Getting Ahead of Post- Concussive Syndrome

Jaime M. Levine, D.O.Brian S. Im, M.D.Heidi N. Fusco, M.D.Emilia Ravski, D.O.

Agenda

•Course is geared towards the difficult concussion patient in the office setting

•Segments1. In-office assessment, Dr. Fusco2. Rehabilitation Interventions, Dr. Im3. Pharmacology, Dr. Levine4. Research on the horizon, Dr. Ravski5. Cases Studies6. Q&A

•FacultyBoard-Certified in Brain Injury MedicineAt Rusk /321

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• Sony Altered ‘Concussion’ Film to Prevent N.F.L. Protests, Emails Show• Robert Griffin III Out With Concussion as the Redskins Reverse Call• Concussions Can Occur in All Youth Sports• Concussion Deal Is Challenged in Court as Insufficient• An Ex-Player at the Center of the N.F.L. Concussion Settlement Dispute• Defending the N.F.L. Settlement of a Concussion Suit• N.F.L.’s Bogus Settlement for Brain-Damaged Former Players• Daughter Honors Seau Onstage at a Celebration Under a Cloud•Mike Pyle, Captain of 9-0 Yale Team and Champion Bears in ’63, Dies at 76• Cloud Hangs Over Hall of Fame Farewell to Junior Seau• Junior Seau’s Family Will Not Be Allowed to Speak at His Hall of Fame Induction• Former Player Opposes Settlement in N.C.A.A Concussion Suit• Ray McDonald, Cut by the Bears on Monday, Is Arrested Again• A Football Player’s Safe Exit• N.F.L. Suspends Use of Helmet Sensors• Family Sues Pop Warner Over Suicide of Player Who Had Brain Disease

(Summer, 2015)

What Is Post-Concussive Syndrome?

•Persistence of symptoms following concussion over a prolonged period of time

•Incorporates somatic, psychological, behavioral, sleep, and cognitive difficulties

•Physiologic effects result in more effort required to perform cognitive and physical tasks leading to fatigue

•No structural injury

The Office Assessment of Post-Concussive Syndrome

Heidi N. Fusco M.D.Clinical Instructor Rusk RehabilitationNYU School of Medicine

Patient History

•Before entering office patient fills out SCAT 3 Symptom Inventory

22 items self-rated on 7-point Likert scaleCan be used seriallyReliable and valid

•Fill out each visit

•Also ask about seizure, falls, bowel/bladder changes, tinnitis, neck pain

Graded Symptom Checklist (GSC)

•Headache•Pressure in head •Neck pain•Nausea/vomiting•Dizziness•Blurred vision •Balance problems•Sensitivity to light •Sensitivity to noise •Feeling slowed down •Feeling like in a fog

•Don't feel right •Difficulty concentrating •Difficulty remembering •Fatigue or low energy •Confusion •Drowsiness •Trouble falling asleep •More emotional •Irritability •Sadness •Nervous or anxious

Patient history

•Date of injury•Work, non-work related•Mechanism of injury•Loss of consciousness•Symptoms after concussion •ED / Urgent care evaluation•Imaging •Treatment: clinicians, medications, therapies•How have symptoms progressed•Most problematic symptom•Hx of disability, ADHD, or other developmental disorder. •Hx of anxiety or depression, or other psychiatric problems•Litigation

Rest of History

•History of prior head injury•PMH•PSH•FH•SH•Meds•Allergies

Focused exam pending patient presentation

•Neurological exam

•Physical exam to focus on system that could explain prolonged symptoms.

weakness/hair loss/cold skin ~ hypothyroidismdistended abdomen ~ gi problem

•Cervical ROM, Tenderness

Concussion-Specific tests and limitations

•Standardized Assessment of Concussion (SAC)Sensitivity in first 48 hours

•King-Devick Test

•Modified Balance Error Scoring System (M-BESS)Full BESS has better sensitivity

•Military Acute Concussion Evaluation (MACE)Not valid if more than 12 hours after injury

•Vestibular/Ocular Motor Screening (VOMS)

Cognitive Assessment/Standardized Assessment of Concussion (SAC)

Orientation- 5 pts

Immediate memory of 5 words practiced 3 times- 15 pts

Concentration- 5 pts

Delayed recall of 5 words- 5pts

King-Devick Test

•1-minute test

•Measures speed and accuracy of reading aloud single digit numbers from 3 test cards.

•Tests for impairments of eye movements, attention, language, and other correlates of suboptimal brain function.

