BR A IN INJURY professional vol. 9 issue 1
The official publication of the North American Brain Injury Society
Post Concussion Disorders Physiologic Post Concussion Disorder Augmenting Neurocognitive Assessment in the Evaluation of Sports Concussion: How Vestibular and Ocular Issues Impact Recovery Cervicogenic Post Concussion Disorder: A Pain In The Neck Suggestions for Facilitating Return to Learn After Concussion Providing a Continuum of Care for Concussion using Existing Educational Frameworks Psychologists Working in Concussion Clinics Concussion Legislation: Variations on a Theme Sportsconcussions.org: A New Resource for Brain Injury Professionals and Families BRAIN INJURY PROFESSIONAL
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BRAIN INJURY professional vol. 9 issue 1
The official publication of the North American Brain Injury Society
north american brain injury society
departments 4 Editor in Chief’s Message 6 Guest Editors’ Message 33 technology corner 34 bip Expert Interview 35 Literature Review 36 Non-profit News 38 Legislative Roundup
chairman Ronald C. Savage, EdD Immediate Past Chair Robert D. Voogt, PhD treasurer Bruce H. Stern, Esq. family Liaison Skye MacQueen executive director/administration Margaret J. Roberts executive director/operations J. Charles Haynes, JD marketing manager Megan Bell graphic designer Nikolai Alexeev administrative assistant Benjamin Morgan administrative assistant Bonnie Haynes
brain injury professional
publisher J. Charles Haynes, JD Editor in Chief Ronald C. Savage, EdD Editor, Legislative Issues Susan L. Vaughn Editor, Literature Review Debra Braunling-McMorrow, PhD founding editor Donald G. Stein, PhD design and layout Nikolai Alexeev advertising sales Megan Bell
EDITORIAL ADVISORY BOARD
features 8 Physiologic Post Concussion Disorder by Barry Willer, PhD and John Leddy, MD 12 Augmenting Neurocognitive Assessment in the Evaluation of Sports
Concussion: How Vestibular and Ocular Issues Impact Recovery bY Anne Mucha, DPT, Michael Collins, PhD, and Jonathan French, PsyD 18 Cervicogenic Post Concussion Disorder: A Pain In The Neck by John Leddy, MD 22 Suggestions for Facilitating Return to Learn After Concussion by Brian Rieger PhD 26 Providing a Continuum of Care for Concussion using Existing
Educational Frameworks by Karen McAvoy, PsyD 28 Psychologists Working in Concussion Clinics by John Baker, PhD 30 Concussion Legislation: Variations on a Theme by Jean Rickerson 32 Sportsconcussions.org: A New Resource for Brain Injury
Professionals and Families by Neal McGrath, PhD
Michael Collins, PhD Walter Harrell, PhD Chas Haynes, JD Cindy Ivanhoe, MD Ronald Savage, EdD Elisabeth Sherwin, PhD Donald Stein, PhD Sherrod Taylor, Esq. Tina Trudel, PhD Robert Voogt, PhD Mariusz Ziejewski, PhD
editorial inquiries Managing Editor Brain Injury Professional PO Box 131401 Houston, TX 77219-1401 Tel 713.526.6900 Fax 713.526.7787 Website: www.nabis.org Email: firstname.lastname@example.org
advertising inquiries Megan Bell Brain Injury Professional HDI Publishers PO Box 131401 Houston, TX 77219-1401 Tel 713.526.6900 Fax 713.526.7787
North American Brain Injury Society PO Box 1804 Alexandria, VA 22313 Tel 703.960.6500 Fax 703.960.6603 Website: www.nabis.org Brain Injury Professional is a quarterly publication published jointly by the North American Brain Injury Society and HDI Publishers. © 2011 NABIS/HDI Publishers. All rights reserved. No part of this publication may be reproduced in whole or in part in any way without the written permission from the publisher. For reprint requests, please contact, Managing Editor, Brain Injury Professional, PO Box 131401, Houston, TX 77219-1400, Tel 713.526.6900, Fax 713.526.7787, e-mail email@example.com
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editor in chief’s message
Ronald Savage, EdD
As we all know, there is nothing “mild” about mTBI, especially if it happens to you. While Mild TBI / Concussion makes up the vast majority of traumatic brain injuries each year, it is only in the last few years that the recognition and management of mTBI has gained the significance it deserves. For many years, there was no universally accepted definition of concussion. Most recently, the US Centers for Disease Control and Prevention proposed and disseminated a comprehensive definition of concussion that attempts to educate physicians, psychologists, and other professionals as to the individualized nature of the injury and which allows a flexible approach to diagnosing and managing the injury. The CDC’s definition is as follows: “An MTBI or concussion is defined as a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. MTBI is caused by a jolt to the head or body that disrupts the function of the brain. This disturbance of brain function is typically associated with normal structural neuroimaging findings (i.e. CT Scan, MRI). MTBI results in a constellation of physical, cognitive, emotional and/or sleep-related symptoms and may or may not involve a loss of consciousness (LOC). Duration of symptoms is highly variable and may last from several minutes to days, weeks, months, or longer in some cases.” This definition is only a start, however, and much more work is needed to understand not only how to best define mTBI / Concussion, but also best practice treatments and management of concussion. Dr. Barry Willer and Dr. John Leddy, our Guest Editors for this issue of BIP, have a long clinical history working with individuals with mTBI / Concussions. They state “There has been an explosion of interest in concussion of late. All of a sudden, it seems, star athletes and celebrities are suf-
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fering life-altering concussions... It is hard to believe that just a short time ago people in the Defense Department or professional sports organizations argued against the very existence of concussions.” Of course, this explosion of interest creates incredible opportunities to educate not only professionals, but also the public at large. Drs. Willer and Leddy have assembled an extraordinary team of professionals working in mTBI / Concussion and the articles in this issue will increase our knowledge base about the thousands of individuals each year who sustain this type of brain injury. In addition, Dr. Willer will also be giving the Plenary Speech at the 2012 NABIS Conference in Miami this September on this very topic. It is also an honor for NABIS to have Dr. Hovda, Director, UCLA Brain Injury Research Center, for our BIP Expert Interview. Dr. Hovda provides us with a wonderful historical review of the topic and, as always, he never shrinks from controversial issues. NABIS gives special thanks to Dr. Willer and Dr. Leddy and their authors for a very informative issue on a complex topic. Finally, I urge all brain injury professionals to mark their calendars for the 10th Anniversary NABIS Brain Injury Conference, scheduled for September 12-15, at the InterContinental Hotel in Miami, Florida. The conference will be a four-day, multi-track event that will cover a wide range of brain injury topics including medical best practices, rehabilitation, research, life-long living, pediatrics, and advocacy. NABIS is pleased to present a series of educational sessions on cutting-edge brain injury technology, as well as special sessions on Blast Injury. Also new this year, NABIS is pleased to partner with the University of Miami Miller School of Medicine to offer a special pre-conference educational day on pediatric brain injury. Details are available on our website, www.nabis. org. We look forward to seeing you in sunny Florida! Ronald Savage, EdD
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guest editorsâ€™ message
Barry Willer, PhD and John Leddy, MD
There has been an explosion of interest in concussion of late. All of a sudden, it seems, star athletes and celebrities are suffering life-altering concussions. And then there is the research coming out of Boston that concussions in sports may produce serious debilitating brain injury, called Chronic Traumatic Encephalopathy (CTE). The really scary thing about the research on possible long-term consequences like CTE is that it points to the possible role of sub-concussive injuries. A recent study by Jeff Bazarian and his colleagues in Rochester found changes in the brains of young football players, when tested before and after one season of play and practice, even though these players did not have a diagnosed concussion. One event that changed the course of how concussion is managed was the injury to a Washington State youth football player. Zackery Lystedt received a concussion in a game and then returned to play too soon. He received a second concussion and this time he was left severely brain injured and physically disabled for life. Through the support of his family and many professionals Washington State passed a law that required decisions about return to sport be made by health care professionals. The Zackery Lystedt law, or slightly altered forms of the law, are now being enacted in many states and jurisdictions that 6
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require systematic return to play to be supervised by a health care professional. Jean Rickerson provides a summary of the legislation and which states passed the legislation. Jean Rickerson is the mother of a young player that also had a career altering concussion and decided to create a consumer oriented web site. The story of her introduction to concussion and the development of her web site is told in the article by Neal McGrath. There has also been a rapid increase in research devoted to concussion and much is being learned about this seemingly minor brain trauma that has mostly been ignored for centuries. Perhaps no one researcher or group of researchers has had a more profound effect on how we understand concussion than David Hovda and his group at UCLA. Dr. Hovda was the first to point out the metabolic changes following a mild brain injury. This provided the essential biological evidence for concussion. It is hard to believe that just a short time ago people in the Defense Department or professional sports organizations argued against the very existence of concussions. The interview with Dr. Hovda provides a nice historical review from someone in the thick of the controversy. There is much we have learned about concussion in the past decade, but there are still many unanswered questions, especially regarding persistent concussive effects. This issue of Brain Injury Professional is devoted to the topic of post concussion disorders (PCD). Our goal is to introduce the concept of PCD and share a perspective regarding persistent post concussive symptoms that, until now, has only been discussed in the hallways during brain injury conferences and only between a few researchers (especially when Dr. Nathan Zasler is present). Most people with a concussion show full recovery without medical intervention within a few weeks. Rest and avoiding exercise is really all it takes to overcome the confusion and dizziness and other symptoms that accompany concussion. But 5 to 15% of people do not recover during the normal period
and in these cases recovery time can be quite extensive. To date, prolongation of symptoms has generally been called post concussion syndrome. We are suggesting that this be changed to post concussion disorder. A syndrome refers to a cluster of symptoms and signs that characterize a single specific disorder. What we have found at the University at Buffalo, and what others are now finding, is that individuals can have a number of different disorders that result from the injury that produces a concussion. For example, our research and our clinical program have focused on physiologic post concussion disorder (PPCD). PPCD is characterized by physiologic changes that persist after a concussion, including alteration and dysfunction of the autonomic nervous system and the autoregulation of cerebral blood flow. We have devised an exercise stress test that has proven to provide a reliable means to diagnose PPCD, and we have even developed a treatment program for PPCD, which we describe in this issue of BIP. Micky Collins and his team at the University at Pittsburgh also recognized and described the heterogeneity of PCD. The Pittsburgh program initially provided leadership for the development of baseline computerized cognitive testing. Now they have focused some of their attention on individuals who primarily have ocular vestibular post concussion disorders. Their article in this issue outlines the pathophysiology and potential treatment of vestibular-based PCD. John Leddy writes about cervicogenic PCD. As our diagnostic tools improve we have discovered that some patients recover from their physiologic concussion but are left with symptoms from the whiplash effect on the upper neck. The symptoms mimic other PCD symptoms (e.g. headache, dizziness, poor concentration, etc.) but require specialized diagnosis and treatment. A recent publication from our research group (Baker et al. 2012) suggests that post concussion disorders will include: physiologic PCD; cervicogenic PCD; ocular-vestibular PCD; cognitive
PCD and emotional PCD. We do not suggest that these disorders always exist separately, but rather that a person with persistent post concussive symptoms may have one or more of these disorders. It is our contention that identification of the nature of the disorder is a necessary first step toward effective treatment. Effective treatment invariably involves more than one discipline. John Baker writes in this issue about the important role of the psychologist in the concussion clinic and highlights the interdisciplinary nature of diagnosis and treatment. Dr. Baker discusses the need to assist patients with persistent cognitive and emotional difficulties, even when the symptoms may be physiologic in origin. Brian Rieger, in his article on ‘return to learn’, provides a more in depth discussion of the issues faced by young people who are attempting to return to school after a concussion. There has been a great deal of attention paid to return to sport so it is refreshing to see attention paid to school adjustment problems by those with persistent symptoms. Dr. Rieger provides a series of recommendations for clinicians, school officials and parents, all designed to facilitate the return to learn process. The article by Karen McAvoy also discusses issues of return to school but highlights the existing structure in place for children with special educational needs and how these can be used to assist children with concussions. We are deeply indebted to our colleagues who were willing to write articles for this issue of Brain Injury Professional. We are also indebted to Ron Savage and Chas Haynes for providing this opportunity to present what we think is a new perspective on a growing concern represented by post concussion disorders.
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Barry Willer, PhD John Leddy, MD References
Baker, JG; Freitas MS; Leddy, JJ; Kozlowski KF and Willer, BS (2012) “Return to full functioning after graded exercise assessment and progressive exercise treatment of postconcussive syndrome” Rehabilitation Research and Practice, Vol 2012; 705309, 7 pages.
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Physiologic Post Concussion Disorder by Barry Willer, PhD and John Leddy, MD
Ray was known as Razor to his friends and teammates. After a concussion three months ago Ray hasn’t seen much of his teammates, or for that matter, much of anyone. He has improved somewhat in the past few weeks. His headache is pretty much constant but low level. He still has light and noise sensitivity but his primary complaint is his inability to concentrate. When he walked into our Concussion Management Clinic at the University at Buffalo he wore sunglasses and looked fairly depressed. His family doctor had heard about our program and liked the fact that we actively treat post concussion disorders and Ray was clearly not benefitting from the more typical approach of rest and withdrawal from activity. Ray saw Dr. John Leddy, the director of the clinic, and told him how he was injured returning a punt for his varsity team. It was a helmet to helmet collision that Ray could describe because he had seen it on film. He had no memory of the event otherwise. After determining that Ray’s symptoms and physical health were such that an exercise stress test would be safe, Dr. Leddy instructed Ray to change into his running shoes and track pants. Ray then nervously stepped on the treadmill. Our Physical Therapist, Scott, has conducted hundreds of these tests and knows just how to help athletes relax. Scott reinforced what Dr. Leddy had already told Ray, that he must not work through any changes in symptoms. Ray was instructed to report everything he experienced. During the treadmill test Scott asks every two minutes about changes in how Ray is feeling. Ray started out well on the treadmill. In fact, he quite enjoyed doing a little exercise after so many months on the couch. He did not know it but his heart rate and blood pressure were increasing faster than they should for an athlete, even an athlete that has begun to de-condition. When his heart rate reached 160 beats per 8
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minute Ray suddenly felt strange and uncomfortable, even though it was not a particularly difficult level of exertion for him. Scott could see the change in Ray’s demeanor and immediately asked how he was feeling. Ray said he was feeling like someone had just tightened a rubber band around his head. Scott stopped the test immediately. Scott also observed that Ray’s heart rate and systolic blood pressure were unusually high for his level of exertion. With the data from the exercise test in hand Dr. Leddy explained to Ray that indeed he was still suffering physiologic effects of his concussion. “However,” he said, “there is good news, as well. A heart rate of 152 means the recovery process is happening and we can speed that recovery process along.” Dr. Leddy then explained that Ray should exercise 20 minutes a day at a heart rate of 130 beats per minute and that after a few weeks we would increase the level of exercise based on his progress. A big smile came across Ray’s face. He could not believe that he could exercise again, even if it was at this relatively low level. A few weeks later when it was determined that Ray could exercise to a heart rate of 178 beats per minute without exacerbation of symptoms, his exercise prescription was increased to 20 minutes at 160 beats per minute, two times a day. Ray could see the light at the end of the tunnel and it wasn’t far away.
