ON THE LEVEL FALL 2015
A Quarterly Newsletter of the Vestibular Disorders Association
By Dr. Jennifer Liss (with Sherron Laurrell)
Corinne Santana, age 13, is the picture of what makes a parent proud. Her parents, Jennifer MacDermott and Eric Santana, have watched with love and awe as their daughter has handled a medical emergency that introduced the family to the overwhelming topic of teenage concussion.
Corinne is an 8th grader and a cheerleader. On September 20, 2014, she was participating in a cheerleading stunt where she was in the second tier lifting another cheerleader to the top of a pyramid. The girl on the bottom lost her hold because of a weakened wrist that was wrapped in a brace. As the top girl fell, Corinne was clobbered in the back of the head. A few minutes later, Corinne hit her chin on another girl’s forehead. Both Corinne’s mom and her coach knew quickly that something was wrong. She was acting strangely and was unresponsive to questions. Her head was bobbing.
Her mom rushed her to the ER. After a CT scan, she was admitted to the hospital and eventually taken by ambulance to the Regional Trauma Center in Atlantic City, New Jersey. Suffering with intense head and neck pain, the doctors prescribed medications that required heart monitoring. For more than a week, Corinne zoned in and out. She remembers nothing of the accident or the days after. The on-call doctor at their family practice, although very sympathetic, did not have much knowledge about concussion. She recommended Corinne be seen by a Sports Medicine Specialist.
Corinne’s school was even less informed about concussions than the family doctor. The middle school just didn’t know what to do, including the school nurse. On October 2, 2014, Corinne was evaluated by a Rothman Institute Sports Medicine Specialist. Although Corinne’s specialist gave her a 504 (academic) Accommodation Plan, some of her teachers would not cooperate. A few were openly critical of her, saying that she was ”exaggerating” and ” faking” her symptoms. Corinne was depressed, full of anxiety, mentally confused, dizzy and in pain. She first came to see me on October 13th.
As a Certified Specialist in Vestibular Rehabilitation I had begun getting numerous referrals to treat postconcussive syndrome. When I initially started treating these patients four years ago I quickly realized they were different from the Traumatic Brain Injury (TBI)/ neurological and vestibular populations. They often have a combination of central and peripheral abnormalities. VOR (vestibulo-ocular reflex) retraining, even with extensive modification, did not progress the way my vestibular patients progressed. Many times the patients seemed to have trouble focusing on a target even with their heads still.
After spending extensive amounts of time with concussion specialists, vision therapists, and attending as much continuing education in this area that I could find, I realized that in order to normalize impaired vestibular reflexes, concussion patients first had to be able to clearly focus on a target.
Corinne’s main symptoms upon examination included headache, dizziness, fatigue, and neck pain. Her symptoms increased with reading, copying from the board, math class (always her hardest) and exertion. Instead of beginning my clinical concussion exam with the standard oculomotor exam, I began with monocular accommodative focus (the ability of an individual eye to focus clearly on a target) and found a significant difference between her two eyes. I then assessed for a convergence insufficiency (normal is 4-6 cm) and found that the same eye that had weaker accommodative focus had more difficulty moving medially and maintaining convergence on a target. This affected saccadic eye movement speed, and endurance strongly impacts reading ability. Copying from the board was even more difficult because it involves repetitive head movement combined with visual accommodation between near and far targets.
I treated Corinne twice a week for five months. Her recovery was slow but consistent. 13-year old girls are the slowest youth population to recover from concussion due to their dramatic hormonal changes. However, thanks to Corinne’s consistent efforts in therapy, she successfully graduated on February 5, 2015. She has returned to her middle school life and her cheerleading!
When Corinne’s mom was asked what she has learned from this experience she was very clear. “Speak up if you see something that looks out of place.” After the fact, she remembers seeing the wrist brace on the girl who was supporting her daughter in the pyramid and wondering why she was performing a cheerleading stunt if her wrist was injured. She also feels residual frustration about the lack of school system knowledge about concussions and how to treat patients. She tries hard to strike a balance between letting Corinne be independent and overprotecting her. This is an understandable reaction from a mom who has seen her daughter through such a powerful event. Corinne’s mom plans to educate those around them about the importance of treating teenage concussions seriously and immediately.
Jennifer Liss is certified in Vestibular Rehabilitation. She is an Adjunct Professor of Kinesiology at Rowan University in Glassboro, NJ. TheraSport Physical Therapy offices are located in New Jersey, where she has practiced for 16 years. She can be reached at JenLiss@Therasport.org. Sherron Laurrell is a vestibular patient who has been treated by Dr.Liss. They now collaborate on case studies to educate and help others.