•Found to be accurate and reliable in identifying athletes with head trauma on sideline and in office

Modified Balance Error Scoring System (M-BESS)

•Evaluation of 3 stances on firm surface only

1. Feet together, hands on hips and eyes closed x 20 seconds

2. Feet in tandem, hands on hips and eyes closed x 20 seconds

3. 1 foot lifted, hands on hips and eyes closed x 20 seconds

•Score: errors out of 30, higher score worse

• http://www.knowconcussion.org/concussion-management/balance-error-scoring-system-bess/

Vestibular/Ocular Motor Screening (VOMS)

•Assesses vestibular and ocular motor impairments with patient reported symptoms provoked in 5 assessments:

1. Smooth pursuit2. Horizontal and vertical saccades3. Convergence4. Horizontal vestibular ocular reflex5. Visual motion sensitivity

•Found to be sensitive in identifying concussed patients

•Correlated with PCSS (GSC)

Clinical Pearls

•Pre-office questionaires can focus complicated history

•Set questions in office, standardized

•Focus treatment plan on most bothersome symptoms

•SCAT 3, King-Devick test, M-BESS, and VOMS can pick up subtle deficits in attention, concentration, processing speed, orientation, memory, language, balance, vestibular and ocular function.

Rehabilitation Management of Concussion

Brian S. Im M.D.Assistant ProfessorRusk RehabilitationNYU School of Medicine

Learning Objectives

•The Learner will be able to identify post-concussive syndrome

•The Learner will be able to recognize the role of rest and exercise in concussion and post-concussive syndrome

•The Learner will understand the different rehabilitation treatment options available for management of persistent concussion symptoms

What Are Some Common Concussion Symptoms?

•Fatigue•Pain•Dizziness•Blurry or Double Vision•Balance Difficulties•Hypersensitivity•Memory Problems •Concentration Difficulties•Irritability•Sleep Disturbance

How Long Should I Rest?

•Unclear what the optimal time for cognitive and physical rest should be but most agree rest is beneficial early on in recovery course

•Recent studies show a graded sub-symptomatic exercise program is beneficial for those with prolonged symptoms

What Is The Current Recommendation For Return To Activity After Resolution Of Concussion Symptoms?

•Return to full cognitive activities should precede return to physical activities

•In regards to sports, follow a gradual step by step regimen for safe return to play after full cognitive recovery

•Student athletes should return to full classes/academic work prior to return to play

Step-by-Step Regimen for a Safe RTP

•Athletes should spend 24-48 hours at each level before progressing to the next

•If symptoms return at any point, the athlete should drop down a step for 24 hours then proceed with the progression as tolerated

•Stages:1. Rest (physical and cognitive)2. Light aerobic exercise3. Moderate to intense aerobic exercise4. Sport-specific activities/noncontact training drills5. Full contact activities6. Game play

What Are Common Treatment Options In A Concussion Rehab Program?

•Vestibular Therapy•Vision Therapy•Physical Therapy•Cognitive Retraining•Psychotherapy and Counseling/Support•Behavioral Management•Vocational Counseling and School Support•Concussion Education•Home Exercise Program

What Is Vestibular Therapy?

•Balance retraining

•Dizziness management

•Reset inner ear equilibrium

What Is Vision Therapy?

•Often done in conjunction or part of a vestibular therapy program

Convergence retraining

Eye movement and tracking retraining

Adaptations for photosensitivity

What Can Physical Therapy Offer for Concussion Management?

•Neck dysfunction can often exacerbate concussion symptoms such as headache

Pain management modalities

Stretching

Manual techniques

What Is The Role of Cognitive Therapy?

•Cognitive dysfunction usually manifests in executive function difficulties

Compensatory strategy training

Cognitive retraining exercises

Is There A Role For Psychological Counseling?

•Psychological problems such as anxiety and depression can exacerbate and prolong concussion symptoms

•Cognitive behavioral therapy

Individual psychotherapy

Support groups

How About Treatment For Behavioral Issues?

•As with other forms of trauma to the brain, emotional control and behavioral difficulties can be seen after a concussion

•Often done in conjunction with psychological treatment

Behavioral management strategies

Social re-integration strategies

Counseling and support

Any Further Rehabilitation Services That May Be Helpful?

