To Schedule An Appointment OR To Book Your Concussion Testing Procedures;
Please Call: (519) 442 -2237
For Concussions it is important to get into the clinic as soon as possible
For more information, click in one of the tabs below
- What Is A Concussion?
- Vision and Vestibular Therapy
- Physical Exertion Testing
- Brain EQ
- Cambridge Brain Sciences - Cognitive Testing
- Advanced Rehab Process
- Links and Resources
- Signs and Symptoms
- Neurotracker Software (3D Training System)
- Cobblestone Physiotherapy and Chiropractic, Chiropractor, concussion, sports injury, rehab, Physical therapist
Definition of Concussion/ mTBI
“Concussions are defined as a COMPLEX pathophysiological process affecting the brain induced by traumatic biomechanical forces.” (Zurich, 2008)
Concussion/mTBI denotes the acute neurophysiological event related to blunt impact or other mechanical energy applied to
the head, neck or body (with transmitting forces to the brain), such as from sudden acceleration, deceleration or rotational
forces. Concussion can be sustained from a motor vehicle crash, sport or recreational injury, falls, workplace injury, assault
or incident in the community. (Ontario Neurotrauma Foundation)
A concussion is a type of traumatic brain injury that results from a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth creating a whiplash effect. This sudden movement can cause the brain to bounce around or twist in the skull, stretching and damaging the brain cells (axons) and creating biochemical changes in the brain not due to bleeding, tearing or bruising of the brain. Concussions result in temporary alteration of mental functioning. Furthermore this can include physical, emotional/social, cognitive symptoms and sleep disturbances. Signs and symptoms can be delayed appearing hours or days later. Concussions cannot be seen on X-ray or CT scan. Concussions do not have to be a result of loss of consciousness. When a student is injured and has a second concussion while he/she still has symptoms from a previous concussion which can lead to permanent disability and even death. The second injury may be very mild but can progress and have serious consequences.
Concussions are caused by a sudden shift of the brain in the skull. This quick shifting of the brain causes the brain to have altered function and metabolic properties resulting in a variety of symptoms that can range from mild to severe. Even blows to the body, face or head can result in shearing effects leading to rotation injuries as well as flexion/extension injuries. Note: Most gold standard imaging techniques such as MRI and CT will also show up as negative.
Concussion/mTBI is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic, and biomechanical injury constructs that may be utilized in defining the nature of a concussion/mTBI include:
1. Concussion/mTBI may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an‘‘impulsive’ force transmitted to the head.
2. Concussion/mTBI typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours.
3. Concussion/mTBI may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
4. Concussion/mTBI results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged. (MTBI guidelines).
Clinical Sub-types of Concussion
Fatigue, tiring more easily,” “forgetfulness, poor memory,” “poor concentration,” and
“taking longer to think,” as being associated with the cognitive fatigue
We identified the two items, “feeling of dizziness” and “balance
problems,” as being associated with the vestibular profile.
We identified the two items, “blurred vision” and “double vision,”
as being associated with the oculomotor profile.
We identified the four items, “being irritable, easily angered,”
“feeling depressed or tearful,” “feeling frustrated or impatient,”
and “restlessness,” as being associated with the anxiety/mood
We identified the four items, “headaches,” “noise sensitivity, easily upset by loud noise,” “nausea and/or vomiting,” and “light sensitivity, easily upset by bright light,” as being associated with
the migraine profile.
Typically associated with whiplash or direct trauma
Lack of sleep, disturbance ” or “drowsiness throughout the day.
Eye Movement Training Improves Early Reading Fluency – Mayo Clinic
Post Injury – Visual Dysfunction – Using Right Vision Software
After Therapy – Using Right Vision Software
4 Weeks, Vision Therapy and Rehab
Top Image – Post Injury Concussion
Bottom Image – Post Therapy Program
The visual system is often significantly affected by concussive injury. In some, symptoms of visual dysfunction may resolve in a short time frame, while in others symptoms may be ongoing for weeks or even months. Symptoms of visual dysfunction following head trauma may include headache, eye pain, difficulty reading, dizziness, focusing issues, and double vision.
