By Sarah Maraniss Vander Schaaff

Blurred vision, painful headaches, and the inability to attend even a half-day of school. When her eight-year-old daughter, Charlotte, took a fall into a metal pole on the playground at school, her mother didn’t expect the ensuing concussion would change the course of third grade.

Charlotte, as you may remember from our post last week, had been twisting a friend on the swing when the friend spun-out rapidly and knocked her down. Charlotte’s head hit the pole, and after a trip to the school nurse, the pediatrician, and a few days of painful symptoms, it was clear the injury was more than a bump.

We pick up today with our interview with Charlotte’s mother at the point she knew Charlotte could not attend school as usual.

How did Charlotte’s recuperation affect her schoolwork and how did the school handle the absences?

She was unable-and she is still unable- to do homework. Until we went to University of Pittsburgh Sports Concussion Program, we really didn’t know what to do. Charlotte would go to school for half-days. She’d get excruciating headaches and sometimes have to come home after only being there an hour.

I learned that the district will grant medical leave in these cases and it will not be held against her grades or progression in school. However, I was very, very concerned that she might have to repeat third grade. I was later assured this would not happen.

When did you start to see progress?

We started to see progress when Charlotte began vision therapy with a pediatric optometrist. She was evaluated about 2 weeks after her concussion and it was determined that she had convergence insufficiency and accommodative dysfunction.

That basically means that her eyes were not working together and focusing properly. It is why she was having double and blurred vision. She started a weekly vision therapy program and eventually a home program on the computer that she does 3 times a week.

About 3 weeks post-concussion, I decided to make an appointment at UPMC, on the strong advice of our pediatrician and good friend, Dr. Gerry Raymond. He had visited the center and was intrigued by their more cutting-edge, aggressive approach. He said that many of his patients being seen by local concussion doctors weren’t getting better, some even after a year or more. So I decided that even if it was going overboard, we’d go to Pittsburgh.

What was UPMC like?

UPMC was like an athletic hall of fame. Signed jerseys decorated the hallways throughout the building, writing great thanks to Dr. Collins and his team. Charlotte and I passed huge athletes who looked like Steelers linebackers.

First, she had a pediatric ImPACT test, which is the standard for concussion testing worldwide and developed by Dr. Collins, the director of the program.

From there, Dr. Henry took a full history from Charlotte, talking directly to her the whole time. He explained that he was there to develop a customized recovery plan just for her and to stop all of the misinformation that we may have heard about post-concussion care.

Then, she was evaluated by a vestibular PT for her vision and balance issues. After that, was an exertion PT evaluation to determine how much physical activity she was capable of. Then she saw an MD to discuss nutrition and possible medications. Then we saw Dr. Henry again who created a comprehensive plan for Charlotte based on the information gathered that day.

He agreed that complete rest in a dark room is indicated, but only for the first week or two post-concussion. Then, it is time to slowing start taking baby steps to return to normalcy. He said that the mistake patients often make is to rest and stay inactive, both physically and mentally, for far too long. That extreme inactivity, in itself, causes fatigue, headaches, dizziness and depression, all symptoms that become nearly impossible to differentiate from the actual concussion symptoms.

He told Charlotte to think of her headaches as a runny nose when you have a cold. The runny nose is the body’s way to try to get better. Her headaches are the same thing. Through all of the evaluations, Dr. Henry determined that she could tolerate any type of non-contact physical activity. Charlotte was ecstatic that she could run around and exercise again! He also said she should begin half-days of school again and if she had a headache greater than a 3, she should go to the nurse to lie down. After a week or so, she would begin ¾ days or full. Dr. Henry also prescribed different daily exercises to do at home to help with her balance. And Charlotte was to continue with the vision therapy protocol from our local optometrist.

How is Charlotte now?

She started full-days of school recently, exactly 10 weeks post-concussion. One doctor at UPMC had prescribed an antiviral medication called amantadine to help ease the symptoms in returning to school. This has seems to really help make the transition back to full-days tolerable. Today is her last full-day of school and she was able to muscle through the past 3 weeks of school all but one day!

Charlotte really wanted to join our pool’s swim team, which I thought was a bad idea, but Dr. Henry told her to go for it. And he was right – she feels great and the exercise relieves a lot of symptoms. The more she has been more active, the more her energy level overall has improved.

Charlotte’s vision issues are greatly improved. And, Charlotte has noticed a fringe benefit of the vision therapy; she seems to read faster than she did pre-concussion. As skeptical as I was about vision therapy going into this, I simply can’t say enough about it now. She gets re-evaluated next week, after completing 10 weeks of vision therapy. I would bet that she is close to normal-range, if not back to normal altogether.

What advice would you give to parents?

Do not believe your pediatrician when he/she tells you that there is nothing you can do about a concussion, so don’t worry about it. There are many proactive things you can do to decrease recovery time and reduce the likelihood of symptoms getting worse. If after 2 weeks, your child is still having headaches, dizziness, fatigue, vision problems, etc., get in to see a concussion specialist as quickly as you can.

As you might expect, the cost of such thorough treatment is not insignificant. In addition to the time involved, there is the expense, much of which has not been covered by primary insurance for this family, although UMPC does accept insurance plans.  Vision therapy, however, has run $120 per session, with a 10-12 session program, following the initial evaluation. 

Charlotte’s mother describes an interesting result of the exertion test her daughter performed at UMPC:

“After she had the exertion PT evaluation, her physical therapist determined that Charlotte was capable of doing some exercise…and the most fascinating thing was that Charlotte had a headache and felt dizzy before starting her exertion PT evaluation. After the evaluation, she felt better and her symptoms subsided. The exercise and activity helped her symptoms, whereas the conventional wisdom out there told her not even to every jump or run or they would “shake up their brain” and re-injure themselves.”

What’s the difference between exertion therapy and “sucking it up” to get back in the game?

To answer that question, Charlotte’s mom referred me to the  5-step program that UPMC developed to gradually work patients through specific exertions over time, a model focused on vestibular rather than heart rate measures.

Click  to see Cara Troutman-Enseki, co-coordinator of the exertional training for UPMC, describe this process.

Photos above: Third-grader Charlotte, doing her exertion PT evaluation as well as her vision evaluation with the vestibular PT at UPMC. They return in early July for a re-evaluation and we’ll check in with them for an update. 

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