Comprehensive Concussion Evaluation
Our comprehensive concussion evaluation program is designed to offer a thorough assessment and targeted care for individuals experiencing concussion symptoms. Through advanced diagnostics, we evaluate each patient’s specific needs, focusing on key areas affected by concussion such as neurological function, balance, vision, vestibular function, cognitive health, and physical abilities, which are assessed through a specialized physical therapy evaluation. By combining state-of-the-art tools with specialized testing, we are able to identify the extent and nature of the injury, providing a detailed analysis to guide the development of personalized treatment plans. This in-depth approach ensures that every aspect of a concussion is thoroughly assessed, allowing us to create a clear roadmap for effective treatment and symptom management.
Below, we outline our approach and the various options we use to determine the root cause of the symptoms, given the complexity of concussions, and how these findings inform our therapy recommendations tailored to your needs.
1. Concussion Symptom Questionnaire
The first step in our concussion evaluation process is to have the patient complete a comprehensive concussion symptom questionnaire. In this questionnaire, patients score each symptom on a scale from 0 to 5, where 0 means they do not experience the symptom at all, and 5 indicates the symptom is severe. This self-assessment covers a wide range of common concussion symptoms—such as headaches, dizziness, fatigue, and concentration difficulties—and provides our providers with an initial snapshot of the patient’s current symptom burden.
This scoring system helps our providers in several ways. It allows us to identify which symptoms are most impacting the patient, track symptom patterns over time, and prioritize focus areas for evaluation and treatment. By gathering this baseline data, we can tailor our diagnostic approach to the patient’s specific needs and monitor their progress through subsequent assessments. This personalized insight is essential for creating an effective, targeted treatment plan.
2. Detailed History
During your initial concussion evaluation, we take a personalized approach to gather essential information for diagnosis and treatment. We begin with a detailed injury history, including how and when the concussion occurred, the mechanism of injury (e.g., impact, whiplash, or sports), and immediate symptoms. We then review all symptoms, noting their frequency, intensity, and any recent changes in severity.
Next, we discuss your treatment history, including past therapies and medications, and their effectiveness. We also examine your medical history, including any prior concussions or neurological conditions, as well as issues like migraines or vestibular disorders. Additionally, we assess how the concussion affects your daily life, including work, sleep, and social activities, and review relevant medical records, such as past imaging studies or tests.
Finally, we address your goals and concerns about recovery and any changes since the injury. Your subjective input on progress is crucial, helping us form a comprehensive understanding of your situation. This thorough history allows us to design a personalized treatment plan tailored to your specific needs.
3. Cranial Nerve Evaluation
Cranial nerves are a set of twelve nerves that emerge directly from the brain, rather than from the spinal cord. They play a critical role in controlling essential functions, such as eye movement, facial sensation, taste, swallowing, hearing, and balance. Each cranial nerve has a specific role, whether in transmitting sensory information (like sight or smell) or controlling muscles (like those that move the eyes or enable facial expressions). Because they directly connect to the brain, these nerves can be affected by traumatic brain injuries, including concussions.
During a cranial nerve evaluation, our providers test each of these twelve nerves to assess their function. This might involve observing eye movement to check for tracking and coordination, testing facial muscle strength, examining reflexes, or assessing hearing and balance. For instance, the oculomotor, trochlear, and abducens nerves control eye movement, and any impairment in these can result in symptoms like double vision or difficulty focusing, which are common in concussion cases.
This examination helps us distinguish whether the injury affects specific cranial nerves, the brain itself, or both. If we find that certain cranial nerves are compromised, it may suggest direct injury to those nerves or pressure on the nerve pathways. Alternatively, if multiple cranial nerves and brain functions are impacted, this could indicate a more generalized brain injury, which is typical in diffuse injuries like concussions. By isolating the affected areas, our cranial nerve exam provides a clearer map of injury patterns, helping us to design a more targeted treatment plan.
