Bears Tight End Zach Miller has Emergency Vascular Surgery Following Knee Dislocation by Sean Sullivan, PT DPT
While orthopedic injuries tend to dominate the headlines in professional sports leagues such as the NFL, neurological or vascular injuries can occur in conjunction and often can be limb/life threatening. Chicago Bears tight end Zach Miller caught a pass in the end zone during their game against the New Orleans Saints when he landed awkwardly on his left leg and came up lame in obvious pain/distress.
His injury was initially diagnosed as a fracture of his leg but was later diagnosed as a knee dislocation. A dislocation the bones that make up that joint are separated often times due to trauma. In Miller’s case, his Femur(thigh bone) and Tibia(shin bone) were separated. It is not known at this time whether Miller suffered any fractures along with this dislocation but it is likely that he will require surgery to repair any soft tissue(ligament) damage that occurred.
What happened in conjunction with Miller’s dislocation turned out to be the more pressing concern for the NFL veteran. Miller also suffered a rupture of his popliteal artery. Miller’s leg was stabilized by on field medical personnel and was rushed to the University Medical Center of New Orleans where he underwent emergency vascular surgery to repair the damaged blood vessel. He is currently being monitored to ensure proper healing/blood flow following his surgery.
The popliteal artery originates from the femoral artery which runs from our groin down the front/inside of our thigh. The Popliteal artery can be found on the posterior aspect of our knee and branches into its various divisions below the knee where it supplies blood flow to our entire lower leg. It is not difficult to see why a rupture of this artery( or any for that matter) is an emergency medical condition. When an artery is damaged, the blood flow to the areas of the body that are supplied by that vessel is impaired which leads to tissue ischemia. Prolonged ischemia of 6-8 hours can lead to irreversible tissue death and can result in amputation being the only means of preserving a limb.
While Miller’s injury is a very rare case, it is important for all medical personnel (on or off the field) to properly evaluate neurovascular integrity of a patient’s limbs following trauma. This means checking all pulses distal to the injury sight and assessing sensation to rule out any nerve or blood vessel damage. Making sure to not forget this crucial step can ensure that patients do not endure long term health ramifications due to late detection of neurovascular damage.
The 2017-18 NBA season tipped off last night with a rematch of last years Eastern Conference Finals pitting the Cleveland Cavaliers against the Boston Celtics. Just minutes into the first quarter Celtic small Forward Gordon Hayward went up for an alley-oop dunk from guard Kyrie Irving when came down awkwardly on his left ankle. The photo below shows Hayward in the air before landing on his left leg. The next photo shows Hayward sitting on the court in visible pain and gives a great view of how his ankle looked after the fall. Those who are squeamish, scroll down with caution.
While further details are still to come on the specifics of Hayward’s injury, what we do know is that he sustained a fracture of his left Tibia(Shin Bone) and a dislocation of his ankle joint. He is set to have surgery on that ankle Wednesday back in Boston. He will likely require a plate/screw/nail fixation(Open reduction with internal fixation) to keep his ankle joint stable and possibly a repair of the ligaments that work to stabilize his ankle. Luckily the Celtics medical staff were able to reduce/relocate his ankle on the court before placing it in an air cast which helped to reduce his pain. He also likely avoided any nerve/blood vessel damage that can occur with this type of injury as this would require immediate surgery.
Rehab for this type of surgery is likely to be at least 3-4 months but possibly longer depending on the degree of soft tissue damage that Hayward sustained. This is important because when a joint is dislocated, often times the surrounding ligaments become compromised, as they work passively to stabilize the joint. As discussed in my post on high ankle sprains, soft tissue such as ligaments do not heal as quickly as bone due to their poor blood supply. If the damage to the surrounding ligaments of Hayward’s ankle is severe, this will likely add months to his recovery and will make his return this season very unlikely.
The NFL suffered another painful blow to their star power when Aaron Rodgers left during the 1st quarter of the Green Bay Packers game against the Minnesota Vikings after suffering a fracture of his right clavicle. Rodgers was tackled by Vikings linebacker Anthony Barr and was drilled into the ground. Barr was not penalized for the hit and while deemed legal by NFL rules many felt the roughness of the tackle was unnecessary. Rodgers will have surgery to repair the fracture which will likely end his regular season.
