” became more of a focus. Somewhere between 1998-1999, I received a call from Tina Bonci, ATC, MS and Head Trainer of the Women’s Athletic Department at The University of Texas. There was an athlete who had suffered dizziness and unsteadiness for almost a year following a concussion.

The athlete’s clinical examination and evaluation revealed signs and symptoms essentially identical to someone who had suffered an inner ear infection and had not fully compensated. Thus, we proceeded through vestibular rehabilitation with excellent outcomes. Considering that I had worked with patients who had suffered head trauma and had solely been seeing patients with dizziness and balance disorders for the last 2 years, not only was it not a huge leap but it just made sense. There were also a growing number of studies from Kevin Guskiewicz, PhD, ATC and colleagues about changes in balance following a concussion. It was more specific vestibular testing, however, that we found to be the most correlated with this particular athlete.  After reviewing the literature, understanding the value of implementing various tests and observing the positive results of vestibular rehabilitation post-concussion, a comprehensive program from baseline to sideline to post-injury to rehabilitation was developed. Today, the integration of these multiple components combined with anecdotal evidence from numerous patients has evolved into a comprehensive concussion program known as Concussion Health.

There are still many unknowns about concussions despite that a distinction of signs and symptoms between traumatic brain injury and a concussion trace back to Dr. Rhazes who lived from 850-923 AD. Certainly, the legislative and media attention we see today is unprecedented. Fortunately, there is also an ever-increasing commitment to establishing best practice guidelines such as those seen in the Zurich 2008 Concussion Guidelines. Experts agree that no tool should be used in isolation. It requires a multi-disciplinary team approach centered around the client/patient whether the injury is sports related, fall related, work related, etc. We have more objective measures today (e.g., computerized testing) to support our clinical assessments as well as guide the rehabilitation process and provide clinicians with a variety of tools to aid them in challenging RTP decisions. I am excited about the evolution of concussion management and grateful to be involved in the process. It is an opportunity to stay aware of what we know, recognize what we don’t know and, above all, keep our eyes open to discover what we don’t even know we don’t know.

So, the intent of this was to tell my story…it started with a brochure in the trash can, which has evolved into a life-long passion.   There are a number of individuals that have paved the way as pioneers and provided me the opportunity to have a career that is not a job but a privilege.  I owe a special thanks to Robert Baloh, MD, Gaye Cronin, OTD, OTR/L, John Epley, MD, Joel Goebel, MD, Kevin Guskiewicz, PhD, ATC, Timothy Hain, MD, Susan Herdman, PhD, PT, Fay Horak, PhD, PT, Gaye-Kronin, OT, Neil Shepard, PhD, Anne Shumway-Cook, PhD, PT, Ronald Tusa, MD, PhD, Susan Whitney, PT, PT, ATC, and David Zee, MD. I specifically choose these people not because they know me but from what I’ve learned from their work and commitment to teach others. Of course, there are countless others who have paved a direct path in my professional career (and might claim to know me). To all I am grateful, especially for loved ones  and the experiences of life that will always remain my teacher as long as I keep showing up for class.