When several experienced clinicians assess someone with a concussion and work together to create an individualized treatment plan, the patient benefits. That is how concussion care is delivered at the Dr. Robert C. Cantu Concussion Center. The center’s impressive multidisciplinary team of physicians, nurse practitioners and rehabilitation staff has increased in size and depth with the arrival of a pediatric neurologist and two neuropsychologists.
The steady expansion of the region’s largest concussion center signals a commitment to provide everything on site that pediatric and adult patients might need. It also acknowledges that some individuals require additional expertise. “We know that 10-15 percent of adults who are diagnosed with a concussion develop persistent symptoms that require specialized testing and care,” says Dr. Cantu, the Emerson neurosurgeon for whom the center was named when it opened two years ago.
Neal McGrath, PhD, (pictured at right) and Alexandra Jackson, PsyD, now provide neuropsychology care at the center, which includes specialized testing and counseling where appropriate. “The concussion field has evolved to where we understand there are several pathways of disability and recovery,” says Dr. McGrath who, along with Dr. Jackson, has special training in brain injury and neurological issues. “There are headaches and migraines, vestibular or balance problems, cognitive and potentially emotional problems. Those with a pre-existing problem, such as anxiety or depression, may have an especially difficult time with recovery.”
“The testing they provide is in addition or supplemental to what our rehab staff, including our speech/language pathologists, perform,” Dr. Cantu notes. Such testing can objectively show the deficits that hold patients back from returning to school or work. Those with persistent symptoms may benefit from counseling.
“If it takes a while for someone to get better, they may become anxious or depressed,” says Barry Levin, MD, a neurologist at the center. “Our patients often tell us how people say to them ‘you look so good!’ But the majority of concussion symptoms are invisible, and they are having a difficult time. Dr. McGrath and Dr. Jackson provide the counseling these patients need.”
For some patients, post-concussion symptoms hang on for weeks or months. “If you’re a high school student who’s not on the sports team anymore and struggling with schoolwork, your identity has probably shifted,” says Dr. McGrath. “It’s not a majority of patients, but if you are one of those with a much slower or more complicated recovery, your life is very different than it was, and you may need extra support as you try to get back to normal.”
Dr. McGrath and Dr. Jackson work directly with schools and spend a lot of time educating young athletes. “There’s an attitude that you keep on playing, no matter what,” says
Dr. Jackson. “We tell them that a concussion is not something you play through. It’s different, and the consequences are far more serious, than other injuries.”
Greater awareness of concussions has led to recognition that females are more vulnerable. “It is partly because women’s necks are not as strong as men’s, and our brains are wired differently,” Dr. Jackson explains. “Also, it has to do with how women’s sports are played. Checking is not allowed in women’s ice hockey, so players aren’t taught the correct way to check, as men are. But if you talk to a female hockey player, they will tell you that checking happens. Similarly, female lacrosse players don’t wear the full helmet and pads that men do — just safety goggles. Women may not be as protected as they need to be when playing sports.”
Students must “return to learn” before returning to play
Kids also are vulnerable for concussions, notes Herbert Gilmore, MD, a pediatric neurologist. It is widely accepted that 10-15 percent of adults develop persistent symptoms after a concussion; Dr. Gilmore believes that number is significantly higher in kids.
“Their necks are relatively weak, their heads are relatively large, and their brains are not yet myelinated, which provides a protective coating,” he explains. “Often, they don’t communicate about their symptoms. I tell parents that any head injury is serious, which is why every brain symptom needs to be checked out. Despite the fact that concussions happen relatively frequently, they are sometimes ignored or denied. Because symptoms are so variable, they can trick clinicians and not be properly diagnosed.
“If a child has repeated concussions, and sometimes after just one concussion, I recommend no further participation in contact sports,” Dr. Gilmore adds. “This can be difficult, especially for teenage boys. I often have to convince families that it is risky to expose their child to further concussions.”
Making a diagnosis is usually pretty straightforward. “The issue is counseling the patient on living with a concussion, treating it appropriately and making sure they receive all the rehab that is helpful,” he says. “Comprehensive care — that’s the reason I joined the Cantu Concussion Center. They’re doing it right, because they know what it takes to treat concussions successfully.”
Dr. Gilmore began sending his concussion patients to Dr. Cantu for consultations 25 years ago. “He was the only physician who showed an interest in concussions,” he says. “Dr. Cantu was — and still is — the go-to guy for complicated concussion patients.”
Dr. Cantu is optimistic about the future of concussion care. “More physicians realize that when someone has persistent symptoms, they need to see a specialist,” he says. “Today there is broad support for therapies — ocular, cognitive, balance, neck pain and counseling — that address specific clusters of symptoms. We know that receiving the appropriate therapy will help a patient recover more rapidly than rest alone. Therapy ideally should begin the first week after a concussion, as long as low-exertion physical therapy does not cause symptoms.
“Finally, when it comes to kids, we focus on ‘return to learn’ before we consider return to play. Back to school first, then progressively back to sports.”
The new staff have joined the premiere concussion program in the region, where their colleagues are pleased to have their expertise. “No other center is as comprehensive as ours at Emerson,” says Dr. Levin. “We have everything patients need on site. But the important thing is that we work together to benefit our patients.”
What is neuropsychological testing?
Neuropsychological testing is used to assess attention, language, executive function, memory, emotional status and personality. Those who play contact sports are encouraged to have baseline testing, which is a type of neuropsychological screening that helps professionals more precisely understand an athlete’s pre-injury level of memory, reaction time and processing speed.
“Baseline testing allows us to see how an individual is prior to an injury, which we compare with the results of testing after an injury,” says Dr. McGrath. “It provides more objective evidence that someone is okay or, importantly, not okay. It’s a way to measure recovery.”
Those who suffer a serious concussion or were not managed appropriately after a concussion may experience symptoms that linger. “The third category is those who have had too many concussions,” he says. “There may be an accumulation of damage.”
Dr. McGrath and Dr. Jackson might see a concussion patient with persistent symptoms several times. “Concussions are a moving target,” Dr. McGrath explains. “We use various tests to track patients as their symptoms improve. This allows us to fine-tune our recommendations to our colleagues at the center.”
As a result, the concussion team gains a broader perspective on how the person is progressing, cognitively and emotionally. “Our testing might lead to a medication adjustment or a change in the frequency of treatment,” he adds. “In other cases, it confirms that the patient is receiving the right approach to their rehab in terms of physical therapy, occupational therapy and speech/language pathology.”
For more information on the Cantu Concussion Center, visit emersonhospital.org/concussion or call 978-287-8250.