The mechanism of injury for Rodgers is typically how a clavicle fracture occurs which is a direct blow or fall onto the lateral shoulder. The most common area of the clavicle to be fractured is the middle third of the clavicle and these types of fractures typically heal well without surgery if the fracture is not complex or displaced. These type of fractures can heal with a period of immobilization in a sling. If the fracture is at the distal end of the clavicle or is a complex fracture, this will almost always require surgical treatment.
It has not come out what type of fracture Aaron Rodgers suffered but what we do know is that he will require surgical treatment which likely will involve an open reduction internal fixation. This means that the surgeon will need to perform an open surgery to allow them to put the fracture back in place and then use some type of fixation(Screw, nail, plate) to hold the fracture in place while it heals. Since the clavicle does move slightly with shoulder elevation, it is important to limit overhead activity for the first few weeks. Rodgers will likely be in a sling for the first 4-6 weeks and will not be able to start throwing until at least 3 months.
Week 4 of the NFL season just concluded on Monday night following the Kansas City Chiefs last second win over the Washington Redskins. As with just about every week of NFL games comes a host of injuries to key players on contending teams, often times of the season ending variety.
Rookie running back Chris Carson of the Seattle Seahawks suffered a season ending left leg injury during the Seahawks win over the Colts on Sunday night. What was originally diagnosed as a fracture of his left lower leg turned out to be more severe. In addition to the fracture that he suffered in his fibula, Carson suffered a severe syndesmosis tear otherwise known as a “High Ankle Sprain”.
The syndesmosis is a series of ligaments that connect the ends of the two lower leg bones, the tibia and the fibula. A tear of one of these ligaments is a common injury in American football and is generally caused when the athlete’s foot/ankle is pushed into extreme external rotation. It can also be caused by a blow to the lateral aspect of the knee/lower leg with the foot planted which causes the syndesmosis to be over stretched which is what happened in Carson’s case as seen in the picture below.
The words “High ankle sprain” are words an athlete never wants to hear. Unlike a typical lateral ankle sprain which is a tear of one of the lateral ankle ligaments, a syndesmosis tear takes more time to heal. If there is a disruption of the any of the syndesmosis ligaments, these ligaments are stressed any time the athlete tries to bear weight on that limb as the athlete’s body weight and gravity put stress through the lower leg and tries to separate the tibia and fibula. This is the primary reason why recovery from a high ankle sprain can take longer to heal and are prone to reoccurrence.
MRIs are the gold standard for diagnosing a high ankle sprain. Depending on the grade of the tear, a patient may or may not be instructed to bear weight following the injury. Upon imaging, if there is no widening of the space between the tibia/fibula, the fracture is considered stable and are treated conservatively with rest/rehab and can weight bear as tolerated. If there is mild widening of less than 4cm, then the athlete is generally immobilized in a walking boot. If there is significant widening of the mortise of greater than 4cm, this will require surgical treatment which unfortunately is what will end Carson’s season. Following surgery, Carson will likely be immobilized in a plaster cast for 2 weeks and transferred to a cast boot for another 4-6 weeks during which he will be non weight bearing to avoid stress to the healing fracture/ligaments.
On Monday night, the San Antonio Spurs bowed to the Golden State Warriors in Game 4 of the Western Conference Finals. It wasn’t much of a contest. After another stellar regular season, early playoff injuries robbed the Spurs of veteran point guard, Tony Parker (quad tendon rupture), and the electric small forward, Kawhi Leonard (ankle sprain). On Saturday, when Spurs’ center/power forward, David Lee partially tore his patellar tendon, it was all but over. This wasn’t the first time that the 34 year-old Lee underwent significant post season surgery. He’d had a torn hip flexor repaired in May of 2013 having seen very limited playoff action once sustaining the injury the month prior. Read More ›
The Boston Celtics announced on Saturday that Isaiah Thomas, their 28-year-old star point guard, re-aggravated a “right femoral-acetabular impingement with labral tear” in game two of the Eastern Conference Finals against Cleveland. The injury will keep him out for the remainder of the playoffs and may require surgery. The initial insult to the hip occurred on March 15th and it was evidently exacerbated in a semifinal round contest on May 12th. Read More ›
Mets first baseman Wilmer Flores was placed on the DL on Friday and spent the weekend in the hospital to receive IV treatment for a knee infection. Evidently, Flores had played with discomfort for a couple of days before seeking medical attention.
