BLOG: Chronic inflammation may delay concussion recovery
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We know patients’ medical histories affect their recovery from concussion in all sorts of ways. For example, people who have depression or migraine prior to a head injury are more likely to suffer from persistent post-concussion syndrome.
Treatment of persistent post-concussion syndrome requires a holistic approach because patients often have symptoms or difficulty functioning in multiple areas, including vision, vestibular, cognitive, sleep, mood, neck pain and others. Addressing all the affected systems requires a team approach that is, fortunately, becoming more and more common in concussion management.
Chronic inflammatory response syndrome
Some aspects of concussion recovery are easily measured. I can determine if a patient’s functional visual field and convergence are better compared with a previous visit, for example. But we have all had patients who are consistent with therapy, seeing a variety of specialists, making improvements in some areas — perhaps they have even been able to return to work or school — but they still don’t feel well. They may be struggling with fatigue, insomnia or cognitive deficits.
When this occurs, we really have to consider what other underlying conditions the individual brought to the concussion, and chronic inflammatory response syndrome (CIRS) should be on that differential diagnosis list.
CIRS is a condition triggered by environmental biotoxins, the most common of which is mold, although other triggers include algae, Lyme disease and viral infections. CIRS was first identified by Ritchie Shoemaker, MD, who was treating Chesapeake Bay fishermen who came down with a mysterious illness following a massive Pfiesteria algae bloom in 1997. The algae bloom killed fish and sickened humans who worked on and around the bay.
Shoemaker reported that the fishermen had a 30% reduction in visual contrast sensitivity compared with those not exposed to the water. The patients in that case, many of whom were suffering from gastrointestinal problems, were successfully treated with cholestyramine, a drug that binds cholesterol and has since been shown to enhance the elimination rate of a variety of biotoxins.
Identifying, screening patients with CIRS
Most people easily mount an adaptive immune response to eliminate biotoxins absorbed from the environment, but about a quarter of the population has a genetic mutation that renders them unable to eliminate biotoxins and therefore makes them more susceptible to CIRS. In patients with this genetic propensity, exposure to a biotoxin can trigger a cascade of inflammatory events that results in multisystem, multi-symptom illness.
CIRS as a term for this group of illnesses has been relatively recently coined, and awareness is still lacking; patients with CIRS are often misdiagnosed with chronic fatigue syndrome, fibromyalgia or psychiatric issues. Unfortunately, I learned about CIRS the hard way, when both my son and I experienced the condition following exposure to mold in our home. Having CIRS has made me much more aware of it as a potential underlying condition in treatment-resistant post-concussion syndrome.
Because CIRS is largely a neuro-inflammatory process, these patients will present to the neuro-optometric practice with many associated visual symptoms such as unexplained nystagmus and oscillopsia, vision motion sensitivity, headaches, light sensitivity, visual snow, brain fog and dizziness. Furthermore, CIRS is not recognized by mainstream medicine, so the neuro-optometrist may be the sole provider to identify patients at risk for the condition.
Should optometrists be treating CIRS? No, but we should be aware of it and ready to screen and refer patients when appropriate, just as we would refer a patient for craniosacral therapy, functional medicine, sleep medicine or depression treatment.
You can find resources for screening patients at VCSTest.com and SurvivingMold.com. Screening is an easy, three-step process:
- Has there been a relevant exposure prior to the start of symptoms? If yes,
- Has the patient failed the standardized visual contrast sensitivity test available on the above websites? If yes,
- Has the patient failed the CIRS Assessment Questionnaire, also available on the above websites?
If the answer to all three is “yes,” the patient should be referred to a physician trained in the Shoemaker Protocol for genetic testing, remediation guidance and treatment.
For more information:
Douglas J. Villella, OD, practices neuro-optometric rehabilitation and vision therapy at Integrated Vision Care in Erie, Pennsylvania. His passion is assisting the recovery of patients with post-concussion syndrome. Additionally, as executive director of Vision for the Poor, he has helped develop 10 social service eye hospitals in eight developing countries. He will be teaching a course on “CIRS: A missing link for treatment-resistant patients” at the 2023 NORA conference on brain-based rehabilitation. For more information and to register, visit https://noravisionrehab.org/about-nora/annual-conferences/2023-annual-conference.
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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