Collaborative care neglected in new CDC concussion guidelines

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While the new CDC guidelines for managing mild traumatic brain injury in children cite vestibulo-oculomotor dysfunction as a part of concussion syndrome, the CDC failed to mention optometry’s role and those of many other integral health care providers that must be included in the comprehensive care of these vulnerable patients.

The CDC published the recommendations, “Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children,” for providers who treat children with mTBI in JAMA Pediatrics in September 2018.

In 2013, the American Academy of Neurology published guidelines related to the management of sports-related concussion in children and adults, and a year later, the Ontario Neurotrauma Foundation also published a guideline for diagnosing and managing pediatric concussion. The CDC’s guideline was based on a literature search from January 1990 to July 2015.

“The CDC guideline is the 10,000-foot view of concussion,” Scott A. Edmonds, OD, FAAO, chief medical officer of MARCH Vision Care, codirector of the Low Vision/Contact Lens Service at Wills Eye Hospital in Philadelphia and a member of the Primary Care Optometry News Editorial Board and one of its bloggers, said in an interview.

The guidelines are a step in the right direction, he said. The CDC moved away from the old recommendation of patients resting until they feel better.

“I think it’s a little disappointing that they didn’t mention us specifically, but it’s a partial victory that they talked about oculomotor problems that go along with concussion,” Edmonds added.

Many patients do not get better if the oculomotor and vision system are not assessed, DeAnn Fitzgerald, OD, told PCON. Fitzgerald is vice president of the Neuro-Optometric Rehabilitation Association (NORA) and runs a primary eye care clinic in eastern Iowa.

“The solution has to be a sports vision performance-type therapy where we are using vision, vestibular, balance and cognition reaction time all swirled together to get that student athlete pre-seasoned and in shape,” Fitzgerald said.

It takes a team of physicians to diagnose, manage and treat concussion, she added.

“We are concerned the CDC’s review and guidelines represent another ‘missed opportunity’ to address the ‘outdated assumptions’ that neglect vision health’s role in the diagnosis and management of mTBIs among children,” then-AOA President Christopher J. Quinn, OD, wrote in a Nov. 28, 2017, letter to the CDC about the guidelines. “Because so much of the brain is involved with the visual system, it is critical that eye doctors are engaged in the mTBI care team to help diagnose, refer and manage mTBIs.”

It is imperative that any child with a diagnosed mTBI be referred to an eye doctor to evaluate and treat any vision impairments caused by it, Quinn said in the letter.

“For children who do not realize that they may be suffering from an undiagnosed mTBI, a yearly comprehensive eye exam, an essential health benefit for children, provides an invaluable opportunity for an eye doctor to detect visual sequelae that may indicate an mTBI and to refer children to appropriate specialists for follow-up diagnosis and care,” he wrote.

Optometrists must be at the forefront to help our colleagues and our student athletes get better, Fitzgerald added. “A concussion with no solution is hysteria.”

What’s new in the guidelines

The previous guidelines recommended that a student athlete could return to play if cleared by a doctor or a certified athletic trainer, Charles Shidlofsky, OD, FCOVD, who practices at Neuro-Vision Associates of North Texas and is the secretary and treasurer of NORA, told PCON.

The new guidelines suggest, and Shidlofsky agrees, that an athlete should never return to the playing field the same day.

“It is now understood that 80% to 90% of adult concussions resolve in 7 to 10 days, but the recovery time for children and adolescents tends to be longer. Previously, all concussions were considered relatively equal,” Shidlofsky said.

Symptoms of concussion in young people can last from weeks to months, he continued. In addition, they may need a longer period of physical rest than adults and then a gradual return to normal activities.

“I like the fact that all activity must be stopped immediately, for the day, if a concussion is suspected,” Shidlofsky said. “There must be strict monitoring and activities restricted until they are fully healed.

James Deom, OD, MPH, FAAO, medical director of the Scleral Lens Institute and the Dry Eye Center of Northeastern Pennsylvania, said that a big change in the recommendations is that a patient returns to active recovery after 2 to 3 days of rest.

“That’s one thing I always talk to my patients about,” he told PCON. “We don’t just lock you away in a room, not doing anything. We want you to get back into a managed recovery program.”

Additionally, the new guidelines are more succinct as to what to do to get the athlete back to play, Fitzgerald said. “It’s so complex, and people want to make it simple, but it’s not. If you’ve seen one concussion, you’ve seen one concussion. That’s part of the problem,” she said.

