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>> Hello everybody,
and welcome to the Return to Learn Fall 2014 Webinar Series,
Students K through 12 with Concussion:
Vision Issues Impacting Academics
This webinar is the fourth webinar in our Fall BrainSTEPS Return
to Learn Concussion Series.
We're very excited to have Dr. Steinhafel with us today.
We're sorry that we had some technical issues,
but we are glad that people are finding their way back on through the new link
that was sent out.
this webinar today will be archived and available online in about a month.
You can find it at PaTTAN.net,
and also at BrainSTEPS.net,
so check back in about a month.
I would like to welcome Dr. Steinhafel.
He joined the Pediatric and Adult Vision Care in Wexford Academy in 2010.
He graduated from Southern California College
of Optometry with a Doctorate in Optometry,
and completed his residency,
specializing in Pediatrics at the University of Alabama
at Birmingham School of Optometry
where he also served as a clinical instructor.
Dr. Steinhafel also holds a Master's of Science degree in Physiology,
with an emphasis in Neurophysiology from Brigham Young University
and a Bachelor's of Science
degree in Zoology from the University of Wisconsin-Madison.
In addition to comprehensive eye exams, fitting contact lenses,
and treating ocular disease for all ages,
Dr. Steinhafel concentrates his practice specializing in pediatric eye care.
This includes routine exams for infants and children,
treating special populations ( autism, cerebral palsy, down's syndrome)
examining those with learning disabilities or developmental delays,
and treating infants through adults with strabismus, lazy eye,
eye tracking problems,
or other binocular vision related conditions.
He also has specialized training in the area of neuro-optometry,
which is why we asked him to speak to us today,
which is examining and treating adults and children
recovering from traumatic brain injury,
or neuro related eye conditions.
I would like to welcome Dr. Nathan Steinhafel.
We will be taking questions at the end, so keep that in mind.
>> Great. Thank you, Brenda.
It's a pleasure being with everybody.
I have to say, this is a unique presentation for me,
because I'm usually presenting on a whole base seminar,
and mostly it is to physical therapists, internists,
[INAUDIBLE], neurology, neuro-optometry,
This is actually an enjoyment to put together,
and this is going to be concepts for the educational professional.
I realize this may include psychology, school nurses,
those in academia, mostly teachers, hopefully,
because most of the time, you're the ones interacting with these patients the most.
What's unfortunate is, I probably see these individuals for 45 minutes
to two hours on my initial work-up and examination, and then after that,
we hope that our recommendations are being followed through,
including therapy, medication,
and school accommodations.
Today I'm going to go over more of the salient points
of the [INAUDIBLE] quality of falling traumatic brain injury;
more so mild traumatic brain injury,
as we know most head injuries are concussion-related.
I am a neuro-optometrist.
I treat pediatrics through adults who suffer from traumatic brain injury
as well as mild traumatic brain injury.
I will be discussing some company's products and some research groups,
but I have no financial interest in any of the aforementioned.
Concussions seem to be a big topic recently in the news.
We do have some lag in the research,
but it seems to be a very ongoing process
when it comes to research,
how do we diagnose a concussion, what's related to a concussion,
and what are the key players in terms of treatment and management?
How do we refer to these people,
how do we organize these individual's lives,
and how do we get them back to school performance?
This is like many articles published in the news,
archived in magazines and research articles.
This study basically indicates in the journal of American Academy of Pediatrics
that the number of emergency room visits
for concussion between the ages of 8 and 13 have doubled,
and have more than doubled
for those who are actively participating in middle school
and high school sports between the ages of 14 and 19 years of age.
Unfortunately, because of the amount of concussions doubling,
the participation in organized team sports
they're not re-enrolling in a lot of these sports-related activities.
You can see from 1997 to 2007,
the unfortunate truth is concussions are on a rise,
or we're just doing a better job of detecting it,
and emergency rooms are finding a better way
to refer to the appropriate people who are treating concussion.
As far as epidemiology, I'm going to talk with a little bit of brevity,
because I could talk about statistics for at least a couple hours,
but I'm going to throw out a couple slides here just showing the prevalence.
