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Doctors of Optometry | Course Notes

OD16 – 1CE Overall Management of Concussion: What I have Learned from Allied Healthcare Professionals

Sunday, February 18, 2018 11:25 am – 12:20 pm Plaza B/C – 2nd Fl

Presenter: Dr. Patrick Quaid Dr. Quaid, originally from the Republic of Ireland, trained as an Optometrist in the UK (University of Bradford School of Optometry) and worked mainly within the UK Hospital Eyecare System (Moorfield’s Eye Hospital, London & Bradford Royal Infirmary) dealing primarily with the management of patients with unusual patterns of progressive glaucoma in addition to working closely with pre and post-strabismus surgery patients and concussion related oculomotor issues. In 2005, Dr. Quaid received his PhD in Vision Science from the University of Waterloo School of Optometry & Vision Science (UWSO) extending the work of V.S. Ramachandran’s on visual illusions.

He has published several papers in high impact optometry and ophthalmology journals on topics from glaucoma (and its specific link to low blood pressure) in addition to binocular vision dysfunction both in paediatric learning disabled populations and concussion patients. Dr. Quaid sits on the Executive Committee for the Ontario regulatory board (Ontario College of Optometrists) in addition to serving on the Board of Directors for COVD International.

On a personal note, at 8 years old, Dr. Quaid was involved in a motor vehicle accident, which knocked him out of commission from academics for almost 3 years. His MVA related concussion resulted in immediate speech impediment and oculomotor issues, which took over three to resolve. Dr. Quaid has a unique ability to not only give the “evidence based medicine” side, but also the vital and over-looked PERSONAL patient perspective.

Course Description

Learn about two of the most effective techniques created by behavioural and cognitive psychology. This course will help drastically increase the number of patient interactions that feel ‘like you’ve known each other forever’. The techniques taught will also help reduce stress, improve staff experience and problem solving, and create for a happier and more productive workplace

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Doctors of Optometry | Course Notes

NOTES:

Overall Management of Concussion:What I have learned from Allied Healthcare Professionals

COPE Approved CE: 50427-FV, 1 hour

Dr. Patrick Quaid, Optometrist, FCOVD, PhDClinic Director & CEO, Vue-Cubed Vision Therapy & Rehabilitation Network (Guelph & Toronto Clinics, Ontario)Consultant Optometrist, David L. MacIntosh Sport Medicine Clinic, University of Toronto Faculty of Kinesiology

Assistant Research Professor (Adjunct), University of Waterloo School of Optometry & Vision ScienceExecutive Committee & Council Member, College of Optometrists of Ontario

Vue Cubed VT Network

Here are some of the main issues...

Quick mention of low DBP (DPP)

“...low DPP appears to be a reasonable predictor of progressive optic neuropathy as determined on HRT TCA....DPP of 56mmHg

or lower appears to be a strong clinical indictor for higher risk of progression”

Quick mention of low DBP (DPP)

Why is low DBP an issue?

Brain is 2% of body weight but 20% of the

body’s energy demands....blood flow

likely key...SCMs contracting reduces

blood flow!

Here is another issue...

Taking concussion / ABI seriously

Why is the neck SO important?

“If you get into trouble with smaller muscles, use the bigger muscles to teach the smaller ones how to move” WC Maples (my FCOVD

mentor, and good friend).

Wait a minute though....what if the “bigger muscles” are constantly going into spasm? We HAVE to deal with the neck EARLY ON!

The neck is a MAJORLY VULNERABLE area for humans!

Media and Hollywood has helped...for a change

What about kids??

Question: How many “IEPs” are “undercover concussion” cases?

VERY little data out there on ages 6-12

Where are there gaps in the research?ANSWER: PEDIATRIC CONCUSSIONS!

“...this study found a significant relationship between head impact exposure and change of

FA (fractional anisotropy) value...using the HITS (Head Impact Telemetry System)”

• N = 25 (male, 8-13), football

• DTI (diffuse tensor imaging)

• HITS system used

• Significant changes noted

• One NFL = 2,000 kids

• Function of head size / neck?

I needed to learn more...I needed to get outside the “eyecare bubble”!