4. Cervical Spine Evaluation
Examining the cervical spine during a concussion evaluation is crucial, as nearly all concussions involve some form of cervical injury. The neck plays an essential role in supporting the head and facilitating movement, and due to the common mechanisms of concussion—such as whiplash or rapid head movement—the cervical spine often sustains injuries like muscle strain, ligament sprains, or joint dysfunction. These injuries can worsen symptoms such as headaches, dizziness, and neck pain.
The cervical spine is also key to proprioception (the body’s ability to sense its position in space) and gaze stabilization (keeping the visual field steady while moving the head). When the neck is injured, these processes can be disrupted, leading to balance issues, coordination difficulties, and blurred vision, which make tasks like reading, driving, or walking challenging.
During the evaluation, we assess the cervical spine by testing range of motion, muscle tightness, spasms, and joint mobility. Identifying areas of restriction or discomfort helps us determine if cervical issues are contributing to symptoms. By addressing these cervical injuries, we can help alleviate symptoms, reduce discomfort, and improve both brain and neck function, leading to a more effective recovery overall.
5. Advanced Imaging
Advanced imaging plays a vital role in evaluating concussed patients, especially when traditional imaging methods, like standard MRI or CT scans, may not provide sufficient insight into the extent of injury. For patients with mild traumatic brain injuries (mTBI), including concussions, these traditional imaging techniques often fail to show significant changes, even though brain function may be impaired. This is where advanced imaging, such as MRI with Diffusion Tensor Imaging (DTI), becomes crucial.
DTI is a specialized type of MRI that is far more sensitive than standard imaging in detecting subtle changes in brain structure, particularly in the white matter. White matter consists of nerve fibers that transmit signals between different regions of the brain, and in concussions, these fibers can be damaged, leading to changes in brain function. DTI can detect this microstructural damage by mapping the movement of water molecules along these fibers, helping to identify areas of injury that traditional MRI may miss.
As part of our comprehensive concussion evaluation, we review any previous imaging studies the patient may have had, and based on the clinical presentation, we may order additional scans, typically an MRI with DTI. This allows us to gather a clearer picture of the brain’s condition, which helps guide treatment decisions. By identifying areas of damage that may not be visible on standard MRI, DTI provides essential information for accurately diagnosing and managing concussion-related symptoms.
6. Computer-Based Neurocognitive Testing
Computer-based neurocognitive testing, such as CNS Vital Signs, is an essential tool in evaluating cognitive function after a concussion. This type of testing uses computerized assessments to measure a variety of cognitive skills, including attention, memory, processing speed, and executive function. Unlike traditional testing methods, which can be subjective or dependent on self-reporting, neurocognitive tests provide objective, quantifiable data that can be tracked over time.
At our clinic, we use CNS Vital Signs to assess baseline cognitive function and monitor changes throughout the recovery process. The tests are designed to detect subtle impairments that may not be immediately obvious but are critical to a concussion diagnosis. By comparing a patient’s results to normative data, we can identify specific areas where the patient is struggling, such as in memory recall or processing speed. These areas of weakness are particularly important in guiding therapy, as they can point to the underlying cognitive deficits caused by the concussion.
As the patient progresses, we use follow-up neurocognitive testing to track improvements or identify any ongoing challenges. This data is invaluable in adjusting treatment plans, ensuring that therapy targets the areas of cognitive function that need the most attention. Whether it’s addressing memory issues, improving focus, or enhancing processing speed, the insights gained from CNS Vital Signs help us tailor therapies to each patient’s specific needs, ensuring the most effective and personalized approach to recovery.
7. Electroencephalography (EEG)
8. Neurotrauma Assessment Test
The Neurotrauma Assessment Test (NAT) is a cutting-edge tool that detects specific proteins, known as biomarkers, which are released into the bloodstream when the brain or spinal cord is injured. These biomarkers, such as GFAP (glial fibrillary acidic protein), serve as indicators of injury severity. After a traumatic brain injury (TBI), these proteins quickly appear in the blood, with some persisting and remaining detectable for months.
