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The MCL – Two MLB Players Out With Sprains

Angels outfielder Cameron Maybin, sustained a Grade 1 right knee MCL sprain in a stolen base attempt on Tuesday. Also on Tuesday, Stephen Vogt, Brewers backup catcher, sprained his left MCL in a collision at the plate with Pirates pitcher Chad Kuhl. Kuhl remained in the game. The Grade of Vogt’s injury was not reported.

Some MCL Anatomy

A Medial Collateral Ligament, or MCL, is a ligament that stabilizes the inner (medial), aspect of joints such as at the knee and elbow. At the elbow, it is the ligament that is reconstructed when pitchers undergo Tommy John surgery. It is a fibrous band of tissue and – in the case of the MCL at the knee – it has both a superficial and deeper layer, each of which has different attachments. For more detail on the medial knee and origins and insertions of the ligament take a look here, or here.

The superficial MCL serves as the primary restraint to check against forces to the outer knee that would result in the knee collapsing inward. This is known as a valgus stress. The superficial portion of the MCL has both anterior (front) and posterior (rear) fibers and the degree to which they are effective in this role depends in large part on the position of the knee when the stress occurs. When the knee is almost extended, the ligament contributes somewhat less to the stability of the joint. Therefore, testing for the integrity of the MCL is done with the knee flexed to 30 degrees, an angle at which the ligament is most effectively isolated.

The deep layer of the MCL is often separated from its superficial counterpart by a bursa, which allows for a greater mechanical advantage and smoother gliding of tissues. A point of note with regards to the deeper layer of the MCL is its attachments to the meniscus both from the femur above and the tibia below (it also inserts directly into the top of the tibia at the tibial plateau). Because of its meniscal attachments, MCL injury can result in meniscal injury as well. Though the deeper layer does not contribute much as a restraint against valgus stress, it does serve as a secondary check to anterior translation of the tibia (which would result in knee hyperextension). The Anterior Cruciate Ligament (ACL) serves as the primary restraint to this motion. The relationship between the two ligaments is the reason that ACL injuries are often accompanied by those to the MCL.

Diagnosis and Treatment

Ligament sprains are graded from Grade 1 – which is a mild tweak causing less damage – to a Grade 3, or complete rupture. Time lost to competition depends on the severity of the injury, the specific location of the tear and the individualized nature of the healing process. Pain can be very localized or more diffuse depending on where the tear occurs. MCL tears at the attachment to the femur can result in a portion of the bone being avulsed, while tears more central to the ligament can cause significant soft tissue damage. Tears at or near the tibial attachment may cause pain to run down the shin and it is also possible to experience an MCL tear deep to the pes anserinus, a site of attachment of several muscles/tendons below the knee at the medial aspect of the tibia.

MRI can be helpful in identifying the location of the tear and the degree of damage. Treatment is generally non-operative with a healing response time for significant tears of six weeks. However, because remodeling of the scar tissue involved in the healing process can take up to a year, the tensile strength of the tissues can be compromised during that extended time. Interestingly, studies have noted that even though mature scar tissue has only 60% of the strength of a normal MCL, the fact that there is a proliferation of this tissue compensates sufficiently so that “the ultimate load to failure is unchanged”.

Surgical intervention may be indicated when a significant gap occurs in the MCL at the area of a tear or when a portion of bone is avulsed.

John Lackey – Pitching With Plantar Fasciitis

John Lackey, right-handed starting pitcher for the World Champion Chicago Cubs, will be 39 years old in October. He is dealing with plantar fasciitis in his right foot, yet will start Tuesday’s game against the Braves after getting some extended All Star Break rest. Lackey was effective over six innings in his last start on July 5th before going on the 10-day DL the following day. This will be his first start since being activated.

Baseball players have successfully played through fasciitis before, Albert Pujols being one of the most visible and recent examples. But eventually Pujols succumbed to surgery as his condition worsened while he continued to play (even with a reduced role as DH). The condition can be quite painful and – even for a non-athlete – get in the way of performing routine activities. However, surgery is only a last resort.