Symptoms versus signs of concussion Several weeks after Ray’s visit we heard from Dr. Sara Meagan, Ray’s family doctor. She was curious about the process we used to evaluate Ray’s post concussion disorder. She was especially curious about the use of an exercise stress test to evaluate Ray. We began by explaining that most clinics diagnose concussion and post concussion disorder on the basis of symptoms. In fact, the DSM IV (Diagnostic and Statistical Manual of the American
Psychiatric Association) and the World Health Organization definitions of post concussion disorders rely heavily on symptoms. Only the DSM IV asks also for evidence of a cognitive deficit based on cognitive testing. Symptoms, of course, are what the patient describes. These include headache, fatigue, sleep disturbance, vertigo, irritability, depression, apathy, sensitivity to light and/or noise, difficulty with concentration, etc. Symptoms describe the subjective experience of the patient and are important to tell the doctor what the patient is feeling. However, for many diseases or disorders, symptoms are not sufficient to establish a diagnosis. Dr. Meagan was well aware that medical signs when detected by a physician provide a far more objective indication of disease or disorder. But she was unaware of the signs associated with concussion. We quickly summarized the relevant research on physiologic characteristics of individuals with post concussion disorders. First and foremost, an individual’s resting heart rate is increased after traumatic brain injury.(King, Lichtman, Seliger, Ehert, & Steinberg, 1997) Perhaps more importantly, the rate at which the heart rate increases with exercise is accelerated in concussed patients.(B. Gall, W. S. Parkhouse, & D. Goodman, 2004) The heart rate increase seen with cognitive stress is also greater in concussed patients.(Hanna-Pladdy, Berry, Bennett, Phillips, & Gouvier, 2001) Individuals with post concussion disorders also have autonomic nervous system dysregulation, which is expressed as overactive sympathetic nervous system activity.(B. Gall, W. Parkhouse, & D. Goodman, 2004; King, et al., 1997) Dr. Meagan remarked that this would explain why many patients complain of light sensitivity. She knew that pupils are dilated during sympathetic activity. We explained that it may also be responsible for why so many patients have difficulty falling asleep. In order to fall asleep, the parasympathetic system has to take charge, and an overactive sympathetic system prevents the individual from entering the relaxed state that is required in order to fall asleep. Finally, we pointed out that patients with post concussion disorder often have difficulty regulating cerebral blood flow.(Junger et al., 1997) Simply put, the brain cannot perform well when the blood pressure in the brain is too high. During exercise or any other time that one experiences a substantial increase in blood pressure, the brain is protected by an auto-regulatory process. After a concussion this auto-regulatory process is disrupted. Dr. Meagan interrupted the educational program: “While I can certainly see the advantages to evaluation of signs versus symptoms of concussion, as a general practitioner I don’t see how I can assess someone for cerebral blood flow or autonomic nervous system balance in my practice”. We pointed out that the disruption of regulatory processes is only revealed when the system is under stress. We only monitor cerebral blood flow during exercise and only in research. However, when we assess patients, like Ray, their inability to regulate cerebral blood flow becomes evident with the exacerbation of symptoms during exercise. Ray’s description of the “rubber band around my head” was typical of the subjective experience of excess blood flow to the brain. “OK. Now your exercise test makes sense. But why did regulated exercise help Ray regain control of his regulatory processes?” Regular exercise helps non-concussed individuals to become fit in part by improving regulatory control of cerebral blood flow and restoring autonomic nervous system balance. By prescribing an exercise program below the threshold at which Ray experienced distress, Ray was able to slowly regain his fit state. As an athlete,
Ray’s recovery will be much faster but the same principles apply to non-athletes. “Are there some who experience post concussion disorders for whom your exercise test and regulated exercise program is not appropriate?” We do not recommend the test for patients who have ongoing symptoms after concussion unless the symptoms persist 3 weeks or more, after which the test is safe. We also do not recommend the test in patients with other health conditions that preclude exercise or increase the risk for a cardiac event during intense exercise. However, the test is very helpful in the differential diagnosis of the nature of the post concussion disorder. When someone is able to exercise fully without exacerbation of symptoms but still has problems, then we consider other causes. Some patients have ocular-vestibular difficulties (see the accompanying article by Mucha, Collins and French) or cervicogenic (neck) problems. There is also a group of patients who have anxiety or depressive disorders. So far we are only recommending the regulated exercise program for those with physiologic post concussion disorder (which we define as inability to exercise to exhaustion due to loss of regulatory control of cerebral blood flow during exercise). Dr. Meagan thanked us for our time and indicated that she would be keen to learn how to assess patients herself. She has access to a treadmill and sees a substantial number of athletes from the local college. We explained that we have been providing training to clinicians at a number of programs and we would be happy to provide that training to her. We also explained that our research articles are available on our website: http://concussion.buffalo.edu.
Ray exercises to exhaustion without symptom exacerbation It has been seven weeks since Ray first visited the Concussion Management Clinic at the University at Buffalo. He has been feeling better and, more important from his perspective, he has been able to return to school and perform up to his normal high standards. But he was nervous once more as he approached the treadmill test. Scott reassured him that he is not likely to do any worse than before and since his last test was so good he was sure to do even better. Ray was able to exercise to exhaustion without that feeling of tightness in his head or any other symptoms. In fact, he felt really good when he completed the treadmill test. He had not experienced the high that comes from a good workout since he had his concussion. He had forgotten how good it feels. Meeting with Dr. Leddy to discuss the results, Ray could not stop smiling. Dr. Leddy’s assessment that he was fully recovered from his concussion came as no surprise, but it was reassuring to hear it from the doctor. Ray asked “So what happens now?” Dr. Leddy indicated that since the football season was over there was no need to worry about return to play. He asked Ray how his studies were going and whether he was able to concentrate. Ray told him studying was no longer a problem. He also indicated that his sensitivity to noise and light was also not presenting a problem. Ray then indicated he was thinking of giving up football and wanted Dr. Leddy’s opinion. “Only you can decide how important football is in your life, but it is true that once you have had a concussion, especially one with long lasting physiologic effects, you are more likely to get a subsequent concussion, if that is what you are worrying about.” “That is precisely what I am worried about. These past months have been difficult and have forced me to evaluate my priorities. I missed school more than I missed football.” BRAIN INJURY PROFESSIONAL
Prologue Ray is a fictional case based on a composite of a number of similar cases we have seen over the past few years since we started to use this physiologic approach to assessment and treatment of post concussion disorders. The chances for individuals with prolonged physiologic symptoms of concussion to improve and return to their normal level of function have improved dramatically over the past decade. In our research we found that 77% of patients recovered fully like Ray (Baker et al, 2012). In some instances, especially with non-athletes, patients who refuse to exercise have very poor outcomes. Those that do follow the exercise prescription but do not recover fully will have signs and symptoms of other types of post concussion disorders. Among the most common disorders that did not fully recover with exercise were patients with ocular-vestibular symptoms and some patients, who despite being able to exercise to full capacity without symptom exacerbation, had persistent difficulty with concentration upon return to school or work. References
Baker, JG; Freitas MS; Leddy, JJ; Kozlowski KF and Willer, BS (2012) “Return to full functioning after graded exercise assessment and progressive exercise treatment of postconcussive syndrome” Rehabilitation Research and Practice, Vol 2012; 705309, 7 pages. Gall, B., Parkhouse, W., & Goodman, D. (2004). Heart rate variability of recently concussed athletes at rest and exercise. Med Sci Sports Exerc, 36(8), 1269-1274. Gall, B., Parkhouse, W. S., & Goodman, D. (2004). Exercise following a sport induced concussion. Br J Sports Med, 38(6), 773-777. Hanna-Pladdy, B., Berry, Z. M., Bennett, T., Phillips, H. L., & Gouvier, W. D. (2001). Stress as a diagnostic challenge for postconcussive symptoms: sequelae of mild traumatic brain injury or physiological stress response. Clin Neuropsychol, 15(3), 289-304. Junger, E. C., Newell, D. W., Grant, G. A., Avellino, A. M., Ghatan, S., Douville, C. M., . . . Winn, H. R. (1997). Cerebral autoregulation following minor head injury. J Neurosurg, 86(3), 425-432. King, M. L., Lichtman, S. W., Seliger, G., Ehert, F. A., & Steinberg, J. S. (1997). Heart-rate variability in chronic traumatic brain injury. Brain Inj, 11(6), 445-453.
ABOUT THE AUTHORs
Barry Willer PhD is a Professor in the Department of Psychiatry at the State University of New York at Buffalo. He is co-founder of the Concussion Management Clinic at the University and serves as the clinic’s Director of Research. Dr. Willer has a long history of research on traumatic brain injury. In his earlier years he focused on issues related to long-term outcomes for moderate and severe brain injury. He authored the Community Integration Questionnaire, which is used in many brain injury programs and many different languages and countries. He is currently principal investigator of a NIDRR funded research project on the treatment of emotion recognition disorders in people with moderate and severe TBI. A little more than a decade ago he authored the first return to play following concussion guidelines for the International Olympics. He is currently involved in research on the physiology of concussion and just completed research on brain metabolism during post concussion disorders. Dr. John J. Leddy is a board certified Internal Medicine and Sports Medicine physician. He is an Associate Professor of Clinical Orthopedics, Internal Medicine, and Rehabilitation Sciences at the University at Buffalo School of Medicine and Biomedical Sciences, and a Fellow of the American College of Sports Medicine and of the American College of Physicians. He is a practicing clinician and active researcher and teaches in the medical school. He is the Medical Director of the University at Buffalo Concussion Clinic, which is the first center in the United States to use a standardized exercise treadmill test to establish recovery from concussion and to use controlled exercise in the rehabilitation of patients with prolonged concussion symptoms. He is published in the fields of orthopedics, physiology, nutrition, concussion and post-concussion syndrome. His primary research interest is the investigation of the basic mechanisms of the disturbance of whole body physiology seen in concussion and how to help to restore the physiology to normal and so help patients to recover and safely return to activity and sport. 10 BRAIN INJURY PROFESSIONAL
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Augmenting Neurocognitive Assessment in the Evaluation of Sports Concussion: How Vestibular and Ocular Issues Impact Recovery bY Anne Mucha, DPT, Michael Collins, PhD, and Jonathan French, PsyD
Most early work in the field of concussion management has been devoted to recognition of concussion and determining when recovery is complete, in order to prevent against Second Impact Syndrome, cumulative effects of concussion and development of Post-concussion Syndrome. On this front, the standard use of neurocognitive assessment has been invaluable. Computerized neurocognitive testing has been established to have 81.9% sensitivity and 89.4% specificity in diagnoses of concussions (Barr and McCrea, 2001; Collins et al., 1999; Erlanger et al., 2003; Erlanger et al., 2001; Iverson et al., 2006a; Schatz et al., 2006). Because of these advances, we are now able to shift focus toward indicators that may assist with determining severity and predicting recovery from concussion. A prospective, observational study on recovery times after a sport-related concussion in high school athletes showed that 12 BRAIN INJURY PROFESSIONAL
50% of athletes at 1 week and 83% at 3 weeks had recovered and returned to play, leaving 17% with protracted recovery times lasting greater than 3 weeks (Collins et al, 2006). The ability to better understand concussive injuries that are slower to recover will assist in decision-making as it relates to school, sport, and occupation. It also provides opportunity to investigate whether the course of these more complex injuries can be modified. Currently, we know that athletes who are younger in age, have learning disabilities, or with migraine history are at risk for more complicated recovery (Collins et al, 1999; Field et al, 2003; Mihalik et al., 2005). Those athletes who are female, or who have a significant (3 or >) concussion history may also be at greater risk (Colvin et al., 2009; Iverson et al., 2006b; Iverson et al., 2004). We also know more about on field signs and
symptoms displayed following concussion and their influence on rapid recovery. On field amnesia (particularly retrograde) appears to be a negative predictor of quick (ie, 72 hrs) recovery; whereas brief, on-field loss of consciousness did not predict whether an athlete was recovered at 3 days post injury. Identifying symptoms in the first 3 days following injury also appears to be helpful in predicting protracted recovery. Those most associated with protracted (>14d) recovery were fogginess, difficulty concentrating, vomiting, dizziness, nausea, headache, slowness, imbalance, light/noises sensitivity and numbness (Lau et al., 2009). Early neurocognitive testing, even in athletes who are symptomatic, is valuable in delineating level of impairment from concussion as well as establishing factors associated with protracted recovery. When tested within 3 days of injury, slowed reaction time and impaired visual memory is highly predictive of > 10 day recovery course (Lau et al., 2011a). When using the ImPACT neurocognitive test, athletes who exhibited 3 of 4 reliable change deficits, relative to baseline levels of functioning, were 94.6% likely to require at least 10 days until recovery occurred (Iverson, 2007). The best model for prediction may be a combined approach where neurocognitive and symptom scores are merged. Recent evidence (Lau et al., 2011b) indicates that in the first few days following concussion, combining ImPACT neurocognitive assessment with symptom cluster is important in predicting whether recovery will extend beyond 2 weeks. A clinician who evaluates a patient within 2 to 3 days after a concussion could accurately predict 73.17% of the time whether the athlete will require a protracted recovery if ImPACT scores and symptoms are used together. Variables contributing most to the classification power were the cluster of symptoms which included dizziness, balance problems and visual problems. The use of computerized neurocognitive testing in conjunction with symptom clusters improves sensitivity, specificity, positive predictive value, and negative predictive value of predicting protracted recovery. This may be due to the key roles that vestibular and ocular motor function play in concussion diagnosis, recovery and management. Vestibular Concerns following Concussion
The vestibular system plays an integral role in balance function and in maintaining visual and spatial orientation. It consists of a network of sensory organs (semicircular canals and otoliths) housed within the bony labyrinth of the inner ear, with projections to the vestibular nuclei, the cerebellum, brainstem, spinal cord, ocular motor nuclei, autonomic nervous system, thalamus, and cerebral cortex. Information about the position and movements of the head with respect to gravity is transmitted from the inner ear via the 8th cranial nerve to the central nervous system. This sensory information is used to adjust eye movements for clear, stable vision (via the vestibulo-ocular reflex) and to adjust muscle reactions of the head and body for balance (via the vestibulo-spinal reflex). Dysfunction in either the peripheral or central structures of the vestibulo-spinal system can result in impaired balance; whereas dizziness, vertigo, blurred/unstable vision, or nausea occurs with disruption to the vestibulo-ocular system. Impairments in the functioning of the vestibular system following mTBI can arise from multiple
