Chronic Traumatic Encephalopathy

 

I wrote this blog post over a week ago.  I was waiting for the right time to publish it.  Well, yesterday 3 elite NFL quarterbacks suffered concussions (Michael Vick, Jay Cutler, and Alex Smith).  I guess the good news is that they were removed from play and received prompt medical attention.  But what about their futures?  and the future of all the student athletes who play on? 

CTE is chronic traumatic encephalopathy.  It is a progressive degenerative disease process that is associated with repetitive brain trauma, such as concussions.  CTE is most often associated with boxers, but more recently, retired football players have been diagnosed with CTE post mortem.   The symptoms of CTE include memory loss, aggression, inappropriate emotional responses, depression, and progressive dementia.

CTE is associated with the build up of a brain protein called tau.  Tau is associated with normal neuronal function.  But mutations to the protein cause it to malfunction and form plaques that are then deposited in the cortex of the brain.  These abnormal depositions occur over an extended time.  While it is not clear how repetitive trauma causes these mutations and the deposition of tau proteins, there is not doubt that it is associated with CTE and other degenerative brain diseases such as Alzheimer’s disease.

The mounting evidence of the association between repetitive brain trauma and CTE has caused significant consideration of how to protect athletes.  The NFL has responded with a combination of rule changes, better equipment, more comprehensive policies concerning the evaluation of players who may have suffered a concussion, and more education of players about the signs, symptoms and consequences of concussion and repetitive head trauma.   Greater awareness is trickling down to college and high school sports and recreational leagues, but with fewer resources, it is more difficult to put effective policies into place.  High schools are not likely to have a board certified neurologist on the sidelines making decisions about whether a player returns to play or sits down for a week.

Return to play decisions are even more important for young athletes because of Second  Impact Syndrome.  If a young athlete sustains a 2^nd head injury before the symptoms and pathopysiology of the 1^st injury have resolved, this second brain trauma can cause very severe and very rapid brain swelling.  This can result in permanent brain damage or death.

Parents, school administrators and coaches are beginning to realize the importance of protecting young athletes and preventing the long-term consequences of repetitive head trauma.  There is now a fast, easy to administer and reliable test that can be used on the sidelines to facilitate return-to-play decisions.  The King-Devick (K-D) test was developed by optometrists to evaluate reading eye movements in children.  The test requires approximately 2 minutes to administer and simply asks the student to read aloud a series of numbers arranged in horizontal rows on each of three test cards.    Although the task appears very simple, rapid number naming requires the integration of many areas of the brain.   An increase in the time to complete the task when compared to a baseline measurement is the result of impaired eye movements and indicative of suboptimal brain function.

Every optometrist must educate the coaches and parents in their communities about the King-Devick Test.  The test should be administered to all student athletes at the beginning of the season to establish a baseline.  The test should be re-administered on the sidelines if there is even the slightest concern that an athlete has sustained a concussion.  If the time to complete the test has increased by even 1 second, the athlete should be removed from play and sent for a complete concussion evaluation.

This is a public health issue and the time to act is now.  A small investment of both time and money can begin the process of reducing the impact of repetitive head trauma and protecting our children from a devastating illness.

Watch the trailer for the movie Head Games.

Read more about concussion and the King Devick Test here.

Read more about CTE here.

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Dr. Harold Solan — Visual Attention and Reading

Dr. Harold Solan received the Skeffington Award in 1990.  At that point, his body of work was quite impressive.  But he was only getting started!  He continued his research, writing and scholarship for many more years.  In many ways, his post-Skeffington Award work was even more influential.  It is very difficult to choose one “topic” or article to highlight his contributions to developmental optometry.  I suppose I shall have to write more about Dr. Solan’s work. 

Dr. Harold Solan

Attention is often defined as the ability to focus on relevant stimuli as well as a decrease in responsiveness to irrelevant information.  In reading, visual attention increases the ability to read efficiently across a line of text.  Readers must learn to use the oculo-motor system to move their eyes accurately.  First they must focus on the first word on the line, then they must shift their attention to the right as they prepare to move their eyes to the next fixation point, then they must sustain their attention in order to allow for processing of the text.  These three principal elements of attention–focus, shift and sustain—are the link between perception and cognition.  Perception makes the visual information available but not necessarily recognizable.  Cognitive processes allow the reader to use the visual information in order to gain meaning.  In other words, reading comprehension is dependent upon visual attention as expressed by accurate oculo-motor control.  Therefore, vision therapy that is directed at improving focus on relevant stimuli, shifting attentional focus within a complex visual environment, and sustaining attention for an appreciable interval might be expected to improve reading comprehension.

