Patient’s eyes hold the answers in newest tests
TORONTO • The most eyeopening portion of Siobhan Karam’s examination of Owen involved, well, his eyes.
The physiotherapist at Toronto’s Sports Medicine Specialists clinic tested Owen for vestibular motor (balance) and ocular motor (visual) dysfunction.
These tests are so new, the most recent concussion-diagnosis protocol employed the world over — SCAT 3 (standardized concussion assessment tool, third version) — doesn’t include them. And yet they’re as fascinating, and perhaps as revelatory, as they are simple.
One is called Smooth Pursuits. With the head still, the patient’s eyes follow an object (usually the examiner’s pen or finger) from left to right, clear across the patient’s field of vision. Owen did this no problem.
Next, Karam turned Owen’s head from side to side while asking him to focus on her nose. He didn’t pass. His eyes fluttered slightly as he tried to focus. We could see it; he couldn’t feel it.
“It’s called nystagmus,” Karam said. “It is a positive finding for vestibular ocular reflex — the VOR. It can be a telltale sign that something’s wrong with the central processing system. It doesn’t necessarily mean the person is concussed. It could mean he had some existing condition such as dyslexia, ADHD or cervical dysfunction.”
Another of Karam’s simple ocular motor function tests is called Near Point of Convergence. She holds a pen about two feet from the patient’s nose, tells the patient to focus only on the pen, then she gradually brings it closer to his nose, until the patient sees two pens. “The norm for seeing two objects is within three, four centimetres of your nose.”
Anything beyond six centimetres could be a flag for medical personnel. Owen passed that test. In another vision test, Karam held her index fingers far apart. Owen, with head still, rapidly switched focus, back and forth, between the two fingers. He encountered no problems, felt no discomfort and passed this test, too.
“With some concussion patients, eye movement can be really slow,” Karam said. “They’ll have trouble switching their eyes back and forth. Some will say, ‘I can’t do this. My head hurts.’ With concussions, the big problems we sometimes see are with the eyes. Not just blurred vision, but dizziness, nausea that comes when you don’t feel balanced, when your eyes aren’t helping you stabilize.”
Karam then walked Owen through newly developed vision and balance exercises he was to perform at home. He donned a head band with an attached red laser aiming straight ahead and stood about six feet from a wall.
Then came a couple of exercises where he moved his head to use the laser’s red dot to trace the letters of the alphabet, or position the red dot in a particular spot on a worksheet taped to the wall, sometimes standing on one leg after closing and opening his eyes. The purpose? Rehab. Most in the medical community have believed concussion patients should stimulate their brains as little as possible during recovery. The more time spent immobile — in a dark, quiet room if necessary — the better.
Now, some concussion experts endorse limited, careful, specific rehabilitation therapy exercises, such as the ones Karam and SMS offer. Karam said she is encouraged by the results.
“The laser point is just a cheap way to have something moving. And then we co-ordinate those with neck exercises,” she said. “They’re habituation exercises. Our body adapts to meet the needs of stresses.
“Let’s say we work out to our anaerobic threshold. The body takes the physiological time it needs to heal from that, and then the next time you go to do the same thing, you can do it at a higher level. But if you go too far, you can over-train and even injure yourself.
“Brains are the same way, except they’re very, very, very sensitive. So we basically are asking patients to do exercises based on what we require in everyday life. It’s training your brain to do a particular exercise at the highest level you can that day, so your body gets used to having that demand. Then it should become easier.”
WITH CONCUSSIONS, THE BIG PROBLEMS WE SOMETIMES SEE ARE WITH THE EYES. NOT JUST BLURRED VISION, BUT DIZZINESS, NAUSEA THAT COMES WHEN YOU DON’T FEEL BALANCED, WHEN YOUR EYES AREN’T HELPING YOU STABILIZE. — PHYSIOTHERAPIST SIOBHAN KARAM