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CME/CE: Neurology
to a behavioral health provider may be
helpful for cognitive behavioral therapy
and to reinforce sleep hygiene techniques.
Balance and vision are two areas that
require additional questions in order to
clarify the true problem. Three systems
maintain balance: the functional nervous
system, the visual system and the vestibular
system. Concussion may cause issues
with vision and/or the vestibular system.
Balance issues may present in a variety
of ways. Many patients complain of “dizziness,”
and clinicians must differentiate what
type of balance difficulties or sensations
they are experiencing. Vertigo causes a
spinning sensation, usually when changing
head position quickly. Benign paroxysmal
positional vertigo is common in association
with concussion and can be treated
by performing a procedure to reposition
the crystals in the semicircular canals of
the inner ear. This is often performed by a
specialist with training in vestibular rehabilitation.
These specialists may include
physical therapists, audiologists or occupational
therapists. Some patients describe
a feeling of rocking on a boat, which can
be indicative of visual disturbances and/or
a milder vestibular issue. In this case, the
patient may require the services of both
vestibular and optometry specialists. Still
others may have occasional lightheadedness
when standing quickly.
Visual problems that may occur after
concussion include photosensitivity,
difficulty maintaining reading focus
(convergence), difficulty with distance
perception (accommodation) and, on
occasion, double vision in one or more
areas of gaze. The patient may or may
not mention these problems, so ask about
vision changes. Regardless of findings,
any patient who reports vision changes
should receive a referral to optometry
or ophthalmology for evaluation with
binocular examination. This examination
can identify difficulties with maintaining
focus. Treatments include eye exercises to
strengthen the ocular nerves and muscles
and possibly a prescription for glasses.
Additional specialties that may be
of benefit, depending on the patient’s
symptoms, are:
• Neurology for management of headaches,
sleep and pain
• Behavioral health professionals for
mood, sleep and pain management, cognitive
testing and related treatment
• Social work and nurse case management
for biopsychosocial evaluation,
education and support based upon this
evaluation
• Speech therapy for evaluation of
speech and language skills, from a foundational
framework
• Occupational therapy for evaluation
of cognitive assessment, from a functional
standpoint
• Audiology for evaluation of tinnitus,
vestibular function and auditory processing
• Physical therapy for evaluation and
treatment of balance, gait and vestibular
management
• Optometry for evaluation of visual
acuity and binocular testing.
Get Connected
Concussions are common and can be a
challenge to treat. The best preparation
is to become familiar with concussion
resources in your area and to equip yourself
with basic knowledge about how to
assess, diagnose and treat mTBI. Table
4 lists resources that can provide further
guidance. ■
References
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States: emergency department visits, hospitalizations,
and deaths: 2002-2006. http://www.cdc.gov/traumaticbraininjury/pdf/blue_book.pdf.
2. Centers for Disease Control and Prevention,
National Center for Injury Prevention and Control.
Report to Congress on mild traumatic brain injury
in the United States: steps to prevent a serious public
health problem. http://www.cdc.gov/ncipc/pub-res/
mtbi/mtbireport.pdf.
3. Armed Forces Health Surveillance Center,
2012. TBI numbers by severity. www.dvbic.org/TBI-
Numbers.aspx.
4. Champion HR, et al. Injuries from explosions:
physics, biophysics, pathology, and required researchfocus.
J Trauma. 2009;66(5):1468-1477.
5. Moss NE, et al. Admissions after head injury:
how many occur and how many are recorded Injury.
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6. Sosin DM, et al. The incidence of mild and moderate
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7. American Congress of Rehabilitation Medicine.
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Trauma Rehabil. 1993;8(3):86-87. http://www.acrm.
org/pdf/TBIDef_English_Oct2010.pdf.
8. Ruff RM, et al; NAN Policy and Planning
Committee. Recommendations for diagnosing a
mild traumatic brain injury: a National Academy
of Neuropsychology education paper. Arch Clin
Neuropsychol. 2009;24(1):3-10.
9. Levin HS, et al. Neurobehavioral outcome following
minor head injury: a three-center study. J
Neurosurg. 1987;66(2):234-243.
10. McCrea MA. Acute Symptoms and Symptom
Recovery. In: Mild Traumatic Brain Injury and
Postconcussion Syndrome: The New Evidence Base
for Diagnosis and Treatment. New York: Oxford
University Publishing Press; 2008: 86.
11. Hoge CW, et al. Mild traumatic brain injury
in U.S. soldiers returning from Iraq. N Engl J Med.
2008;358(5):453-463.
12. Alexander MP. Mild traumatic brain injury:
pathophysiology, natural history, and clinical management.
Neurology. 1995;45(7):1253-1260.
13. Ruff RM, et al. Miserable minority: emotional risk
factors that influence the outcome of a mild traumatic
brain injury. Brain Inj. 1996;10(8):551-565.
14. Department of Veterans Affairs & Department
of Defense. Clinical Practice Guideline. Management
of Concussion/Mild Traumatic Brain Injury. http://
www.healthquality.va.gov/mtbi/concussion_mtbi_
full_1_0.pdf.
15. Guskiewicz KM, et al. Cumulative effects associated
with recurrent concussion in collegiate football
players: the NCAA concussion study. JAMA.
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16. McKee AC, et al. Chronic traumatic encephalopathy
in athletes: progressive tauopathy after
repetitive head injury. J Neuropathol Exp Neurol.
2009;68(7):709-735.
17. National Institute of Neurological Disorders and
Stroke. Traumatic brain injury: hope through research.
Bethesda, MD: National Institutes of Health; 2002.
NIH Publication No.: 02-158. http://www.ninds.nih.
gov/disorders/tbi/detail_tbi.htm.
18. Haydel MJ, et al. Indications for computed tomography
in patients with a minor head injury. New Engl
J Med. 2000;343(2):100-105.
19. Oullet MC, Morin CM. Efficacy of cognitivebehavioral
therapy for insomnia associated with
traumatic brain injury: a single-case experimental
design. Arch Phys Med Rehab. 2007;88(12):1581–1592.
20. King NS, et al. The Rivermead Post Concussion
Questionnaire: A measure of symptoms commonly
experienced after head injury and its reliability. J
Neurol. 1995;242(9):587-592.
21. Ponsford J, et al. Impact of early intervention on
outcome following mild head injury in adults. J Neurol
Neurosurg Psychiatry. 2002;73(3):330-332.
22. Frenchman KA, et al. Neuropsychological studies
of mild traumatic brain injury: a meta-analytic
review of research since 1995. J Clin Exp Neuropsychol.
2005;27(3):334-351.
23. Gioia G, et al. New approaches to assessment
and monitoring of concussion in children. Topics in
Language Disorders. 2009;29(3):266-281.
24. Jagoda AS, et al. Clinical policy: neuroimaging and
decision making in adult mild traumatic brain injury in
the acute setting. Ann Emerg Med. 2008;52(6):714-748.
25. Cifu D, et al. Repetitive head injury syndrome.
http://emedicine.medscape.com/article/92189-overview.
26. Arciniegas DB, et al. Mild traumatic brain injury: a
neuropsychiatric approach to diagnosis, evaluation, and
treatment. Neuropsychiatr Dis Treat. 2005;1(4):311-327.
27. Zasler ND. Advances in neuropharmacological
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