causes including concussion to the labyrinth of the inner ear (labyrinthine concussion); post-traumatic benign paroxysmal positional vertigo; post-traumatic migraine; concussion to the brainstem; post-traumatic endolymphatic hydrops, and perilymphatic fistula (Furman et al., 2010). Poor balance and impairments in postural control following concussion have been reported in numerous studies (Geurts et al., 1996; Guskiewicz et al., 1997; Guskiewicz et al., 2000). In order to maintain balance in response to environmental demands, vestibular, visual and somatosensory information are integrated in brainstem structures to achieve the appropriate balance reaction. Dysfunction in balance is often due to abnormal central processing of the vestibular, visual and somatosensory information. It appears that, in particular, the ability to utilize and process vestibular information needed for postural control may be affected in concussed athletes (Peterson et al., 2003; Guskiewicz, 2001). Dizziness is a frequent symptom of concussion, occurring in 23% to 81% of cases in the first days after injury (Griffiths, 1979; Kisilevski et al., 2001; Maskell et al., 2006; Maskell et al., 2007; Terrio et al., 2009). In blast-related mTBI, dizziness has been found to be the most common post-injury symptom (Hoffer et al., 2010). There is also evidence that dizziness may be a common symptom reported in mild TBI patients who experience persistent post-concussion disorders, with prevalence as high as 32.5% at 5 years (Masson et al., 1996). In addition, the presence of vestibular symptoms even acutely may provide valuable prognostic information. In a recent article, (Lau et al., 2011a) presence of on-field dizziness was the sole factor predictive of protracted time to recovery (>21 days). Dizziness, when due to vestibular causes, typically arises from impairment in the vestibulo-ocular and gaze stability systems, where normal coordination between eye and head motion is impeded, particularly as speed of movement increases. Vestibular Rehabilitation
Beyond the diagnostic and prognostic value that vestibular symptoms have in the presentation of concussion, a key question is whether problems arising from the vestibular system can improve with treatment. While literature regarding the efficacy of vestibular rehabilitation specific to mTBI is limited, the value of vestibular rehabilitation in managing individual vestibular conditions is well-documented. A recent Cochrane review (Hillier et al., 2007) concluded that there is moderate to strong evidence for efficacy of vestibular rehabilitation for peripheral vestibular dysfunction; and for the use of repositioning maneuvers performed by vestibular therapists in the management of benign paroxysmal positional vertigo. Dizziness due to migraine, as well as patients with central vestibular dysfunction have been shown in studies to improve with vestibular physical therapy intervention (Whitney et al., 2000; Brown et al., 2006). Hoffer and colleagues (Hoffer et al., 2004) examined dizziness following mTBI in a population of active duty military individuals. They found that after a 6-8 week vestibular rehabilitation program, patients had improved with respect to symptoms of dizziness, perception of balance function, and measures of vestibulo-ocular function. Gottshall (Gottshall and Hoffer, 2010) detailed the benefits of a vestibular physiBRAIN INJURY PROFESSIONAL
cal therapy program on improving measures of gaze stability, ocular motor function and dynamic visual acuity following blast-related mTBI. In addition, Alsalaheen and colleagues (Alsalaheen et al., 2010) looked at the response of a population of concussed patients to vestibular physical therapy. In this retrospective analysis, data from 114 patients referred for vestibular rehabilitation following concussion were examined. A significant treatment effect was noted for fifteen different measures of dizziness severity, balance confidence, gait and static/ dynamic balance. Ocular Motor Issues following Concussion
In addition to vestibular dysfunction, concussion may also result in disturbances to the visual system. While true changes in visual acuity are unusual in mTBI, (Brahm et al., 2009) research suggests that impairments in control of eye movement are observed frequently (Kapoor and Ciuffreda, 2002; Rutner et al., 2006; Stiller-Ostrowski, 2010; Thiagarajan et al., 2011; Chan and Trobe, 2002). According to a 2007 study by Ciuffreda and colleagues, (Ciuffreda et al., 2007) disorders of accommodation, version, vergence, strabismus, and cranial nerve (CN) palsy were observed most frequently following mTBI. Symptoms attributed to poor ocular motor function include: blurred vision, diplopia, difficulty reading, eye strain, headache, loss of place when reading, and difficulty with visual scanning. Functionally, ocular motor issues can result in poor school or work performance, motion sensitivity, inability to do computer work, difficulty driving and/or riding in vehicles, and can greatly contribute to post-concussion disability. Binocular Function
As humans, we rely on the ability to fuse the images from each eye into a single representation. Binocular vision permits not only a wider field of vision, but it also allows depth perception (stereopsis). Problems with binocular vision result in varying degrees of diplopia and may be due to strabismus or vergence dysfunction. An ocular misalignment, or strabismus results when the visual axis of each eye does not line up in the same direction. Strabismus may be caused by weakness in one or more extra-ocular muscles, palsy of the cranial nerve supplying the extra-ocular muscles, or by impaired coordination between the extra-ocular muscles. Ocular alignment is tested via cover tests. Vergence movements require both eyes to fixate on a midline target as it is moved closer or farther away. Convergence requires each eye to turn inward towards each other to view an object as it becomes closer; while divergence is the ability to move the eyes out away from each other as an object moves further away. Normal individuals should be able to maintain focus on a midline object brought toward the nose (i.e., converge) without diplopia to at least 6 cm (Scheiman et al., 2003). Accommodation is a function closely associated with vergence movements in which the shape of the lens adjusts in order to focus on objects clearly at near or far. Impaired accommodation results in blurred vision when an object is viewed at near distances. Ocular Motor Function
Ocular motor function refers to the ability to move the eyes in a manner that allows transmission of accurate visual informa14 BRAIN INJURY PROFESSIONAL
tion to the brain. Eye movements are accomplished via the coordinated activation of the six extra-ocular muscles which surround each eye. The basic types of voluntary eye movements are versions â€“ where the eyes move together in a coordinated fashion; ductions, which are movements of a single eye; and vergence â€“ discussed above. Examples of version movements are pursuits - the ability to follow a slow moving object with the eyes accurately; and saccades - the ability to quickly move the eyes from one target to another accurately. Assessment of pursuit, saccadic and vergence eye movements should be part of standard screening following concussion. Management of Ocular Motor Dysfunction
While surgical/medical interventions by ophthalmology or neuro-opthalmology is recommended in cases of complex diplopia, strabismus that is due to muscle paralysis or nerve palsy, or ocular-health issues, many ocular motor problems can be managed conservatively with vision training or modification to lenses (Kapoor and Ciuffreda, 2002). Recent studies have demonstrated that vision programs are effective in management of convergence insufficiency, accommodative deficit, impaired version movements, and minor ocular misalignments (Scheiman et al., 2011; Ciuffreda et al., 2008; Scheiman et al., 2011). Vision training has traditionally been an area of controversy; however, emerging evidence supports efficacy of visual exercise for specific ocular motor problems. Summary
With continuing research into concussion, it is evident that the assessment and treatment of concussion is more complex than previously thought. It is an injury that can have unique effects depending on a multitude of factors. These acquired deficits require a multi-method assessment approach in order to accurately assess and dictate the course of treatment. With this knowledge it can guide interventions that have the potential to reduce recovery time, and ensure full recovery. The underlying premise of concussion management is rest; however, specific vestibular and visual rehabilitation may be beneficial in certain cases. While novel, there is empirical support for this treatment, and future research will clarify if the addition of these therapies leads to reduced recovery time, as well as improved sensitivity in decision-making for return to play. References:
Alsalaheen, B. A., Mucha, A., Morris, L. O., et al., (2010). Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion. Journal of Neurologic Physical Therapy, 34, 87-93. Barr, W. B., & McCrea, M. (2001). Sensitivity and specificity of standardized neurocognitive testing immediately following sports concussion. J Int Neuropsychol Soc, 7(6), 693-702. Brahm, K. D., Wilgenburg, H. M., Kirby, J., Ingalla, S., Chang, C. Y., & Goodrich, G. L. (2009). Visual impairment and dysfunction in combat-injured service members with traumatic brain injury. Optom Vis Sci, 86(7), 817-825. Brown, K. E., Whitney, S. L., Marchetti, G. F., Wrisley, D. M., & Furman, J. M. (2006). Physical therapy for central vestibular dysfunction. Arch Phys Med Rehabil, 87(1), 76-81. Chan, R. V., & Trobe, J. D. (2002). Spasm of accommodation associated with closed head trauma. J Neuroophthalmol, 22(1), 15-17. Ciuffreda, K. J., Kapoor, N., Rutner, D., Suchoff, I. B., Han, M. E., & Craig, S. (2007). Occurrence of oculomotor dysfunctions in acquired brain injury: a retrospective analysis. Optometry, 78(4), 155-161. Ciuffreda, K. J., Rutner, D., Kapoor, N., Suchoff, I. B., Craig, S., & Han, M. E. (2008). Vision therapy for oculomotor dysfunctions in acquired brain injury: a retrospective analysis. Optometry, 79(1), 18-22. Collins, M., Lovell, M. R., Iverson, G. L., Ide, T., & Maroon, J. (2006). Examining concussion
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rates and return to play in high school football players wearing newer helmet technology: a threeyear prospective cohort study. Neurosurgery, 58(2), 275-286; discussion 275-286.
Schatz, P., Pardini, J. E., Lovell, M. R., Collins, M. W., & Podell, K. (2006). Sensitivity and specificity of the ImPACT Test Battery for concussion in athletes. Arch Clin Neuropsychol, 21(1), 91-99.
Collins, M. W., Grindel, S. H., Lovell, M. R., Dede, D. E., Moser, D. J., Phalin, B. R., et al. (1999). Relationship between concussion and neuropsychological performance in college football players. Jama, 282(10), 964-970.
Scheiman, M., Cotter, S., Kulp, M. T., Mitchell, G. L., Cooper, J., Gallaway, M., et al. (2011). Treatment of Accommodative Dysfunction in Children: Results from a Randomized Clinical Trial. Optom Vis Sci, 88(11), 1343-1352.
Colvin, A. C., Mullen, J., Lovell, M. R., West, R. V., Collins, M. W., & Groh, M. (2009). The role of concussion history and gender in recovery from soccer-related concussion. Am J Sports Med, 37(9), 1699-1704.
Scheiman, M., Gallaway, M., Frantz, K. A., Peters, R. J., Hatch, S., Cuff, M., et al. (2003). Nearpoint of convergence: test procedure, target selection, and normative data. Optom Vis Sci, 80(3), 214-225.
Erlanger, D., Feldman, D., Kutner, K., Kaushik, T., Kroger, H., Festa, J., et al. (2003). Development and validation of a web-based neuropsychological test protocol for sports-related return-toplay decision-making. Arch Clin Neuropsychol, 18(3), 293-316.
Scheiman, M., Gwiazda, J., & Li, T. (2011). Non-surgical interventions for convergence insufficiency. Cochrane Database Syst Rev(3), CD006768.
Erlanger, D., Saliba, E., Barth, J., Almquist, J., Webright, W., & Freeman, J. (2001). Monitoring Resolution of Postconcussion Symptoms in Athletes: Preliminary Results of a Web-Based Neuropsychological Test Protocol. J Athl Train, 36(3), 280-287. Field, M., Collins, M. W., Lovell, M. R., & Maroon, J. (2003). Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. J Pediatr, 142(5), 546-553. Furman, J., Cass, S., & Whitney, S. (2010). Vestibular disorders: a case-study approach (3rd ed.). New York, NY: Oxford University Press. Geurts, A. C., Ribbers, G. M., Knoop, J. A., & van Limbeek, J. (1996). Identification of static and dynamic postural instability following traumatic brain injury. Arch Phys Med Rehabil, 77(7), 639-644. Gottshall, K. R., & Hoffer, M. E. (2010). Tracking recovery of vestibular function in individuals with blast-induced head trauma using vestibular-visual-cognitive interaction tests. J Neurol Phys Ther, 34(2), 94-97. Griffiths, M. V. (1979). The incidence of auditory and vestibular concussion following minor head injury. J Laryngol Otol, 93(3), 253-265. Guskiewicz, K. M. (2001). Postural stability assessment following concussion: one piece of the puzzle. Clin J Sport Med, 11(3), 182-189. Guskiewicz, K. M., Riemann, B. L., Perrin, D. H., & Nashner, L. M. (1997). Alternative approaches to the assessment of mild head injury in athletes. Med Sci Sports Exerc, 29(7 Suppl), S213-221. Guskiewicz, K. M., Weaver, N. L., Padua, D. A., & Garrett, W. E., Jr. (2000). Epidemiology of concussion in collegiate and high school football players. Am J Sports Med, 28(5), 643-650. Hillier, S. L., & Hollohan, V. (2007). Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev(4), CD005397. Hoffer, M. E., Balaban, C., Gottshall, K., Balough, B. J., Maddox, M. R., & Penta, J. R. (2010). Blast exposure: vestibular consequences and associated characteristics. Otol Neurotol, 31(2), 232236. Hoffer, M. E., Gottshall, K. R., Moore, R., Balough, B. J., & Wester, D. (2004). Characterizing and treating dizziness after mild head trauma. Otol Neurotol, 25(2), 135-138. Iverson, G. L., Brooks, B. L., Collins, M. W., & Lovell, M. R. (2006). Tracking neuropsychological recovery following concussion in sport. Brain Inj, 20(3), 245-252. Iverson, G. L., Brooks, B. L., Lovell, M. R., & Collins, M. W. (2006). No cumulative effects for one or two previous concussions. Br J Sports Med, 40(1), 72-75. Iverson, G. L., Gaetz, M., Lovell, M. R., & Collins, M. W. (2004). Cumulative effects of concussion in amateur athletes. Brain Inj, 18(5), 433-443. Kapoor, N., & Ciuffreda, K. J. (2002). Vision Disturbances Following Traumatic Brain Injury. Curr Treat Options Neurol, 4(4), 271-280. Kisilevski, V., Podoshin, L., Ben-David, J., Soustiel, J. F., Teszler, C. B., Hafner, H., et al. (2001). Results of otovestibular tests in mild head injuries. Int Tinnitus J, 7(2), 118-121. Lau, B., Lovell, M. R., Collins, M. W., & Pardini, J. (2009). Neurocognitive and symptom predictors of recovery in high school athletes. Clin J Sport Med, 19(3), 216-221. Lau, B. C., Kontos, A. P., Collins, M. W., Mucha, A., & Lovell, M. R. (2011). Which On-field Signs/Symptoms Predict Protracted Recovery From Sport-Related Concussion Among High School Football Players? Am J Sports Med. Lau, B. C., Collins, M. W., & Lovell, M. R. (2011). Sensitivity and specificity of subacute computerized neurocognitive testing and symptom evaluation in predicting outcomes after sports-related concussion. Am J Sports Med, 39(6), 1209-1216. Maskell, F., Chiarelli, P., & Isles, R. (2006). Dizziness after traumatic brain injury: overview and measurement in the clinical setting. Brain Inj, 20(3), 293-305. Maskell, F., Chiarelli, P., & Isles, R. (2007). Dizziness after traumatic brain injury: results from an interview study. Brain Inj, 21(7), 741-752. Masson, F., Maurette, P., Salmi, L. R., Dartigues, J. F., Vecsey, J., Destaillats, J. M., et al. (1996). Prevalence of impairments 5 years after a head injury, and their relationship with disabilities and outcome. Brain Inj, 10(7), 487-497. Mihalik, J. P., Stump, J. E., Collins, M. W., Lovell, M. R., Field, M., & Maroon, J. C. (2005). Posttraumatic migraine characteristics in athletes following sports-related concussion. J Neurosurg, 102(5), 850-855. Peterson, C. L. P. A. T. C., Ferrara, M. S. P. A. T. C., Mrazik, M. P., Piland, S. M. A. A. T. C., & Elliott, R. M. D. (2003). Evaluation of Neuropsychological Domain Scores and Postural Stability Following Cerebral Concussion in Sports. [Article]. Clinical Journal of Sport Medicine July 2003;13(4):230-237. Rutner, D., Kapoor, N., Ciuffreda, K. J., Craig, S., Han, M. E., & Suchoff, I. B. (2006). Occurrence of ocular disease in traumatic brain injury in a selected sample: a retrospective analysis. Brain Inj, 20(10), 1079-1086.