Though this diagnosis may not sound like much, it is one that can be quite serious. It is considered an emergent condition with high risk of morbidity or mortality if not quickly and aggressively addressed. The outcome of treatment hinges on it. Read More ›
Mets’ first baseman Lucas Duda suffered a hyperextended left elbow in the fifth inning on Wednesday when Cesar Hernandez, the Phillies’ second baseman, tried to run out an infield hit up the first base line and ran into Duda’s glove with his left shoulder as he fielded the throw from the pitcher. Though he remained in the game through the half inning, Duda was removed for a pinch hitter in the bottom of the fifth. Duda will likely have an MRI today to determine the extent of his injury.
We’ve all heard much about the dangers of football and the alarming incidence of concussions in the sport. Also about the NFL’s initial resistance to acknowledging the probable relationship of concussions to Chronic Traumatic Encephalopathy (CTE), which currently can only be diagnosed on autopsy.
CTE – as defined by the Boston University CTE Center16 – is “a progressive degenerative disease of the brain found in athletes (and others) with a history of repetitive brain trauma, including symptomatic concussions as well as asymptomatic subconcussive hits to the head… This trauma triggers progressive degeneration of the brain tissue, including the build-up of an abnormal protein called tau. These changes in the brain can begin months, years, or even decades after the last brain trauma or end of active athletic involvement. The brain degeneration is associated with memory loss, confusion, impaired judgment, impulse control problems, aggression, depression, and, eventually, progressive dementia.”
The concern many have is not only for the health and safety of the athletes. Others who have suffered mild traumatic brain injury want to know if they are susceptible to CTE as well. No one really has that answer yet. However, lets look carefully at the information that is out there and how it can be interpreted.
First, scary as it may be, recognize that the high incidence of CTE reported in studies reflects several biases. The most significant of these is self-selection. The brains that have been examined on autopsy are primarily those of athletes who have donated their brains for research due to symptoms they’ve experienced, or those whose family has suspected the diagnosis. This clearly inflates the percentages of athletes diagnosed with the condition.
One such study done by Boston University and the US Department of Veteran’s Affairs17 established that 87 of 91 football players had signs of CTE on autopsy, while Boston University also found the condition in 79% (131 of 165) of football players across all levels.17
These frightening results are mildly contrasted by another study18 that looked at 60+ former NFL players – all aged 60-69 – to try to identify symptoms of CTE in living people. Their age range indicates that these were players who played before heightened concussion awareness and before protocols were initiated by the NFL. The results showed that 60% had completely normal age-appropriate cognitive decline. Of the remaining 40%, 6% met the criteria for dementia. It would be interesting – and possibly revealing – to be able to correlate the findings on these men with how their brains subsequently present on autopsy.
Though this group also played before helmets were improved, the sturdier helmets may even have encouraged harder hitting. The NFL’s response has included recent rule changes to modulate direct hits to the head, though the game will likely see an even greater proportion of debilitating but less threatening lower body injuries as a result. The players of today are also typically stronger, bigger and faster than those in the era of those tested in this study. This too likely influences the frequency and outcomes of traumas that they experience.
Though the brain has the ability to recover from one injury, long-term effects are more likely after multiple incidents.
However, keep in mind that football players sustain blows to the head (direct and/or indirect) on almost every play. This cumulative subconcussive microtrauma may be as much or more of a factor in causing CTE than one or few isolated incidents of concussive trauma. Not at all good for football or soccer players, but an encouraging note for others who fear the long term effects of having sustained a concussion, or even several of them.