Dr. Solan and colleagues investigated this relationship in a group of 6^th graders with moderate reading disabilities.  These students attended public school in New York City.  On a standardized reading test, their reading comprehension scores averaged 2.2 years below their grade level.  The students’ attention skills were assessed using a standardized testing battery.  Then they received 12 one-hour sessions of vision therapy.  The therapy consisted of specific procedures which were aimed at improving or enhancing focusing, shifting and sustaining visual attention during oculo-motor (eye movement) activities.  After completing the 12 hour therapy program, the students were retested with both the standardized reading and attention tests.  Their scores improved significantly on both measures.  After 12 hours of vision therapy over 5 months, their average reading scores jumped an entire grade level, from the 4^th to 5^th grade level.  This is in sharp contrast to the first 5 years of schooling, when their reading scores improved from a 1^st grade to a 4^th grade level.

Dr. Solan’s research supports the notion “that a link exists between visual attention, oculomotor readiness, and reading comprehension…”  He acknowledged that uncertainties still exist.  For example, the therapy also incorporated memory, speed of processing and executive functions.  How does the engagement of this triad influence cognitive performance and reading comprehension?  Dr. Solan’s research always answered BIG questions but at the same time, left more questions to consider.  That way, he never ran out of ideas for his next research project.  Now, he has left these unanswered questions for others to consider.

Read more about eye movements here.

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Perceptual Malnutrition

Dr. Tole Greenstein received the Skeffington Award in 1973.  This discussion is based on his writings for the Optometric Extension Program from 1967-8.  The resultant monograph is entitled Optometric Child Vision Care and Guidance. 

When young children learn how to manipulate objects with their hands, they must learn how to REACH for the object, and then GRASP onto the object.  This allows the child to MANIPULATE the object and learn what it feels like and perhaps decide if it is familiar or not.  Then the child must RELEASE the object in order to be ready to reach for something else and initiate this cycle once again.  REACH-GRASP-MANIPULATE-RELEASE.

As children progress developmentally, they learn this same process utilizing the visual system.  The child will reach for an object with the eyes instead of the hands; then grasp the object with the eyes in order to explore the object and determine what it is and what it means; then release the visual “lock” on this object in order to get ready to reach and grasp the next object worthy of “seeing.”

Many children with vision problems have great difficulty with this cycle of VISUAL Reach-Grasp-Manipulate-Release, especially the “grasp” part.  They may be able to find an object with their eyes, but they have significant difficulty keeping their eyes on the target long enough to manipulate the object and figure out what the object is, what it means and how they might want to interact with it.  Without grasping and manipulating, their visual processing is reduced to Reach-Release-Reach-Release.

This visual problem will be evident during very simple procedures to evaluate the quality of eye movements.  The child will be asked to perform saccadic eye movements, which are jump eye movements from one object to another.  These children cannot wait until they are instructed to jump to the other target; they cannot grasp the object.  As soon as they reach the first target, they release and grasp on the 2^nd target; then they release again and jump back to the 1^st target; all this despite instructions to try to keep looking at the 1^st target until told to look at the 2^nd target.  These children will make several round trips without ever visually grasping long enough to manipulate the object.  When asked to fixate a small object, such as a small bell, and keep the eyes on the bell as it is moved into different positions, they have similar deficits.  These children cannot maintain their grasp on the bell; they will release their grasp and look at something else: Reach-Release-Reach-Release.

What is the result of this inability to visually grasp and manipulate?  Dr. Tole Greenstein described this as PERCEPTUAL MALNUTRITION.  These children do a good amount of “looking,” but very little “seeing.” Without the grasp and manipulation, these children have very little useful information; very little visual “food” to feed their visual processing and thinking.  How would a child with PERCEPTUAL MALNUTRITION behave in a classroom?  When reading across a line of words in a book, they may never learn to identify the words.  Every time they see words that are repeated on the same page, they are unable to use past experiences.  Words strung together in a sentence have no meaning.  Pieces have no relationship to a whole.  Maps, graphs and diagrams are incomprehensible.  What about the playground? How can these children react to a moving target if they can’t keep their eyes on the ball?

