EIM Concussion Management: Half Way


Sure, this is the fifth post of 2016 – and its July – however there is a good reason for it. I continue to be an on the field athletic trainer, I continue to educate on concussion, I continue to be active on Twitter but more importantly I am concentrating more on being a father and husband. Blogging ain’t easy, folks; let’s be honest the coverage of concussion has blossomed well since 2009 when this blog started.

All of that being said, I am also in the process of gaining further education in concussion. This is not your typical education about the injury but right were my mantra for the past six years has been:

The injury of concussion is not the true problem; it is the mismanagement of this brain injury that is the real issue.

As noted in March I began the Evidence in Motion Concussion Management Course. This is a 34 week program that was designed to bring collaboration and current information to those that can impact the real problem of this injury, the clinicians.

We have arrived at the half way point in the program, marked by the weekend intensive course – which met in Chicago this past weekend. Many have wanted to know has it been worth it. The answer is unequivocally, YES.

Before I get to the hands on of the weekend let me recap the first half of the program. One word cannot do it justice but in our search for snippets of information and quick reaction, that one word could be “trailblazing”.

Previously I wrote about how the program was basically going in terms of mechanics and what we were doing at the time. Since then I have read more research (current), discussed, and most importantly learned how to better help those that have been concussed.

We finished the Therapeutic Neuroscience Education and moved into the specifics of the concussion and its management. We spent a week on each of the following parts of the concussion continuum:

  • Emergency Department – evolution and how they view the injury
  • Orthopedics – how concussion relates to bones and muscles (neck)
  • Vestibular Rehab – not only the vestib system but really focusing on the eyes
  • Adult/Migraines – a previously unthought of link/predisposition for concussion
  • Vision Rehab – what I feel will be the next area of focus for recovery from concussion
  • Neuropsych/Return to Learn – how we all fit together in these areas as clinicians
  • Speech Language Pathology – unknown to me how these professionals can and will help

Those seven weeks, plus the last week of summary were probably the most challenging for me in terms of timing and my work/home schedule. Yet, I could not wait to read, watch and interact with my cohorts each week. I was engaged the entire time. Even with the subject matter I may have struggled with (vestibular) previously I was able to learn in a way that made it completely applicable to me as an athletic trainer. In fact, I have been implementing processes and techniques into my training room, real-time.

Before beginning not only was I apprehensive about the time demands and testing, I was also concerned about the weekend meeting where we got hands on and dove deeper into specifics as clinicians. I knew I was going to be one of the few dedicated on-the-field ATs in the room (in fact only one other was there among the 30+ in attendance); fearful of the stupid stuff of profession bias and my education. I couldn’t have been more wrong.

EIM has labeled this as “weekend intensive”, and the term “intensive” is not enough to describe the depth and breath of what we had the opportunity to learn and discuss. Both Jessica Schwartz, PT, DPT, CSCS and Michael Furtado, PT, DPT, NCS were our faculty. They probably have forgotten more about their niche in concussion than I have ever learned in all of concussion. Heck they were both summonsed to the AAN concussion conference in Chicago happening at the same time to meet and greet.

Not only did I meet some wonderful and smart clinicians (mainly from the Chicagoland area) but I was able to learn MORE info on how to help my community when it comes to concussion. The take home points I got from this past weekend were:

  • Ocular assessment is an absolute necessity – not the normal scan but deeper
  • Vetibular function with vision is often overlooked and under utilized
  • Combining cognitive, vestibular and vision tasking needs to be addressed
  • Getting back to “light” (relative to each case) activity ASAP should be pushed
  • Possible insights (with medical direction) in to Mg supplementation
  • Those in attendance had not heard the one about “mild concussion” and being pregnant

The overall impact and goals of this course is not to churn out these credentialed individuals that will have the best and most current education at that time (we know concussion is constantly changing). The overall goal is to develop clinicians within the TEAM who treat concussion that can relate, communicate and supplement one another to get those injured better, faster.

I can say as an athletic trainer not only is this needed this is paramount; all clinicians (AT, PT, OT, SLP, MD/DO, PysD, and the whole alphabet soup) need/must be on the same page and help one another. We have to stop the “owning” of the injury and work as a team. A team that not only includes the clinicians but the patient, caregivers and the community.

