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Concussion in Kids: Less-Recognized Visual Changes

Here, Christina Master, MD, a pediatric sports medicine specialist at the Children’s Hospital of Philadelphia (CHOP) talks about vision issues following concussion in children.

«In our clinical and research practice here at CHOP, we have found that a number of children have visual issues after a concussion, but they’re not typically visual acuity issues. This is something we’d like to get the message out about.

The kids we see in our offices who have had a concussion often also have oculomotor issues (eye movements), whether they are related to problems with smooth pursuits (following an object), saccadic function (going from one object to another), or the vestibulo-ocular reflex function (vision and balance).

We find that they are often very sensitive to motion and vestibular stimuli, especially from busy and active environments. We also find that they have issues in school in regard to looking back and forth between a notebook, smartboard, monitor, or tablet. We’d like you to keep an eye out for these oculomotor issues. Many of them also seem to be related to binocular visual function (how the eyes function together); in particular, we notice that a convergence insufficiency can be a problem. These kids have problems focusing on objects that are far, and then transitioning from far to near and near to far again.

Photo from: https://www.todaysparent.com/kids/kids-health/concussions-hockey-problem/

As you can imagine, much of schoolwork is very visually oriented, and these issues can present problems. What we would encourage everyone to remember when assessing a child who has had a concussion is not only to look at visual acuity but also to assess oculomotor function, including smooth pursuits, saccades, and convergence. In treating these kids as they gradually return to school, it is also often helpful to recommend accommodations to allow them to have extra time, printed notes, larger-font printed materials, and, in general, extra support from a visual standpoint while their functions recover over time.

Please remember these issues when you’re evaluating kids in your office with concussion. Remember that these issues are not just about visual acuity but also include oculomotor and binocular visual issues like convergence insufficiency.»

From: http://www.medscape.com/viewarticle/876689

 

Eye Test Screens for Traumatic Brain Injury, Concussion

 

 

Photo from: https://www.washingtonparent.com/articles/1503/1503-concussions-in-kids-dr-bills-advice-for-worried-parents.php

Of the more than 340,000 cases of traumatic brain injury clinically confirmed from 2000 to 2015, mild injury accounted for 82.5%, according to US Department of Defense statistics.

However, traumatic brain injury is often only identified when moderate or severe head injuries have occurred, leaving mild cases undiagnosed, Dr Capó-Aponte and his colleagues explain in their scientific poster.

“Since approximately 30 areas of the brain and seven of the 12 cranial nerves deal with vision, it is not unexpected that the patient with traumatic brain injury may manifest a host of visual problems, such as pupillary deficit, visual processing delays, and impaired oculomotor tracking and related oculomotor-based reading dysfunctions,” Dr Capó-Aponte pointed out.
To see whether they could identify reliable biomarkers of mild traumatic brain injury that could be detected with an easily reproducible screening test, he and his colleagues looked for subtle visual changes that could be measured in the office or in the field.

From: http://www.medscape.com/viewarticle/865691

Vision and the Brain

The visual system includes 25 neocortical areas that are predominantly or exclusively visual in function, plus an additional 7 areas that are regarded as visual-association areas on the basis of their extensive visual inputs. A total of 305 connections among these 32 visual and visual-association areas have been reported. This represents 31% of the possible number of pathways if each area were connected with all others. The actual degree of connectivity is likely to be closer to 40%. The great majority of pathways involve reciprocal connections (in both directions) between areas.

From : https://www.ncbi.nlm.nih.gov/pubmed/1822724

 

Since approximately 60% of the nerve pathways are related to the processing of visual information, it is not surprising that severe visual problems occur in one or more concussions.

 

10 things you need to know about concussions

1. A concussion is a brain injury that can cause a variety of easy-to-miss symptoms. Doctors can’t “see” concussions using imaging. You don’t need to lose consciousness and a well-fitting helmet will not necessarily prevent one.

2. Symptoms can include headache, nausea, vomiting, light sensitivity, dizziness, confusion, slurred speech, poor balance, irritability, memory problems, blurred vision, sleepiness, sadness, anxiety or feeling in a fog. If you suspect a concussion, call the doctor.

3. If his head hurts, he’s off the ice, no questions asked. It doesn’t matter if he’s in the third period of a tied championship game.

4. Do not give Advil or Aspirin. Administered in large amounts, Advil and Aspirin can cause further bruising or internal bleeding. Tylenol is a safer bet; ask your doctor about proper dosages.