Vulnerability differs amongst athletes on the field. Dr. Steven Erickson noted that offensive linemen face forces “that are generally linear and the players know they are coming. Consequently, the head doesn’t move very much, so the brain doesn’t move very much. This may still represent brain trauma, but less often to the degree of causing concussion.”
He contrasted this with receivers. Though the “magnitude of the forces they sustain may be lower, the rotational component to the trauma, the player not being able to anticipate the nature of the hit and the degree of subsequent brain motion all make it more likely they will sustain a clinical concussion.”
A study by the Mayo Clinic, published in December 2015, found that one in three amateur athletes who participated in contact sports while in school developed CTE. 19 That statistic will likely cause even more scrutiny of the games and cause some to weigh the risk-reward of participation differently than before. Again though, this study also reflected issues of self-selection.
I asked Dr. Erickson about the cheating (underperforming) on baseline screening that we have read about occurring in the NFL, and whether this effort by some players to lessen the likelihood that a subsequent concussion will be diagnosed can be detected.
His response was that “though it may be possible, there are internal checks with ImPACT™ whereby validity scores can generally identify when an individual is cheating.”
Dr. Erickson commented that “this is another advantage of the vestibular test (see Part 2 of this series) advocated at the Banner Concussion Center, because a non-physiologic response is detected with intentional underperformance or anxiety responses to testing, We benefit from the fact that athletes don’t know how to cheat to underperform on the test.”
He added that “of course, best medicine is for an athlete to put in best effort at baseline as well as post injury. The motivation factor is very real. Sometimes those not particularly motivated in baseline testing are very motivated to achieve in order to return to play,”
Hopefully more athletes and their coaches are acknowledging that playing through will not serve them well either in the short or long term.
So, does the Banner Concussion team advocate keeping kids from playing sports? Most definitely not… Each member acknowledges the many benefits of sport, such as exercise, physical development and emotional growth. Developing mental toughness and learning life lessons such as teamwork and how to deal with adversity while enjoying a healthy social outlet that is fun, challenging and productive trumps fear.
They stress that concussion can happen almost any time – even to those who don’t play sports – and that sports can be made safe. The key to addressing concussion is education and diligence. It is important to be able to identify concussion if/when it happens and seek appropriate assessment and care. By managing the symptoms, recovery is accelerated and the likelihood of recurrence minimized. The value of baseline testing cannot be stressed enough nor can the importance of not allowing an athlete of any age to return to play after sustaining a head trauma resulting in symptoms without undergoing an evaluation.
Though most who suffer a concussion recover fully and within a four-week period, the caution is to understand that symptoms left untreated – can result in long lasting consequences.
As for those who sustain multiple head traumas and, quite possibly – or especially – those who have also suffered repeated microtrauma, the long term effects are coming into better focus with the further study of CTE.
References for Parts 1-3 of the Concussion Series:
- Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control. Report to Congress on mild traumatic brain injury in the United States: steps to prevent a serious public health problem. Atlanta (GA): Centers for Disease Control and Prevention; 2003.
- Lescohier I, DiScala C. Blunt trauma in children: causes and outcomes of head versus intracranial injury. Pediatrics 1993;91(4):721-5.
- Langlois JA, Rutland-Brown W, Wald M. The epidemiology and impact of traumatic brain injury: a brief overview. Journal of Head Trauma Rehabilitation 2006;21(5):375-8
- Finkelstein E, Corso P, Miller T and associates. The Incidence and Economic Burden of Injuries in the United States. New York (NY): Oxford University Press; 2006.
- Fung M, Willer B, Moreland D, Leddy J. A proposal for an evidence-based emergency department discharge form for mild traumatic brain injury. Brain Injury 2006;20(9):889-94.
- Alexander, Andrew L., Lee, Jee Eun, Lazar, Mariana, Field, Aaron, S.
Diffusion Tensor Imaging of the Brain. Neurotherapeutics. 2007 Jul; 4(3): 316–329.doi: 10.1016/j.nurt.2007.05.011
- Field M, Collins M, Lovell M, Maroon J. Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. The Journal of Pediatrics 2003;142(5):546-53.