These children are often diagnosed with an oculomotor dysfunction, which describes their inability to perform age appropriately on the eye movement tests.  Dr. Greenstein wrote, “it is important to talk about what the findings indicate that his life-world response in a given task would be.”  The diagnosis of oculomotor dysfunction is meaningless unless you discuss the consequences.  The resultant perceptual malnutrition and the inability to perform in and out of a classroom are of great consequence.  Dr. Greenstein described vision therapy as a program of learning, teaching these children how to control their environment instead of allowing the environment to control them.  The benefits of vision therapy will be different for every child.  If you think your child may be suffering from PERCEPTUAL MALNUTRITION, find a developmental optometrist and start writing your child’s success story.

 

Read more about eye movements here and here.

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100,000 Saccades per Day

Saccades are eye movements from one object of regard to another.  These “jump” eye movements allow us to fixate objects with the fovea, which is the part of the retina that we use to discriminate details and determine, “what is this.” Reading across a line of printed words requires a series of saccades and fixations. First we make a saccades to bring our eyes to the first word in the sentence, then we fixate to allow our brains to process what we are seeing, then we make another saccade to a point a little further along in the sentence and once again fixate to allow our brains to process the visual information.  Saccade-fixate-saccade-fixate.  This pattern continues for as long as it takes to complete the reading .  But saccades aren’t only about reading.  They are the basis for using vision in everyday life.  Every time we want to “look” at something, we have to make a saccade to bring that something onto our fovea.  Saccade-fixate-saccade-fixate.  This happy dance continues all day long.  On average, we make 100,000 saccades per day.

What if you had difficulty with saccadic eye movements?  What if it took you a little longer to make that saccade?  Or you were inaccurate and your eyes landed in the wrong place? Or this put additional stress on your binocular system because you had difficulty coordinating the eyes during saccades?  And now imagine making these errors 100,000 times a day.  The happy dance is no longer very happy.  Welcome to the world of the learning disabled child.

At the annual meeting of COVD, Dr. Zoi Kapoula presented a distillation of her years of work studying saccadic eye movements.  This included the evaluation of the saccadic eye movements of a group of dyslexic children during “real text reading;” recording eye movements as their eyes moved in a sequence of fixations across the text.  The dyslexic children made more saccades, more regressions (moving their eyes backward along the line of text instead of forward), and it took them longer.  In addition, they had more difficulty keeping their eyes properly aligned during the reading task.  This resulted in greater stress on their binocular systems in an attempt to prevent the words from going double.  Dr. Kapoula concluded that these inefficiencies might complicate letter or word recognition processes and “supports the suggestion that besides impaired phonological processes, a visual/oculomotor deficit exists in dyslexics that might perturb the fusional process. “  That’s the double whammy.  Poor eye movements not only make it difficult to read, but make it more difficult to maintain binocular vision while reading which also makes it hard to read.  It’s the proverbial downward spiral.

But there is hope.  Research has shown that vision therapy can be effective at improving both eye movement and binocular skills.  These improvements in visual skills can translate to better academic performance.  It’s time to get your child’s visual “happy dance” back on track.

Percy has great dance moves and eye moves!

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Eye Movements

Today’s guest blogger is Dr. Ron Berger.  Dr. Berger practices in Ellicott City, MD.  He loves working with children, athletes and individuals with special needs.  When he is not providing vision care, Dr. Berger can be found on the ski slopes and the golf course.  He is also a private pilot and and participates in a volunteer program flying pets to locations in which they can be adopted into new homes.

We don’t often think about eye movements, mainly because as parents we look at our children’s eyes only for appearance and to be certain that we have their attention when speaking to them.  The only time that we look critically at the movement of the eyes is when there is an obvious problem such as turning of one eye outward or inward with respect to the other eye (strabismus) or when “jiggling” (nystagmus) is readily apparent.

However, when examined by a professional, eye movements have much different meanings and consequences.  For example, pediatricians ask children to follow a penlight in all directions of gaze to ensure the existence of neurological integrity, and police officers perform the same test to gauge the loss of reaction time of a driver who has been drinking.

Developmental optometrists view eye movements as insights into how and what a person is thinking.  While reflex eye movements do exist, voluntary eye movements are determined by the brain or the mind of the person.  We do not move our eyes randomly; rather, we move them to that place where we expect to get the most information from whatever we are attending to at the moment.   We might be following the flight of a ball and attempting to determine where it will land so that we may put ourselves into the proper position to catch it.  We might be viewing the landscape before we venture out into the street (look both ways, please).  We might be trying to read and determining where our eyes should land within the line on the page, or where the next line of print begins.