For athletes suffering from persistent concussion-related symptoms, it is vital that they undergo visual screening to determine if a dysfunction is present. Most disorders of the visual system following head trauma are highly treatable if identified.
Our Health Professionals in the clinic are trained to identify and treat those athletes who may be suffering from a visual dysfunction post-concussion or post trauma. If further more specialized treatment procedures are necessary we can refer them to our qualified on- site Optometrist for assessment and rehabilitation as required. We currently have an Optometrist on staff who provides our specialized vision rehab resources and specialized eyewear if necessary.
Below are some amazing results we have had in the clinic with vision therapy and prism glasses:
Example Case Studies
Actual Patient 1 – No glasses and beginning vision/vestibular therapy
Same Patient – Given Prescription reading glasses, 3 weeks Vision/ Vestibular therapy
Same Patient – Given Specialized Prism eyewear, 4 weeks Vision/Vestibular therapy
Strong Vestibular dysfunction due to car accident head trauma
No compression garments/postural support
Now Adding Compression Garment/ Postural support
Amazing results and improvement!
As athletes return to sport we run ALL athletes through physical exertion testing specific to their sport.
Full 7500 sqr ft gym facility used for all our exertion testing procedures. The facility is connected to our main rehab facility Cobblestone Medicine and Rehab Centre.
Some of our amazing athletes performing parts of their Cobblestone exertion testing program!
EQ initially evolved as a series of concepts in the minds of the founders in response to what they saw as challenges within the current status quo of functional neurologic assessment.
During the last decade, the scientific understanding of human brain function shifted dramatically from a perceived static functioning organ to one that was, in fact, dynamic and capable of daily change. However, the assessment of brain function remained ‘dated’. The assessment of neurologic function continued to focus on “snapshot” assessments. This lack of development in assessment failed to match the rapid evolution in the understanding of function.
EQ sought to address this gap and to do so capitalizing on another evolving trend; the prevalence of mobile medical technology and game culture. EQ was developed as a means of measuring neurological function in a manner that is clinically relevant, scientifically accurate and technologically contemporary. The data that EQ captures and presents provides a clinical perspective of the user that is a ‘movie’; a movie of the function of the mercurial organ that is the human brain.
The founders identified challenge and opportunity, and it is this opportunity that is the heart of true innovation.
The EQ Balance test evaluates the vestibular (inner ear) and proprioceptive (ankle, knee, hip) system and the circuits connecting these areas. The balance system is affected in a variety of medical conditions and is of critical concern in sport, work, and of course aging.
EQ utilizes the internal accelerometer in mobile devices (phone/tablet) to measure the subject’s movement of the center of mass (COM) while performing stances in three different positions with the eyes closed.
Functional visual assessment evaluates large aspects of the geography of the brain with some aspects located in the frontal, parietal and brainstem movement centers. These systems represent 50% of the brain’s pathways and are frequently affected by a variety of conditions that are of critical concern in traumatic brain injury, sport performance and visually demanding occupations. In addition, since the visual system is present in so much of the brain’s geography, it is sensitive to deteriorations in overall processing speed as is seen in many age-related neurologic conditions.
The EQ visual test, utilizing a phone/tablet, is a timed, rapid tactile indication of arrow direction designed to capture eye movements in saccades as well as vergence and other aspects of vision and visual information processing.
EQ evaluates elements of executive function, letter and number recognition, mental flexibility, and reaction time utilizing variations of established clinical assessments.
EQ cognitive testing provides scoring in each of the above cognitive metrics utilizing just the mobile device.
Typical symptoms that are reported following concussion include headache, dizziness, visual difficulties, nausea, difficulty concentrating, difficulty with memory, neck pain and feeling like in a fog. These symptoms may be caused by a variety of different sources, thus a multifaceted assessment to evaluate numerous different systems is recommended. EQ contains seven tests that measure key brain health metrics relevant to concussion.