Literature is quite divided when it comes to how many
were actually seen and treated in a year,
but anywhere between 1 and 4 million concussion cases per year.
The unfortunate thing, as well,
is it's estimated that most of them are going undiagnosed,
so the true numbers of this is much higher.
The World Health Organization estimates that 70 to 90 percent
of traumatic brain injuries are actually concussion-related,
so we call those MTBI, Mild Traumatic Brain Injuries.
There's nothing mild about it.
are suffering with symptoms beyond your typical two-week mark.
In fact, those who are doing a lot or reading
and a lot of studying in their lives are quite active,
being around a lot of people at school with a lot of noise.
These symptoms are not going away after the typical time period
that we used to think about.
According to the CDC,
most of the common causes of traumatic brain injury involve sports.
Naturally, we are putting ourselves at risk
when we are participating in impact sports.
Fall's a big time of the year.
We see a lot of football-related injuries,
soccer-related injuries, cheerleading injuries,
but sports aren't the only reason people are coming into the office.
Motor vehicle accidents,
and that is a whole other animal that I will not get into today,
but we're mainly going to be talking about mild traumatic brain injury
related to sports-related concussion in the middle school
and high school population.
Assaults, struck by particular things, freak accidents;
those are also on the list,
but on the lower end.
Without going too much into the descriptive literature,
is found in about a quarter to a third of these patients,
and in many times goes undiagnosed.
There's a lot of different criteria to diagnose Persistent
those who are suffering from a concussion
and their symptoms are longer than two-weeks, three-weeks, four-weeks.
ICD-10 has put out their own criteria.
DSM-IV has put out their own criteria.
If you look at the box on the top right, we know that headaches are involved,
dizziness, fatigue, increased irritability,
patients have trouble falling asleep or even staying asleep.
Much of this is affecting their concentration,
affecting their memory, their mode.
Patients become more irritable.
is the Diagnostic and Statistical Manual of Mental Disorders.
There are a lot of other criteria,
but all of them have a lot of common points to talk about,
including eye skills, balance skills, personality changes,
so I don't think there is really one set criteria, however,
depending on your diagnosis or what diagnosis criteria you're using,
I think any one of these would be satisfactory.
The goals and objectives today for the professional educators
is to understand the prevalence and this mirage of visual symptoms
as a result of concussion.
It's not just headaches,
and it's not just memory and concentration difficulties.
I'd like to identify the most common visual system impairments
occurring after mild traumatic brain injury.
There is a long list of visual issues that come after concussion,
but I'm going to touch upon the main three or four
that I want educational professionals to be aware of.
We'll discuss screening and assessment techniques that perhaps athletic trainers
could use in addition to some of the sideline screeners
or perhaps school nurses,
other allied health professionals
who treat concussion can use as part of their concussion diagnosis criteria.
I'll elucidate that the levels, large or small,
in the visual impairments in the classroom.
Like I said, teachers are the ones
that are going to be interacting with these patients and students the most,
and for them to create strategies for them to accommodate them
and help them get through this time of recovery is very, very important.
Concussion and clinical strategies.
When we look at the concussion on the broad scope,
we're not just treating a concussion.
We're not just allowing them to take time off.
We're looking at their mood and their anxiety.
From a physical standpoint, do they have neck or back pain?
In many cases, and in most cases,
they're suffering from a chronic post-traumatic headache, as well.
There are cognitive components, fatigue that comes with that,
and a big one is vestibular, including dizziness, balance, vertigo;
that disequilibrium that patients complain about.
However, today we're going to be discussing vision,
or the ocular component.
Again, this could be a weekend conversation.
What was difficult was to compact it into 45 minutes to an hour here.
It was an interesting challenge.
A lot of parents and other physicians
will ask, "What are the main areas of the brain affected from the concussion,
when it comes to vision?" Vision involves a lot of different areas,
not just including the occipital cortex,
which is the very, very back of the brain where the cerebral cortex is.
Vision is involved with the cerebellum when it comes to balance,
and movement, and body mobility.