•Home Exercise ProgramTo carry over gains learned in therapy

•Concussion EducationNormalization of concussion symptomsFacilitate understanding of complexity of issues

•School ServicesAssist with return to learn and school planLiaison with school administrationResource for feedback and support

Summary

•Persistent concussion symptoms are often rooted in a complex interaction between physical/physiologic and psychological factors and neither aspect should be ignored

•A comprehensive rehabilitation and medical management program can aide in recovery for patients with persistent symptoms following a concussion

•There is a role for both cognitive rest and physical activity in the recovery from concussion. Current evidence suggests treatment for concussion symptoms that persist after an initial period of rest is to consider a sub symptomatic graded exercise program.

The Role of Pharmacology in Management of Post-Concussive Syndrome

Jaime M. Levine, D.O.Clinical Assistant ProfessorRusk RehabilitationNYU School of Medicine

Why Use Pharmacology in PCS?

•How do we recover from a brain injury?

1. Spontaneous recovery

2. Rehabilitation strategies

3. Secondary prevention

4. Pharmacology

Neuropharmacology Rules of Thumb

•Limit polypharmacy •Start low and go slow•Informed consent essential•Seek feedback from interdisciplinary team•Reevaluate often•Strive for one prescriber•If past psychiatric history or significant headache history, consider referring back for continued management•Withdrawal of an agent to see if spontaneous recovery has caught up

Agents to Support Better Sleep

Melatonin: What We Know

•Melatonin has value for sleep disorders following head injury.

•Consensus is that about 30% of patients following head injury have insomnia.

•Little published on its use in TBI

•One case report of a 15-year old girl with head trauma who developed a delayed sleep phase syndrome. (Nagtegaal, J.E. 1997)Physiological markers monitored:

Sleep-wake rhythm, plasma melatonin, body temp, wrist activityAll markers returned to normal after treatment with 5mg melatonin

•A few studies on melatonin in neurologically impaired children with neutral to favorable results.

•Ramelteon is a pharmaceutical grade analogue of melatonin

• Jorge et al, 2010

Melatonin and Amitriptyline: What We Know

•Melatonin and Amitriptyline have value for sleep disorders following head injury.

• Kemp et al (2004) did a randomized double-blind controlled cross-over trial with melatonin (5mg) or amitriptyline (25mg).Minimum 6 months post-TBI16-65 y/oSleep variables measured:

1. Alertness2. Duration3. Quality4. Latency

Also measured neuropsychological functioning and moodResults:

Melatonin: improved daytime alertness Amitriptyline: improved sleep duration and shortened latency Most patients were unimpaired on neuropsychological tests of

attention and speed of processing No changes in cognitive performance or mood No adverse drug effects

Trazodone: What We Think We Know

•Trazodone is a multifunctional drug that helps patients with TBI sleep.

•Mechanism of action is unique: has dose-dependent actions

Hypnotic actions at low doses due to blockade of:5-HT2A receptorsH1 histamine receptorsAlpha1 adrenergic receptors

Higher doses block the serotonin transporter (SERT) and have antidepressant properties

(Stahl, 2009)

Agents to Support Healthy SleepTake Home Points From the Literature:

•Melatonin and amitriptyline have value for sleep disorders following head injury.

•Ramelteon is a pharmaceutical grade analogue of melatonin

•Trazodone is a multifunctional drug that helps patients with TBI sleep.

Agents to Support Healthy SleepAnecdotes from My Practice:

•Ramelteon at 4mg dosing is great to have onboard.Few to no contraindicationsViewed as a “supplement” not drug to some

•Trazodone 50-200mg QHSCaution in young menAvoid with other serotonergics, especially at higher doses

Antidepressant effect at higher doses

•Neurontin Back-load dosing• Instead of 300mg Q8, can give 300mg QAM and 600mg QHS

•Mirtazapine 7.5mg, may increase to 15mg

Antidepressant effectsCan increase appetite

Headache Management

Post-Traumatic Headaches

• Definition Onset usually within 7 days, but within 3 months usually accepted as post-traumatic

An underlying primary HA disorder exacerbated by TBI

• Treatment GoalsAbort attackDecrease frequency/duration

Decrease severity/disabilityPrevent chronicity

•Before MedicationsAvoid triggersEmphasize healthy diet, sleep, exercise (if appropriate) and stress management

Identify comorbidities in preparation for drug selection

Mood disorder Seizures Poor sleep Other types of pain

Post-Traumatic Headaches: Treatment Considerations

•Considered chronic if persist > 3 months

•If persist > 6 months, likely to continue for many more months

•If persist beyond 2 months, consider prophylactic therapy

If multiple stressors or co-morbidities, consider earlier

•Prophylactic Rx may take up to 4 weeks to take full effect

Post-Traumatic Headache Pharmacotherapy by HA Type

Tension Migraine

Abortive Tx NSAIDs NSAIDs or Triptans (<3X/week). Avoid opioids

When to Prophylax

If >10 HA/month and significant disability

If >2 HA/week not relieved by abortive therapy

Prophylactic Tx AmitriptylineNortriptyline

Topiramate Amitriptyline or nortriptylinePropranolol LA Valproate Gabapentin Onabotulinum toxin A