• Hormone function and concussion (MD, OB/GYN background), how important?

• How exactly the neck and back is involved in concussion (PT PhD)

• How a TMJ dentist can majorly help the patient to SLEEP (DDS, TMJ only)

• How a COLLABORATIVE neuro-ophthalmologist can be invaluable (MD, PhD)

• How a Board Certified Audiologist with AIB (American Institute of Balance) certification can be the quarterback for tinnitus / mesophonia / ceasing VRT?

• VITAL for us to ensure there is no uncompensated vestibulopathy present (as opposed to a unilateral vestibular weakness which is likely visual issues masquerading as vestibular dysfunction to vestibular docs!)

• Importance of a neuro-psychologist...what exactly do they do?

My ultimate goal: What is the RIGHT approach in concussion but more importantly what is

the RIGHT sequence?

What if we are ALL right....how do we move forward TOGETHER?

Something this complex MUST be multi-disciplinary!

But...surely we can try to simply the management??

Why are hormones so important?

• Treatment of menopause: 34-54% reduction in cardiovascular disease20% decreased risk of diabetes10% reduction in breast cancer rate29% decrease in overall mortality rates

• Treatment of andropause:40% reduction in stroke / heart attacks23% reduction in depression ratesNo increase in rate of prostate cancer using bio-identical hormones

Sleep issues

Hormonal issues

Speech dysfunctionNeck pain

Photophobia

Depression

Otic (tinnitus)

Mental “fogginess”

Lets look at the most common main “issues” with concussion:

Anxiety

Aggression

Tracking issues

Memory

BalanceHeadaches

Teeth grinding

Lets look at my “Sandbox” of colleagues:

Neuro-Optometry

Neuro-Ophthalmology

AIB Audiologist

PhD PT

TMJ DDS

Neuro-Psychologist

Hormone specialist

How...lets look at development of the human being (normally)

• Vestibular system fully functional at 52 days GESTATION

• Neck comes on-line about 3.5 months

• Visual system aligns between 3.5 and 4 months (1 month after neck stabilizes)

• Sleep cycles normalize once these stages are COMPLETE (by about 12 months)

• 3-4% of the human brain is auditory (not including vestibular function though)

• 40% of the human brain is PRIMARILY visual machinery

• So...vestibular first develops, then neck and back tone....and then vision

• BUT the VOR reflex depends on BOTH sight input and vestibular input

How do we “know where we are in space”

VOR communicationSC / pulvinar (ambient system)

Neck and spinal cord

Sight

Proprioception (SCM function)

Vestibular

Not all “saying same thing at same time” = NAUSEA

What we (sandbox group) think....• VRT contraindicated in visual dysfunction and with uncompensated vestibulopathy

• VRT is contraindicated when there is SCM or neck issues as head motion occurs

• Sleep issues need to be addressed EARLY as lack of sleep prevents recuperation

• Neck / back issues are usually causing sleep problems (grinding common)

• If the masseter muscle of the jaw is NOT relaxed, the neck muscles do not relax

• Clenching of the teeth at night is quite common on concussion (ask your patients!)

• Female patients often have irregular menstrual cycles post-concussion (hormones!)

• Women can enter early menopause, men often have dramatic drops in testosterone

• Depression usually a consequence of LACK OF INTERVENTION (i.e. not primary)

• Anxiety is often situational (i.e. when the senses are overwhelmed, not primary)

The sequence that we have used:

Sleep issues

Speech

Neck pain

Otic (tinnitus)

Headaches

Photophobia

Anxiety

Tracking issues

Memory

Balance

Hormonal issues

Depression

Aggression

ASAP Within 6 weeksIf not resolving

within 3 months*

If ANY suicidal tendencies stated (ASK!) then depression

management (neuro-psychologist) becomes urgent!

• VRT cannot be effective in the presence of oculomotor or neck dysfunction!

• In fact, in presence of the above (especially with migraine) VRT can make Px worse!

• Ocular teaming cannot really occur without proper neck function (WC Maples!)