Eye and motion skills comes from much of the midbrain, the pons, the medulla,
and the brain stem.
The brain stem, we have found obviously,
it's in very close proximity to the spinal cord.
With a lot of rotational linear head injuries,
this area is a very sensitive area,
so many ocular motor dysfunctions
will come as a result and visual symptoms will go awry.
If you've taken any biology classes,
we know that the brain is made up of tissues.
It's an organ,
and individual tissues in organs are made up of individual cells.
The blue schematic drawing here is an individual cell.
It has a functional nucleus as the power house.
It contains mitochondria in many different parts,
including cytoskeleton and microtubules.
This is an area that becomes damaged from concussion.
The unfortunate thing is when we put a patient
through a CT scan or neuroimaging such as a MRI of the head and the brain,
we don't see anything physically,
but what's happening is on the metabolic scale.
Physically, yes, there is things happening.
We have potassium that leaves the cell,
sodium that comes into the cell.
With a concussion, it's almost like too much sodium coming into the cell,
too much calcium coming into the cell.
That homeostatic environment,
that relationship of what goes in and what goes out becomes disrupted.
The brain is communicating to different parts of the brain
based on neuron function.
I threw in a little color here.
This is really a metabolic dysfunction when you talk about concussion,
and it results in basically an energy crisis.
Neurons have a hard time communicating with one another,
because the nerve's extremely vulnerable,
and there has been physical damage and harm to this area of the brain
which results in a massive release or non-release in neurotransmitters.
That's what helps different neurons communicate from one to the other
and allows us to have proper visual function.
I'm not going to get in to much of the research here,
but I want you to see from a visual standpoint
that this is an electron micrograph of axons of the optic nerve.
The optic nerve is a part that connects the eye to the brain,
speaking with a lot of brevity here.
Top left here, we have a longitudinal section
looking at the inter[INAUDIBLE] film and spacing of a normal axon.
that's a normal looking cross-section, if you think of it that way.
This is taken from pig samples that were subjected to blasts.
Subjecting to blasts, basically,
just struck that spacing or the parts of the neuron within.
On Slide B, you can see that that looks very different then Slide A does.
Following stretch and injury, there's a compaction of neuron filaments
observed when looking at it from a microscopic research standpoint.
Similarly, we look at the optic nerve from a transverse section.
Individual neurons have microtubules, which are like the skeleton
or the backbone in those individual dots there
that you see with an arrow point to them.
Those are individual axons following stretch, injury,
This is on a very extreme example.
Slide D just looks a lot different, doesn't it?
The microtubules are disrupted,
and in many cases, that skeleton of the nerve can fall apart.
We just don't see that on MRI.
We are learning a lot more about functional MRI and the way
it can give us more information about concussion,
but I want you to know that it's not just functionally
we end up with some difficulties,
but physically, there is harm.
It's a metabolic and structural issue.
This is just another example of neurons that can have swollen end bulbs,
and there's hundreds and hundreds,
and thousands of neurons that can become effective.
You can see that these neurons here are not supposed to have these large clumps.
There's too much metabolic activity here.
It should be more of a nice, long string,
and in that symmetrical fashion.
Again, the terminal end bulb here of the nerve
is just swollen or ballooned up from just too much metabolic activity.
Just a last side of our research here,
and this gets into more of the functional aspect
of what happens with concussion and vision.
If you look at studies from a retrospective standpoint,
in 2007, Ciuffreda and his group
looked at a number of individuals who suffered concussion.
He found that these individuals
who suffered concussion had more focusing or accommodative problems,
or more vergence problems.
We can think of that as eye-teaming skill deficits.
That was the most common thing that he found in the concussion group,
lazy eyes, strabismus,
to crossed eyes,
cranial nerve palsies
were the most common to this cerebral vascular subgroup;
those who had aneurism,
microvascular accidents related to perhaps stroke or diabetes respectively.
What happens with concussion compared to stroke victims
is that it's a functional deficit,
not a physical palsy or a bleed that actually happens.
Another retrospective study in the case that, again,