Post-Traumatic Headache Pharmacotherapy by HA Type

Cervicogenic Occipital Neuralgia

Workup Imaging

Intervention Trigger Point Injections Occipital Nerve Block

Adjuvant Therapy

Physical Therapy

Gabapentin

Nortriptyline/Amitriptyline

NSAIDs

Trileptal

Gabapentin

NSAIDs

Mood Changes

When Mood is Affected

•Combination of post-traumatic headache, poor sleep and depressed mood amitriptyline or nortriptyline

•Depression or anxiety alone vast sea of medications to choose among

•Premorbid history of depression or anxiety Adjust dose of current regimenSimply add non-pharmacological strategies to treat exacerbationRefer back to original treater

A Word on Fatigue

•Fatigue is one of the most troubling and disabling symptoms following any type of brain injury.•Secondary versus primary fatigue/physical versus mental fatigue•Compounded secondary fatigue in PCS is multifactorial:

RestMedicationsPainMental fogginess•How to treat?

ExerciseStreamlining fatiguing activitiesAllow time and spontaneous recovery to help

Emilia Ravski, D.O.

Primary Care Sports Medicine Fellow University of Pittsburgh Medical Center

Physical Medicine and Rehabilitation Resident, Class of 2015 NYU-Langone Medical Center Rusk Rehabilitation

New Research in Post-Concussive Syndrome

• Prospective cohort study

• Examined the concentration of plasma T-tau and serum S-100B and NSE

• Included 88 professional Ice Hockey players from the Swedish Hockey League

• Baseline levels collected from players

• 28 concussed players– Blood levels collected at:

• 1, 12, 36, 48 and 144 hours after injury

• T-tau levels were significantly higher in all samples after concussion compared to pre-season

• T-tau and S-100B at 1hr– Highest levels – Correlated with the number of days it took for concussion symptoms to resolve

• T-tau level at 1hr – Predicted the duration of symptoms and time to return to play

• T-tau level at 144hrs – Significantly elevated in players with PCS for more than 6 days vs players with PCS for less than 6 days

• No significant difference in NSE levels

Serum tau Fragments Predict Return to Play in 

Concussed Professional Ice Hockey PlayersShahim P, Linemann T, Inekci D, Karsdal MA, Blennow K, Tegner Y, Zetterberg H, Henriksen K. J. Neurotrauma. 2015 Jan 26.

• Fragmented Total-tau into tau-A and tau-C

• Serum tau-A concentrations– Were higher in those with PCS vs short term symptoms – Potentially can be utilized as a predictive factor for RTP

• Retrospective, case-control study

• Used the Vanderbilt Concussion Clinic Database to identify athletes who sustained a concussion while playing sports– Study group

• 40 athletes (9-18yo) who reported PCS (> 3months)– Control group

• 1:2 matched controls who reported resolution of

symptoms by 3 weeks

• Variables evaluated– Demographics– Medical, psychiatric and family history– Acute post injury symptoms (0-24hrs)– Subacute post injury symptoms (0-3wks)

J Neurosurg Pediatr. 15:589-598, 2015

• Risk for development of PCS – Personal history

• Mood disorders• Psychiatric illness• Significant stressors

– Family History• Mood disorders• Psychiatric illness• Migraine

– Delayed symptom onset (≥3 hrs post injury)• 10 times more prevalent among athletes with PCS compared to control group

– No association found between initial symptoms (0-24hr) or delayed symptoms (0-3weeks) and development of PCS

J Neurosurg Pediatr. 15:589-598, 2015

• Data gathered from a randomized controlled trial that examined the efficacy of a web-based psychoeducational intervention on PCS (Belanger et al. Milt Med. 2015)

• 158 participants with a self-reported mTBI within 2 yrs and symptomatic at time of enrollment – Civilian and military – 18-55 years of age

• Web based questionnaire used to evaluate: • Sleep quality Copyright © Cedric Hohnstadt 2011. All rights reserved.