The likelihood that ten days of rest will have resolved Lackey’s problem is not great. It becomes more about how (or if) the condition can be managed enough for the pitcher – whose numbers have suffered in comparison to the 1916 season – to be effective.

The Plantar fascia

The word plantar refers to the sole of the foot, and the plantar fascia is a thick fibrous band of connective tissue in this region that extends from the heel to the forefoot. It assists with stabilization of the arch. Fascia occurs throughout the body and overlays the muscles, organs, nerves and blood vessels. It acts as a restraint to keep our tissues and structures in place.

“Itis” means inflammation, in this case of the fascia. As with tendinitis, it is generally felt that a degree of degeneration is also occurring. This is known as tendinosis when referring to tendons. It is much like what happens with conditions such as tennis elbow or patellar tendinitis, which are also due to overload.

The fascia in the foot is particularly strong and is prone to stresses and small tears. Plantar fasciitis, a common cause of foot pain, is an overuse syndrome set off by too much tensioning of the fascia’s attachments to the heel. Though there is an increase incidence of heel spurs in sufferers of fasciitis, spurs, which are generally not within the fascia, do not always cause pain. However they may contribute to a predisposition to the condition.

Weakness of the muscles of the calf or foot/ankle impact function and also predispose to injury by placing more stress on all the related tissues. There is reportedly no definitive evidence that either a high or low arched foot predisposes to plantar fasciitis.

The onset of fasciitis is usually gradual rather than from trauma, and the problem is often stubborn, especially if left untreated. Generally speaking, the faster treatment is initiated after the onset of symptoms, the more accelerated is the recovery.

Women who wear high heels much of the time are prone to fasciitis because the calf muscles and fascia become tight due to the positioning of the foot and ankle. People whose work requires that they spend an inordinate amount of time standing or walking (particularly on hard surfaces) and those who are significantly overweight are also more prone to plantar fasciitis. Prolonged walking, and especially running, which requires a more forceful push-off, are likely to increase inflammation and pain. Jumping will do likewise.

The pain that occurs with this condition is often exaggerated in the morning because the fascia and heel cord (Achilles) are relaxed during sleep. Those first steps when the area is put on stretch can be especially problematic. That is why night splinting to keep the area on mild stretch is so helpful in treatment. The pain, which can be either sharp or dull, often feels like a pulling and is more common after inactivity than with movement. Hence standing for long periods worsening symptoms.

Fasciitis can involve tenderness along the band of the fascia in the arch or be more toward the heel. Putting the fascia on stretch by bending the toes back (dorsiflexion) – especially along with dorsiflexing the ankle (flexing it toward one’s head) – makes the area much more tender to touch. Plantar fasciitis must be distinguished from other conditions such as Heel Pain Syndrome, where the pain is more exclusively localized to the heel.

Treatment for plantar fasciitis focuses on relief of inflammation as well as stretching the fascia itself and reducing its soft tissue restrictions as well as stretching the calf and Achilles. Fascia stretching has proven most effective when it is non weight-bearing and specific to the area. There are many other ways in which to stretch, especially by taking a more dynamic approach and focusing on inhibiting muscles that limit the flexibility of the tight structures. One note of caution if stretching statically and when weight-bearing is to AVOID hanging the heel down off a step. This puts the midfoot structures at risk and also increases incidence of future Achilles rupture. It is best to keep the foot supported on the floor or on a wedge when stretching in in this position.

Treatment of fasciitis should also include assessment of, and attention to, areas of the foot that are related and may impact flexibility of the calf or pliability of the fascia. For instance, if the ankle or the joint at the base of the big toe lacks full mobility (into dorsiflexion) the soft tissues may not be able to stretch adequately. In these instances, restoring mobility to the joints may be necessary to get the desired result.