• Ocular and neck issues cause increased headaches, pain and anxiety (i.e. PA issues)

• Sleep required to recover, cannot occur with jaw clenching (bruxism, triggers neck)

• Prolonged issues with sleep will add to fatigue which will further hamper recovery

• Stress will add to anxiety and lead to depression (lack of ability to work / perform)

• VRT when required, should be effective within 3-4 SESSIONS (Dr. Richard Gans)

• While vertigo is usually vestibular in nature, 95% cases of dizziness = normal vestib.

Here goes the rationale... Neuromuscular PhD

AIB D.AudNeuro-Psych*

TMJ DDS

Rehabilitative VTFCOVD PhD

MD (Hormone Dysfunction)

Neuro-Psych

After rest (4-6 weeks max)* ASAP if suicidal tendencies

6 weeks post-stage one

Six weeks of 2-3x week Tx

3 months of 1-2x week VT, get neuro-ophthalmologist to back it if required

(sad, but true)

2-3 months on bio-identical hormones

(if indicated)

Baseline and discharge assessment (3rd party validation and usually very beneficial in terms of getting funding

approved by insurance!)

VRT (if required, 2-3 weeks)

START HERE

STAGE ONE

STAGE TWO

STAGE THREE

STAGE FOUR

• Neck / back intervention must start within 4-6 wks with TMJ DDS assessment

• Assessment ASAP to determine inner ear damage (i.e. canal dehiscence, tinnitus)

• If tinnitus present and otic exam normal, only other cause RCM muscle (neck!)

• If hearing aid (to dampen mesophonia and / or tinnitus) helpful, do it ASAP!

• Main aim of PT / PhD to increase motion of SCM (using electrodes & stretches)

• 4-6 weeks into PT PhD program, start rehabilitative VT to work on tracking / PA

• Have hormone battery assessed about 6 month point (as may normalize during Tx)

• Usually within 4-6 months Px should be feeling MARKEDLY better (84% at GVTC)

• Neuropsychology oversight wise at onset and completion to document / validate

• VRT is actually CONTRAINDICATED in migraine patients with neck / visual issues!

Some pearls I wish I had known sooner! General sequence and pearls.....

Neck / back Txwith night guard(+neuropsych)

R/O vestibulopathies!

Vision Rehabilitation

& Hormone

assessment

Vestibular Rehabilitation Tx

(if required)

• Migrainers (they tend to not recover as well, especially female migrainers).

• Px’s with a history of severe motion sickness (higher change of MDDS).

• Px’s with connective tissue disorders (i.e. EDS) as they don’t recover well overall.

• Tx to MRP, give QUANTITATIVE DATA, know when to quit (not “rent a friend”).

• Pre-existing IEP / LD issues may mean a longer Tx plan with lower MRP prognosis.

Watch for:

What is currently done (likely wrong sequence) in most mTBI cases

• VRT is perfectly appropriate for CONFIRMED vestibular dysfunction (not pathology)

• Vision aspects outside of “20/20 acuity” are simply not even being TESTED at present!

• Hormones off the radar as is neuropsychology intervention at the present time.

• VT, neuro-psych and hormone aspects not considered until poor recovery obvious

• By this point the $50k max funding (i.e. when CAT considered) usually well spent!

Points to state:

Physiotherapy &

VRT (!!) withoutany formal

diagnoses from either vision or

vestibular

Back and neck work overall

(cervicogenic)

Very likely a dismal “MRP” as VRT in suchcases will not

work

What does the phrase “Hodge’s Knowing” mean?

Bottom line: If you think you know “everything” and are getting complacent, you are likely under-

performing and likely should consider retiring!

Why a neuro-psychologist can be vital...dad an MDThought his son was “faking it”....enough said

What is new and on the horizon?

- QEEG: Listening to “brain chatter”

- 256 “nodes” used to record data

- Looking at memory tasks in real time

- Seeing how tools such as yoked prism instantly and positively affect QEEG data (LOTS of normative data!)

What have I ultimately learned from my colleagues?

“The difference between an average healthcare professional and an excellent one is that the excellent one knows when to get

OTHERS involved” Dr. Eric Singman MD PhD (Chief of Neuro-Ophthalmology, Johns Hopkins)