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Healing Mild Traumatic Brain Injury

A Physical Therapist hopes to show that timely assessment and treatment of concussion can prevent long-term harm to the brain.

Jim Buskirk, MSEd, PT ’83, SCS, AIB-CON, has helped drive advancements in the assessment and treatment of concussion among amateur and professional athletes, work rooted in his clinical practice and research on behalf of the Department of Defense (DOD) and NASA.

Concussion is the physiologic and functional response to mild traumatic brain injury (mTBI). In sports alone, it accounts for as many as 3.8 million reported injuries per year, according to the federal Centers for Disease Control. Awareness of mTBI has grown over the past decade due to high-profile litigation involving the NFL and former football players who show evidence of neurodegeneration linked to repeated and generally untreated blows to the head. Today, mTBI is recognized as a major public health issue.

Mr. Buskirk has worked at the cutting edge of research and the development of tools and protocols to assist in the diagnosis and treatment of concussive response to mTBI. He is driven to discover if timely testing and treatment can prevent serious, long-term changes to the brain.

“This is a very big area of research,” he said. “We now know how to properly assess mTBI, and while that science is continually evolving, we currently have instruments that can accurately measure what’s changing in the brain. Future research will help us answer the question: If we properly assess and treat mTBI in athletes, do they continue to have similar problems as the population who didn’t receive appropriate assessment and treatment?”

Physical therapists, who have long been integrated as members of interprofessional healthcare teams, should play a key role in the assessment and treatment of mTBI, argues Mr. Buskirk, who cites multiple studies like one conducted at the Children’s Hospital of Philadelphia that found nearly 57 percent of concussions were improperly diagnosed and treated in its emergency department.

“We’re missing the boat on clinical evaluations,” Mr. Buskirk said. “Physical therapy (PT), as a profession, needs to step up and say, ‘We can assess and treat this!’ We’re the movement specialists. We have the tools to do a proper assessment, but they’re not always being used. A team approach to treatment is a must. It’s a combination of medical management, physical therapy (vestibular rehabilitation) and psychological help for any residual cognitive deficits.”

For the past three years Mr. Buskirk has conducted clinical research on mTBI at the University of Miami Miller School of Medicine’s departments of otolaryngology, sports medicine and neurology, and helps educate RFU’s PT students on mTBI/concussion assessment and management. During a recent lecture he stressed a team approach in an overview of the latest sideline and in-clinic screening and evaluation tools that include: Sport Concussion Assessment Tool 5, various cognitive tests, vestibuloocular and oculomotor screening (VOMS), functional movement screens (FMS), and static and dynamic balance assessment protocols.

Mr. Buskirk is an expert in PT-administered vestibular and balance tests that are considered the gold standard in the assessment of mTBI, often along with formal neuropsychology and audiology evaluation and testing. At the University of Miami, he both treats and collects data on injured high school and college athletes from across Miami-Dade County who seek treatment at the UHealth concussion clinic.

“We employ a team approach and the PT plays a lead role,” he said. “Our injured athletes need to go through the rehab process and get cleared for participation. They then return to their athletic trainer and the trainer, who puts them through sport-specific GRTP (gradual return to play) protocols. First and foremost, they have to return to full participation as students.”

Mr. Buskirk has used data collected from patient mTBIs across his previous practices to create his current concussion treatment and return-to-participation programs. Data collection from objective testing, including rehabilitation techniques and outcomes with return-to-play protocols, is crucial given the culture of under self-reporting for mTBI, a fact underscored by a CDC advisory warning that “current data sources may capture only one out of every nine concussions across the nation.”

He is also part of a Miller School multidisciplinary team investigation of a potential therapeutic for mTBI/concussion — a combination of CBD (a cannabinoid derivative of hemp) and an antiinflammatory drug. The study will soon enter the clinical trial phase.

“The goal will be to collect data over a period of time and gauge the effects,” he said.

Mr. Buskirk’s initial interest in mTBI research was sparked after he spent the summer of 1987 as a PT consultant for the Detroit Lions, then playing inside the Pontiac Silverdome. “It was the only indoor football arena and the field was artificial turf,” he said. “The mechanisms and biomechanics of injury were totally different than on grass. Injuries on turf were more severe. We saw a huge difference in head trauma.”

He returned to Chicago and developed his private practice where he and physician colleagues soon made the connection between vestibular function and head trauma.

“I looked for other people around the country who had similar interests and found the DOD was the place to be,” he said. “The Navy was searching for a way to screen for previous head injuries and how those might impact performance in the military.”

Mr. Buskirk developed research protocols in conjunction with the Department of the Navy and its hospital in San Diego, which was designated as the intake for head trauma for all branches of the U.S. military. He helped build a database using patient data from his practice and a collaboration with Naval Station Great Lakes, and compared military blast injuries to sports-related or direct head trauma. The differences were significant.

“The prevailing thought was head trauma is head trauma is head trauma and that you treat all head trauma, including sports concussion injuries, the same,” Mr. Buskirk said. “We discovered that every head injury is different and should be treated uniquely. Brains are different. Mechanisms are different. It’s very complex. We developed the first research design study to show there are differences in mechanisms and types of concussive injuries.”

Mr. Buskirk and his research colleagues likely saved the DOD millions of dollars by treating mTBI/concussion and related vestibular dysfunctions in aviators, SEAL teams, deep divers and other high-performing, high-risk service members. That success led to work for NASA, where he helped develop vestibular rehabilitation protocols for astronauts who, dropping back into earth’s gravity aboard a space capsule, suffered spatial disorientation.

“The space shuttle changed the whole mechanism,” he said. “We had to figure out how to help them employ a protocol onboard so they could land the ship. We developed a plan that’s still in use by aviators today.”

Mr. Buskirk is currently consumed by a pressing question about sports-related mTBI: Why is there such a high recurrence rate and does that reflect a failure in current assessment and treatment approaches or duration of recovery?

“We monitor recovery time across all our clinics,” he said. “In sports, the main criterion is how quickly you can get someone back to participation. But now we’re thinking that’s maybe not the best measure to use. The number one predictor of a future injury is a previous one. The latest research says that after you sustain a concussive injury, receive treatment and return to your sport, you are 12 times more likely to suffer a non-contact orthopedic injury.

“Either we’re not doing something correctly in our rehab or maybe it’s the time we’re taking to get people back to full functionality. We’re looking at athletes who return to participation to see what the recurrence rate is and if that lines up with the published data. We’re also looking at the incidence of orthopedic injuries after sustaining mTBI.

“We have to scrutinize our methodologies of assessment and treatment,” Mr. Buskirk said. “We have to ask, ‘What are we missing? Why are athletes who get back into competition suffering so many recurrent and new orthopedic injuries?’

“We as PTs have to carry the flag. We’re the profession that can find and fix the problem.”

Posted August 20
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