– Psychologic Distress– Postconcussion symptoms

• Higher distress level and worse sleep

quality were associated with greater

severity of postconcussion symptoms– Psychological distress was a more significant factor– Difficulty falling asleep was the main quality of sleep complaint

Hyperbaric Oxygen

Postconcussion Syndrome

• Multicenter, double blind, sham-controlled clinical trial

• 72 military service members with ongoing symptoms at least 4 months after mTBI– All participants received routine PCS care– Randomized into 3 groups

• 40 HBO sessions administered at 1.5 atmospheres absolute (ATA) • 40 sham sessions consisting of room air at 1.2 ATA • No supplemental chamber procedures

• Primary outcome measure– The Rivermead Post-Concussion Symptoms Questionnaire (RPQ)

• Secondary outcome measure– Neurobehavioral Symptom Inventory

JAMA Intern Med.2015;175(1):43-52

• HBO showed no benefit over an air sham compression procedure

• Symptoms in both HBO and sham groups improved compared to those without supplemental chamber treatment

– Improvement likely due to placebo effect

JAMA Intern Med.2015;175(1):43-52

Thank you!

Cases

The Unhappy Bus Driver

•52 yo male presents with his wife 3 years after he lost control of an empty school bus and drove into a telephone pole•+ LOC “doesn’t know”•Went to ED via ambulance CT neck and head negative. Discharged home•Since injury has been unable to work, has had severe deficits in ability to function and perceived cognition, has had vision changes, headache, neck pain, nausea, photo/phono sensitivity, weakness, complains of falling 3 times per week. •Has seen >10 physicians and done PT. Would also like scripts for Xanax, oxycodone, oxycontin.•MRI of head WNL, neck with mild DJD•Symptom inventory on SCAT3 is 6/6 on all 22 questions•On exam, medical exam normal, tender back muscles diffusely, +crying during SCAT 3 questions, King Devick test elicits crying and unable to stand without his cane. •There is pending litigation

The Cabinet Injury

•46 year old female ER RN stood up quickly and hit head on open cabinet. No LOC. + Subgaleal hematoma on inspection. No CT imaging. •Went to occupational health, told to go home, reported to ED after 24 hours with worsening HA, photo and phono-sensitivity. Exam normal, No CT imaging•Presents after 3 weeks with ongoing symptoms of 10/10 headache, neck pain, photosensitivity, dizziness, and reported deficits in speech, language, and attention. •On exam, WNL medical exam, TTP of cervical paraspinals diffusely and normal ROM of neck with guarding, + horizontal nystagmus with EOM, BESS Normal, and good performance on King Devick. On SCAT 3 questions everything normal except 0/5 on delayed recall.

Prescribed Treatment

•Taken out of work for 6 weeks

•Rx for vestibular rehabilitation

•Neuroophthalmology referral

The Childcare Worker

•22 year old female presents 2 days after being hit in head with a wooden block thrown by a 3 year-old.•Has been working, but is very irritable and fatigued. Unable to tolerate reading or computer use. + HA, Dizziness, and reports vertigo, photo and phono sensitivity•Only taking homeopathic agents and will not take medications•She went to the gym this morning but had to stop her workout on the elliptical after 3 minutes for dizziness, fatigue and headache.•4-5/6 on SCAT 3 symptom inventory•On exam everything within normal range.

High School Interrupted

•15 y/o healthy male with no significant past medical history is brought in by his parents with reports of multiple concussions over past several years.

•Major symptoms include: headache, photo- and phonosensitivity, dizziness

•He has been out of high school for the past two years because his concussion symptoms have been too severe to tolerate an academic or structured setting.

•Has had numerous neuroimaging tests.

•Has tried many types of therapies, including conventional rehabilitation (vestibular, vision) as well as hyperbaric O2 and acupuncture.

•Can’t participate in any cognitive, physical, or structured task for longer than 15 minutes prior to needing to lie down for an hour in a dark, quiet room.

•Neuro exam normal

The Roller Dancer

•58 y/o female with history of multiple episodes of hitting head on obstacles in her path. The first instance was due to a “claustrophobic crisis” as she felt confined in a small crowded area, and ran out of there in a rush to find more space. The second was also when she was in a rush, because she ran into an open door on her right side.

•She reports several other similar stories, none involving LOC.

•Has noticed a reduction in her ability to perform during her roller dancing practice sessions, and an inability to write calligraphy as was her hobby.

•Saw her primary care physician who suggested she follow-up with her psychiatrist for exacerbation of underlying psychiatric illness, including claustrophobia and mild OCD.

The Roller Dancer (Continued)

• On Exam: Neuro exam is non-focal except for a dense right homonymous hemianopsia.

