Concussion care should be patient-driven, not policy-driven

Recently, a coalition of four healthcare groups published advice in the journal Pediatrics on screening, identification and initiation of clinical management of visual symptoms in pediatric patients with concussion (Master et al).

DeAnn M. Fitzgerald

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 assessed: field visual, facial sensation, orbit, eyelids, pupils, conjunctiva, cornea, anterior chamber, fundus, smooth pursuits, saccades, vestibulo-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 concussions on children and adolescents and their quality of life.

Educating primary care physicians about the central role that visual and oculomotor symptoms play after concussion is very important. Unfortunately, however, the accompanying statements from the coalition (American Academy of Pediatrics) and the AAO make some missteps in terms of who should perform these assessments 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 evaluation and treatment. This list did not include optometrists, who were educated and trained to diagnose and manage ocular dysfunctions and visual processing deficits related to brain damage.

Optometrists play an essential role as members of health care teams dedicated to the care of patients with brain injuries. 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 items recommended in the journal report. In Iowa, for example, there are optometrists in 98 of our 99 counties, while only a few counties have an ophthalmologist or neurologist.

After an initial evaluation, patients with brain injuries should be referred to professionals qualified in the diagnosis, management and rehabilitation of concussions. 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 essential for successful rehabilitation. Some patients may also need help managing their sleep, nutrition/hydration, or anxiety. As President of the Neuro-Optometric Rehabilitation Association and treating brain-injured patients for over 30 years, I strongly believe in the importance of an interdisciplinary and integrated team approach.

Organizations have noted that most patients make a full recovery 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. par). It is important to begin symptom-limiting cognition, exercise, and other symptom-mitigating activities after only 3-7 days of rest.

In its statement, the AAO specifically warned against vision therapy for the treatment of concussions, suggesting that there is insufficient evidence of effectiveness. Vision therapy has been found to help the visual system recover from post-concussion syndrome and is supported by evidence-based, peer-reviewed published articles. It is absolutely true that simple vision exercises, in the absence of comprehensive treatment, will not successfully treat a concussion. For example, working only on the near focal point will cause symptoms and worsen the patient’s condition. Vision rehabilitation using the peripheral visual system, vestibular system, balance, and gait is necessary to help patients get better.

Concussion requires a team diagnosis and a team effort towards the common goal of rehabilitation. Each profession brings needed skills to the table. To help our patients, we need to work better together, rather than let professional politics get in the way of patient care.

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DeAnn M. Fitzgerald, DO, has been providing eye care in eastern Iowa since graduating from the University of the Pacific School of Optometry in 1984. She operates a busy primary care clinic where she diagnoses and treats eye diseases and evaluates patients with brain damage. It also operates a multidisciplinary clinic, Cedar Rapids Vision in Motion, which provides low vision and vision skills rehabilitation services, with an emphasis on vestibular and visual skills, as well as a sports vision clinic and concussions, 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 stated. This blog is for informational purposes only and does not replace professional medical advice from a physician. NORA does not recommend or endorse any specific test, physician, product, or procedure. To learn more about our website and online content, click here.