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Stiller-Ostrowski, J. L. (2010). Fourth cranial nerve palsy in a collegiate lacrosse player: a case report. J Athl Train, 45(4), 407-410. Terrio, H., Brenner, L. A., Ivins, B. J., Cho, J. M., Helmick, K., Schwab, K., et al. (2009). Traumatic brain injury screening: preliminary findings in a US Army Brigade Combat Team. J Head Trauma Rehabil, 24(1), 14-23. Thiagarajan, P., Ciuffreda, K. J., & Ludlam, D. P. (2011). Vergence dysfunction in mild traumatic brain injury (mTBI): a review. Ophthalmic Physiol Opt, 31(5), 456-468. Whitney, S. L., Wrisley, D. M., Brown, K. E., & Furman, J. M. (2000). Physical therapy for migraine-related vestibulopathy and vestibular dysfunction with history of migraine. Laryngoscope, 110(9), 1528-1534.
About The Authors
Anne Mucha, DPT, MS, NCS is the Coordinator of Vestibular Rehabilitation for the University of Pittsburgh Medical Center Sports Concussion Program Centers for Rehab Services. She received her Bachelor’s and Advanced Master’s degrees in Physical Therapy from the University of Pittsburgh; and her Doctor of Physical Therapy degree from Temple University. She is a board certified clinical specialist in Neurologic Physical Therapy with advanced training in vestibular rehabilitation. She is an adjunct faculty member in the Department of Physical Therapy at the University of Pittsburgh and has over 20 years of clinical experience in treating individuals with neurologic conditions. Anne is actively involved in ongoing research projects with the Sports Concussion Program within the University of Pittsburgh Medical Center. She was recently appointed an at-large expert member of the consultant workgroup on Concussion for the American Physical Therapy Association. Michael (Micky) Collins, PhD, is a nationally renowned expert in sportsrelated concussion. A leading clinician and researcher, Dr. Collins is Director of the UPMC Sports Medicine Concussion Program. In addition to his extensive clinical experience, Dr. Collins has been a lead author on several major groundbreaking studies of high school and college athletes published in JAMA, Neurosurgery, American Journal of Sports Medicine, and Pediatrics, and an author on more than 50 peer-reviewed research articles for other prestigious medical journals. He is a national leader in teaching and implementing the proper use of baseline and post-injury neuro-cognitive testing as a tool to help determine injury severity and recovery for safe return to play for young athletes. In addition to training hundreds of physicians and athletic trainers in the diagnosis and management of sports-related concussion, he was the co-lead author of the Centers for Disease Control’s “Concussion Tool Kit for Physicians,” which has been disseminated nationwide to several physician subspecialties as an education standard regarding concussion management. He is an advisor to numerous athletic organizations, including USA Rugby, US Lacrosse, and Cirque De Soleil, as well as a concussion consultant for several other national and international sports organizations and teams. Jonathan French, PsyD, graduated from Widener University in 2010 with his doctorate in Clinical Psychology with concentrations in forensic and neuropsychology. He completed his internship in the assessment unit of Delaware Youth and Family Services. He focused his research at Widener on traumatic brain injury as well as the evaluation of malingering in neuropsychological testing. His dissertation examined personality characteristics of individuals engaging in malingering during neuropsychology assessment. Upon completion of his doctorate, Jonathan was recruited to join the UPMC Sports Medicine Concussion Program as neuropsychology fellow. His fellowship has consisted of conducted clinical evaluations with both Dr. Lovell and Dr. Collins. He is also involved in numerous research projects. Currently, he is the primary investigator in a study using MEG to evaluate brain activity in the acute stages of concussion.
Post-concussion care and the management of a concussion should be done by a trained medical professional. This is where ImPACT® can help. ImPACT can assist clinicians in making these return-to-play decisions. ImPACT is not meant to be used as a stand-alone tool.
What is ImPACT? State-of-the-Art Neurocognitive Test Battery; Computer-based program developed to help clinicians evaluate recovery following a concussion; Evaluates and documents multiple aspects of brain function — Impulse Control; Sustained Attention; Visual-motor Processing Speed; Visual and Verbal Memory; Working Memory; Selective Attention; Reaction Time; and Response Variability.
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Neurocognitive Testing has been defined as the “cornerstone” of concussion management by an international panel of sports medicine experts; Athletes will often fail to report symptoms of concussion because they are either unaware or they hope they minimize symptoms and get back to the playing field more quickly; Decisions about when an injured athlete can return to play following a concussion are often subjective and very difficult.
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Cervicogenic Post Concussion Disorder: A Pain In The Neck by John Leddy, MD
Joelle is an 18-year-old high school soccer player who sustained a head injury 3 months ago during a game. While going for a header, an opponentâ€™s head struck her on the side of the head and knocked her to the ground. Observers on the sidelines saw how her head twisted to the opposite side prior to hitting the ground. Joelle has no independent recollection of this. All Joelle knows is that she continues to experience daily headaches, dizziness and difficulty with concentration and memory in school despite resting from sports and physical activity since the day of her injury. She has been told that she is suffering from post concussion disorder because her brain is not yet recovered from the injury. Upon close questioning, Joelle says that her headaches begin from the top of her neck and radiate to the forehead and that her dizziness is exacerbated by looking right and left. She is having trouble concentrating and remembering things because she has a headache most of the day and she is not sleeping well. She has not tried to return to any physical activity and her parents have asked that the school make accommodations for her. Her brain MRI is normal and she has taken and passed a computerized neuropsychologi18 BRAIN INJURY PROFESSIONAL
cal (NP) test. Nonetheless, she does not feel ready to return to sports or even to recreational activities with her friends. Patients who experience prolonged symptoms after concussion are classified as having post concussion disorder (PCD). It is, however, becoming more appreciated among medical professionals that prolonged symptoms after a head injury may not in all circumstances be related to the brain injury per se. This is because symptoms such as headache, dizziness and poor concentration are not specific to brain injury. Rather, they may represent other pathologies, some of which are related to the initial trauma and some of which may not be. The challenge for clinicians is to establish as best they can the underlying cause of the symptoms so that proper treatment can be initiated. One cause of prolonged symptoms after head injury is a concomitant neck injury. This may not be fully appreciated by the patient or by health care professionals because the focus is usually on the seriousness of the brain injury. Traumatic brain injury (TBI) often involves a whiplash or twisting mechanism that can also injure the neck. The upper cervical spine is particularly vulnerable to trauma because
it is the most mobile part of the vertebral column with a complex proprioceptive system (Treleaven, Jull, & Sterling, 2003). Proprioception is defined as the sense of the relative position of neighboring parts of the body. The proprioceptive system of the cervical spine is particularly important since it tells us where our head is in space and has rich connections to the vestibular (balance) and visual systems of the brain (Treleaven, et al., 2003). The symptoms of whiplash injury can be prolonged, with the most common complaints being cervical pain, headache, vertigo and dizziness (Endo, Ichimaru, Komagata, & Yamamoto, 2006). Whiplash patients also endorse cognitive complaints such as poor concentration and memory deficits, even when not associated with concurrent brain injury (Sturzenegger et al., 2008). Furthermore, NP test results may not discriminate between whiplash patients and those with TBI (Taylor, Cox, & Mailis, 1996). Cervical proprioceptive disturbances might be an important factor in the maintenance, recurrence, or progression of various symptoms in patients with neck injury associated with TBI and may in fact be responsible for persistent symptoms thought to be due to PCD, even
though the brain injury has resolved. It is very important for clinicians to establish the mechanism of injury in patients with head injury and to realize that acceleration and deceleration of the head is often accompanied by a whiplash mechanism to the cervical spine. Clinicians should perform a careful physical examination of the neck in all patients with PCD. If a cervicogenic source is suspected to contribute whole or in part to ongoing symptoms after TBI, it is recommended that therapy be instituted that progressively addresses neck position and movement sense as well as cervicogenic oculomotor disturbances, postural stability, and cervicogenic dizziness (Kristjansson & Treleaven, 2009). There are no controlled trials of this form of therapy in those with persistent symptoms after concussion but anecdotal evidence indicates we can do a great deal to assist in recovery. The differential diagnosis of post concussion headache includes migraine, cervicogenic, and other types of post-traumatic headaches (Sallis & Jones, 2000). Treadmill testing using a standardized exercise treadmill protocol to establish physiologic recovery from concussion has recently been found to have very good inter-rater and sufficient re-test reliability for identifying patients with symptom exacerbation from concussion (Leddy, Baker, Kozlowski, Bisson, & Willer, 2011). This physiologic test can help with the differential diagnosis of physiologic PCD. Concussion symptoms, for example, are typically exacerbated by exercise prior to reaching full exercise capacity (Leddy et al., 2010). If patients can exercise to exhaustion without reproduction or exacerbation of headache or other concussion symptoms, and demonstrate a normal physiological response to exercise, then the symptoms are due to another problem, most commonly a cervical injury or a post-traumatic headache syndrome such as migraine. This information is vital to directing therapy to the cause of persistent symptoms. Joelle exercised on a treadmill and reached physical exhaustion. She had some neck pain and headache that increased gradually in intensity but did not stop her from exercising. In fact, her symptoms improved by the end of the treadmill test. Joelle’s neck examination revealed upper cervical tenderness. The physical therapist found that Joelle had very abnormal cervical proprioception. Using a laser pointer taped to the side of her head, af-
ter having demonstrated the ability to hit a target with eyes open, Joelle could not consistently return to the spot on the target with her eyes closed. She kept missing wide to the left. After a course of cervical muscle strengthening and proprioceptive retraining, Joelle’s cervical proprioception improved and her headaches and dizziness subsided. Treating the cervical spine was the key to Joelle’s recovery from prolonged post concussion symptoms. References
Endo, K., Ichimaru, K., Komagata, M., & Yamamoto, K. (2006). Cervical vertigo and dizziness after whiplash injury. Eur Spine J, 15(6), 886-890. doi: 10.1007/s00586-005-0970-y Kristjansson, E., & Treleaven, J. (2009). Sensorimotor function and dizziness in neck pain: implications for assessment and management. J Orthop Sports Phys Ther, 39(5), 364-377. doi: 2317 [pii] 10.2519/jospt.2009.2834 Leddy, J. J., Baker, J. G., Kozlowski, K., Bisson, L., & Willer, B. (2011). Reliability of a graded exercise test for assessing recovery from concussion. Clin J Sport Med, 21(2), 89-94. doi: 10.1097/ JSM.0b013e3181fdc72100042752-201103000-00003 [pii] Leddy, J. J., Kozlowski, K., Donnelly, J. P., Pendergast, D. R., Epstein, L. H., & Willer, B. (2010). A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clinical Journal of Sport Medicine, 20(1), 21-27. doi: 10.1097/JSM.0b013e3181c6c22c 00042752-20100100000004 [pii] Sallis, R. E., & Jones, K. (2000). Prevalence of headaches in football players. Medicine and Science in Sports and Exercise, 32(11), 1820-1824. Sturzenegger, M., Radanov, B. P., Winter, P., Simko, M., Farra, A. D., & Di Stefano, G. (2008). MRI-based brain volumetry in chronic whiplash patients: no evidence for traumatic brain
injury. Acta Neurol Scand, 117(1), 49-54. doi: ANE939 [pii] 10.1111/j.1600-0404.2007.00939.x Taylor, A. E., Cox, C. A., & Mailis, A. (1996). Persistent neuropsychological deficits following whiplash: evidence for chronic mild traumatic brain injury? Arch Phys Med Rehabil, 77(6), 529535. doi: S0003-9993(96)90290-7 [pii] Treleaven, J., Jull, G., & Sterling, M. (2003). Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error. J Rehabil Med, 35(1), 36-43.
About the Author
Dr. John J. Leddy is a board certified Internal Medicine and Sports Medicine physician. He is an Associate Professor of Clinical Orthopedics, Internal Medicine, and Rehabilitation Sciences at the University at Buffalo School of Medicine and Biomedical Sciences, and a Fellow of the American College of Sports Medicine and of the American College of Physicians. He is a practicing clinician and active researcher and teaches in the medical school. He is the Medical Director of the University at Buffalo Concussion Clinic, which is the first center in the United States to use a standardized exercise treadmill test to establish recovery from concussion and to use controlled exercise in the rehabilitation of patients with prolonged concussion symptoms. He is published in the fields of orthopedics, physiology, nutrition, concussion and post-concussion syndrome. His primary research interest is the investigation of the basic mechanisms of the disturbance of whole body physiology seen in concussion and how to help to restore the physiology to normal and so help patients to recover and safely return to activity and sport.
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conferences 2012 MARCH 21-25 – Ninth World Congress on Brain Injury, Edinburgh, Scotland. For more information, visit internationalbrain.org. This is the official World Congress of IBIA. 27-28 – Brain Injury Association of West Virginia: Sports Concussion- Not Just a Bump on the Head, Charleston, WV. For more information, visit www.biausa.org/WVirginia/news.htm April 2-3 – 18th Annual Sol Adler Memorial Conference- Brain Injury: Evidence-based Practice Identification, Evaluation, & Treatment of Children, Adolescents and Young Adults, Knoxville, TN. For more information, visit www.uthsc.edu/allied/asp MAY 3-5 – Fourth Annual Brains, Trains & Automobiles Seminar, Napa Valley, CA. For more information, visit www.media-rich.com . JULY 22-25 – NNS 2012: The Spectrum of Neurotrauma, Phoenix, Arizona. For more information, visit www.neurotraumasymposium.com.
SEPTEMBER 11-15 – 25th NABIS Annual Conference on Legal Issues in Brain Injury, Miami, FL. For more information, visit www.nabis.org 11-15 – 10th NABIS Annual Conference on Brain Injury, Miami, FL. For more information, visit www.nabis.org OCTOBER 9-13 – ASNR/ACRM 2012 89th Annual Meeting: Progress in Rehabilitation Research, Vancouver, BC, Canada. For more information, visit http://acrm.org/meetings . 11-12 – Concussions in Athletes: From Brain to Behavior, University Park, PA. For more information, visit www.hhdev.psu.edu/ConcussionIn-Athletics NOVEMBER 7-10 – National Academy of Neuropsychology 32nd Annual Conference, Nashville, TN. For more information, visit http://nanonline.org/ NAN/Conference/Conference.aspx 15-18 – 72nd Annual Assembly of the AAPM&R, Atlanta, GA. For more information, visit www.aapmr.org.
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BRAIN INJURY PROFESSIONAL
Suggestions for Facilitating Return to Learn After Concussion
by Brian Rieger PhD
Most people recover from concussion within a week or two, but symptoms can sometimes linger for months, causing significant distress and disrupting day-to-day functioning (Kirkwood et al. 2008, McRae et al. 2009). Children and adolescents appear to be at particular risk for more prolonged recovery (Guskiewicz et al., 2011). As symptoms improve, individuals will begin to feel better at rest, but will often find that exertion and activity will aggravate symptoms or cause them to return, indicating that recovery is not complete. Athletes who return to play before they are fully recovered may be at increased risk for re-injury and for more severe or prolonged symptoms. Accordingly, current return-to-play guidelines require athletes to be symptom-free at rest â€” and to remain symptom-free while progressing through a graduated program of increased physical challenge â€” before being released to contact or collision activities (Zurich guidelines). While considerable media and research attention has been devoted to return-to-play after sports concussion, the focus of this article is on return-to-school after concussion, which, if not handled properly, may also complicate or prolong recovery. Unfortunately, there is little research to guide the practitioner in optimal management of return-to-learn, so current practice is 22 BRAIN INJURY PROFESSIONAL
based primarily on accumulated clinical experience and on a general understanding of the pathophysiology of concussion.
