It’s All in Your Head

New Diagnosis and Treatment Protocol Helps Trainers and Coaches Assess Concussions

Jason J. York, M.S., ATC, LAT, received his athletic training undergraduate degree from Canisius College in Buffalo, New York, and his master’s degree from West Virginia University in Morgantown, West Virginia. He worked as associate professor of anatomy and physiology at Southwestern University in Georgetown, Texas, before becoming director fo sports outreach for Vestent® in Austin, Texas.

In the past, very little was known about the impact of concussions, which affect more and more athletes every day. Recent studies (The Need for Balance Centres, NeuroCom International, Inc.) indicate that the rate of concussions has grown to about a half million per year, with a majority of concussions occurring between the ages of 15 and 24. There are two possible reasons for the increase: either we as a society are more aware of concussions, or athletes are truly getting bigger, faster, and stronger.

Whatever the case, 79 percent of athletes who required some form of hospitalization as a result of a concussion continued to suffer headaches, dizziness, and/or memory problems three months later – even though their neurological exams were labeled “completely normal” upon release. It was once theorized that these effects would continue to diminish an athlete’s quality of life, which motivated researchers to learn more about the effects of a concussion on an athlete and what can be done to treat and prevent them.

As a result, Vestent®, a company based in Austin, Texas, has developed an innovative new diagnostic methodology and treatment protocol to treat and prevent post-concussion syndrome in athletes following concussions and mild head injuries. Vestent’s sideline testing protocol, called EPIC (Evaluation Post-Injury Concussion), was designed to objectively pre-screen an athlete’s injury potential, as well as produce objective sideline information for the trainer or physician to predict a safe return-to-play criteria.

Research in the field of concussion-related injuries has revealed that not all concussions are related specifically to injury of the brain. Vestent’s research division coordinated with the University of Texas at Austin to identify and link common symptoms such as nausea, dizziness, loss of coordination, short-term memory loss, inability to focus, and altered emotional status to abnormalities in inner-ear fluid balance, which occurs following minor head injuires. Post-injury vestibular abnormalities can be directly correlated to concussional-type forces to the head. Once damaged, the inner-ear function can vary with seasonal allergies, stress, and/or illnesses, producing fluctuating or poor athletic performance. A concussion is defined as an acute deceleration event causing temporary or permanent damage to the inner ear or brain. The mechanism of injury determines the severity of symptoms. Therefore, there are three types of concussion: vestibular concussions (inner ear); cerebral concussions (brain); and a combination of both (inner ear and brain).

The ability to correctly diagnose the type of concussion is essential to establish an appropriate care plan for the athlete. Both vestibular and cerebral concussions can have the same type of symptoms, making it difficult to distinguish between the two. In the past, clinicians have treated all concussions with conservative methods of rest and inactivity. However, clinicians must understand that the treatment for each should be significantly different, and periods of rest can actually slow and prevent the compensation process of a vestibular concussion. This factor alone can dramatically affect the athletes’ ability and safety in returning to activity.

The purpose of the Vestent protocol is to identify athletes with inner-ear abnormalities by assessing both the vestibular spinal reflex (VSR) for balance strategies and the vestibular ocular reflex (VOR) for eye and head symmetry. The VSR coordinates appropriate synergistic muscle coordination for dynamic balance. The VOR, on the other hand, is responsible for stabilizing vision during movement. Abnormalities in the vestibular system can lead to decreased athletic performance and place the athlete at a higher risk for secondary injury. The Vestent screening protocol will provide valuable baseline information if the athlete ever sustains a concussion. Comparison of post-injury testing to baseline-screening information will help determine the athlete’s ability to return to play with decreased risk of further injury.

Following a concussion or mild head injury, secondary central nervous system side effects are universally seen and are related to end organ or vestibular apparatus dysfunction. Therefore, damage to a vestibular end organ causes continuous misinformation regarding an athlete’s position in three-dimensional space to be sent to the brain. Symptoms may include dizziness, imbalance, sleep-pattern disruptions, short-term memory loss, distractibility, fatigue, and decreased concentration. Central responses to this continuous misinformation more than likely involve an adaptive response of the reticular activating system (RAS), resulting in a lower level of consciousness described by patients as a “foggy” or “fuzzy” sensation in their head. This adaptive depression of central function is subjectively described as a “lack of concentration” or “focusing” abnormality.

Objectively, these patients have difficulty with cognitive tasks and are routinely described by friends and family as having difficulty with short-term memory.

Vestent uses a neuropsychological exam to measure and monitor these symptoms objectively. This depression of RAS function is seen in athletes as poor overall performance and may be severe enough to lower reflex speed.

Modification of the CNS interpretation of the vestibular input can be accomplished by aggressive vestibular therapy through a cerebellar adaptive mechanism.

The possibility exists that early medical intervention may protect the vestibular apparatus following mild head injury and may secondarily prevent the post-concussion syndrome.

Additionally, routine intervention with customized vestibular therapy following concussional injuries, in the absence of other CNS pathologies, may speed the return to play and minimize the post-concussion return-to-play dilemma.

Vestent’s EPIC care protocol provides a more standardized, objective evaluation of the mild head injury on the sidelines, allowing the team physician, athletic trainers, and coaches to make an accurate, immediate prediction of an athlete’s potential for additional injury.

Post-concussional Vestent protocols standardize treatment guidelines for mild head injuries. Vestent machines integrate VOR and VSR testing, which provides a more detailed evaluation of the entire balance system and a higher degree of certainty regarding an athlete’s return to play with minimal risk of further injury.

In 1997, the Centers for Disease Control (CDC) estimated that 300,000 sports-related traumatic brain injuries (TBI) of mild to moderate severity occur in the United States each year. While it was not determined what proportion of these concussions are repeat injuries, there is apparently an increased risk among those who have had at least one previous TBI. The report also shows that repeated TBIs over months or years can result in cumulative neurological and cognitive deficits.

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