BLOG: The order of things after concussion
by Patrick Quaid, MCOptom, FCOVD, PhD
I believe that the difference between a good health care practitioner and an excellent one is that an excellent one knows when to get others involved.
The reality is that none of us is an expert on everything, so we need to find like-minded colleagues with different areas of expertise to benefit our patients, particularly when it comes to the complexities of concussion care. However, it can be difficult to figure out not only who should do what, but in what order.
Steps for treating concussion
After years of working collaboratively with other professionals, here is my take on how to best treat concussion patients:
Rest. For most concussion patients, there should be a period of rest immediately following an acute head injury. However, this “rest” should be a week or two, not several months, as has been previously espoused.
Start with the neck and back. When symptoms persist beyond that initial rest period, I like to first ensure that we stabilize the larger muscles in the body so they can “teach” smaller muscles how to move. Therapy of any kind will be more effective if patients are sleeping well and can ambulate with relative ease. At this stage, one might consider involving chiropractic, physical therapy/physiotherapy, neuromuscular specialists or even a dentist who specializes in treating temporomandibular joint disorder.
Neuro-optometric assessment. Within 3 to 4 weeks of the injury, the patient should have a neuro-optometric assessment to diagnose any visual problems contributing to their symptoms. Vision is by far the dominant sense. Consider this: There are 1.2 million ganglion cells (a type of neuron) in each optic nerve, but only about 30,000 ganglion cells for each ear. Call me biased, but the anatomy is telling us something here.
Once diagnosed, patients can be treated as needed with tints, yoked prism, binasal occlusion and vision therapy as needed by the neuro-optometrist.
Vestibular assessment. The vestibular system develops at just 48 days gestation and is extremely important for human development and healthy function. Most concussion patients with dizziness or balance issues actually don’t have otic (ear) or vestibular problems. Vertigo, on the other hand of course, is indeed a vestibular issue. In dizziness, rather, there is essentially an underlying issue or a basic mismatch between vision and vestibular inputs.
In addition to a thorough neuro-visual work-up, an assessment by a functionally oriented ear, nose and throat specialist or a doctor of audiology who is American Institute of Balance-certified can complement very well work that is being done on the neuro-optometric front.
Remember, diagnosis before prognosis is key here. Ultimately, formal diagnosis of visual system issues is the domain of the neuro-optometrist, and diagnosis of vestibular issues is the domain of the doctor of audiology/ENT specialist at the end of the day. This is the first step.
In working with colleagues from other specialties, it is essential that we all collaborate, but at the same time learn how to stay in our own “lanes.” In other words, each practitioner should know where his or her role ends and not try to do everything, essentially. It can take some time to find the sort of colleagues who excel both at concussion care and at the collaboration and communication necessary to make it work seamlessly. But it’s worth the effort. Ultimately, we all need to become experts in our own fields but also an expert referral mechanism to other disciplines that complement our treatments when required. If the patient is not getting better, put your thinking cap on; you likely need to get someone else involved.
I have seen many patients who have been “spinning their wheels” for literally months (sometimes years), bouncing from one practitioner to another, without relief from their post-concussion symptoms. I firmly believe that if we do the right thing, in the right sequence, the vast majority of patients will get significantly better. In addition, your practice will grow faster as more allied professionals will get to know what you do also. It is a win-win!
How do you work with your concussion patients and colleagues from other specialties? Please share your thoughts and experiences in the comments section.
For more information:
Patrick Quaid, MCOptom, FCOVD, PhD, is the founder and CEO of VUE3 Vision Therapy, with two clinics, in Toronto and Guelph, Ontario. He is also an adjunct professor at the University of Waterloo School of Optometry & Vision Science. He has co-authored a book chapter on visual dysfunction in brain injury with Eric Singman, MD, PhD (head of Neuro-Ophthalmology, Johns Hopkins) in the medical textbook, Neurosensory Disorders in Mild Traumatic Brain Injury. Quaid is also chair of the Ontario College of Optometrists Registration Committee and has given more than 500 lectures on topics including visual dysfunction in concussion, visual dysfunction in reading-based learning issues, and glaucoma and low blood pressure. Quaid can be reached at www.vuetherapy.ca.
Quaid will provide an update on new data on concussion management at the NORA annual conference, Sept. 19-22, 2019, in Scottsdale, Ariz. For schedule and registration, visit https://noravisionrehab.org/about-nora/annual-conference.
Disclosure: Dr. Quaid reports no relevant financial disclosures.
Disclaimer: The views and opinions expressed in this blog are those of the authors and do not necessarily reflect the official policy or position of the Neuro-Optometric Rehabilitation Association unless otherwise noted. This blog is for informational purposes only and is not a substitute for the professional medical advice of a physician. NORA does not recommend or endorse any specific tests, physicians, products or procedures. To access our website, click here.