I am looking forward to the second half of this course and wrapping this up, but I am not excited about not being in this cohort and part of this group on a daily basis. Rest assured that I will be calling my classmates, as I would expect them to talk to me.

Get yourself in a place to take up this certification course; forget the time barriers (if I can do it as an AT father/husband with three kids under the age 11) anyone can do it.

Advertisements

3 thoughts on “EIM Concussion Management: Half Way

  1. Gary Zeman July 11, 2016 / 13:54

    Concussions and other injuries (even permanent) continue in Minor Football. Regardless of the number of Concussion related courses etc — should School ( taxpayer related) Football Programs be dropped? Health costs should be a factor. The # of “safeguards” needed for Football are telling factors. The “GAME” may not be worth it at the High-school level.

  2. Peoria Windows July 11, 2016 / 15:40

    Good luck on the rest of your concussion education course. With all of the young kids playing contact sports, it’s important now more than ever to understand everything we can about concussions.

    • Dustin,

      Just realized that i previously posted my draft and not the final copy. Thus please substitute the below copy for the above post. Thanks.

      Don

      ===================================================

      Dustin,

      Nice to read another post from you.

      Re some of your content…I am adding on to what you have shared…and also stating the obvious that is often not seen as obvious… below are 4 excerpts from my 2004 Dissertation that remain pertinent today.

      The adverse effects of a concussion are pervasive…and not limited to a few areas of the brain…as any part(s) of the brain may be damaged…thus more concussion symptoms will be readily noticed such as migraine headaches, multiple vision issues, slowness in thinking, mental fatigue and speech…when looking for these and other symptoms.

      Below are edited excerpts from my 2004 Dissertation research re Active & Retired NFL Players’ Knowledge of Concussions that further support a comprehensive concussion/brain injury evaluation. This doctoral research was competed as part of my PhD requirements in the area of Clinical Psychology.

      Though the research results were completed 12 years ago…these findings remain pertinent.

      =====================================================

      Dissertation 2004 Excerpt 1:

      In an extensive review of research pertaining to mild brain injury, internationally known neuropsychologists Reitan & Wolfson (2000) strongly cautioned that many researchers who have examined mild brain injury have typically not employed comprehensive neuropsychological test batteries in their methodology.

      The authors perceive this as a MAJOR FLAW in evaluating the impact of mild brain injury, because they firmly believe that standard neuropsychological test batteries have frequently been shown to be sensitive to both focal and diffuse brain damage. They also pointed out that researchers typically have limited their assessment and focus due to:

      “a premature presumption that neuropsychological impairment is limited to a rather narrow range of deficits, and that a restricted range of tests is all that is required for adequate neuropsychological assessment. Our clinical experience suggests that mild brain injury produces diversified and even widespread neuropsychological losses in some patients (p.97).”

      “The medical evaluation component of a brain injury assessment is also highly suspect since typical medical assessment methods (i.e., neurology exam, EEG, brain-imaging techniques) utilized in determining adverse effects of mild brain injury are rather gross and insensitive, and thus false conclusions may be derived which report no neurological deficits were sustained (p.43).”

      A similar perspective pertaining to false conclusions was shared by McClelland (1996) when he cautioned, “…the absence of evidence is not evidence of absence” (p. 566). This view was reiterated by Gronwall (1991), who stated, “…it is impossible to prove the null hypothesis. Failure to show a deficit does not prove that no deficit exists, and the neuropsychologist has a responsibility to make sure that appropriate tests for assessment are selected” (p. 257).

      Damasio (1994), during a case presentation in which he discussed a particular patient, also noted problems with tests not being sensitive enough to adequately measure brain dysfunction/ impairment; he declared that “a problem here lies with the test, not with the patients. The tests simply do not address properly the particular functions compromised and thus fail to measure any neurocognitive decline” (p. 41).

      ============================================================

      Dissertation 2004 Excerpt 2:

      Evans (1987, 1994) outlined descriptions of frequently observed symptoms of mild brain injury. According to Evans, symptoms attributed to the effects of a concussion may also be called postconcussion syndrome. The symptoms listed by the author are: “headaches, dizziness, vertigo, tinnitus, blurry vision, double vision, memory dysfunction, impaired concentration, personality changes, anxiety, depression, sleep disturbances, decreased libido, irritability, noise and light sensitivity, fatigue, and slow information processing” (1987, p. 49). King, Crawford, Wenden, Moss, and Wade (1995), along with Evans (1987), provided excellent overviews of the various symptoms a person may experience after sustaining a concussion. The authors’ respective lists are found below in Table 1 A & Table 1 B.