- Bryan Kolb, PhDand Robbin Gibb, PhD: Brain Plasticity and Behaviour in the Developing Brain . J Can Acad Child Adolesc Psychiatry. 2011 Nov; 20(4): 265–276.
- Guskiewicz K, et al. Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA Concussion Study. JAMA 2003;290(19):2549-55.
- Pellman EJ, Lovell MR, Viano DC, Casson IR. Concussion in professional football: recovery of NFL and high school athletes assessed by computerized neuropsychological testing–Part 12. Neurosurgery 2006;58(2):263-74;discussion 263-74
- Kashluba S, Casey JE, Paniak C. Evaluating the utility of ICD-10 diagnostic criteria for postconcussion syndrome following mild traumatic brain injury. Journal of the International Neuropsychological Society 2006;12(1):111-8.
- Dean PJ, O’Neill D, Sterr A. Post-concussion syndrome: prevalence after mild traumatic brain injury in comparison with a sample without head injury. Brain Inj. 2012;26(1):14-26. doi: 10.3109/02699052.2011.635354.Epub 2011 Nov 22
- McManus, C. Stress-Induced Hyperalgesia: Clinical Implications for the Physical Therapist Orthopedic Physical Therapy Practice. 2012;24(3):165-168. (http://carolynmcmanus.com/publications/mcmanus-stress-induced-hyperalgesia.pdf)
- UPMC Sports Medicine Website
- Boston University CTE Center: http://www.bu.edu/cte/about/what-is-cte/
- Hart, J.J., JAMA Neurology 2013
- Mayo Clinic Press Release: Mayo Clinic: Evidence suggests contact sports played by amateurs increase risk of degenerative disorder http://newsletter.carehubs.com/t/ViewEmail/j/2B6E3073A3AD413C/59F3204D88C0AFA89A8E73400EDACAB4
- Aubry M, et al. Summary and agreement statement of the first International Conference on Concussion in Sport, Vienna 2001. Clinical Journal of Sports Medicine 2002 Jan;12(1):6-11
Baseline testing should be a high priority of every athletic department, coach, parent (of a student athlete) and athlete, and should include cognitive, vestibular and visual assessment. Cognitive testing alone – frequently performed without the other components – is insufficient. This holds true in cases of post injury assessment as well.
For athletes who have had the benefit of baseline testing (performed pre-season and prior to injury), the comparison to their normative values – after a concussion occurs – proves very helpful in assessing the degree of dysfunction and determining complete recovery. Since the rest of us may not have this advantage, it is the thorough post-injury assessment alone that is the key to determining the loss of function and in guiding treatment.
One caveat that Dr. Erickson of the Banner Concussion Center stresses is that in a game situation, it is NOT okay to simply ask the athlete who may have suffered a concussion if he or she is okay and trust that the information received is accurate. The athlete should be removed from play and evaluated. Keep this in mind if you are an adult participating in recreational sports – sitting out may be the tough but obvious best option. You may not know until later that what seemed like jarring but manageable contact was, in fact, concussive.
If when consulting a provider for care following concussion, you – or a loved one – does not receive an assessment of all the components of a thorough assessment that are described below, please seek care elsewhere. Whether the center you go to can meet your needs in-house or relies on outside referrals to do so, any piece of the puzzle that is omitted might result in overlooking an element that could influence recovery.
The assessment should include:
- A physical exam by a physician specializing in sports medicine/internal medicine to rule out more serious pathology, diagnose concussion and to identify any other injuries (particularly of a musculoskeletal nature) that may have occurred along with the mild head injury.
- ImPACT™ 15: ImPACT™ – which stands for Immediate Postconcussion Assessment and Cognitive Testing – is a computerized neurocognitive tool developed in 2000 by a medical team at the University of Pittsburgh Medical Center (UPMC). It is used to assess brain processing speed, verbal and visual memory, reaction time and visual motor skills (in those at least 11 years old). This tool was established after its developers had first utilized paper and pencil testing methods, and prior to professional sports leagues acknowledging that cognitive testing was necessary in the management of concussions. In addition to its vital role in identifying dysfunction, ImPACT™ is utilized to help determine the degree of recovery. In each instance, scores are compared to normative values.