Though cortisone injections may provide temporary relief (studies show most patients have recurrence), they also come with an increased risk of rupture. The interesting thing is that treatment of chronic plantar fasciitis sometimes includes surgically lengthening the fascia (a procedure that Albert Pujols had), something that rupture may accomplish naturally. The downside is the time spent totally out of commission while healing in either case.

Thumb UCL Sprains – Understanding Mike Trout’s Injury

Mike Trout, the Los Angeles Angels’ star outfielder, will undergo surgery tomorrow for a torn ulnar collateral ligament (UCL) in his left thumb. The injury occurred – as most of these do in baseball – when the 25 year-old slid into second on a stolen-base attempt on Sunday. Trout, who throws and bats right handed, had an MRI later that day that confirmed the tear. This will be Trout’s first stint on the DL and it will be for a significant period. Read More ›

Explaining Adductor Tears: The NBA’s Latest Playoff Injury

Houston Rockets’ 34 year-old backup-center Nenê Hilario suffered a tear of his left hip adductor muscle in the first quarter of yesterday’s playoff game against the San Antonio Spurs. Though the Rockets’ subsequent win tied the series at two apiece, Nenê will be out for the duration. An MRI reportedly revealed the tear. A treatment plan has yet to be announced. Read More ›

Understanding Tony Parker’s Quad Tendon Rupture

The San Antonio Spurs lost point guard Tony Parker to a quadriceps tendon tear in the fourth quarter of game two in their series against the Rockets on Wednesday. Parker, who now faces surgery, was a big reason that San Antonio evened up the series that night at one apiece. Like the Clippers’ loss of Blake Griffin to a season-ending playoff injury, this one could cost the Spurs the ability to advance.

At age 34, Parker’s numbers this season were at a career low (10.1 ppg), though he’d ramped that up to an eight game playoff average of 15.9 on 53 percent shooting. Now he faces a long road back and, with his age and overall declining regular season numbers, a questionable return to the NBA. Read More ›

Why Wilmer Flores’ Knee Infection is Serious Business

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 ›

Concussions – Part 3: Football and CTE

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.

The Takeaway

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:

  1. http://www.cdc.gov/concussion/headsup/pdf/Facts_for_Physicians_booklet-a.pdf
  2. 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.
  3. Lescohier I, DiScala C. Blunt trauma in children: causes and outcomes of head versus intracranial injury. Pediatrics 1993;91(4):721-5.
  4. 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
  5. 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.
  6. 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.
  7. 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

  1. 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.
  2. 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.
  1. Guskiewicz K, et al. Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA Concussion Study. JAMA 2003;290(19):2549-55.
  2. 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
  1. 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.
  2. 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
  1. 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)
  2. UPMC Sports Medicine Website
  3. Boston University CTE Center: http://www.bu.edu/cte/about/what-is-cte/
  4. http://www.pbs.org/wgbh/frontline/article/new-87-deceased-nfl-players-test-positive-for-brain-disease/
  5. Hart, J.J., JAMA Neurology 2013
  6. 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
  1. 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

 

 

 

 

Concussions: Part Two – Assessment and Follow-Up

The Assessment

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

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

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

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

The assessment should include:

  1. A physical exam by a physician specializing in sports medicine/internal medicine to rule out more serious pathology, diagnose concussion and to identify any other injuries (particularly of a musculoskeletal nature) that may have occurred along with the mild head injury.
  2. ImPACT15: ImPACT™ – which stands for Immediate Postconcussion Assessment and Cognitive Testing – is a computerized neurocognitive tool developed in 2000 by a medical team at the University of Pittsburgh Medical Center (UPMC). It is used to assess brain processing speed, verbal and visual memory, reaction time and visual motor skills (in those at least 11 years old). This tool was established after its developers had first utilized paper and pencil testing methods, and prior to professional sports leagues acknowledging that cognitive testing was necessary in the management of concussions. In addition to its vital role in identifying dysfunction, ImPACT™ is utilized to help determine the degree of recovery. In each instance, scores are compared to normative values.