The examiner of eye movements may use tests of performance such as tracking moving objects while watching the actual movements of the eyes, tracking non-moving objects (such as numbers on a printed page) for speed and accuracy, and eye-hand coordination tasks to evaluate how well the person is matching eye movements with hand and finger actions.  In addition, some developmental optometrists may use infrared tracking technology to obtain a graphic record of eye movements during different tasks such as reading.

When eye movements are determined to be less than optimal, noted symptoms such as poor general coordination, poor athletic skills, skipping words and lines during reading, not recognizing the same word even on the same page, and similar behaviors become easier to understand.  Depending upon each individual and the relationship of eye movements to one’s brain and mind, vision therapy may be appropriate.   Vision therapy has a long history of successfully treating such disorders.

Here’s more about eye movements:

Eye movements are linked to academic success

Reading eye movements improve with vision therapy

Watch a video pre-vision therapy and post- vision therapy

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There’s More to Concussions than Meets the Eye

Today’s guest blogger is Dr. Robert Fox.  Dr. Fox graduated fromSUNY-State College of Optometry in 1985, after which he completed a residency in Rehabilitative Optometry at the Northport VA Medical Center.  He is in private practice in Schenectady, NY, and also consults on brain injury related vision problems at the Sunnyview Rehabilitation Hospital in Schenectady.  When not busy at his practice Dr. Fox likes to snowboard, play hockey, and golf.

A recent article in USA Today, highlighted the use of a simple eye test in the detection of concussions.  The test, known as the King-Devick test, is a test for eye movement speed and accuracy.  The goal of the test is to read lines of numbers off a page as quickly as you can.  Research conducted at the University of Pennsylvania School of Medicine has shown that poor performance is a confident indicator that a concussion has occurred.

Awareness of concussions has grown rapidly over the past few years.  Professional and scholastic athletes are now being required to sit out much longer than in the past to recover from severe blows to the head.  Blows to the head are not limited to football.  As an optometrist who consults with a local bring injury rehab center, I have seen injuries in activities such as hockey, lacrosse, gymnastics, dance (yes, dance), and soccer.  One of the most important aspects of this new article is the connection between vision function and brain injury.  Even mild concussions can cause major visual function problems.  These can include:

*blurred vision – especially when reading

*headaches associated with reading

*double vision

*eye pain

*poor reading comprehension

*light sensitivity

*frequent loss of place when reading

For the student athlete, these symptoms can have a huge effect on learning and school performance.  These vision problems can also linger months after the initial pain and headaches associated with the concussion have gone away.  The most common causes of these problems are a convergence insufficiency (eyes that don’t work well together at near) and/or accommodative (focusing) insufficiency following the injury.

The good news is that these vision problems respond well to optometric intervention.  The King-Devick test is just one of a larger battery of tests designed to evaluate eye function and the integrity of the vision system.  Treatment usually consists of a combination of glasses for reading and optometric vision therapy.  These treatments allow the student to return to their academic activities much sooner than just waiting for things to clear up on their own.

Further information on vision therapy and brain injury is available from the College of Optometrists in Vision Development and the Neuro-Optometric Rehabilitation Association.

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More About Reading: Improvements Following Vision Therapy

The Visagraph Eye Movement System (Visagraph) records and analyzes a student’s eye movements while reading.  The analysis provides grade level equivalents for various measurements such as fixations and regressions per 100 words and reading speed in words per minute.  The Visagraph provides objective information which typically correlates with a student’s subjective symptoms, such as loss of place when reading, skipping lines and poor reading comprehension.  The optometric diagnosis is usually “oculomotor dysfunction.”  Recent research by Dr. Barry Tannen and student Noah Tannen evaluated the impact of vision therapy on Visagraph measurements and symptoms in patient’s diagnosed with oculomotor dysfunction.

Forty six children between the ages of 8 and 17 years had Visagraph measurements completed at 2 levels:  first, at their independent reading level and then at 2 years below their independent reading level.  The hallmark of an oculomotor dysfunction is poor eye movements at both levels.  The eye movement dysfunction is evident even when the reading material is “easy” or below grade level.  The 46 children received optometric vision therapy (VT), according to their individual needs.  Visagraph measurements were obtained post-VT, again at 2 reading levels.  All Visagraph measurements at both reading levels showed a significant improvement from pre-VT levels.  For example, reading speed improved by more than 50% following VT. The improvements in Visagraph meaurements correlated with a reduction in symptoms that occurred in 93% of the patients.

Eye movements are an important visual skill, so integral to the reading process. Dr. Tannen’s research provides evidence of the impact of VT on eye movements, reading performance and associated symptoms.  Take the time to consider whether your child has any symptoms associated with a visual dysfunction.

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