According to Dr. Erickson, the NFL began to require baseline neuropsychological or neurocognitive testing in 2005-2006 and MLB also instituted a program in 2006. The NHL also currently mandates baseline testing, as does NASCAR. The NBA, Formula One and WWE also currently utilize ImPACT™ baseline testing, as do a number of NCAA Division One Programs.
- Audiology evaluation: screens for dizziness, hearing, tinnitus and inner ear disorders associated with mild traumatic brain injury.
- Neurovestibular and balance testing (ideally using the Banner or University of Pittsburgh Medical Center Protocol):
Many treatment facilities test balance without attention to its integration with the visual and vestibular system. This is a significant omission.
The vestibular system provides important sensory information about motion, equilibrium, and spatial orientation. The utricle, saccule, and three semicircular canals within each ear comprise the vestibular apparatus. The utricle and saccule detect gravity (vertical orientation) and linear movement.
The smallest bones in the body are the three ossicles of the middle ear. They are the link transmitting vibrations from the eardrum to the inner ear. They also serve to amplify sound. A blow to the head can cause displacement of the ossicles resulting in vestibular disturbance and complaints of feeling like the room is spinning or foggy-headedness. Identifying the nature/direction of this displacement is crucial to pinpointing the type of treatment the physical therapist should perform.
The Banner NVP TM protocol was developed in 2013 by Shelly Massingale, MS, PT and Dr. Steven Erickson of the Banner Concussion Center, in conjunction with Bertec® and utilizing Bertec® force plate technology and Computerized Dynamic Posturography. This trademarked protocol was designed to stimulate and assess a person’s ability to integrate feedback from visual, vestibular and somatosensory systems following MTBI. It incorporates functional balance conditions that directly stimulate the vestibular ocular reflex (known as the vestibular ocular reflex suppression test). This reflex reflects the relationship between the visual system and that of the inner ear and is responsible for enabling fixation of the eyes during head movements.
- Fine motor skill testing: assesses coordination using timed measures of fine motor dexterity.
- Visual motor testing: Functional visual integration testing using static (without movement) and dynamic (with movement) visual acuity screening to assess eye movement and head coordination.
Neha Amin, O.D., FAAO, the lead optometrist at the Banner Concussion Center shared some of the visual dysfunctions frequently identified on the optometry exam. They include:
- Blurred vision: It is possible someone might have had mild blurring pre-injury that he or she is able to compensate for, but a concussion may cause it to worsen and for the patient to become symptomatic.
- Double vision – this is very common. The eyes may be clear individually but have difficulty working together.
- Tracking Issues – With tracking issues, the eye movements are very inaccurate as it relates to the two eyes working together. Pre-accident, one eye may be stronger and one weaker. Post-injury, a patient may no longer be able to tolerate that imbalance.
- Focusing –(accommodative dysfunction) the ability to focus and relax that focus for seeing distance to near, and vice versa (i.e., in the classroom – blackboard to desk). A dysfunction in focusing can result in double/unclear/blurry vision, headaches, attention deficits or a seeming loss of visual acuity.
- Vergence Issues – convergence and divergence
Convergence, when the eyes move inward toward each other, is important for all near vision tasks and must occur automatically when an object approaches you. When insufficient, double vision is a common side effect.
See if you notice… look in the distance across the room. Now hold a pen in front of your head around 12 inches from your nose. Look from across the room to the pen. Do you feel your eyes turning in? Now pull the pen towards your nose… how close can you bring it before it becomes double?
Many times the ability to converge the eyes is overlooked in eye exams. Do you ever get tired and feel difficulty in “focusing” on a book or computer screen? Do you ever feel like you see double? This is likely due to poor eye alignment. Poor alignment can cause headaches due to the strain to keep your eyes aligned. This same near stress can decrease concentration, and reading accuracy. Attention deficit disorder is heavily linked to this ocular stress.
Dr. Amin noted that convergence Insufficiency has a very high success rate in therapy. Most people exhibit marked improvement after two weeks, noticing diminished eyestrain and headaches along with enhanced attention. Most cases can be alleviated in 3-6 months, depending on the motivation of the patients.
