By Terrie Enis, PT, MSPT
Today, the physical therapists, occupational therapists, and speech therapists at Emerson Hospital’s 1-year-old Center for Rehabilitative and Sports Therapies treat nearly 200 patients every day. Approximately 12% to 15% of them are patients of all ages who are affected by concussions or traumatic brain injuries. Many of these patients are seen first at the adjacent Dr. Robert C. Cantu Concussion Center at Emerson Hospital. This article explores the specialized approach therapists at the hospital system take treating a growing population of people who have concussions, and the importance of creativity, research, and focusing on doing what is best for patients in an effort to excel in the diagnoses and treatment of head traumas.
In 2011, Emerson Hospital’s Center for Rehabilitative and Sports Therapies was just beginning its journey of self-discovery. Its staff mantra was “discover your professional passion.” Passionate therapists foster ideas that enhance not only patient care, but the patient experience. Patients benefit most when therapists love what they do and are given the latitude to branch out and gain professional knowledge and skills. At that time, the outpatient rehab center was located in an old nursing home across the street from the main hospital. It employed primarily orthopedic and sports medicine-focused therapists, along with a few therapists who had a passion for neurological rehabilitation.
Headlines Prevail – An Idea Is Sparked
During this time, there was a dramatic increase in public awareness of concussions due to media stories about head injuries suffered from professional athletes. In October 2011, the CDC released an article under this headline: “60 Percent Increase in Youth Athletes Treated for TBI (Traumatic Brain Injury).” The CDC article warned the public that symptoms could be mild, but if not diagnosed and managed properly, they could lead to lifelong cognitive, psychological, and physical impairments. At that time, the center received referrals from a smattering of primary care physicians who had a patient diagnosed with a concussion. The center’s therapists were treating the patients’ symptoms—mostly headache, neck pain, and light sensitivity—with mixed outcomes.
As the facility began to see more patients with concussions, a small group of therapists performed a self-assessment and realized they needed more education and training to provide the best care to these patients. The clinicians dove deep into research about concussion diagnosis, management, and treatment. Coincidentally, therapists with a neurological background, while treating athletes with sports injuries—especially female soccer players and young adults involved in motor vehicle accidents—noticed an interesting pattern. The patients were reluctantly reporting other symptoms such as headache, neck pain, and dizziness. Some of them also had balance deficits. With further assessment, the therapists found a common thread: head injury, repetitive head and neck impact incidents, and whiplash, which were not reported as part of the medical history.
Meanwhile, the athletes were focused on the orthopedic injuries that kept them on the sidelines and out of their games. The therapists began to wonder if there was something deeper going on than orthopedic injuries: perhaps the brain was injured, too. They immersed themselves in the latest research on brain injuries in sources such as the study, “Traumatic Encephalopathy Related to Sports Injury, Helmets and Mouth Guards: The Role of Personal Equipment in Preventing Sport-Related Concussions”1; and the feature, “Inside Sports-Related Head Injury: Tau Inclusion Bodies and Proteins in a Tangle.”2 Throughout their research, the same clinical source appeared: Robert C. Cantu, MD, neurosurgeon at Emerson Hospital and a concussion expert.
Up for the Challenge
In order for the therapists to fully treat patients who were given a concussion diagnoses, there were several challenges to overcome. One was that the therapists treating these patients, many of whom were student athletes anxious to return to their sport, needed to educate parents about what it means to have a possible concussion injury, including the signs, symptoms, and the need to seek additional assessment by a physician. The therapists also had to educate coaches and athletes about the dangers of returning to play too early. This was when it was decided the concussion patient population likely was greater than originally thought. The therapists needed to go to their own expert: Cantu.
A group of therapists, armed with anecdotal evidence of what they were seeing in patients treated at the center, tests and measures, met with Cantu. They gathered as a small team of professionals, sharing knowledge and ideas, and asking questions about ways they could improve treatment for these patients so they could heal faster and resume their normal activities. Cantu listened to their concerns and confirmed that what the therapists were noticing may indeed be symptoms of concussion. Likewise, Cantu had many questions about rehabilitation treatment. What other symptoms do these athletes or young adults present with? What therapies are available? And, most importantly, how do we continue the conversation? At the end of the first meeting, each therapist left thinking, “We may be onto something here.” They knew they had an exciting opportunity to do something special, advance their knowledge, and improve patient care.