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

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

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

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

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

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

  1. Fine motor skill testing: assesses coordination using timed measures of fine motor dexterity.
  1. 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 

Concussions: So Much More Than Football And CTE

Though the media has bombarded us with articles, news reports and even a film on concussions, the confounding thing is that so little of the information geared to the general public has served to really educate and inform. There is so much more to this story than football and chronic traumatic encephalopathy (CTE). For instance, how do you know if you’ve suffered a concussion? If you have, what should you expect? Where should you go to receive optimal care, and what should that entail? How scared should you be? Buckle up, take a deep breath and relax… there is a wealth of information to share.

The mild traumatic brain injury (MTBI) that is a concussion happens to countless ordinary people every day. You or someone you love may even have been one of them. The injury might have resulted from a simple fall or a tumble taken in sports like skiing or cycling. Trauma sustained in a car accident or in a war zone blast might be to blame, or maybe you sustained a contact injury in a heated game of just about any team sport. Regardless of the mechanism of injury, the course of care should follow a very specific process. A thorough assessment is step one, in order to identify any cognitive, visual or vestibular and balance dysfunctions (all of which will be explained later) as well as a myriad of possible symptoms that must be addressed. This should be followed by highly personalized treatment focused on restoring symptom free and full function.

Concussion care is a fairly new specialty because for so long little was understood about the injury itself as well as the appropriate course of treatment. There remains much to learn. The medical management of concussions is a specialty that requires post-graduate education regardless of the professional discipline involved (neuropsychology, vestibular/physical therapy (PT), neuro-optometry, occupational/visual therapy and sports medicine (physicians, orthopedic PTs & athletic trainers). Experience counts for a lot and, as with professionals in any field, not all are created equal. Educated consumers have to know what to look for in order to best advocate for themselves and their loved ones.

The important thing to emphasize, however, is that with accurate diagnosis and appropriate treatment, the overwhelming majority of people with MTBI recover fully, even those with post concussion syndrome; More on that to follow.

Some Statistics

The CDC (Center for Disease Control) literature1 reports “that an estimated 75%-90% of the 1.4 million traumatic brain injury (TBI)-related deaths, hospitalizations, and emergency department visits that occur each year are concussions or other forms of MTBI. 2,3 In addition, approximately 1.6 – 3.8 million sports and recreation-related TBIs occur in the United States each year”, 4 and many “of these are MTBIs that are not treated in a hospital or emergency department.” There are many other places to go for care.

The numbers reveal an economic factor at play as well – even outside of the NFL. A study done in the US in 2000 found that direct as well as indirect costs – such as lost productivity from MTBI – totaled an estimated 12 billion dollars 5

A little background information on concussions:

It is important to recognize that not every head blow causes a concussion. This was the first thing Dr. Steven Erickson, emphasized when we spoke. Dr. Erickson, who, in addition to being a co-founder and the Medical Director of the Banner Concussion Center in Phoenix, AZ, is a consultant for MLB umpires.

Any head trauma that results in the onset of temporary neurologic symptoms (be it from a direct or indirect blow) is considered to be a concussion. The injury is due to the brain moving quickly within the skull and may or may not entail a loss of consciousness; Typically, a collection of cognitive, physical, emotional and/or sleep-related symptoms results.

This includes some of the 22 common symptoms specifically listed and rated on a 0-6 scale on a form that each Banner client completes both prior to and following every treatment (See the list in Figure 1 below), as well as neck pain and ringing in the ears (tinnitus). It also includes any less typical symptoms a patient might report, such as “seeing the color green”.

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Figure 1: Banner Concussion Center’s In-Office Symptom Score Sheet

Clients rate each symptom on a 0-6 scale prior to and following every treatment session.