Return to Learn
After concussion, a student may miss only a few days of school, if any at all, and experience little academic stress. Typical medical advice is to stay out of sports and to go to school if feeling well enough, with some general reassurance that things will be better in a week or two. Fortunately, this is usually the case, and any missed work can be made up in short order. For a substantial minority of students, however, symptoms will not resolve so quickly, and return to school will be more problematic. Physical symptoms of concussion such as headache, dizziness, or fatigue can make it difficult to be up and moving about, let alone study or go to class. Once these symptoms start to improve, students will want to get back to school, often with a sense of relief at feeling back to normal. However, much as physical exertion can worsen concussion symptoms or provoke their recurrence, so too can mental exertion or stimulation (Majerske et al. 2008, Guskiewicz 2011) . Thus, the student who wakes up feeling good a few days after injury
may end up feeling quite miserable after a noisy bus ride to school, a math quiz, band rehearsal, or lunch in the cafeteria. When this occurs, the student—and her parents— are often surprised when she ends up in the nurse’s office or needs to leave school early, as they were not aware of the worsening or aggravation of concussion symptoms that can accompany the return to school. This pattern can sometimes repeat itself for days or weeks, frustrating the student, parents, and teachers. After all, “it’s just a concussion.” Poor mental stamina appears to be a common problem after concussion, such that the student fatigues much more rapidly than before injury, with an associated deterioration in cognitive and academic performance. The student may do well in Science class during 1st period, but have great difficulty concentrating and remembering material in French class during 5th period. Increasing mental fatigue can also be accompanied by a subjective sense of feeling overloaded and overwhelmed, often to the point that the student becomes quite anxious or irritable . Other post-concussion symptoms that can affect students’ academic functioning include getting confused easily and frequently losing track of what they’re doing or thinking about, difficulty putting thoughts into words, slowed processing speed, poor reading comprehension, blurred vision, and sensitivity to light or sound. It’s not hard to imagine how such difficulties might interfere with preparation for a test, writing a paper, or completing homework assignments. From a teacher’s perspective, it is often difficult to understand how a concussion can cause problems in French class but not Science class, leading to questions about what is really going on with the student. Indeed, one of the more vexing problems in cases of persistent post-concussion symptoms is the invisible nature of the injury. There are no medical tests that can confirm residual brain-related effects of concussion, and the student usually looks perfectly fine. Within this context, questions often arise about the validity of the reported symptoms, or about their link to the injury. And while it is well-established within the research literature that non-injury factors can cause or contribute to the persistence of concussion symptoms (Krikwood et al. 2008), these dynamics can be difficult to sort out on a case-by-case basis. Parents, school staff, and medical professionals may question whether subjective symptoms such as fatigue or nausea are really due to concussion, or if the student is using the injury to avoid some activity or responsibility. Students themselves may end up feeling that they have to prove they are having problems, or that they are just supposed to “get over it.” There can also be incentives for the student to minimize or hide symptoms so as to avoid unwanted attention, avoid falling behind in school, or get back to otherwise restricted activities. For example, a student who is considering going to the nurse’s office may choose instead to fight through a worsening headache so as not to miss a Social Studies review class or to avoid teasing from peers. “Why do you have to go to the nurse’s office every day? It’s just a concussion. Are you sure you just don’t want to play soccer anymore?” Medical management of the student experiencing a prolonged recovery from concussion can be complicated by the social and academic stress associated with changes in the stu-
dent’s functioning, and often by the increasing frustration of the student and family with the slow pace of improvement. Teachers are focused on maintaining the child’s learning and grades, while medical providers may be emphasizing the need to reduce activity and exertion so as to keep symptoms in check and foster recovery. The student herself may feel caught in a tug-of-war between academic imperatives and medical directives, such as hearing from her doctor that she has to stay out of physical education class, and from her physical education teacher that if she does not attend class she will receive a failing grade for the marking period. With these issues in mind, several general recommendations for optimizing a student’s return to school after concussion are outlined below. Procedures (and enthusiasm) for implementing these accommodations will vary across classrooms, schools and districts. In many cases, supports will be put in place immediately after the school receives a letter from the student’s medical provider. In other settings, a formal accommodation plan (e.g., 504 plan) may have to be drawn up, especially if there is a prolonged need for academic support. In general, any effort to promote communication within the school about the student’s difficulties and to ensure agreement on the recommended interventions is going to be helpful, including a meeting between teachers, parent(s), and the student. Reduce academic demands and expectations to a level that is manageable for the student and provides adequate time for rest. In some cases, a student may need individual tutoring for a while, and may only tolerate an hour or two (if that) of mental exertion each day. For students who are able to attend school, it can still take much more effort and energy to accomplish assigned work, so reducing homework demands and eliminating non-essential assignments or material for a while may help ensure continued academic progress and also allow adequate rest-time. Attending school on a part-time basis or taking scheduled rest breaks during the school day can help to minimize symptoms and re-energize the student, especially if a concurrent plan to deal with missed class time or assignments is developed so as to avoid increased academic stress. Limit the aggravation of symptoms due to environmental stimulation. For some students, crowded hallways, noisy cafeterias and gyms, bright classrooms, and cacophonous band rooms can all exacerbate post-concussion headache, fatigue, irritability or other symptoms. Strategies to minimize this effect include allowing the student to eat lunch in a quiet room (with one or two friends to avoid social isolation), wear sunglasses or a baseball cap in bright classrooms, change classes a little early or late to avoid crowded hallways, and exercise outside the gym. Minimize the risk of re-injury, but allow physical activity and exercise as tolerated. Return-to-play guidelines aim to reduce the risk of re-injury while an athlete is still recovering from concussion. In the school setting, the focus of these guidelines tends to be on interscholastic sports, but physical education class, crowded stairwells, and the playground can also be problematic for a student with concussion-related balance problems, vision difficulties, or slowed reaction time. Efforts to reduce the risk of re-injury should therefore encompass all of the student’s activities, but should not necessarily involve restricting the student from all exercise. To the contrary, there BRAIN INJURY PROFESSIONAL
is emerging research suggesting that exercise that does not exacerbate symptoms may actually promote recovery, especially in student-athletes accustomed to such activity (Leddy et al., 2010). Provide individualized academic accommodations based on the student’s particular symptom picture. There is no one-sizefits-all program for return-to-learn after concussion. For example, some students will find reading to be very slow and effortful after concussion, usually due to vision or cognitive problems or both, while others may have no trouble comprehending or remembering what they read but experience significant difficulty solving math problems. Impaired organizational ability may lead to missed homework assignments or trouble prioritizing work, slowed processing speed may force the student to take much longer to complete an essay or exam, and poor concentration may leave the student more vulnerable to distraction. While some of these problems can be managed by simply reducing the overall amount of work assigned, additional academic accommodations specific to the student’s needs may also be necessary. Examples include extended time and a quiet location for tests, preferential seating in the classroom, ensuring that the student has written down homework assignments, providing class notes or auditory versions of books, and utilizing test formats that minimize memory demands such as open-book or multiple-choice exams. Promote communication and collaboration between all those involved in managing the student’s medical and academic difficulties. In cases of prolonged recovery from concussion, clinical management is best accomplished by a multidisciplinary team approach (REF). Likewise, when it comes to school-related problems, communication and collaboration between medical providers, school staff, and the student and parent(s) is essential. Simply informing teachers that a student is struggling with post-concussion symptoms is a good start. Parents and student-athletes might assume that the coach or team trainer has told others in the school about the concussion suffered by a student in last week’s basketball or soccer game, but this is not always the case. When the student keeps showing up in the nurse’s office with a headache, acting a bit odd in math class, or uncharacteristically falling asleep in study hall, the uninformed nurse or teacher may attribute these behaviors to problems other than concussion, such as the poor sleep habits typical of a teenager. The sooner that everyone involved knows what’s going on, the sooner the student can get the understanding and support that will foster optimal recovery and reduce academic duress. A brief meeting between teachers and parents can significantly improve the exchange of accurate information and shared concerns. With middle- and high-school age youth, including the student in the meeting is usually very helpful as they can best describe their particular difficulties and are alert to any adverse social consequences of accommodations intended to be helpful. For example, the adults may want an eighth-grader to eat lunch in the quiet art room with a favorite teacher, but the student may recognize that arrangement as an invitation for ridicule from friends. Recognize and validate the student’s symptoms and difficulties, while encouraging a gradual return to normalcy. As noted earlier, questions about the legitimacy of a student’s post-concussion complaints can emerge for a variety of reasons, often based 24 BRAIN INJURY PROFESSIONAL
on valid concerns about non-concussion factors that may be influencing the student’s symptoms and behavior, but just as often based on a poor understanding of the injury and its effects. In general, it is probably best for medical and school staff to validate the student’s symptoms and difficulties while at the same time encouraging a gradual increase in activity and return to normalcy. In most cases, things will eventually get back to normal, even when there are non-injury factors in play. In more complicated cases, especially where symptoms seem to worsen over time rather than improve, it is especially important that the student be managed by a specialized concussion program, and that the medical and academic teams work in collaboration with the patient and family.
Academic difficulties are common after concussion, and both mental exertion and academic stress can aggravate symptoms and may prolong recovery. While much attention is devoted to return-to-play after concussion, proper management of returnto-school is equally important. In general, the primary intervention that is needed is to reduce academic demands to a level that is manageable by the concussed student and that allows for adequate rest. Too often, teachers and school staff don’t realize that a student is having concussion-related difficulties until after the student has fallen behind and both the student and parent(s) have become anxious, frustrated, or angry. Early intervention is recommended to promote communication about the injury, reduce the risk of re-injury and over-exertion, and reassure the student and family. Specific academic accommodations should be implemented on an individualized basis as needed, and physical education should be modified to allow exercise as tolerated (after medical clearance). A brochure and short video entitled “Concussion in the Classroom” can be viewed at www.upstate.edu/concussion.
Guskiewicz KM & Valovich McLeod TC, Pediatric sports-related concussion, PM&R. 3: 353-364, 2011. Kirkwood MW, Yeates KO, Taylor HG, et al., Management of pediatric mild traumatic brain injury: A neuropsychological review from injury through recovery, Clinical Neuropsychologist. 22: 5, 769-800. Leddy JJ, Kozlowski K, Donnelly JP, et al., A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome, Clinical Journal of Sports Medicine. 20(1): 21-7, 2010. Majerske CW, Mihalik JP, Ren D, et al., Concussion in sports: Postconcussion activity levels, symptoms, and neurocognitive performance, Journal of Athletic Training. 43(3): 265-274. McCrory P, Meeuwisse W, Johnston K, et al., Consensus statement on concussion in sport—The 3rd international conference in Sport held in Zurich, November 2008. Clinical Journal of Sports Medicine. 19(3): 185-200, 2009. McRae M, Iverson GL, McAllister TW, et al., An integrated review of recovery after mild traumatic brain injury (MTBI): Implications for clinical management. Clinical Neuropsychologist. 23: 8, 1368-1390.
About the Author
Dr. Brian Rieger is Chief Psychologist and Clinical Assistant Professor in the Department of Physical Medicine and Rehabilitation at SUNY Upstate Medical University in Syracuse, NY. He is the director of the Concussion Management Program and Sports Concussion Center at Upstate , and is a member of the New York State Public High School Athletic Association (NYPHSAA) Concussion Management Team. Dr. Rieger also serves on the Injury Prevention and Public Awareness Committee of the New York State Traumatic Brain Injury Coordinating Council.
BRAIN INJURY PROFESSIONAL
Providing a Continuum of Care for Concussion using Existing Educational Frameworks
by Karen McAvoy, PsyD
An estimated 1.6 to 3.8 million concussions occur each year (Langois, Rutland-Brown & Wald, 2006). Fortunately, state concussion bills are advancing concussion awareness, early identification and early intervention efforts. In the field of education, an initiative in the United States called “Response to Intervention (RTI) also focuses on awareness, early identification and early intervention for learning and behavioral disabilities. As an approach to dealing with students with potential difficulties, RTI has grown in acceptance and support since its introduction in the Reauthorization of IDEA (Individuals with Disabilities Education Act) in 2004 (idea.ed.gov). RTI is an educational initiative in special education law defined by the National Association of State Directors of Special Education (NASDE) as: The practice of providing high-quality instruction and intervention matched to student need, monitoring progress frequently to make decisions about change in instruction or goals and applying child response data to important educational decisions. (www. ieanea.org)
The essential elements of RTI are often displayed on a three level pyramid with 80 to 90% of students benefiting from the foundational Tier 1 (“Universal Level”). With good teacher training and awareness, problems can be detected in students in the collective setting of the general education classroom and can be immediately supported with adjustment of curriculum within the classroom. Interventions are proactive and preventive (Batsche, 26 BRAIN INJURY PROFESSIONAL
Elliott, Graden, Grimes, Kovaleski, Prasse, Reschly, Schrag & Till, 2005). At Tier 2, an estimated 5 to 10% of students will need more targeted assessment and/or intervention (“Targeted Level”). Progress monitoring of these students may reveal a specific or continued need and may require small group instruction or accommodation of curriculum. Finally, an estimated 1 to 5% of students will not respond to interventions at Tiers 1 or 2. They will need the most individualized intensive intervention of Tier 3 (“Intensive Level”). Special Education identification is usually necessary at this level allowing for modification of curriculum, concentrated and individualized instruction and/or specialized placement.