Divergence is the opposite of convergence. Divergence means to move the eyes outward and away from each other and usually occurs when looking at an object moving further away.
If you are doing close reading, your eyes will need to diverge to see far away. Divergence excess means the eyes turn out too much when looking in the distance. This creates a problem for the patient, who will either see double when looking far away, or suppress an eye (shut an eye off).
Likewise, divergence insufficiency means the eyes do not spread apart enough to see in the distance. When the patient is looking far away, the eyes may appear crossed, or one eye may appear turned in slightly. Again, either one eye will shut off or the patient may see double.
Post Concussion Treatment:
Treatment should be individualized to address all of the specific dysfunctions determined to be present during the assessment. It is progressed by determining the reactiveness of the symptoms to the exercises that are prescribed and making adjustments as necessary. Visual, balance and vestibular exercises (with the latter’s focus on combining balance with rapid head movements) are patient specific, as are those that gradually restore each client to full physical activity. The idea is to challenge each of the systems sufficiently that symptoms (i.e., nausea, headaches) may be provoked or amplified mildly yet briefly and resolve to pre- treatment levels or better very quickly (within five minutes). If an exercise fails to sufficiently challenge symptoms, it should be advanced.
The brain responds to habituation (accomplished with repetition), and so patients are advised to do their home exercises three times daily. They are also urged to gradually re-introduce functional activities. If instead they avoid those things that reproduce symptoms (like exposure to light, head movements, or being in a car) the brain becomes even more sensitized. It is important to get out, to walk, to socialize and to seek enjoyment. In addition to the inherent value of such activities, they enhance mood and in that way also accelerate recovery.
With treatment, the vestibular piece typically resolves quickly – often with only one or two sessions in the hands of a skilled physical therapist to reposition ossicles that are out of alignment. There is currently more objective data established via research to determine vestibular recovery than that for the visual system.
The visual piece is less clear. There are fewer objective tests and it is more difficult to assess. Not knowing an individual’s pre-injury status also makes it more complicated, as issues may have predated concussion. This can take much longer to improve, and treatment should continue – though on a much less frequent basis – long after a person tests normally.
Repeated assessment throughout the recovery process enables therapists and doctors to effectively monitor patient progress across all systems. Symptom resolution generally correlates to achieving normative values.
The primary role of the neuropsychologist in the Banner treatment model is to evaluate cognition and assess any possible confounding factors. ImPACT™ results and a client’s neuropsych performance are correlated. Cognitive and emotional issues are identified, and appropriate follow-up education is provided.
Dr. DenBoer noted that many clients do not understand why they are having problems such as issues with attention, concentration and processing speed. Repeated neuropsychology assessments determine the degree to which the various therapies are working on a neuropscyh and cognitive basis.
The neuropsychologist on the treatment team also provides intervention regarding sports psych issues for patients dealing with psychological variables/anxieties with return to school, work or play. This may include seeking academic accommodation for students seeking return to full participation in the classroom, or modified duty for those requiring accommodations at work. While the other therapies provide care to restore function, the neuropsychologist on the team addresses strategies to return to a pre-injury lifestyle and improve coping skills.
Headaches can throw recovery off course:
Chronic intractable headaches, not uncommon after concussion, are a symptom that can get in the way of recovery.
Occipital nerve blocks are done with some regularity by neurologists for the treatment of migraines. These entail steroid injections to the nerve at the base of the skull. Dr. Erickson opts for this strategy at Banner when he feels the intervention is necessary to eliminate post concussion headaches. This enables patients to effectively perform and respond to the various therapies (visual, balance and vestibular), curtailing factors that may have been causative of the headaches in the first place. By the time the block wears off, the other systems have been normalized and the headaches generally do not return.
Should headache symptoms persist after an initial injection, or if they return, an additional block may be administered or the patient treated with Botox injection. At Banner, these patients are referred for consultation with a neurologist.