Measuring TBI biomarkers provides valuable insights into the extent of brain injury, yet they are only one part of a comprehensive evaluation. Other diagnostic tools, such as CT scans or MRIs, may still be necessary for a full understanding of the injury’s impact. Biomarker testing offers unique advantages by providing information on both the type and amount of brain injury, which can help predict outcomes and shape treatment plans.
The study of blood-based biomarkers in TBI is a growing field, with researchers continually identifying and exploring new biomarkers. As our understanding of TBI advances, biomarker blood tests like NAT are expected to become increasingly central to TBI diagnosis and management, offering a powerful tool for guiding care.
9. Vestibular Assessment
The vestibular assessment is a targeted evaluation of the inner ear and its role in balance, spatial awareness, and stability—critical areas often affected after a concussion. This includes positional testing for issues like benign paroxysmal positional vertigo (BPPV), a condition where small crystals in the inner ear become dislodged, causing dizziness with certain head movements. Using the Dix-Hallpike maneuver, we position the patient in ways that trigger dizziness if BPPV is present, helping to confirm whether this condition is contributing to their symptoms.
Another key part of the vestibular assessment is vestibulo-ocular reflex (VOR) testing, which evaluates the reflex that stabilizes vision during head movements. The VOR head impulse test challenges the patient’s ability to focus on a target while the head moves; if they struggle to keep their focus, it may indicate VOR impairment. We also use dynamic visual acuity testing, where patients read from an eye chart while moving their heads, to assess visual stability. Any blurring in this test suggests that head motion is disrupting visual focus, a common vestibular issue after a concussion. Each of these tests helps us pinpoint specific vestibular system deficits, guiding us in designing effective treatments to reduce dizziness, improve stability, and restore balance control.
10. Oculomotor Assessment
The oculomotor assessment focuses on eye movements and visual coordination, both of which are frequently affected by concussions. This evaluation includes smooth pursuit testing, which measures the eyes’ ability to smoothly track a moving object. Any jerkiness in eye movement may suggest issues with visual tracking and coordination. Saccadic testing is also performed, assessing rapid eye movements between two fixed points to gauge attention, focus, and processing speed.
In addition, the gaze stability test is crucial for examining the vestibulo-ocular reflex (VOR) during visual fixation. This test checks if the patient can maintain a steady gaze on a target while their head moves, which is essential for visual clarity during motion. We also test convergence and divergence, which involves shifting focus between near and far objects, to evaluate eye teaming and depth perception. Disruptions in these visual skills can lead to symptoms such as double vision, eye strain, and headaches. The results from the oculomotor assessment help us design targeted therapies to restore visual control, reduce symptoms, and improve the patient’s ability to interact with their environment.
11. Balance Assessment
Our balance assessment is an in-depth evaluation of stability and sensory integration, crucial areas often impacted by concussions. We begin with the Romberg Test, where the patient stands with feet together, arms by their sides, and eyes closed. By removing visual input, this test evaluates the body’s reliance on proprioception and vestibular feedback for balance. Any swaying or loss of balance can indicate a sensory integration issue or vestibular dysfunction.
We then proceed to tandem stance, asking the patient to stand heel-to-toe in a straight line. This position increases the demand on the proprioceptive system, especially when performed on an uneven surface or with closed eyes, and reveals the body’s capacity for fine motor balance control.
For tandem walking, we assess dynamic balance as the patient walks heel-to-toe along a straight line. This test allows us to observe coordination and gait stability, which can be compromised in post-concussion patients and impact their day-to-day mobility.
Lastly, we use the Clinical Test of Sensory Integration and Balance (CTSIB) to examine how different sensory systems—visual, vestibular, and proprioceptive—contribute to balance. This test involves standing on firm and foam surfaces with both eyes open and closed, helping us identify which sensory systems are working harder to compensate for deficits.
Each of these assessments—Romberg, tandem stance, tandem walking, and CTSIB—offers insights into the patient’s balance abilities and helps us identify specific areas to target in their treatment plan to enhance stability and alleviate concussion-related symptoms.