Response to Management RTM:
Until recently, educators have felt that brain injury, aka concussion, is a medical condition out of the realm of their expertise. However, as schools become more integrally involved in the world of concussion, the RTI serves as a model for district-wide concussion management policy and protocol. The concepts of increased levels of intervention, progress-monitoring and family involvement are necessary elements for good concussion management, leading to a “Response to Management (RTM)” framework. Research shows that 80 to 90% of concussions will respond to management in 3 to 4 weeks (Collins, Lovell, Iverson, Ide & Maroon, 2006). A model school district in Colorado
(Cherry Creek School District, 2011) has built their district-level Concussion Management protocol on the RTI/RTM pyramid, establishing that with education, early identification, early intervention and with a Multi-Disciplinary Team Approach (known as REAP), they can positively effect the recovery of 80 to 90% of concussed students on the “universal” level (see Figure 1). The REAP protocol (which stands for Reduce/ Educate/ Accommodate and Pace) outlines a multi-disciplinary team approach including: the Family Team, the School Academic Team, the School Physical Team and the Medical Team working collaboratively over 3 to 4 weeks to help promote recovery. For more information on REAP, visit www.youthsportsmed.com. However, REAP, and most current concussion management approaches, stop at typical recovery. If research determines that 80 to 90% of concussions resolve in 3 to 4 weeks, at least 10 to 20% of students with concussion do not recover in that timeframe. The actual percentages of protracted recovery are yet unknown but there is scientific and clinical agreement that at least 10% of concussed individuals significantly struggle with physical, cognitive, emotional and sleep/energy symptoms beyond the expected recovery period, potentially meeting DSMIV criteria for Post-Concussive Syndrome (PCS) (Willer & Leddy, 2006). With the RTM model, a student who does not respond to interventions at Tier 1 can be systematically moved on to the next level (“Targeted” Tier 2). The multi-disciplinary teams would continue to collect data on symptoms, communicate and collaborate and would create a plan for the student. Formalized plans at this level are often called Health Plans, RTI Plans, or Section 504 Plans. The objective of Tier 2 is to expand and strengthen academic accommodations to effect greater recovery from the concussion. At the peak of the RTI/RTM pyramid is the 1 to 5% of students who have not adequately responded to concussion management efforts at Tiers 1 and 2. Again, the actual numbers of students at this level of protracted recovery is unknown due to lack of research. Suffice it to say, a small, but significant, percentage of students with concussion are suffering severe and longterm neurocognitive and physiologic effects. These students would not perplex a school district familiar with RTI/RTM. Students resistant to management attempts at Tiers 1 or 2 would simply be advanced to the most “intensive” level of assessment and intervention provided at Tier 3 (“Intensive”). Brain injury partners in the state of Colorado have designed a website called www.COKidswithbraininjury.com for educators and practitioners needing guidance in assessment and intervention of students with brain injury at Tiers 2 and 3. The objective of Tier 3 is to thoroughly assess and understand the underlying neurological issues for the application of intensive and individualized interventions. Interventions at this point usually warrant the formal label of special education and an intervention plan called an Individualized Education Plan (IEP). Interventions at this level can range depending upon severity but usually include modification of curriculum, specialized instruction and/or placement. Disabilities at this level are usually considered long-term and permanent. The entire process from Tier 1 to Tier 3 may span months or years. During this time, parents, school personnel and the Primary Care Provider are integral members of the multi-disciplinary team. Parents will understandably go through stages of grief,
as it will likely be inconceivable to them how their child could suffer a seemingly “benign” concussion and end up with permanent brain damage. School districts no longer need to think of concussions as a mystical medical condition that cannot be supported in the schools. Instead, with an RTM model, schools are empowered to be proactive in the creation of a seamless continuum of care for concussions. References
Batsche, G.; Elliott, J.; Graden, J.L.; Grimes, J.; Kovaleski, J.F.; Prasse, D.; Reschly D.J.; Schrag, J; and Tilly, D.W. (2005). Response to intervention: Policy considerations and implementation. Alexandria, VA: NASDSE Cherry Creek School District 5, 2011, Concussion Management Protocol, Greenwood Village, CO 80111 Collins, M.W., Lovell, M.R., Iverson, G.L., Ide, T., & Maroon, J. (2006). Examining concussion rates and return to play in high school football players wearing newer helmet technology: A three year prospective cohort study. Neurosurgery, 58(2), 275-286. Langlois, J.A., Rutland-Brown, W., & Wald, M.M. (2006). The epidemiology and impact of traumatic brain injury: a brief overview. Journal of Head Trauma and Rehabilitation, 21(5), 375-378 McAvoy, K (2009). REAP Reduce, Educate, Accommodate and Pace. REAP The Benefits of Good Concussion Management. www.youthsportsmed.com Willer, B. & Leddy, J.J. (2006). Management of Concussion and Post-Concussion Syndrome. Current Treatment Options in Neurology, 8:415-426 rtinetwork.org idea.ed.gov/ www.ieanea.org www.sterncenter.org
About the Author
Karen McAvoy, PsyD, is dually credentialed as a Licensed Clinical Psychologist and a School Psychologist in Colorado. She was the School Psychologist at the high school attended by Jake Snakenberg before he passed away from “Second Impact Syndrome” in 2004. As a result, Karen developed the multi-disciplinary team approach to community-based concussion management known as REAP (Reduce/Educate/Accommodate and Pace). Seven years later, in 2011, the Colorado Concussion Bill is named the “Jake Snakenberg Youth Concussion Act”. After 20 years in schools, Karen took a half time position with the Colorado Department of Education as the Principal Consultant on Brain Injury. In addition, she took a half time position as the Director of the Center for Concussion with the Rocky Mountain Hospital for Children. Her positions in both an educational setting and a medical setting give her a unique perspective to develop policy and effect change in the area of concussion/brain injury. BRAIN INJURY PROFESSIONAL
Psychologists Working in Concussion Clinics by John Baker, PhD Multidisciplinary Concussion Clinics are becoming more common as a referral source for patients with persistent symptoms after concussion, as well as for patients in the acute phase of recovery. Clinical psychologists with training and experience in neuropsychology, rehabilitation psychology, health psychology and other areas often play a role in the assessment and treatment of concussion. Traditional neuropsychological assessment, using a comprehensive battery of paper and pencil tests, has been important in the management of concussion. As more psychologists work as members of multidisciplinary clinic teams, their role is evolving beyond just traditional testing. Computerized neuropsychology testing, although controversial, has allowed for tracking of changes in concentration and processing speed during recovery from concussion. It is being used increasingly as part of return to play decisions, often with comparison to an individualâ€™s baseline performance before their concussion. During the acute phase of concussion, psychologists may participate in return to play decisions, integrating brief cognitive test results and psychological factors, such as underreporting of symptoms, into discussions with physicians, physical therapists, athletic trainers, and other members of a multidisciplinary team. As our understanding of acute concussion and the transition to persistent symptoms develops, psychologists can contribute to educational interventions. They can tailor their educational interventions during the acute phase to the personality and coping style of the individual patient. Studies 28 BRAIN INJURY PROFESSIONAL
have shown that this type of intervention can reduce the likelihood of later post concussion symptoms (Mittenberg, Tremont et al. 1996). Some studies would suggest that when symptoms persist after a concussion, psychological factors are the primary cause (McCrea 2007). A multidisciplinary approach to assessment and treatment of persistent symptoms may provide other perspectives. For example, psychologists can be alert to the possibility of a co-occurring neck injury contributing to headaches, concentration difficulties, and many other symptoms often attributed to concussion, as noted by Dr. Leddy in his article in this issue. Problems with autoregulation of cerebral blood flow and autonomic nervous system imbalance may persist in some individuals after the acute phase of concussion (Leddy, Kozlowski et al. 2007). These persistent physiological factors may interact with psychological factors, for example when anxiety may be worsened by heightened sympathetic nervous system activity, in addition to distortions in thinking. PTSD symptoms after a car accident may be enhanced by the effects of concussive injury on the brain (Reger, Poulos et al. 2011). PTSD in turn may delay a return of physiological homeostasis after concussion (Beck and Coffey 2007). Although contributions of psychological distress, such as depression or anxiety, to reduced performance on neuropsychology tests is routinely considered, contributions from physiological dysfunction have recently been receiving more
attention. Studies of cerebral blood flow during working memory tasks using fMRI have shown abnormal cerebral blood flow patterns with persistent symptoms after concussion. In some studies, cognitive performance has been affected (Lovell, Pardini et al. 2007) and in others blood flow returns to normal with recovery and resolution of symptoms (Chen, Johnston et al. 2008). Exercise rehabilitation may facilitate this return to normal cerebral blood flow during working memory tasks (Leddy 2012, March). The potential for cerebral blood flow and autonomic dysfunction to affect attention, working memory, processing speed, and other aspects of cognitive performance provides a unique opportunity for psychologists to participate in multidisciplinary assessment and treatment. For example, when concentration and memory difficulties are reported, psychologists can contribute to sorting out the relative contributions of persistent physiological dysfunction versus diffuse or focal cerebral injury. More importantly, improving attention and developing compensatory strategies for other cognitive domains can benefit from psychologists’ contributions to cognitive rehabilitation as part of a multidisciplinary team (Cicerone, Langenbahn et al. 2011). When the outcome of cognitive rehabilitation is viewed in terms of improving daily functioning and mood, rather than just cognition, psychologists can also contribute to these aspects of rehabilitation (Tiersky, Anselmi et al. 2005). Psychologists are uniquely qualified to provide cognitive behavioral therapy (CBT) to patients with prolonged symptoms after a concussion. This type of intervention involves monitoring and changing thoughts about a situation and monitoring and changing activities in order to reduce distress. Cognitive behavioral therapy can also be used to help patients manage the symptoms they are experiencing to improve their daily functioning. When decreased cognition makes it more difficult for patients to engage in this type of treatment, psychologists can help to develop compensatory strategies. Cognitive behavioral therapy has been shown in randomized controlled trials to help patients with persistent symptoms after concussion (Al Sayegh, Sandford et al. 2010). As we begin to develop a taxonomy of different types of post concussion disorders, psychological post concussion disorder may refer to persistent symptoms of a psychological or cognitive nature. Patients may have been experiencing psychological distress before their concussion, or they may not have developed adaptive ways of coping with a physical illness such as concussion. Someone who is used to confronting challenges by trying harder may not rest adequately after a concussion. Depression or anxiety may develop when headaches, dizziness, nausea, neck pain, and fatigue won’t go away. Cognitive behavioral therapy can also include training patients in self management approaches to coping with persistent concussion symptoms, helping patients to develop a sense of self efficacy in addition to improving their daily functioning. Many self management approaches that have been developed for chronic pain problems are directly applicable to prolonged symptoms after concussion (Hanson and Gerber 1993). For example, knowing one’s physical and concentration limitations, and becoming more active within these
limitations, can help to resolve these limitations. Relaxation techniques such as breathing exercises, guided imagery, meditation, and listening to relaxing music may help to ameliorate increased sympathetic nervous system activity and give patients a sense of control over headache pain and other unusual physiological sensations. Other simple behavioral approaches to self management can include goal setting, activity scheduling, self monitoring of activities, and self reinforcement. Self instruction in the form of self help books may also be helpful, especially for individuals who may be reluctant to talk with a therapist or who have difficulty accessing mental health treatment. “Feeling Good: The New Mood Therapy” (Burns 1999), and “Mind over Mood” (Greenberger and Padesky 1995) are two self help introductions to cognitive behavioral approaches to managing psychological distress. Our awareness of the importance of recognizing and treating concussion has increased greatly in the past several years. As our understanding of the interaction between physiological and psychological aspects of acute and persistent symptoms after concussion grows, the role of psychologists on multidisciplinary teams will likely evolve in new ways. References
Al Sayegh, A., D. Sandford, et al. (2010). “Psychological approaches to treatment of postconcussion syndrome: a systematic review.” Journal of Neurology, Neurosurgery & Psychiatry 81(10): 1128-1134. Beck, J. G. and S. F. Coffey (2007). “Assessment and treatment of posttraumatic stress disorder after a motor vehicle collision: Empirical findings and clinical observations.” Professional Psychology: Research and Practice 38(6): 629. Burns, D. D. (1999). Feeling good: The new mood therapy, Harper Paperbacks. Chen, J. K., K. M. Johnston, et al. (2008). “Recovery from mild head injury in sports: evidence from serial functional magnetic resonance imaging studies in male athletes.” Clinical Journal of Sport Medicine 18(3): 241. Cicerone, K. D., D. M. Langenbahn, et al. (2011). “Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008.” Archives of physical medicine and rehabilitation 92(4): 519-530. Greenberger, D. and C. A. Padesky (1995). Mind over mood: Change how you feel by changing the way you think, The Guilford Press. Hanson, R. W. and K. E. Gerber (1993). Coping with chronic pain: A guide to patient self-management, The Guilford Press. Leddy, J. J., Cox, J. L., Baker, J. G., Wack, D. S., Pendergast, D., Willer, B. S. (2012, March). Exercise Treatment For Post Concussion Syndrome: A Placebo Controlled Pilot Study of Changes in fMRI Blood Flow and Symptoms International Brain Injury Association Annual Meeting. Edinburgh Scotland. Leddy, J. J., K. Kozlowski, et al. (2007). “Regulatory and autoregulatory physiological dysfunction as a primary characteristic of post concussion syndrome: implications for treatment.” NeuroRehabilitation 22(3): 199-205. Lovell, M. R., J. E. Pardini, et al. (2007). “Functional Brain Abnormalities Are Related To Clinical Recovery and Time To Return-To-Play in Athletes.” Neurosurgery 61(2): 352. McCrea, M. (2007). Mild traumatic brain injury and postconcussion syndrome: The new evidence base for diagnosis and treatment, Oxford University Press, USA. Mittenberg, W., G. Tremont, et al. (1996). “Cognitive-behavioral prevention of postconcussion syndrome.” Archives of Clinical Neuropsychology 11(2): 139-145. Reger, M. L., A. M. Poulos, et al. (2011). “Concussive Brain Injury Enhances Fear Learning and Excitatory Processes in the Amygdala.” Biological Psychiatry. Tiersky, L. A., V. Anselmi, et al. (2005). “A trial of neuropsychologic rehabilitation in mild-spectrum traumatic brain injury.” Archives of physical medicine and rehabilitation 86(8): 1565-1574.
About the Author
John G. Baker, PhD, ABPP is a neuropsychologist who works with Dr. Leddy and Dr. Willer in the University at Buffalo Concussion Clinic. He is involved with the UB concussion research program, and has studied with Kenneth Ottenbacher, Ph.D., OTR as an NIH fellow. Before coming to UB, he worked at Rancho Los Amigos National Rehabilitation Center in Downey, California. BRAIN INJURY PROFESSIONAL
Concussion Legislation: Variations on a Theme by Jean Rickerson
Most states have now passed concussion legislation, designed to protect millions of youth athletes from the debilitating effects of the injury and prevent catastrophic outcomes. About 400,000 high school athletes sustained a concussion during the 2005-2009 school years,1 with an unknown number occurring among the estimated 44 million youth who participate in organized youth sports each year. Football, ice hockey, boysâ€™ lacrosse and girlsâ€™ soccer are among the organized sports with the highest incidence of reported concussions.2 Bicycle riding results in the most emergency room visits for head injuries for those under the age of 19, followed closely by injuries sustained on the playground.3 While concussion laws typically address only organized sports, it is obvious that in time, attention must be paid to the consequences of the injury resulting from other activities as well. Current concussion legislation might someday provide fertile ground for that larger platform. At the national level, Democratic lawmakers reintroduced 30 BRAIN INJURY PROFESSIONAL
the Protecting Student Athletes from Concussions Act in January 2011, co-sponsored by U.S. Rep. George Miller (DCA), ranking Democrat on the Education and The Workforce Committee, and Rep. Tim Bishop (D-NY). This legislation would set minimum requirements for concussion safety and management in public schools, including a plan for 1) parent, student, and school staff education 2) support for students returning to school after an injury and 3) best practices for safety standards, treatment, and concussion management. The NFL and the American College of Sports Medicine co-sponsored a Congressional briefing regarding this legislation on September 23, 2011, where congressional leaders heard testimony from medical experts. Rep. Bill Pascrell Jr. (D-NJ-8) and Sen. Robert Menendez (D-NJ) sponsored similar legislation in 2009, the Concussion Treatment and Care Tools (ConTACT) Act, which passed in the House but was never voted on in the Senate prior to the end of the congressional session. They did not reintroduce
the legislation. On September 27, 2011, the New Jersey legislators announced that the Centers for Disease Control and Prevention (CDC) would establish national guidelines for concussion care and management by the beginning of the 2014 school year. These guidelines will provide valuable information for school districts, teams, and other organizations that are subject to state concussion laws, but lack adequate management resources. In May, 2009, Washington State became the first to adopt concussion legislation that includes the three most widely accepted tenets of current concussion laws 1) education of parents, athletes, and others 2) removal from play at the time of injury if an athlete is suspected of having suffered a concussion 3) requiring an athlete to obtain written return-to-play authorization from a medical professional trained in the diagnosis and management of concussion. Washington State’s law was named after Zackery Lystedt, a middle school football player who suffered a catastrophic brain injury during a game in 2006 at the age of thirteen. He sustained a concussion while playing, sat out for a brief time, returned to the same game and was hit a second time. He collapsed on the field. Lystedt was airlifted to a Seattle trauma center where he underwent a craniotomy. He subsequently suffered a series of strokes and spent the next three months in a coma. It was nine months before he spoke his first word. Zackery’s parents and a coalition of medical professionals, lawyers, and others, lobbied for the passage of what is now known as the Lystedt Law. By October 2010, NFL Commissioner Roger Goodell had endorsed the law and contacted 44 governors in states that lacked legislation, urging them to adopt similar regulations. It worked. According to the National Athletic Trainers’ Association, as of October 18, 2011, 34 states and the District of Columbia have passed concussion laws. States without any pending legislation include Arkansas, Georgia, Kentucky, Mississippi, Montana, and West Virginia. Many states have incorporated the three main parts of the Lystedt Law into their own; 1) education, 2) removal from play if an injury is suspected, 3) return to play with written medical authorization. However, there are variations on the theme. Concussion education is a provision under almost every law. That is the extent of Idaho’s legislation; education of coaches, athletes, and parents. Massachusetts on the other hand, requires concussion training for parents of student-athletes, physicians and nurses who volunteer with extracurricular activities, athletic trainers, athletic directors, and directors of marching bands. Training program requirements must meet specific guidelines outlined in the law, all of which are satisfied by completion of an on-line course offered by the CDC or the National Federation of State High School Associations (NFHS). States that leave concussion training decisions up to individual school districts see a variety of solutions. Some districts institute policies that require parents to sign an information sheet on the signs/symptoms of concussion, and that is the totality of the education effort. Others, such as Virginia’s Fairfax County School District, have developed an online train-
ing program to be completed by parents and athletes before a sports season begins. Similarly, Arizona requires all high school athletes to complete an online concussion course and pass an exam through their Brainbook program. Two areas where state laws differ are to whom they apply and who is authorized to provide written medical authorization enabling an athlete to return to play. Most laws encompass student-athletes involved in public school athletic activities; others such as those in Arizona and Washington include recreational sports as well. The District of Columbia was the first to include students from elementary through high school, in public and private schools, as well as recreation leagues. The DC law also applies to students in gym class. Medical personnel with authorization to “clear” an athlete can be specifically stated in the law as is the case in Washington State, that has approved MD, DO, PA, NP, and ATCs. Other states simply call for clearance from a physician. Defining those professionals who are qualified to issue return to play authorizations has proven to be quite a task for lawmakers, who have witnessed debates over the inclusion of athletic trainers, physical therapists, and chiropractors. Several states that have a unique approach are North Carolina, which requires an emergency action plan (EAP) to be developed by each school district, and Rhode Island, where lawmakers considered mandating computerized neuropsychological testing, but were unsuccessful in amending the law. Concussion laws and heightened media attention have resulted in the swift evolution and increased emphasis on the diagnosis and management of youth athletes who have suffered concussions. As the science evolves, additional data will become available to guide amendments to existing legislation, so our youth remain protected. Legislation is a great first step. Implementation, often the difficult part, is where the effectiveness of the laws is truly tested. Time will tell if the momentum regarding the seriousness of the concussion issue will remain strong, if current education mandates are thorough enough, and if athletic programs will permanently adopt this additional emphasis on player safety. The burden to protect our youth is shared by schools, coaches, parents, athletes, and lawmakers, as we discover together that much more is at stake than we ever realized. References 1. 2. 3.