Shidlofsky also said no routine imaging is recommended. However, a protocol exists for when a child should be imaged.

Post-concussion syndrome is now defined as symptoms 3 months in duration including three or more of the following: fatigue, disordered sleep, headaches, dizziness, irritability or aggressiveness, anxiety or depression, personality changes and/or apathy, Shidlofsky added.

The guidelines specifically mention vestibulo-ocular reflexes as a condition that might need a referral, Deom said.

The guidelines also recommend confirming whether there are significant comorbidities with the concussion and, if so, that the patient gets the appropriate referral.

Christina L. Master, MD, FAAP, CAQSM, said in an interview that the new guideline includes age-appropriate symptom scales to help diagnose concussion clinically. She is a sports medicine physician at the Children’s Hospital of Philadelphia and professor at the Perelman School of Medicine at the University of Pennsylvania.

Where the guidelines can improve

Aside from optometry, the guidelines left out the role of the neuropsychologist, occupational therapist, and speech and language therapists, Edmonds and Shidlofsky agreed.

“I was unhappy they did not mention optometry, convergence insufficiency and accommodative facility. We weren’t singled out as a resource or as knowledgeable practitioners to diagnose and treat mTBI,” Edmonds said.

He is hopeful that will come with later iterations of the guidelines.

When those with mTBI are referred to a neuro-optometrist they will check for binocular function and accommodative amplitude and will find abnormalities, Edmonds said. The most common is convergence insufficiency.

In young people, typically, their focusing and convergence do not line up, Edmonds said. “Interestingly, the CDC’s report has listed this as a problem in mTBI, but they lump it together with vestibulo-ocular symptoms. It’s at least a step in the right direction.”

“Optometry has to be and needs to be at the table,” Fitzgerald added. “Unresolved cognitive issues and unresolved anxiety issues are often unresolved vision vestibular problems [Collins et al.].”

The guidelines are good, but they are not based on the latest research, she said.

“I wouldn’t say that the guidelines fall short, it’s that the field is rapidly changing, and it is difficult to incorporate the latest findings into broad guidelines,” Master said. “There is still not much mentioned of vision system problems after mTBI, which is a rapidly evolving area of interest in the field.”

Her own paper from 2016, which showed a high prevalence of vision diagnoses such as accommodative, binocular convergence and saccadic eye movement disorders in 100 adolescents with a concussion, was left out of the guidelines because of the cutoff date of July 2015.

Fitzgerald noted that Joe Clark, PhD, professor of neurology and associate director of the University of Cincinnati Sports Neuroscience Initiative, utilized a holistic concussion prevention program that strengthened athletes’ peripheral vision, reaction time and eye-hand coordination. Within 4 years the University of Cincinnati football team saw an 85% reduction in concussion, which they attribute to prevention tactics, using the Dynavision D2, a visuomotor and neurocognitive and sports training device.

Additionally, she added that proper diet and fitness is not often made a priority. The importance of core and neck strength, a diet with low sugar, high protein and no caffeine drinks, and the appropriate supplements should be stressed to athletes and parents, she said.

Fitzgerald has examined many children who think they have had a concussion, but they actually suffer from an unresolved neck injury or hydration problem or they are highly/overly caffeinated.

Additionally, Deom said there is a lack of consensus for using diagnostic scales.

“There are probably 10 validated scales that are listed in the scale section of the guidelines,” Deom said. “It’s hard for a new practitioner to decide how to grade a person’s level of dysfunction.”

The Glasgow Coma Scale is cited, but that only has to do with whether a patient is conscious, he noted.

The abundance of scales available, with no standardization, makes it difficult to communicate between offices when practitioners are using different ones, Deom added. “It would be nice if we could agree on one scale that would be applicable and useful in concussion care.”

Collaborative efforts, moving forward

Edmonds hopes optometrists will read the guidelines and be aware to look for oculomotor problems and triage properly. “I hope more optometrists take an interest in how to treat these patients.”

He would like to see more collaborative efforts with neurology, physiatry, sports medicine, psychology, physical therapy, occupational therapy, athletic trainers, and speech and language pathologists.

In Philadelphia he works within several different groups specializing in comprehensive concussion management. Magee Rehabilitation, Jefferson Comprehensive Concussion Center and the Rothman Concussion Network all integrate optometrists, physiologists and physicians who can diagnose, treat, recommend and write prescriptions for therapy.