5. For the first 48 hours, be vigilant for signs of deterioration. Severe headache or persistent vomiting means you should go to the ER.

6. Concussion risk increases with each one. The brain is more likely to get reinjured if it hasn’t properly healed the first time. A child’s brain needs both physical and mental rest to heal (no jumping, no math problems).

7. Screens exacerbate a concussion headache. That means you have to limit the three things kids are most addicted to: TV, computer and phone.

8. If he says his head hurts, and the pain won’t go away, believe him—even if, ordinarily, your kid will do anything to skip school. The boredom of staying home and off screens will drive him—and you—so batty, there’s no way he’s faking.

9. His brain needs to rest in a dim room. This means no screens, pulling the curtains and keeping sunglasses handy. Contact teachers about making up homework in stages and catching up gradually.

10. Don’t send him back to school or sports until he’s symptom-free. Even with a mild concussion, this means no school or sports for at least a week—sometimes two.

From: https://www.todaysparent.com/kids/kids-health/concussions-hockey-problem/

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Concussions and Vision – 2

Photo JPL-blogueA concussion is a traumatic brain injury that alters the way your brain functions. Effects are usually temporary but can include headaches and problems with concentration, memory, balance and coordination. Although concussions usually are caused by a blow to the head, they can also occur when the head and upper body are violently shaken. These injuries can cause a loss of consciousness, but most concussions do not. Because of this, some people have concussions and don’t realize it. Concussions are common, particularly if you play a contact sport, such as football. But every concussion injures your brain to some extent. This injury needs time and rest to heal properly. Most concussive traumatic brain injuries are mild, and people usually recover fully. The signs and symptoms of a concussion can be subtle and may not be immediately apparent. Symptoms can last for days, weeks or even longer. Concussion01Common symptoms after a concussive traumatic brain injury are headaches, loss of memory (amnesia) and confusion. The amnesia, which may or may not follow a loss of consciousness, usually involves the loss of memory of the event that caused the concussion. The post-concussion syndrome is a complex disorder in which various symptoms such as headaches and dizziness pain can last for weeks and sometimes months after the injury that caused the concussion. A concussion is a mild traumatic brain injury, usually following a blow to the head.

Loss of consciousness is not necessary for a diagnosis of concussion or post-concussion syndrome. In fact, the risk of post-concussion syndrome brain does not appear to be associated with the severity of the initial injury. In most people, symptoms of post-concussion syndrome occur in seven to ten days after the blow and may disappear within three months, but may also persist for a year or more.

Reduced cognitive abilities with visual activities

Visual perceptual deficits can be caused by concussions and have dramatic effects on school and even athletic success. Speed of visual processing and visual reaction time can be reduced. Processing speed may slow in an athlete both on and off the field. The speed with which an athlete processes visual information affects many aspects of competitive sport, including reading of the playing field, the judgment of the speed of a moving ball or puck, and judgment the speed of the other players in the field.

Post-traumatic visual syndrome and midline shift syndrome

Following a neurological event such as a traumatic brain injury, cerebrovascular accident, multiple sclerosis, cerebral palsy, etc., it has been noted by clinicians that persons frequently will report visual problems such as seeing objects appearing to move that are known to be stationary; seeing words in print run together; and experiencing intermittent blurring. More interesting symptoms are sometimes reported, such as attempting to walk on a floor that appears tilted and having significant difficulties with balance and spatial orientation when in crowded moving environments. These types of symptoms are not uncommon. Frequently, persons reporting these symptoms to eye care professionals (optometrists and ophthalmologists) have been told that their problems are not in their eyes and that their eyes appear to be healthy. What is often overlooked is dysfunction of the visual process causing one of two syndromes: Post Trauma Vision Syndrome (PTVS) and/or Visual Midline Shift Syndrome (VMSS). Recent research has documented PTVS utilizing Visual Evoked Potentials (VEP). This documentation concludes that the ambient visual process frequently becomes dysfunctional after a neurological event such as a TBI or CVA. Persons can often have visual symptoms that are related to dysfunction between one of two visual processes: ambient process and focal process. These two systems are responsible for the ability to organize ourselves in space for balance and movement, as well as to focalize on detail such as looking at a traffic light.