Concussion in High School Sports (GAO-10-569T , 2010). Trends In Sports-related Concussion Incidence At The High School Level 1997-2008 ( Medicine & Science in Sports & Exercise 42 (2010): 474; Lincoln et al., 2010). Nonfatal sports and recreation related traumatic brain injuries among children and adolescents treated in emergency departments in the United States, 2001-2009 (MMWR 2011; 60(39);1337-1342, Gilchrist et al., 2011)
About the Author
Jean Rickerson holds a B.S. from the University of Maryland. She is the CEO and founder of SportsConcussions.org, a leading sports concussion education organization with five chapters across the U.S. She is a member of the Emergency Services for Children committee at the state and national level and serves on the Washington State TBI conference committee. She was recently honored as a “Real Hero” by the American Red Cross for her concussion advocacy. BRAIN INJURY PROFESSIONAL
Sportsconcussions.org: A New Resource for Brain Injury Professionals and Families by Neal McGrath, PhD In recent times we have seen an upsurge of public awareness about brain injuries arising from two issues: traumatic brain injury and blast injuries sustained by our troops in the Middle East, and rising concern about the safety of athletes due to concussions in contact sports. Sports-related concussions affect the health of thousands of our nation’s youth every year, from their earliest participation in the primary grades through elite college athletics. Parents with a son or daughter who has sustained a concussion in sports suddenly find themselves having to learn more about brain injury than they ever imagined and often feel unsure where to turn for reliable information about concussion risks, signs and symptoms, evaluation methods, and treatment. In the last two years a valuable resource has helped to fill this void. As so often happens in the world of brain injury, this work is the result of a concerned parent who was determined to make sure that others who followed her would have a better path. In November of 2008 Drew Rickerson was playing quarterback for his high school in Sequim, Washington. He sustained a concussion in a helmet-tohelmet hit. Like many athletes, Drew continued playing, unaware of his condition and the risks of further trauma. He later came to the bench severely symptomatic. Drew was out of school for two months and it took his mother, Jean Rickerson, 10 weeks to find a specialist to evaluate and treat his concussion. As Drew finally began to recover, Jean, a former video producer for the U.S Navy, made it her goal to educate her son’s football team about concussions. Putting out a call to the community for other football concussion cases, she was flooded with stories from all over – and not just in football. She moved on to organize the first of several conferences in June 2009 just as the Zackery Lystedt Law, the catalyst for nationwide state concussion safety legislation, was signed into effect in Washington State. SportsConcussions.org was launched by Jean in January of 2010. Knowing that she as a parent in crisis had found her way to important knowledge about concussions through the Internet, she decided that a website devoted to making accurate information on the topic available to the public could be a valuable public resource. Jean established a professional advisory board of concussion experts which 32 BRAIN INJURY PROFESSIONAL
included a Harvard University physician, leading university researchers, and the president of the National Athletic Trainers’ Association, who helped direct the mission. The site has been included in the New York Times, the Washington Post, and is part of the SafeKids campaign sponsored by Johnson & Johnson. Among the resources available on SportsConcussions.org is basic information on concussions including signs, symptoms, and risks as well as current return-to-play guidelines. The site also contains downloadable resources and has hosted hundreds of articles on the topic. A unique contribution made by SportsConcussions.org is that it provides one of the most current and comprehensive summaries of stateby-state concussion safety legislation as laws are continuously enacted and revised around the nation. The site tracks many current stories and controversies as well as providing detailed information pages for athletes, coaches, and parents. Also available through SportsConcussions.org is iBaseline, which helps connect schools and organizations to concussion specialists for baseline testing, education, and other services and is aimed especially to help bring these resources to more rural areas. iBaseline has facilitated testing for hundreds of studentathletes nationwide. Jean was recently honored by the American Red Cross as a “Real Hero” for her work within communities. Whether you are a parent in need or a brain injury professional looking for current information and news in the rapidly changing of sports-related brain injuries, SportsConcussions.org can be a valuable stop. About the Author
Neal McGrath PhD is a neuropsychologist in the Boston area and specializes in the evaluation and treatment of brain injury. He is the Clinical Director and founder of Sports Concussion New England. In the fall of 2010 Dr. McGrath served on the Massachusetts Department of Public Health’s Clinical Advisory Committee to assist with the development of departmental regulations for the state’s new concussion safety law. In 2011 Dr. McGrath was presented with the National Athletic Trainers’ Association Clint Thompson Award for Clinical Advancement for his paper “Supporting the Student-Athlete in the Classroom after a Sport Related Concussion” which appeared in The Journal of Athletic Training in October/November 2010.
It’s Done! It’s Done! Is an app that helps individuals with brain injuries with memory problems remember whether they turned off the stove, locked the door, or took their medication. The app instantly confirms the completion of everyday routine tasks and can also notify other family members and caregivers that a task has been completed. The It’s Done! app can also automatically generate a text message or email to notify others when a task is done. So within seconds of taking a daily medication and check-marking It’s Done!, a family member and/or caregiver immediately receives a text or email confirming it and eliminating their need to call or worry. The FINR Brain Atlas The FINR Brain Atlas was developed as an educational tool for individuals with brain injuries, family members and students, as well as medical and rehabilitation professionals. Users of the atlas can explore the anatomy of the brain and common brain injuries in a 3-dimensional model. Detailed descriptions include the function of normal structures, related structures, common injuries to those areas, and resulting deficits due to damage. The app uses pop-up labels that
can be tapped and manipulated to locate a colored region on the brain. The labels that appear green, with an underline are hyperlinked to corresponding structures. Simply tap on a link to load its structure. Injury illustrations include: aneurysm, anoxic/hypoxic encephalopathy, cerebral contusion, cerebral infarction/stroke, diffuse axonal injury, intraventricular hemorrhage, penetrating head wound, subarachnoid hemorrhage, and subdural hematoma.
Concussion Recognition & Response APP The Concussion Recognition & Response APP is a new tool that helps coaches and parents recognize whether an individual is exhibiting and/or reporting the signs and symptoms of a suspected concussion. Using information from the CDC’s “Heads Up: Concussion in Youth Sports” program, the App guides users through a set of questions. The information gathered from the questions can then be emailed to a heath provider to provide accurate documentation of the child’s condition at the time of the injury. The App also provides “Home Symptom Monitoring”, “Return-to-Play Guidelines”, and information on concussion for coaches, parents and schools. BRAIN INJURY PROFESSIONAL
bip expert interview David Hovda
how can we increase their plasticity and how can we make them less vulnerable.
It seems to many of us in the field that we have learned more about concussion in the last decade than in the century preceding. You have been a major contributor to this new understanding of concussion. When did you first look at the issues of concussion and what was your motivation? When my research started I was not interested in concussion. We were interested in surgical lesions in the brains of animals and wondered why some animals recover better than others. When I came to UCLA my colleagues in TBI were very interested in trying to find ways to stop brain cells from dying after the injury. At the moment of trauma there is a neurochemical cascade that occurs and cells can go on to die much the same as stroke. I thought that what might be more interesting is to examine cells that go on to survive the injury. What made these cells more sensitive to secondary injury? What changed in their environment to make it more difficult for these cells to take over functions that were lost? We started to make models where we produced very mild injury so that we didn’t induce cell death. We just wanted to expose these cells to a biomechanical load similar to what they would see in a mild injury like concussion. Out of this research came an understanding of why cells were vulnerable. We were approached by some sports organizations and athletes who were very concerned that after a concussion the person may be more vulnerable to a second concussion. Our research provided several neuroscientific explanations for that phenomenon. Then we found out how we could image the process and apply this to human TBI. Fortunately at UCLA we had the imaging capability to translate this work. We have applied this work to the full range of injuries from mild to severe. We are known for our work on concussion but it wasn’t concussion per se that we were interested in but rather what happens to the cells that survive, and
Although others had looked at some aspects of metabolism post concussion it seems that you and your group at UCLA were the first to really bring the findings of a ‘metabolic cascade’ to light. Did your early findings cause others to wonder what you were doing or was there an immediate acceptance of your novel findings and ideas? Our results were not well received by professional sports organizations. In 1989 I was introduced to Jose Sulaiman to help him understand how to make boxing a more civilized sport. He wanted to do something to protect his athletes. New rules had been imposed that prevented boxers with concussion from not only fighting but sparring, which cut significantly into their income. In the ‘90s we began to have communication with the NFL and NHL. There was enormous resistance on the part of players and owners. Owners did not want to face possible costs of long term disability clauses and players did not want to be forced to miss playing time and possibly not make financial incentive goals. It wasn’t until 2009 that the NFL formally acknowledged that concussion was an issue and the NFL was going to do something about it. New guidelines for management of concussion have now been put in place in these professional sports leagues but that does not address all of the players in high school and Pop Warner football programs where the medical expertise is not necessarily on the sidelines. The legislation now being considered and passed in many states is a major step forward in dealing with concussions with amateur athletes. We also faced resistance from the U.S. Defense Department. In 2009 I was approached by two high ranking generals and the secretary of the VA and asked to give a briefing at the Pentagon about mTBI. I was told I could not use slides. I gave the fifteen-minute briefing to medical staff of the joints chief of staff. Afterwards I was told that what I was presenting was “bad science” and there was no scientific evidence that a concussion could occur following a blast. Further, if we were to remove someone affected by a blast from the field of battle that we would be practicing bad medicine. What started as a fifteen-minute briefing turned into a three-hour food fight. This meeting was kept confidential for three or four months until I was asked by the Pentagon to speak with a reporter at the Washington Post. This lead to a request to put together a blue ribbon panel on concussion and PTSD, which led to an order for the military to adopt protocols similar to those adopted by the NFL and NHL. The military has now developed a center of excellence devoted specifically to concussion and PTSD. For my efforts, I was awarded the Strength
34 BRAIN INJURY PROFESSIONAL
of the Nation Award from the United States Army in 2011. This is the highest award given to a civilian each year by the United State Army. Over the decade or more that you and your colleagues have been measuring and describing the metabolic changes that accompany concussion can you please describe the major implications of your work for assessment and treatment of concussed athletes? With respect to assessment we have made great leaps. It is still a clinical assessment based on symptoms and clinical judgment. There is no true biomarker for concussion. There are really fancy imaging techniques that one could use but this requires expensive MR imagers. Our center and others have been investigating the use of noninvasive imaging for assessment of concussion. We simply can’t rely on the symptom-based assessments. Some people exaggerate their symptoms. Athletes tend to deny they have symptoms because they want to go back to play. There is no treatment for recovery of function after traumatic brain injury. That is one of the most frustrating things that I have been exposed to in my academic career, that I do not have anything to offer individuals. We have some ideas. There have been hundreds of clinical trials for TBI and they all failed. There are lots of reasons for this but one of the reasons is that we need a way to get surrogate markers of the metabolic changes we identified in animals, so that we might identify responders versus non-responders. At UCLA we identified the metabolic changes that follow a TBI and found that everything from injury to recovery requires an enormous amount of energy. The brain operates on about 116 watts of power per hour. At UCLA we think the fuel demands of the injured brain are different from the normal brain and we need to come up with a better fuel. You might say we are looking for the Gatorade for the brain, a Brainade if you will. A number of athletes with post concussion disorders have had ocular and vestibular disturbance as their primary complaint. Has your research or the research of others on metabolic changes after concussion been able to link these metabolic effects to specific symptom clusters such as vestibular issues? Most cases where people experience ocular or vestibular problems after head trauma is not due to metabolic changes or changes of any kind in the brain. The cause is usually damage to the fine cochlear hair cells. They are crystals that are set into a membrane in the inner ear that help you determine if you are stable. The vestibular system is coordinated with your eyes so that if you move your head side to side you can maintain your focus on a particular object. In head injury these crystals
fracture and break off. All of a sudden everything starts to move around. People experience dizziness and difficulty focusing. Fortunately, there is a variety of treatment procedures available and these do work. Similar to the preceding question, research has now identified neurophysiologic changes that accompany concussion especially in those where concussive symptoms persist. For example, there are changes in the autonomic control (with patients caught in sympathetic overdrive and subsequent inability to utilize the parasympathetic system at appropriate times, such as when trying to go to sleep). Have we been able to link metabolic changes to autonomic nervous system imbalance? We have not seen the relationship between metabolic changes and the autonomic nervous system changes but largely because we have not looked for this relationship. I am very interested in this relationship because of the systemic effects that go along with autonomic nervous system imbalance. The evidence of second impact syndrome in humans is based on a small number of case studies. Is there evidence from your research on mice that a second concussion before the first has healed can lead to more serious outcomes in terms of physiology or cognition? It depends on your definition of second impact syndrome. If your definition is that a second injury to the brain soon after the first injury will cause more extensive damage then yes, we have seen that. If your definition is that a horrific, debilitating brain injury can occur with a second injury then we have not seen that. Much more serious could occur but it is really rare. We can say with confidence that the initial concussion leaves the brain vulnerable for a period of time. If a second injury occurs with similar or less magnitude than the first injury before the brain has healed they are much more compromised. Based on your research, what direction might we go to find pharmacologic interventions to assist in recovery from concussion? We have all worked for the last thirty years trying to find the silver bullet and we have learned that there is probably not going to be one bullet or one drug that helps in concussion recovery. We have also learned that there is probably a window of time after the injury that therapeutic interventions will work. We may find that different drugs have different windows in time. I think we also have to think outside the box. Instead of doing pharmaceutical interventions we might start thinking about activation interventions, whereby we use cognitive or physical therapy or rehabilitation in a novel way to enhance neurogenesis. Post concussion symptoms may be part of the recovery and not part of the problem. Alleviating these symptoms may not actually help recovery. Interview by Barry Willer, PhD
literature review Public Knowledge of “concussion” and the different terminology used to communicate about mild traumatic brain injury (MTBI) McKinlay, A., Bishop, A., & McLellan, T. (2011) Brain Injury 25(7-8), 761-766. While brain injury continues to be represented in the popular press whether through well known personalities who experience injury, athletic injuries or those sustained by servicemen and women, there remains confusion about what is a brain injury and how to respond after an injury. Certainly some of this confusion is perpetuated by professionals as they struggle to best define impact beyond the commonly used yet insufficient diagnostic categories of mild, moderate and severe. In particular this is most relevant to the terms used to describe mild traumatic brain injury and concussion. This most recent article written by Audrey McKinlay and her colleagues from New Zealand continues to verify the importance of providing consistency in the terminology and descriptors used to define brain injury. Their findings indicated, as expected, that few of the responders could accurately identify statements about concussion, more negative attributes were associated with the term brain injury in comparison with the term head injury and those that experienced concussion did not believe they had sustained a brain or head injury. Clearly lay persons have a tendency to gradiate the terms with concussion on the lower end of the severity spectrum to brain injury at the higher end of the spectrum. While the popu-
lation surveyed was a convenient and limited sample, their findings are consistent with other authors. This lack of consistency in terminology the authors argue is also representative of much of the resources available on the internet and in peer-reviewed literature and text books. The public’s uncertainty about the definition and severity of symptoms also then creates confusion about what type and if healthcare should be sought. While recent efforts to educate the public on brain injury are to be applauded, McKinlay and her colleagues continue to make it clear that as professionals we are obligated to make it easier by providing a consistent terminology that then helps guide the public’s appropriate response to care.