      In addition, R.W. Evans, MD, a Neurologist, is rarely cited as a trailblazer within the concussions/brain injuries arena. Note Evan’s possible specific symptoms of concussions that are listed below and the corresponding years, 1987 and 1994, these peer reviewed articles were published…. Migraine headaches, multiple vision issues, and emotional concerns were listed as symptoms…nearly 3 decades ago !!!

      ============================================

      Table 1 A

      Postconcussion Symptoms

      Headaches

      – Muscle contraction type

      – Migraine

      – Occipital neuralgia

      – Secondary to neck injury

      – Secondary to temporomandibular joint syndrome

      – Due to scalp lacerations or local trauma

      – Mixed

      Dizziness

      Vertigo

      Tinnitus

      Blurry vision

      Diplopia

      Memory dysfunction

      Impaired concentration

      Personality change

      Anxiety

      Depression

      Sleep disturbance

      Decreased libido

      Irritability

      Noise and light sensitivity

      Fatigue

      Slowed information processing

      (R. W. Evans, 1987)

      ========================================

      Table 1 B

      Headaches

      Feelings of dizziness

      Nausea

      Noise sensitivity

      Sleep disturbance

      Fatigue

      Being irritable

      Feeling depressed

      Feeling frustrated

      Forgetfulness

      Poor concentration

      Taking longer to think

      Blurred vision

      Light sensitivity

      Double vision

      Restlessness

      (King et al., 1995)

      ==========================================

      Dissertation 2004 – Excerpt 3:

      Possible Physical, Cognitive and Social-emotional Impairments of a Concussion:

      A- Physical impairments:

      speech, vision, hearing another sensory impairments

      headaches

      lack of coordination

      muscle spasticity

      paralysis

      seizure disorders

      problems with sleep

      dysphagia — a disorder of swallowing

      dysargthgia — a disorder of articulation in the muscular motor control of speech

      B- Cognitive impairments

      short and long-term memory deficits

      slowness of thinking

      problems with reading and writing skills

      difficulty maintaining attention and concentration

      impairments of perception, communication, reasoning, problem solving, planning, sequencing and judgment

      C- Behavioral impairments: [social-emotional]

      mood swings

      denial

      depression and/or anxiety

      lowered self-esteem

      sexual dysfunction

      restlessness and/or impatience

      lack of motivation

      inability to self monitor, inappropriate social responses

      difficulty with emotional control in the anger management

      inability to cope

      excessive laughing or crying

      difficulty relating to others

      irritability and/or anger

      agitation

      abrupt and unexpected acts of violence

      delusions, paranoia, mania

      (Brain Injury Association of America, 2003)

      ===============================================

      Dissertation (2004) Excerpt 4:

      In addition to frequently observed acute symptoms of TBI, numerous long-term effects of a concussion have also been acknowledged. Long-term effects of concussion include: physical damage to the brain, physical damage to the body, cellular biochemical effects and general physical changes, and cognitive decline and psychosocial /behavioral/emotional changes.

      Inferential evidence that the brain has been permanently compromised becomes evident in the general physical changes that are sustained. These include: decline or loss of vision, hearing, smell, or taste; headaches; speech and language impairments; reduced endurance; cognitive decline in short- and long- term memory; difficulties with concentration, judgment communication, and planning; and psychosocial/behavioral changes such as anxiety, depression, mood swings and emotional liability (Scientific American, 1999; NYS Education Dept., 1997).

      Furthermore, children who sustain TBI’s may experience delayed effects that become more apparent at a later stage of cognitive development (NYS Education Dept, 1997).

      Conclusions:

      Given the possibility of numerous and pervasive concussion-related symptoms emerging, an extensive concussion/brain injury evaluation needs to be conducted to assist in ruling in and ruling out the presence of adverse concussion symptoms. In addition, the absence of measured symptoms is not evidence that no concussion symptoms exist. Clinical observations along with corresponding tests used may not be sensitive enough to adequately detect and measure actual brain dysfunction/ impairment.

      Peace.

      Don

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s