  1. Headache                                                                                12. Sensitivity to noise
  2. Nausea                                                                                     13. Irritability
  3. Vomiting                                                                                  14. Sadness
  4. Balance Problems                                                                  15. Nervousness
  5. Dizziness                                                                                  16. Feeling more emotional
  6. Fatigue                                                                                      17. Numbness or tingling
  7. Trouble falling asleep                                                            18. Feeling slowed down
  8. Sleeping more than usual                                                     19. Feeling mentally foggy
  9. Sleeping less than usual                                                        20. Difficulty concentrating
  10. Drowsiness                                                                               21. Difficulty remembering
  11. Sensitivity to light                                                                   22. Visual problems

Patients are also questioned regarding these additional common symptoms:

  • Neck Pain
  • Ringing in your ears

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The most common symptoms after concussion include: visual disturbances, sensitivity to light or noise, headaches, nausea or vomiting, difficulties concentrating or remembering, balance problems, emotional changes and alterations in sleep pattern.

While more severe traumatic brain injuries cause structural damage, the clinical signs and symptoms of altered brain function after MTBI can be attributed more to dysfunction of brain metabolism. This entails “a complex cascade of ionic, metabolic and physiologic events.” 6

Making the Diagnosis:

A thorough initial evaluation is of paramount importance to determine whether the injured person has something even more serious. Concussion is a diagnosis of exclusion – emergent conditions such as skull fracture or an acute subdural hematoma (a bleed between the covering of brain – the dura – and the brain itself) must first be ruled out.

Dr. Erickson stressed that the best place to start is at the Emergency Room, where greater awareness and improved training has resulted in movement away from automatic CT scans for mild head trauma.

Tests such as Magnetic Resonance Imaging (MRI) or Computerized Tomography (CT) are not able to diagnose the disturbance of brain function typical after concussion because there are generally no associated abnormalities on structural neuroimaging. Mild concussive trauma is unlikely to cause tearing of the tissues in the brain and so no bleeding results. It is the collection of blood that would otherwise be evident on imaging.

Dr. John DenBoer, Clinical Neuropsychologist/Sports Psychologist at Banner, whose outside private practice affiliation is with Mental Edge Neuropsychology in Scottsdale, emphasized that with “almost any other injury or illness, you do a scan or run a blood test and you can define it… whereas the testing after concussion focuses on function.” He commented that though “diffusion tensor imaging (DTI) 7 shows how the white matter tracks in the brain are disrupted by concussion, this is not widely used due to cost and availability. They have it in only ten clinics around the country and currently use it largely for legal cases or research studies.”

Diagnosis can sometimes prove tricky because symptoms can mimic those of other diagnoses (such as headache syndromes, PTSD…) and may have a delayed onset. However, once concussion is diagnosed, it is best to seek care within the first week.

When examining a patient after head trauma, gaining an understanding of the nature of the force sustained can be helpful; was it a direct blow to the head or a body (indirect) blow? A body blow may cause a whiplash injury where the head moves forward then backward rapidly. If the impact was a direct one, where was the hit absorbed? Different symptom patterns may emerge depending on the specific mechanism of injury.1

In addition, the severity of symptoms may relate to the degree of impact. Those who have sustained multiple concussions may exhibit more involved symptoms than expected, a reflection of their vulnerability and/or a psychological overlay whereby increased anxiety about the consequences of sustaining another blow can amplify symptoms.

Patients should be screened for amnesia, which may result after sustaining concussion. This sometimes affects recall of events prior to the injury (retrograde amnesia), or may affect memory of event that followed (anterograde amnesia). In addition, the examining physician generally relies on bystanders to determine whether the individual suffered seizures (an atypical occurrence). Family members can also contribute valuable information regarding signs of mild brain trauma that they may have observed since the injury was sustained.

The immediate post injury period:

If concussion is suspected, it is important to avoid physical activity and mental exertion (stimulation such as watching television, using a computer or reading), get plenty of rest, stay well hydrated and avoid caffeine or alcohol (information on brain foods that boost cognitive function can be found here). This initial protective phase after injury is key. A medical provider should be consulted and, in the event of severe symptoms, going to the ER immediately is crucial.