About the reviewer
Dr. Debra BraunlingMcMorrow is an international consultant in brain injury. She was the Vice President of Business Development and Outcomes for NeuroRestorative until 2011. She currently serves on the board of the North American Brain Injury Society and is the recipient of the 2007 NABIS Clinical Service Award. Dr. McMorrow is a past chair of the American Academy for the Certification of Brain Injury Specialists (AACBIS) and has served on the Brain Injury Association of America’s board of executive directors as the Vice-Chair for Program Outcomes. She has published in numerous journals and books and has presented extensively in the field of brain injury rehabilitation and has been working for persons with brain injuries for over 25 years. She may be contacted by email at: firstname.lastname@example.org.
BRAIN INJURY PROFESSIONAL
non-profit news North American Brain Injury Society
Dr. Tina Trudel and the NABIS conference planning committee is hard at work putting the educational program together for the 10th Annual Conference on Brain Injury which will be held at the InterContinental Hotel in Miami, Florida, September 12-15, 2012. The conference will have a special focus on brain injury and technology and will feature internationally recognized speakers and panelists. The Call for Abstracts is now opened: submit your original research by visiting www.nabis.org. As in past years, all accepted abstracts will be published in the Journal of Head Injury Rehabilitation. New this year, NABIS is pleased to announce a partnership with the KiDZ Neuroscience Center, Department of Neurosurgery & The Miami Project to Cure Paralysis at the University of Miami Miller School of Medicine, on a special full-day pre-conference session entitled “Perspectives in Pediatric Brain Injury”. This session will be chaired by Dr. Gillian Hotz and the preliminary program is now available on the NABIS website. Thanks to the generous support of the Toral Family Foundation, several scholarships are now being offered for the conference. For more information and to apply, please visit www.toralfamilyfoundation.org. The 25th Annual Conference on Legal Issues in Brain Injury will be held concurrently with the NABIS medical conference. Co-chairs Simon Forgette, Kenneth Kolpan and Bruce Stern have begun to craft a varied educational program featuring some of the leading trial attorneys and medical experts in North America. More details are available on the NABIS website, www.nabis.org.
retary Virginia (Ginny) Lazzara, RN, BSN, CRRN. BIAA also welcomed new board members: Sharese Bullock-Bailey; Marie M. Cavallo, Ph.D.; Philicia L. Deckard, LSW CBIST; Ramon Diaz-Arrastia, M.D., Ph.D.; Bud Elkind, M.S., CBIS-T; Sheldon L. Herring, Ph.D.; Caroline Suplizio, EED; and Tina M. Trudel, Ph.D. More than 70 people attended the 2012 Brain Injury Business Practice College in Las Vegas, which focused on “Excellence in Brain Injury Services Demands Sound Business Practices.” Attendees enjoyed presentations on influence, business ethics, payments from third-party payors, business ramifications of brain injury as a disease, reports on health care reform and advocacy, best practices and business metrics, and a fascinating conversation led by Scott and Joan Bolzan, who have written My Life, Deleted. After analyzing President Barack Obama’s proposed FY2013 budget, BIAA is pleased to report that programs authorized by the TBI Act, including the Health Resources and Services Administration (HRSA) Federal TBI Program and the Centers for Disease Control and Prevention’s (CDC’s) important TBI work, have both been recommended to receive level funding found in FY11 final and FY12 CR appropriations bills. The funding would include $10 million for HRSA and just under $7 million for CDC. In the current fiscal climate, this is good news for TBI advocates. This would indicate TBI funding is not on the chopping block when the government is looking to cut a trillion and a half dollars in federal spending.
DEFENSE CENTERS OF EXCELLENCE Brain Injury Association of America
BIAA launched a new, multi-year campaign in March to kick off Brain Injury Awareness Month with the theme: Anytime, Anywhere, Anyone – Brain Injuries do Not Discriminate. BIAA provided graphics and a promotion guide for state affiliates and advocates to use. Brain Injury Awareness Day is scheduled to take place on Capitol Hill March 21, 2012. Go to www.biausa. org/brain-injury-awareness-month.htm for more information. The BIAA board approved its 2012 slate of officers: Chair James F. Humphries, Esq.; Vice Chair Daniel S. Chamberlain, Esq.; Treasurer Dennis R. Hays, Esq.; and Sec36 BRAIN INJURY PROFESSIONAL
Continuing education units (CEUs) and continuing medical education (CME) credits are now available through many of the monthly webinars offered by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE). These monthly webinars, open to the public, are hosted by DCoE to provide information and facilitate discussion on a variety of topics related to psychological health and traumatic brain injury. The credits are available from Saint Louis University by pre-registering through DCoE’s Adobe Connect platform. Details on accreditation for Saint Louis University offering the credits can be found on the DCoE Website. Just navigate through the “Training and Events” button and see the Monthly Webinars link. That leads to
comprehensive information about the Saint Louis University’s CEU/CME accreditation. DCoE provides a number of opportunities to earn CEUs and CME credits in addition to the monthly webinar series. Among them are: • Mild TBI Web-based Case Studies The Mild TBI Web-based Case Studies are a series of modules utilizing actual patient vignettes to assist health care professionals to understand mild traumatic brain injury (TBI) to include screening, diagnosis and management of symptoms in the non-deployed setting. One free CEU/CME credit is offered per course. • PTSD and TBI Training Events A variety of training opportunities across the Defense Department specifically related to evidence-based treatments for post-traumatic stress disorder and traumatic brain injury. Information regarding these events and how to register can be accessed via an online training calendar on DCoE’s website. Many of these courses offer CEUs. For information on any of these opportunities and more, please visit the DCoE website, www.dcoe.health.mil.
International Brain Injury Association
The International Brain Injury Association is putting the finishing touches on the Ninth World Congress on Brain Injury that will be held at the Edinburgh International Conference Centre from March 21-25, 2012, in the historic and picturesque city of Edinburgh, Scotland. IBIA is pleased to announce that this will be the largest World Congress to date! In addition to 120 invited speakers and panelists, there will be 225 oral presentations selected from the over 900 abstract submissions. The program will also feature informative “meet the expert” sessions, satellite symposia and over 600 poster presentations. In addition to a broad and varied scientific program, the Congress will feature several exciting social activities. As treat to our delegates, the Congress will mark the world premiere of the movie “Headgames”. This film, produced and directed by internationally honored filmmakers Steve James (“Hoop Dreams”) and Bruce Sheridan along with Pulitzer Prize nominated Alan Schwarz, “Headgames” takes a hard look at the real potential dangers of amateur and professional
contact and collision sports. There will also be a reception with the international contingent of exhibitors, a Gala Award Banquet at the National Museum of Scotland, and a post-meeting excursion to Glasgow, the city famous for ground-breaking brain injury research. NABIS members will be pleased to know that the Tenth World Congress will be held in San Francisco in 2014. Details as they become available will be posted to www.internationalbrain.org.
NATIONAL ASSOCIATION OF STATE HEAD INJURY ADMINISTRATORS
As this publication goes to press, NASHIA, and its collaborators, are preparing for the March 21st Congressional Brain Injury Task Force [CBITF] Awareness Day on Capitol Hill in Washington, DC. Sponsored by CBITF this day provides an excellent opportunity for networking, information sharing and learning about key national issues effecting brain injury. The day will include an Awareness Fair featuring exhibits from national organizations and federal programs, a briefing and a congressional reception. Please Join Us! SAVE THE DATE: The 23rd Annual State of the States meeting will be held in conjunction with the National Home & Community Based Services [HCBS] Conference at the Hyatt Regency in Crystal City, Virginia September 10 to 13. We are honored to join with the National Association of States United for Aging and Disabilities [NASUAD] sponsor of the HCBS Conference NASHIA continues its focus with the Congressional TBI Taskforce and its partners on the re-authorization of the TBI Act. The Act authorizes three main areas: • The Health Resources and Services Administration (HRSA) to provide funds to states to develop TBI programs that improve access to service delivery for individuals with TBI. • Funding to Protection and Advocacy services in each state. • Funding to Centers for Disease Control and Prevention (CDC) for surveillance, outreach, and prevention efforts. Let your voice be heard by joining NASHIA! Visit our website www.nashia. org for additional information, and thank you for your continued support! BRAIN INJURY PROFESSIONAL
legislative roundup Perhaps given the state of the economy it is difficult to believe the glass is half full. But, there are opportunities for advocates to speak to the need for rehabilitation and short-term and long-term services and supports for individuals with brain injury and their families. On March 21, the Congressional Brain Injury Task Force will host a number of activities in our nation’s Capital in keeping with March Brain Injury Awareness Month. The Task Force will host an Awareness Fair in the First Floor Foyer of the Rayburn House Office Building, featuring national and federal organizations and agencies who will exhibit information on a number of issues from research to prevention, treatment, rehabilitation, vocational and community long-term services and supports. That afternoon, the Task Force will sponsor a briefing on “The Impact of Traumatic Brain Injury: Any Time, Anyone, Any Age”, featuring a panel representing Centers for Disease Control and Prevention (CDC), research, families and individuals with brain injury. A reception will be held that evening honoring the Task Force and celebrating the 20th anniversary of the CDC’s National Center on Injury Prevention and Control. Meanwhile, sponsors are being lined up for reauthorization of the Traumatic Brain Injury (TBI) Act of 1996, as amended, which authorizes funding for CDC TBI data and surveillance, prevention, and public education activities; and for the Health Resources and Services Administration (HRSA) Federal TBI Program, which awards grants to States to improve service delivery and to state Protection & Advocacy Systems to respond to legal and system issues on behalf of individuals with TBI and their families. On February 22, the President signed legislation extending payroll tax cuts and unemployment benefits, which also included provisions to extend exceptions for
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A pessimist is one who makes difficulties of his opportunities and an optimist is one who makes opportunities of his difficulties. – Harry S Truman
reimbursements for doctors and therapists treating Medicare patients. The exceptions process, which has been in place since Congress passed the Balanced Budget Act in 1997, created an annual financial cap on physical therapy and speechlanguage pathology services as well as a separate cap on occupational therapy for most outpatient settings. Earlier in the month, President Obama transmitted his $3.8 trillion Fiscal Year (FY) 2013 budget request to Congress. The Budget proposes to level-fund many disability and health programs, including the HRSA TBI Grant Program, while recommending small increases for a few programs, and cutting or consolidating other programs. With regard to research the Budget recommends level funding for the National Institutes of Health. Overall, the CDC took the largest cut for any division within the Department of Health and Human Services. The President is recommending cutting the Prevention and Public Health Fund, established under the Affordable Care Act (ACA), by $4 billion over the next 10 years. For FY 2013 the President is proposing that $903 million from the Fund be used to supplant, not supplement, CDC’s budget. The Birth Defects and Developmental Disabilities programs would be almost entirely ($107 million) supported by the Prevention and Public Health Fund. The President’s budget proposes to cut funding for the Substance Abuse and Mental Health Services Administration (SAMHSA) by nearly $200 million, including a nearly $50 million cut to the Center for Mental Health Services, nearly $60 million cut to the Center for Substance Abuse Prevention and roughly a cut of $70 million to the Center for Substance Abuse Treatment. With regard to special education the President’s Budget request includes additional dollars ($20 million) for Infants
and Toddlers (Part C Grants) for a total of $462 million. These funds would increase the average State allocation to help States serve an estimated 370,000 infants and toddlers, and encourage States to extend early intervention services to children through age 5. The President is proposing to consolidate Title I Vocational Rehabilitation programs: the Supported Employment State Grants program; the Migrant and Seasonal Farmworkers program; and the portion of Training program funds currently provided to VR agencies to support in-service training for personnel. Of course, the President’s budget request is just the first step in the appropriations process. House and Senate Appropriations’ subcommittees are holding hearings and are beginning to mark up their annual appropriations bills. With this being an election year there will probably be much political posturing regarding federal expenditures and the federal deficit. Advocates should view these times of debate as opportunities to educate and to promote support for various federal programs and policies that will improve the lives of Americans living with a brain injury. Remember, an optimist is one who makes opportunities of his difficulties.
About the Editor
Susan L. Vaughn, S.L. Vaughn & Assoc., consults with States on service delivery and is the Director of Public Policy for the National Association of State Head Injury Administrators. She retired from the State of Missouri, after working nearly 30 years in the field of disabilities and public policy, and was the first director of the Missouri Head Injury Advisory Council for 17 years. She founded NASHIA in 1990, and served as its first president.
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Special issue on Post Concussion Disorders, edited by Barry Willer, PhD.