Concussion patients are in the chairs of optometrists all over the country, but clinicians must know what to look for so they can catch it.
Boston-Concussion patients are in the chairs of optometrists all over the country, but clinicians must know what to look for so they can catch it.
Keith Smithson, OD, and Jason Clopton, OD, FCOVD, spoke with American Optometric Association (AOA) annual meeting attendees to dispel the top 10 myths about concussion treatment and how optometrists are the prime clinicians to address the concerns raised. Dr. Smithson serves at team optometrist for five pro sports teams and brought the athletic perspective while Dr. Clopton works in specialty units for concussion patient care.
Part of the problem with concussion treatment, Dr. Clopton says, is that some of the symptoms are overt while others are covert. He recalls a patient who was in the army for about 20 years with silent symptoms of concussion, and when a prism was held in front of her eyes, she started crying, relieved to finally have an eye exam.
While those on the outside of optometric practices may think some of the practices are “voodoo” and work like magic, he says, he is here to dispel that notion and to explain the science behind why a certain technique can be effective in treating or evaluating patients.
1. It is unproven
Wrong. We have more and better levels of studies available today than years ago.
2. You can’t bill insurance
Wrong. See AOA coding and dilling for vision therapy and neuro-rehabilitation.
3. Primary care optometrists can’t do anything
Wrong. They are actually the most fit for concussion detection and treatment.
4. There are not many concussion patients in my practice
Wrong. You won’t see them if you’re not looking for them.
5. I can’t order or bill for ancillary testing
Wrong. Check with the specifics of your state board.
6. I have to be specialized to do this.
Wrong. Many of the tests explained are what optometrists do on a daily basis.
7. I can’t do neurology
Wrong. “If I can do it, anyone can,” says Dr. Clopton.
8. There are no referrals to other ODs.
Wrong. Try AOA vision rehabilitation, COVD, and NORA.
9. It isn’t profitable.
Wrong. The majority of cases at Dr. Clopton’s practice are concussion patients, and he stays busy.
10. I have to have special equipment.
Wrong. All you need is some therapy knowledge, an Rx pad, and some knowledge.
Concussions in pro sports
Dr. Smithson says that he doesn’t believe the burden of first-line concussion detection, or controlling when athletes can return to play, is not the responsibility of optometrists. Rather, optometrists serve as a vital element in the diagnosis and treatment of the concussion, as well as communicating that with the officials who make decisions about return to play.
To be cleared from a visual standpoint, an athlete must be symptom free at four progressive stages: at rest, with an elevated heart rate, during on field training, and finally, with contact play.
These are the stages of return to play progressions that Dr. Smithson follows. If symptoms arise at any of the stages, the team will go back until the patient is symptom free. The gradual progression of return to play procedures is a mandate in all 50 states.
However, therapy in patients with concussions should begin only after the acute phase, which gives patients time to recover.
What does a concussion look like?
It’s important that clinicians realize there is no blanket therapy for concussions, Dr. Smithson says, meaning the patients need to be treated on an individual level.
One tenth of concussion sufferers have persistent symptoms, which equates to about 250,000 people every year, Dr. Smithson says.
Often, symptoms for concussions include:
being slow to get up
• Irregular speech
• Irregular gait
• Not being oriented to self, place, or time
• Reading problems
Many of these symptoms are caused by the visual/vestibular dysfunction.
Covert symptoms include things you may not see unless you are specifically looking for them, such as visual neglect (postural and positional), convergence, accommodative function, and visual vestibular balance problems.
“A primary exam can change someone’s life,” Dr. Smithson says.
Clinicians need to be aware that many times patients with concussions can be very sensitive and emotionally raw.
He encourages performing a refraction and says optometrists should not be afraid to experiment with various treatment options to see what benefits the patient. Immediate primary interventions can frequently halt the progression of the ailment.
If an optometrist is not comfortable treating concussive patients, referring out is always an option-but Dr. Smithson says there is no physician more qualified to treat these cases than optometrists, and they need to speak up and take their spot at the concussion table.
He says many hospital complexes are waiting to refer to optometrists who are willing to say, “I will take someone with visual symptoms after a concussion.”
“We belong in this discussion,” he says. Concussions do involve a collaborative process, but optometrists hold a special role.
“If we do not start taking ownership on this, shame on us,” he said.
Secondary concussions can often arise when someone with a concussion tries to walk and falls, which most commonly occurs in rehab centers. Physicians should anticipate types of occurrences by starting exams while the patient is seated wherever possible and by using gate belts when progressing to the standing position.
Secondary concussions are more complicated. This normally involves muscular and binocular accommodative components, which require further testing and training.
A tertiary concussion involves neuro-visual rehab, which is done in conjunction with a specialized neurology provider.
There are six trajectories for symptoms of concussions:
• Cognitive fatigue
Be on the lookout
Be on the lookout for:
• Visual trajectory
• Visual acuity
• Ocular motor
• Visual motion sensitivity
• Photo sensitivity
• Dry/wet eye
• Visual neglect/field loss
Major advances are in the pipeline for EOM testing, which can be of a great help in this area.
Testing for the following is encouraged:
- Often at midlines
- Trouble with fixation maintenance
- Decreased stereopsis
- Reduced peripheral vision
- Neuromuscular/sensory motor
- K-D and DEM
“Watch your patients!”Dr. Clopton says, adding that if you watch your patients from the time they come into the office, you should have a diagnosis by the time they sit down. Some problems, like strabismus, can be seen when they walk.
It is not necessary to know neurology in depth, but only to know that it is involved in concussion patients. Try polarized lenses and prisms in these patients and you can see the benefits, Dr. Smithson says.