BLOG: Concussion care should be patient-focused, not political
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Recently, a coalition of four health care groups published guidance in the journal Pediatrics on screening, identifying and initiating clinical management of visual symptoms in pediatric concussion patients (Master et al).
The report, authored by the American Academy of Ophthalmology (AAO), American Academy of Pediatrics, American Association for Pediatric Ophthalmology and Strabismus, and American Association of Certified Orthoptists, recommends that all of the following be evaluated: visual field, facial sensation, orbit, eyelids, pupils, conjunctiva, cornea, anterior chamber, fundus, smooth pursuits, saccades, vestibular-ocular reflex, horizontal and vertical versions and ductions, convergence, accommodation and ocular alignment. The groups noted that early identification and appropriate management of visual symptoms can mitigate the negative effects of concussion on children and adolescents and their quality of life.
Educating primary care doctors about the central role that vision and oculomotor symptoms play after a concussion is very important. Unfortunately, however, accompanying statements from the coalition (American Academy of Pediatrics) and the AAO make a few missteps in terms of who should conduct these evaluations and how concussion should be treated.
The statements recommend referral to specialists with experience in comprehensive concussion management, “such as those in sports medicine, neurology, neuropsychology, physiatry and ophthalmology,” for further assessment and treatment. This list failed to include optometrists, who have been educated and trained to diagnose and manage ocular dysfunctions and visual processing deficits related to brain injuries.
Optometrists serve an integral role as members of health care teams devoted to the care of brain-injured patients. In many parts of the country, optometrists are, by far, the most accessible starting point for a comprehensive eye exam that includes all of the elements recommended in the journal report. In Iowa, for example, there are optometrists in 98 of our 99 counties, while only a handful of counties have an ophthalmologist or neurologist.
After an initial evaluation, patients with brain injury should be referred to professionals who are skilled in concussion diagnosis, management and rehabilitation. Incorporating the training and expertise of a variety of professionals with knowledge of vision and oculomotor function, vestibular function, cognition, balance and gait can be vital for successful rehabilitation. Some patients may also need help with managing sleep, nutrition/hydration or anxiety. As president of the Neuro-Optometric Rehabilitation Association and someone who has been treating brain-injured patients for more than 30 years, I strongly believe in the importance of an interdisciplinary, integrated team approach.
The organizations noted that most patients fully recover within 4 weeks of a concussion. However, a 2019 study that evaluated nearly 1,200 patients with mild traumatic brain injury found that 53% of them still had functional limitations, including visual and oculomotor problems, 1 year after the injury (Nelson et al). It’s important to begin symptom-limiting cognition, exercise and other symptom-mitigating activities after just 3 to 7 days of rest.
In its statement, the AAO specifically warned against vision therapy for the treatment of concussion, suggesting that there is insufficient evidence of efficacy. Vision therapy has been found to assist the visual system to recover from post-concussion syndrome and is supported by evidence-based and peer-reviewed, published articles. It is absolutely true that simple vision exercises, in the absence of comprehensive treatment, will not successfully treat concussion. For example, working on near point of convergence alone will provoke symptoms and make the patient feel worse. Vision rehabilitation using the peripheral visual system, vestibular system, balance and gait is needed to help patients get better.
Concussion requires a team diagnosis and a team effort toward the common goal of rehabilitation. Each profession brings needed skills to the table. To help our patients, we have to work better together, rather than let professional politics get in the way of patient care.
References:
- American Academy of Pediatrics. Vision and concussion: Symptoms, signs, evaluation and treatment. https://publications.aap.org/pediatrics/article/doi/10.1542/peds.2021-056047/188533/Vision-and-Concussion-Symptoms-Signs-Evaluation?autologincheck=redirected. Published July 18, 2022. Accessed July 26, 2022.
- Master CL, et al. Pediatrics. 2022;doi:org/10.1542/peds.2021-056048.
- Nelson LD, et al. JAMA Neurol. 2019;doi:10.1001/jamaneurol.2019.1313.
- What ophthalmologists want you to know about kids and concussion. https://www.prnewswire.com/news-releases/what-ophthalmologists-want-you-to-know-about-kids-and-concussion-301588578.html/. Published July 18, 2022. Accessed July 26, 2022.
For more information:
DeAnn M. Fitzgerald, OD, has been providing eye care to eastern Iowa since graduating from Pacific University School of Optometry in 1984. She runs a busy primary care clinic where she diagnoses and treats ocular disease and evaluates patients with brain injury. She also operates a multidisciplinary clinic, Cedar Rapids Vision in Motion, which provides low vision services and vision skills rehabilitation, with an emphasis on vestibular and visual skills, as well as a sports vision and concussion clinic, Active Evolution Studio. She is president of the Neuro-Optometric Rehabilitation Association (NORA).
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. For more on our website and online content, click here.
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