“It’s never just the eye; it’s often cognitive, speech and vestibular. You need a comprehensive team to manage concussion properly,” Edmonds added.

Furthermore, he wants young optometrists to learn how to look for, refer and manage mTBI and join teams where they are able to provide this level of care.

“In my mind [the guidelines] mean that we must continue to educate the public about the services we offer and how we can help,” Shidlofsky said. “In addition, we must continue to promote our services to pediatricians, rehabilitation facilities, concussion clinics, neurologists, etc. Lastly, we must continue to do a good job helping our patients and teach other ODs what and how we do what we do.”

Shidlofsky also recommends courses from NORA, the International Sports Vision Association, Optometric Extension Program Foundation and the College of Optometrists in Vision Development.

To Master, ideal mTBI treatment would include: A timely recognition of the injury, timely acute evaluation, appropriate early acute management, brief rest, and a gradual return to school and recreational activities, with adjustments made for cognitive and visual stamina issues following concussion.

Trained personnel would implement school- and learning-related adjustments immediately after the injury to facilitate timely return, Master added.

The appropriate gradual return to physical activity involves limiting the risk of repeat head injury and then a supervised return to risky activities, including contact and collision sports, she said. Patients with persisting deficits would receive referral to the appropriate specialists for active rehabilitation therapy, whether it includes vestibular, aerobic or vision rehabilitation or treatment of persisting migraine or mood disorder.

Deom has a unique perspective, as his wife is a physical therapist who is certified to work with brain injury. Physical therapists are looking for ODs to partner with, he said.

“Even though the CDC guidelines don’t mention it, PTs are aware, and they know their limitations. All it takes is an optometrist making a visit to their local facilities, and they will have a strong referral source. I’ve done it a handful of times,” Deom added.

He practices at two offices, seeing only concussion patients at one, and gains 10 to 15 new patients with concussion per week, he said.

“And we aren’t in an urban area. Our interdisciplinary team is actively engaged in concussion work and extremely aware of the need and optometrists’ abilities,” Deom said.

He added that it is a great mode for practice growth that begins with a desire to treat this population.

• References:
• Collins MW, et al. Knee Surg Sports Traumatol Arthrosc. 2014;doi:10.1007/s00167-013-2791-6.
• Lumba-Brown A, et al. JAMA Pediatrics. 2018;doi:10.1001/jamapediatrics.2018.2853.
• Master CL, et al. Clin Pediatr. 2016;doi:10.1177/0009922815594367.
• UC bearcats train the eyes to save the brain. https://magazine.uc.edu/editors_picks/recent_features/bearcats_concussion.html. October 2014. Accessed December 20, 2018.

• For more information:
• James Deom, OD, MPH, FAAO, is medical director of the Scleral Lens Institute and the Dry Eye Center of Northeastern Pennsylvania and practices at Hazleton and Stroudsburg Eye Specialists. He can be reached at: dr.deom@gmail.com.
• Scott A. Edmonds, OD, FAAO, is chief medical officer of MARCH Vision Care, co-director of the Low Vision/Contact Lens Service at Wills Eye in Philadelphia, and a member of the PCON Editorial Board and one of its bloggers. He can be reached at: scott@edmondsgroup.com.
• DeAnn Fitzgerald, OD, is vice president of NORA and runs a primary eye care clinic in eastern Iowa. She can be reached at: drfitznora@gmail.com.
• Christina L. Master, MD, FAAP, CAQSM, is a sports medicine physician at CHOP who specializes in brain injury and a professor at the Perelman School of Medicine at the University of Pennsylvania. She can be reached at: masterc@email.chop.edu.
• Charles Shidlofsky, OD, FCOVD, practices at Neuro-Vision Associates of North Texas and is secretary and treasurer of NORA. He can be reached at: dr-s@dr-s.net.

Disclosures: Deom and Fitzgerald report no relevant financial disclosures. Edmonds works with the Rothman Orthopaedics Concussion Network with locations in Pennsylvania and New Jersey. Master has received funding for research from NIH/NINDS, CDC, NCAA, DoD, AMSSM and CHOP. Shidlofsky is secretary and treasurer for NORA, a founding member and vice president of the International Sports Vision Association, and an instructor for a course in acquired brain injury for the Optometric Extension Program.