The professional collaboration between the therapists and Cantu continued to develop. Therapists brainstormed to develop a standard assessment protocol for patients who experienced head trauma. Noting that balance was critical for assessment, they used the standard balance assessment that they used on their neurological patients. This included the Romberg EO/EC (eyes open/eyes closed), single-leg stance, mimiBEST, and Berg balance scale. Cantu recommended they look into baseline testing. The timing was perfect, as the therapist’s development team had just compiled community research data that indicated concussions were rising to the top of community concerns. Working with Cantu, the therapists learned the different domains of concussion. The more robust the baseline tests, the better for the patient and their physician should a concussion be sustained. Early baseline testing included BESS (Balance Error Scoring System) and a computerized balance system to test balance as well as the ImPACT for cognitive assessment.
Discovering Missing Pieces
When treating concussion patients, referrals and therapy were primarily focused within the physical therapy scope of practice instead of leveraging the other disciplines. The therapists were missing pieces to a complex puzzle. Their consultations with Cantu continued. One piece of the puzzle that was identified was cognitive therapy by a speech language pathologist. People suffering concussion symptoms appear “normal” and fully functional. However, upon an in-depth comprehensive interview, sensitive testing and assessment, deficits are often identified that can be quite debilitating and prevent the individual from returning to the academic or work setting while still recovering. Without high-level testing that teases out cognitive deficits, the therapists ran the risk of missing key deficits that negatively impact function related to high-level cognitive skills, such as complex critical thinking. The goal was to obtain objective data on patient performance with complex cognitive and executive function skills. Armed with this information, the treating therapists can establish appropriate, specific goals to address the needs of the individual patient.
The Learning Curve and a Need for New Space
As the therapists continued to learn and hone their skills to treat post concussion syndrome (PCS) patients, they realized the physical construct of their aging rehab center was not conducive to treating this population. PCS patients with light and sound sensitivity had to attend therapy sessions in a noisy treatment room and gym, with nonadjustable bright lights. Therapists continued to work within each discipline to expand their knowledge and improve patient care. They attended additional concussion seminars, which often featured Cantu as a keynote speaker. They discovered additional commonalities with many PCS patients.
Balance and vestibular deficits were extremely apparent, as well as TMJ symptoms. Ongoing research and consultations with Cantu revealed a need to improve baseline testing to include visual tracking to fully assess people. It became apparent that in order to test accurately and efficiently while reducing variability, improvement would be needed in tests and measures. The King-Devick test was adopted to assess rapid eye movement, attention, and language. The King-Devick is a series of tests of rapid eye movement and number naming. Obtaining a baseline on a healthy brain may help diagnose and treat a patient in the event of a future concussion. Early identification of abnormal eye movements and function as compared to a baseline will help identify concussion symptoms and direct effective treatment.
OT as a Critical Puzzle Piece
The next piece of the puzzle was to add occupational therapy for those PCS patients affected by visual disturbances. Many patients reported difficulty reading on the computer, dizziness, and altered depth perception. The occupational therapists had significant background in many of the necessary areas related to concussion treatment, such as adaptive strategies to manage symptoms of visual stress, healthy routine management, and modification of workspace. However, additional education and training was required to develop a high level of clinical expertise with visual rehabilitation.
The therapists developed eye exercises for the muscles to increase visual efficiency and activities to improve visual processing speed, saccades, reaction time, and visual-perceptual skills. Additionally, the occupational therapy team recommended a light-based reaction time training assessment tool as a necessary piece of equipment for this patient population with visual issues. This tool measures an individual’s eye-hand coordination and dynamic visual skills. It is used to stimulate peripheral and spatial awareness, challenge visual-motor reaction time, pair visual stimuli with proprioceptive and cognitive challenges, and also as a means to monitor progress in these areas over time.
Working Together for Optimal Patient Care
As the group of therapists continued to grow, gain professional experience, clinical expertise, and develop a deeper professional relationship with Cantu, they noted that each discipline was working independently of one another. They were working with an emerging patient population, and had therapists at different stages of development in terms of clinical experience, skill set, and knowledge base. As a result, several issues began to surface. The most obvious was that the siloed approach to PCS treatment created some internal conflict between therapists and disciplines. Questions followed: Who is right? Which therapy was most important? Which therapy treats which PCS domain? Because of the siloed effect, patients received mixed messages from the therapists, causing confusion. It was time to pause and assess the current status of treatment—and the direction in which treatment needed to go.