My research has led me to believe that multiple injections are not necessarily the answer in the event headaches return some time after the initial trials. Chronic headaches that may be a factor in persistent post concussion syndrome or that result from repeated trauma might best be approached with biofeedback and other alternative strategies along with nutritional guidance and exercise to best modulate symptoms.
Banner’s Care Delivery Model
The best concussion care employs a very specific, methodical and solitary approach to concussion that results in a very individualized rehab plan for every individual. Though everyone is tested the same way, each client’s experience can be unique.
The Banner program, established in 2013, was the first center of its kind offering an integrated and comprehensive program in which all disciplines work together closely under one roof. This profoundly enhances care. The professionals work as a team, providing each client with a comprehensive assessment. They meet regularly to customize the course of treatment, monitor each patient’s progress and determine readiness for discharge. There is little need to refer outside of the practice (other than as needed for orthopedic physical therapy, neurology or medical imaging offered at the medical center’s outpatient facility across the street).
The Banner Center’s medical model is also unusual in that it’s director, Steven Erickson, MD, is a sports medicine specialist, and not a neuropsychologist. He guides and oversees the entire team. That team includes physical therapists whose specialization is in the vestibular system/balance, ocular specialists (a board certified neuro-optometrist specializing in diagnosis and visual therapy, and an occupational therapist/patient care coordinator who also specializes in visual therapy), neuro/sports psychologists and athletic trainers.
Another distinguishing factor that gives Banner a distinct edge is the unique dynamic method of computerized neurovestibular testing that they developed. It provides objective measures of neurologic function by assessing balance (in double leg stance – meaning on two feet) and it’s relationship with the visual system and head movement (the vestibular component). The force plate technology employed enables objective measures that are far more exacting than the subjective assessment utilized by most outside professionals. Many still test balance more traditionally – without movement (statically), and utilizing various standing positions (including single leg stance) that do not account for the presence of an orthopedic condition that would influence the outcome. By testing in this way, others likely miss dysfunctions that should be addressed in treatment.
Shelly Massingale and Steven Erickson will soon publish their methods and data regarding the rational and methods for the type of testing they do. It is their hope that others will incorporate it into their programs. Though force plate technology is state of-the-art, there are ways to improvise and utilize this information even in the absence of these expensive tools.
There are other concussion centers out there that offer pieces of Banner’s model. The closest is at the University of Pittsburgh Medical Center (UPMC), which as previously noted, developed the computerized ImPACT™ program that is considered to be the gold standard in working with brain injuries. UPMC also independently developed a balance-testing format much like Banner’s. If you are based on the east coast, want a great assessment, and are willing to travel, Pittsburgh is the place to go. The Cleveland Clinic is another highly regarded facility that developed an interesting iPad based neurocognitive program that is different than the ImPACT™ program. They, like UPMC and Banner are also advancing the model of care.
Other smaller centers offer components but not the integrated on-site team approach that is so ideal. These providers refer out for patients to receive the full complement of therapies they may need. For emphasis, it can’t be overstated that if you or someone you know seeks post concussion care at a smaller center, each piece of the assessment and treatment puzzle must be a part of the plan of action. It may be left up to the patient – or someone advocating for that individual – to see to it that the appropriate referrals are obtained along with consistent follow-up treatment.
Return to Activity
Once the acute post concussion phase has passed, limiting academic or work hours as well as cognitive and physical demands is recommended. Incorporating periods of rest proves very helpful.
Progression to full performance of academic or employment responsibilities should be stepped up gradually. It is important to avoid fatigue, excessive stress or symptom exacerbation in a quest to return to full function.
Criteria for returning to sports participation include:
- Complete resolution of symptoms at rest and with cognitive or physical exertion
- Demonstration of normal function on neurocognitive, visual, vestibular and balance testing
- The Concussion in Sport Group established a specific return to play protocol20. It begins with rest and then stresses a gradual increase in activity that first incorporates aerobic exercise and then progresses to sport-specific training. The program advances further by adding non-contact drills (such as cutting and other lateral movements) and ultimately includes full contact controlled training. A return to full participation in any sport – contact or otherwise – is predicated on successful completion of all phases without any symptom provocation.
Part Three will conclude the series on concussions with discussion of football and CTE