Post Trauma Vision Syndrome results when there is dysfunction between the ambient and focal process causing the person to over emphasize the details. Essentially individuals with PTVS begin to look at paragraphs of print almost as isolated letters on a page and have great difficulty organizing their reading ability. It has been found that the use of prisms and binasal occlusion can effectively demonstrate functional improvement, while also being documented on brain wave studies by increasing the amplitude (this is like turning up the volume on your radio). Concussion02 Visual Midline Shift Syndrome also results from dysfunction of the ambient visual process. It is caused by distortions of the spatial system causing the individual to misperceive their position in their spatial environment. This causes a shift in their concept of their perceived visual midline. This will frequently cause the person to lean to one side, forward and/or backward. It frequently can occur in conjunction with individuals that have had a hemiparesis (paralysis to one side following a TBI or CVA). The shifting concept of visual midline actually reinforces the paralysis, by using specially designed yoked prisms that can be prescribed, the midline is shifted to a more centered position thereby enabling individuals to frequently begin weight bearing on their affected side. This works very effectively in conjunction with physical and occupational therapy attempting to rehabilitate weight bearing for ambulation.

The symptoms of the syndrome shift of midline visual may include:

  • dizziness or nausea
  • spatial disorientation
  • always heading towards the right or left along a corridor
  • locomotion or posture problems as to lean back on your heels, forward or to one side when walking, either standing or sitting in a chair
  • perception of uneven pavement (or having a sloping side or the other)
  • neuromotor difficulties associated with balance, coordination and posture

Fortunately, many vision problems after a concussion can be resolved with rest and by allowing the brain to heal. But there are still many problems that can linger even after years, especially regarding spatial localization. Vision therapy, also called neuro-optometric rehabilitation, can be very effective in cases where visual symptoms persist, even when other symptoms such as dizziness or balance problems are solved.

Reading problems and concussion Reading deficits can come from various problems after stroke or injury or a blow to the head. It is crucial that the type of reading problem is diagnosed. Problems can occur individually or as part of a constellation of related problems PTVS. The treatment of PTVS by various neuro-optometric rehabilitation interventions can solve many of the problems. In the next article, we will continue discussing visual problems and concussions.

Source : Lagacé JP. Les commotions cérébrales et la vision – généralités. Revue L’Optométriste – Volume 37 No 2, Mars-avril 2015.

Children, adults and mTBI (mild traumatic brain injury) – 1

Photo JPL-blogueNote: since the beginning of this blog, I have mainly discussed visual problems related to learning problems and on the subject of myopia, I will now include a new topic (after one year of leave – to finish a book for optometrists) people are talking more and more about: brain injury (mild, moderate or severe) in children.

These blows to the head cause a multitude of symptoms including sensory deficits affecting, among others, vision and perception. With regard to these two aspects, symptoms often go unnoticed or people do not realize or forget that many of these complaints relate to visual-perceptual aspects.

Vision therapy can be not only very practical and effective but many times essential. After evaluation, examination and consultation, the optometrist determines how a person processes information after an injury and where that person’s strengths and weaknesses lie. The optometrist then prescribes a treatment regimen incorporating lenses, prisms and specific activities designed to improve control of a person’s visual system and increase vision efficiency. This in turn can help support many other activities in daily living.

A mild traumatic brain injury (mTBI), also referred to as a concussion, is a disturbance in brain function that can be caused by a blow to the head, jaw, face, neck or body.

Disorders that result from brain injury can affect all brain functions – awareness, motor skills, language, behavior, character and cognitive functions and, in children, impair the ability of future learning. (1)

Road accidents, domestic accidents, sports accidents (skiing, biking, horseback riding …) and violence (shaken baby syndrome, attacks …) are the main causes of head trauma in children. (1)

Common signs and symptoms of an MTBI

  • headaches
  • nausea and vomiting
  • dizziness
  • loss of consciousness
  • feeling dazed and confused
  • memory loss
  • poor balance or coordination
  • drowsiness
  • irritability
  • agitation
  • fatigue

Signs and symptoms following an MTBI usually last 1 to  3 weeks but may occasionally last longer. Frequently reported are: headache, dizziness, nausea, sleep disturbances, fatigue, irritability and restlessness, sensitivity to light, sound and motion, difficulty with memory, concentration, attention span, judgment or balance.

We will see later that all these symptoms may in fact last much longer than we can imagine…

(1) http://www.integrascol.fr/fichemaladie.php?id=68