Balance Error Scoring System (BESS Poses)
Clinical trajectory: Balance
Neurological function: Vestibular & proprioception
Game name: Tire Toss
This test measures vestibular and proprioceptive function (balance and reflexes). These functions are often affected when someone suffers a concussion, and can also be affected by nausea, headache, orthopedic injury, ear infection, medications, dehydration and lack of sleep. Dizziness and postural instability have been reported in 40% to 50% of children after concussion and acute dizziness and imbalance have been correlated with a prolonged concussive recovery in young athletes.
The balance score is measured as the cumulative movement of the player’s center-of-mass during each test, then averaged across the five tests for the final performance score (out of 100).
Clinical trajectory: Visual
Neurological function: Binocular Vision and Visual processing
Game name: Dance Off
This task requires rapid visual processing and eye movement control, as well as sensorimotor control and coordination. The visual system can be affected by headache, stress, anxiety and lack of sleep and is often affected when someone suffers a concussion.
Clinical trajectory: Cognitive
Neurological function: Executive function
Game name: Pylon Pivot
This test measures multiple processes, often referred to collectively as ‘executive function’, including attention, visual scanning, sequencing and shifting, psychomotor speed, flexibility, planning, and maintaining two trains of thought. These functions are often affected by concussion and can also be impacted by headache, fatigue, stress, anxiety and lack of sleep. The cognitive function of athletes after concussion is now commonly used to determine suitability to return to play and to inform rehabilitation strategies.
Clinical trajectory: Cognitive
Neurological function: Verbal memory – immediate recognition
Game name: Recipe Recall
This test measures the ability to recognize the difference between previously-seen words vs. novel words, often referred to as ‘immediate memory discriminability’. This function is often affected when someone suffers a concussion, and can also be affected by headache, fatigue, stress, anxiety and lack of sleep.
Clinical trajectory: Cognitive
Neurological function: Verbal memory – delayed recognition
Game name: Recipe Recall with delay
This test measures delayed memory. These functions are often affected when someone suffers a concussion, and can also be affected by headache, fatigue, stress, anxiety and lack of sleep. A recent study has found that results of this test correlate highly with the Standardized Assessment of Concussion (manuscript under review).
Clinical trajectory: Cognitive
Neurological function: Working memory and attention
Game name: Jersey Reversey
This test measures attention and working memory. These functions are often affected when someone suffers a concussion, and can also be affected by headache, fatigue, stress, anxiety and lack of sleep.
Clinical trajectory: Cognitive
Neurological function: Reaction
Game name: Fastball
This test measures reaction time. These functions are often affected when someone suffers a concussion, and can also be affected by stress, anxiety and lack of sleep. Research has found that 75% of athletes have reduced reaction time within 48h of a concussion.
What is CBS Health?
CBS Health is an online brain health assessment service that accurately measures core elements of your cognitive
function, including memory, attention, reasoning and verbal abilities. Your healthcare practitioner will use these
measures to assess, monitor and manage core areas of cognition that are key to your mental health and wellness.
Benefits of CBS Health
Convenient – CBS Health is web-based and flexible. Assessments can be
completed on desktop, laptop and tablet devices, no pen and paper or
special hardware required
Engaging – CBS Health tasks take only 1.5 – 3 minutes to complete, and
are highly engaging, enjoyable and unintimidating. Plus, interactive and
repeatable task tutorials will ensure you get up to speed on the task
Actionable – CBS Health allows you to quantify the core elements of
cognition and track your cognitive trends over time, validating that
treatment or wellness plans are having the desired effects, or allowing
you to detect episodic changes to your cognition.
- Tasks used in 300+ peerreviewed
studies of cognition
- Over 8 million tasks completed
globally, and counting
- Backed by over 25+ years of
I feel like I did not do well on my assessment – should I be concerned?
You should not be concerned if you feel you did not do your best – there is no such thing as “best” for this type of assessment.
The tasks are designed to be challenging and to assess your limits by getting increasingly difficult as you answer questions
correctly. Please be aware that this is only a snapshot of your cognition at the moment you are completing the assessment and that cognitive performance tends to fluctuate naturally from day to day depending on many factors (like your sleep quality, stress level, nutrition, exercise regiments, etc.).
I could not complete my assessment due to an interruption or technical issue – what should I do?