In 2012-2013, a directive was given to develop a collaborative care team approach to treat the facility’s concussion patients. The vision was to make the patient’s experience and recovery the top priority. The goal of the directive was for the line between the professional disciplines to blur such that each member of the care team understood the role of the other disciplines. Each discipline was tasked with establishing a core set of competencies for the concussion therapist. Collaboration was the key to success. After several months of work, the groups created a comprehensive set of skills and knowledge that each therapist on the concussion team must complete. Following are several highlights: Physical therapists must be able to perform a return demonstration as well as a verbal review of the BESS, King-Devick, DHI, and VOMS. They must demonstrate proficiency with Frenzel lens goggles and complete learning modules on TMJ and the vestibular system.
Occupational therapists must demonstrate proficiency in the administration and interpretation of vision screening that includes convergences, fixation, light tolerance, localization, movement tolerance, and ocular ROM. They determined it necessary to also demonstrate proficiency in administration and interpretation of the DTVP, Rivermead, and visual motor integration. The speech language pathologists determined that 1 ASHA-approved concussion course per year was required along with proficiency in the administration and interpretation of numerous tests such as the FAVRES, TOMM, and the Woodcock Johnson Test of cognitive abilities. To further the collaboration, each member of the concussion team must attend collaborative care team meetings regularly.
Creating stringent competencies for each discipline led to inter-professional discussions on PCS management, and resulted in each professional in each discipline developing a strong collaborative culture and a growing respect among disciplines and clinicians. This tremendous shift in culture had a positive effect on patient care and outcomes. The mantra became: Therapies are medicines with strong side effects, and care should be given when prescribing, ensuring the right therapy, at the right time in the right dose for each patient.
A New Patient-Focused Center Opens
During this time, Emerson Hospital received a generous donation from a family in the community to create a brand new Center for Rehabilitative and Sports Therapies, a 16,000-square-foot purpose-built center that would have state-of-the-art equipment to match the expertise of all of its therapists. Cantu supported the creation of the Dr Robert C. Cantu Concussion Center, which would be housed adjacent to and under the same roof as the new rehab center. It was designed for the specific needs of concussion patients. Dimmable lights, soundproof walls, soft colors, and ease of access to the rehabilitation center are key features of its design.
The goal was to continue the collaborative, care team approach with Cantu as medical director for concussion diagnosis, management, and treatment. The new Clough Family Center for Rehabilitative and Sports Therapies and the Dr Robert C. Cantu Concussion Center opened in August 2015. The difference it has made in the continuing evolution of PCS care has been tremendous. The facility’s team of physicians, NPs, and concussion rehabilitation therapists continues to evolve. Cantu and his medical team are completely accessible and conveniently located to the therapists, and the medical team has complete access to the therapists. An academic culture between the concussion center and the rehabilitation team has emerged to the benefit of patients.
The Center for Rehabilitative and Sports Therapies, along with the Dr Robert Cantu Concussion Center at Emerson Hospital, has developed a care team model that is unique in every sense. The medical team and the rehab team are together both physically and—more importantly—ideologically. The patient experience is a seamless model, where the patient sees the physician then goes directly to his therapy appointment without missing a beat.
As a director, there is nothing more rewarding than to have a team of professionals who are passionate about what they do, invested in their profession and not afraid to identify opportunities for improvement. This team of professionals has worked through challenging times and emerged with a comprehensive, collaborative approach to patient care that has resulted in truly the best care for patients with brain injuries. RM
Terrie Enis, PT, MSPT, is Director of Rehabilitation, Emerson Hospital, Concord, Mass. She graduated from the University of Massachusetts, Lowell, with a master’s degree in physical therapy. She has 25 years of experience in the field of physical therapy and has been in a leadership role at Emerson Hospital for the last 7 years. Her clinical expertise includes rehabilitation of the athlete and spinal rehabilitation. She was named Clinical Educator of the Year by the New England Consortium of Academic Coordinators of Clinical Education and is certified as a clinical instructor by the APTA. For more information, contact [email protected].
1. Daneshvar DH, Baugh CM, Nowinski CJ, McKee AC, Stern RA, Cantu RC. Helmets and mouth guards: the role of personal equipment in preventing sport-related concussions. Clin Sports Med. 2011;30(1):145-163.
2. Chin LS, Jayarao M, Cantu RC. Inside Sports-Related Head Injuries. AANS Neurosurgeon. 2011;20(1).