The Roller Dancer (Continued)

• Sent for ED where CT of her head which revealed a hemorrhagic mass.

• Admitted for workup. MRI revealed a large hemorrhagic mass in her left parieto-occipital junction.

• Went to the OR for removal the next day and is currently undergoing adjuvant treatment for a high grade glioma.

The Roller Dancer

Jaime.Levine@nyumc.orgBrian.im@nyumc.org

Heidi.fusco@mountsinai.orgRavskie@upmc.edu

Questions?

References

•Galetta et al. The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters . Neurology 76 April 26, 2011 •Galetta KM, et al, The King–Devick test and sports-related concussion: Study of a rapid visual

screening tool in a collegiate cohort, J Neurol Sci (2011), doi:10.1016/j.jns.2011.07.039 • Iverson GL. Silverberg N. Lange RT. Zasler ND. Conceptualizing outcome from mild traumatic brain

injury. In: Zasler ND, Katz DI, Zafonte RD, editors. Brain Injury Medicine. 2nd ed. New York: Demos medical; 2013. p 470-97.• Collins MW. Iverson GL. Gaetz MB. Meehan WP. Lovell MR. Sports-related concussion. In: Zasler

ND, Katz DI, Zafonte RD, editors. Brain Injury Medicine. 2nd ed. New York: Demos medical; 2013. p 498-516.•Makdissi M. Cantu RC. Johnston KM. McCrory P. Meeuwisse WH. The difficult concussion patient:

what is the best approach to investigation and management of persistent (>10 days) postconcussive symptoms?. [Review]. British Journal of Sports Medicine. 47(5):308-13, 2013 Apr. • Schneider KJ. Iverson GL. Emery CA. McCrory P. Herring SA. Meeuwisse WH. The effects of rest

and treatment following sport-related concussion: a systematic review of the literature. [Review]. British Journal of Sports Medicine. 47(5):304-7, 2013 Apr. • Leddy JJ. Kozlowski K. Donnelly JP. Pendergast DR. Epstein LH. Willer B. A preliminary study of

subsymptom threshold exercise training for refractory post-concussion syndrome. Clinical Journal of Sport Medicine. 20(1):21-7, 2010 Jan. • Lange RT. Iverson GL. Rose A. Depression strongly influences postconcussion symptom reporting

following mild traumatic brain injury. J Head Trauma Rehabil 26:127–37, 2011.

References

• Alsalaheen BA. Mucha A. Morris LO. Whitney SL. Furman JM. Camiolo-Reddy CE. Collins MW. Lovell MR. Sparto PJ. Vestibular rehabilitation for dizziness and balance disorders after concussion. Journal of Neurologic Physical Therapy. 34(2):87-93, 2010 Jun. •Gottshall K. Vestibular rehabilitation after mild traumatic brain injury with vestibular pathology.

Neurorehabilitation 29:167–71, 2011.• Doble JE. Feinberg DL. Rosner MS. Rosner AJ. Identification of Binocular Vision Dysfunction

(Vertical Heterophoria) in Traumatic Brain Injury Patients and Effects of Individualized Prismatic Spectacle Lenses in the Treatment of Postconcussive Symptoms: A Retrospective Analysis. PM&R 2(4):244-53, 2010 Apr.• Scheiman M. Cooper J. Mitchell GL. A survey of treatment modalities for convergence insufficiency.

Optom Vis Sci. 79(3):151-7, 2002• Jull G. Trott P. Potter H. A randomized controlled trial of exercise and manipulative therapy for

cervicogenic headache. Spine 27(17):1835-43, 2002.• Helmick K. Members of Consensus Conference. Cognitive rehabilitation for military personnel with

mild traumatic brain injury and chronic post-concussional disorder: Results of April 2009 consensus conference. Neurorehabilitation 26(3):239-55, 2010. • Potter S. Brown RG. Cognitive behavioural therapy and persistent post-concussional symptoms:

integrating conceptual issues and practical aspects in treatment. Neuropsychological Rehabilitation. 22(1):1-25, 2012. •Gagnon I. Galli C. Friedman D. et al. Active rehabilitation for children who are slow to recover following sport-related concussion. Brain Injury 23:956–64, 2009.

References

•Mucha et al. A Brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions: preliminary findings. Am J Sports Med. 2014 Oct;42(10):2479-86. doi: 10.1177/0363546514543775. Epub 2014 Aug 8.•Meeryo and Giza. Diagnosis and Management of Acute Concussion. Semin Neurol 2015;

35(01): 029-041.