If you’re interrupted or experience a technical issue during the assessment, contact your healthcare practitioner and describe the situation, as well as the task you were on, so that results for that specific task can be interpreted appropriately. If you experience a technical issue that prevents you from accessing the assessment, let your practitioner know the operating system
and browser you are using.
How long does the assessment take?
Assessments can vary in length depending on the number of tasks your practitioner has chosen. A four-task assessment will
take roughly 15 minutes, while a full 12-task assessment may take approximately 40 minutes. You can view the approximate
length of the assessment on the first page of your assessment.
How will my practitioner use the results?
CBS Health is used in a variety of different ways, ranging from annual monitoring of your cognition to evaluating recovery from
injury to validating treatment plans or interventions designed to improve your brain health. We encourage you to speak with your healthcare practitioner to learn more.
What does a CBS Health report look like?
You can view a sample report here. Reports will indicate raw scores and percentile ranks compared to others of the same age
and gender, as well as tracking your results over time (if you’ve taken assessments previously).
At Cobblestone Medicine and Rehab we use collaberative rehabilitation care using the latest evidence and research to get the individual back to their NORMAL life as soon as possible.
- Proper Pacing and detailed concussion education
- Impact Concussion testing (Baseline and post injury testing will be completed on the first visit and usually 2-4 weeks thereafter)
- Our extensive concussion trained multidisciplinary rehab team includes physiotherapy, sports chiropractic, acupuncture, Bioflex laser therapist, counselling, kinesiologists, personal training and family medicine physicians [/one_half]
- Visual/ocular rehab, Vestibular rehab, balance rehab, strength/stretching exercises, gait analysis, postural analysis and heart rate/BP analysis
- Proper return to learn techniques following evidence based methods
- Proper return to play/sport following evidenced based methods
- Final Sign off with our clinic family medicine physician and/or referral back to patients family physician
RETURN TO PLAY
Current recommendations are for a stepwise return to play program. In order to resume activity, the athlete must be symptom free and off any pain control or headache medications. The athlete should be carrying a full academic load without any significant accommodations. Finally, the athlete must have clearance from an appropriate health care provider. The program described below is a guideline for returning concussed athletes when they are symptom free. Athletes with multiple concussions and athletes with prolonged symptoms often require a very different return to activity program and should be managed by a physician that has experience in treating concussion. The following program allows for one step per 24 hours. The program allows for a gradual increase in heart rate/physical exertion, coordination, and then allows contact. If symptoms return, the athlete should stop activity, notify their healthcare provider before progressing to the next level. When returning, the athlete must start with the step last completed successfully.
Stage 1 – Complete cognitive and physical rest
Stage 2 – Light aerobic exercise
Stage 3 – Increase sport specific exercise
Stage 4 – Non contact practise
Stage 5 – Full contact practise
Stage 6 – Return to Full Activity
Recognition of the signs and symptoms are crucial when diagnosing a concussion. Symptoms can vary from physical dysfunctions, mental disturbances, emotional changes and sleep changes. These symptoms will vary from patient to patient.
Signs May include:
Dazed, confusion, reduced memory, “unsureness”, clumsy, slowly answers questions, possible loss of consciousness, and slower behaviour.
Symptoms May include:
Blurred or double vision
Seeing stars or lights
Sensitivity to light or noise
Sleeping more than usual
Difficulty falling asleep
Feeling “slowed down”
Feeling “in a fog” or “dazed”
Red Flags – Get Medical Help ASAP!
1. Progressive worsening headache
2. Worsening vomiting and nausea
3. Unequal dilated pupils
4. Decline in mental status
5. Deteriorated sleep habits
Injured athletes can exhibit many or just a few of the signs and/or symptoms of concussion. However, if an athlete exhibits any signs or symptoms of concussion, the responsibility is simple: remove them from participation. “When in doubt sit them out.” It is important to notify a parent or guardian when an athlete is thought to have a concussion. Any athlete with a concussion must be seen by an appropriate health care provider before returning to practice (including dryland/weight lifting) or competition.