The Recovery Process:

An uncomplicated course of recovery is generally seven to 14 days for adults and 14 to 21 days (for children and adolescents). This is interesting because – though younger people have increased plasticity of the nervous system8 – the immature brain takes longer to recover from trauma. 9,10,11

If you’ve had one concussion are you more likely to sustain another?

Dr. Erickson, noted that his “guess is that at least 10% of those with full symptomatic recovery and complete cognitive recovery may still have vestibular dysfunction that predisposes to other injury.” This actually represents an incomplete recovery. In other words, even if you think you are better, you may not be. Inadequate care may leave you with residual vestibular or visual dysfunction, creating an otherwise avoidable susceptibility to additional head trauma.

Dr. Erickson’s experience has also shown that there is what he refers to as “a concussion threshold that is lowered even after a complete visual, cognitive and vestibular recovery and when an individual is symptom free. Individuals are more likely to have a subsequent concussion for a period of several weeks to months even with less impact involved. There is no definitive formula.

At the most extreme end of the spectrum is what is referred to as Second Impact Syndrome. Dr. Erickson noted that this condition is preventable. “An emphasis must be placed on kids reporting injury, and then getting them off the field immediately thereafter. Many play through, and every year a few kids die of this syndrome. Another big head blow very shortly after an untreated concussion can result in a loss of control of the auto-regulation of blood flow. This results in swelling and death. Second Impact Syndrome has been seen only in kids. There have been no reports in the literature of this occurring in adults.

This can’t be researched for obvious reasons – it would entail intentionally delivering a second blow and monitoring the outcome.”

Post Concussion Syndrome:

According to Dr. Erickson, approximately 70% of concussions follow an uncomplicated course. Recovery that occurs outside the normative recovery curve (longer than what is expected) is referred to as post concussion syndrome. Here, the literature is confusing, with some publications saying that symptoms persisting for three or more months constitute post concussion syndrome 12, while others note that it begins after four weeks (Banner), and still others only after a year.13

I believe the discrepancy in these definitions is due in part to the fact that clients at the Banner Center receive care that identifies and addresses any and all deficits across the various systems. Because of this, the typical patient has an uncomplicated course of recovery within the expected time period.

A prolonged recovery is generally due to persistent vestibular, visual or cognitive deficits, usually with some emotional or psychological stress or anxiety. The psychological component – which is a biological response that may also include depression – is “completely understandable for those with delayed recovery and persistent debilitating symptoms, such as headaches.”

Sherry Massingale, MPT, Senior Clinical Manager at the Banner Concussion Center, noted that with post concussion syndrome, “the overarching concern – and the fear of further trauma or setbacks that often accompanies delayed recovery – can serve to worsen or perpetuate physical symptoms or symptoms of depression. It may also result in self-limiting behavior due a fear of returning to the activity that resulted in injury or any activity that subsequently exacerbates symptoms”

Though post concussion syndrome is more likely after each successive concussion, 10 there is no definitive generic pattern. The higher incidence is more likely due to alterations neurochemically or psychologically, especially if the sufferer/athlete has had prior longer-term recoveries. Persistent symptoms are also more common after mild brain injury to those with a history of anxiety/depression, or those who have previously exhibited neurologic hypersensitivity. This population typically has a heightened somatic response to psychological stress – whereby pain is more readily elicited or amplified. Dr. DenBoer stressed that this type of pain – though very real and not at all imagined – can be effectively modulated or resolved via strategies such as mindfulness or other behavioral modification techniques.

The biologic responses that occur with these techniques provide strong scientific evidence of their benefits in the prevention and treatment of chronic pain as well as in effectively boosting mood.14

Part 2 of this article will focus on Assessment, and Part 3 on Football and CTE. Articles referenced and footnoted will appear at the conclusion.