“Having even just one sign or symptom may be a sign that the athlete has had a concussion and should be looked at by a experienced health professional dealing with head injuries”
NeuroTracker As A Concussion Tool
NeuroTracker Clinician is a 3D visual training system that provides a uniquely valuable tool to aid professionals in the assessment and treatment of concussion and brain trauma. NeuroTracker stimulates vision, vestibular and cognitive systems to help patients with PCS recover their ability to integrate and interpret multiple streams of sensory information. NeuroTracker enables clinicians to precisely align the intervention to the needs of the patients.
Adaptable to individual level of recovery
Sensitive to changes in high-level cognition function
Provides a practical baseline
Produces objective session scores
Applies to areas beyond recovery, such as performance training & assessment
How does NeuroTracker apply to the concussion recovery process?
NeuroTracker is a versatile rehabilitation tool that facilitates concussion rehabilitation in three distinct ways:
1. Post-concussion syndrome rehabilitation
NeuroTracker allows for stabilization, integration, and loading of the systems affected by concussion and brain trauma.
NeuroTracker session options can be personalized to provide controlled neurostimulation in short 6-minute sessions.
2. Injury assessment and Return-to-Play
NeuroTracker is sensitive to the changes in high-level cognitive function that occur when an individual sustains head trauma.
Following an injury, the drop in NT score can be used as an objective measure to help assess injury and determine safe RTP status.
3. Simple protocol, flexible treatment options
Trainers typically treat their patients with NeuroTracker twice a week for a month, for 15 to 20 minutes per visit.
The training can be administered inpatient, outpatient or remotely as a telemedicine application under supervision.
Once patient has recovered, NeuroTracker can also be used for performance enhancement and readiness assessment. For advanced training, NeuroTracker can be combined with a variety of dual-tasks, such as balance or skill-specific exercises, which increase the difficulty and make the training relevant to performance objectives.
By measuring deviations from baseline scores, coaches can assess whether an athlete is cognitively ready to perform or whether their training load should be altered. This assessment can be performed daily by the athlete on a personal computer or tablet.
“Our goal is to make our therapies and rehabilitation strategies as functional as possible for the patient so that we can ensure transfer into the demands of their daily activities. This is where NeuroTracker has become an invaluable tool in our practice.”
What Can We Do To Prevent Concussion
1. Education for coaches, staff, parents and students to:
a) Recognize the symptoms of concussion;
b) Remove the athlete from play;
c) Refer the athlete to a physician.
2. Wearing the protective equipment appropriate for the sport engaged in:
a) Equipment should fit properly;
b) Equipment should be well maintained;
c) Equipment should be worn consistently and correctly
3. Students should follow their coaches’ rules for safety and the rules of the sport
4. Instruct absent student/athletes on previously taught safety skills prior to next activity session
5. Parents need to teach their child that it is not smart to participate in sports if they received a head injury
6. It is not a badge of honour to play injured
7. Discourage others from pressuring injured students to play
8. Parents/coaches must not convince the child/student that he/she is “just fine”
9. Sharing of information with the school and the school coaches about any concussions the student may have suffered in the past
10. Provide reassurance, support and request/offer academic accommodations as needed
11. Outline the risks associated with the activity/sport for a concussion
12. Demonstrate how the risks can be minimized e.g. teach proper sport techniques – correct tackling in football, effective positioning in soccer, how to avoid over-crowding when using the creative playground. Take attendance in class and interschool sports and instruct absent student/athletes, on previously taught safety skills, prior to next activity session
13. Document safety lessons e.g. date, time, brief content, list of students in attendance
14. Teach skills in proper progression
15. Enforce the rules of the sport
16. Emphasize the principles of head-injury prevention e.g. keeping the head up and avoiding collision
17. Eliminate all checks to the head
18. Eliminate all hits from behind
19. Check that protective equipment is visually inspected prior to activity and well maintained. Enforce the principles of: respect for the rules of the game and practice fair play.
OUR PROMISE TO YOU
To improve and provide the best evidenced based practices in the treatment of Concussion and Traumatic Brain Injury. To help reduce the severity of concussions in the local school boards, and surrounding areas. To educate the community, coaches and parents about concussions including the signs and symptoms, treatment, rehabilitation and progressions.