Eye Movements Research Laboratory (EMRLab)|
Vestibular and Oculomotor Clinic (VORClinic)
Co-Directors: Dr. Claudio Busettini, Dr. Jennifer Braswell Christy
Executive Committee: Dr. Katherine Weise, Dr. Mark Swanson, Dr. James Johnston
The facility is located in the Henry Peters Building, School of Optometry, 1716 University Blvd, ground floor pediatric area. Please e-mail or call Dr. Busettini (firstname.lastname@example.org 205-934-2601) or Dr. Katherine Weise (email@example.com 205-934-8964) for inquiries and/or a tour of the facility.
Dr. Claudio Busettini is an Associate Professor at the Department of Vision Sciences of the UAB School of Optometry. Dr. Jennifer Braswell Christy is an Associate Professor at the Department of Physical Therapy of the UAB School of Health Professions. Dr. Katherine Weise is an Associate Professor and Dr. Mark Swanson a Professor at the Department of Optometry of the UAB School of Optometry. Dr. James Johnston is an assistant professor in pediatric neurosurgery at the Department of Neurosurgery of the UAB School of Medicine/Children's of Alabama and medical director of ThinkFirst Alabama.
In the US, there are annually more than 2 million cases of traumatic brain injuries (TBI) and of those, 75% are labeled as mild (mTBI) or concussion. An additional 5.3 million patients suffer from TBI-related disabilities (CDC, 2013). TBI is the most frequently occurring brain disorder, ahead of stroke and dementia. (Mondello 2013).
Symptoms of mild traumatic brain injury (mTBI) include headache (83%) and dizziness (70%) (Bergman K, 2013) as well as blurred vision, emesis, and nausea. These symptoms are likely related to altered function of the vestibular system and/or abnormalities in eye movements.
The Vestibular-Ocular-Reflex (VOR) works to keep vision clear while the head is in motion, such as when walking and reading a road sign, or running and throwing a football. The vestibular system uses accelerometric sensors located in the inner ear to stabilize the eyes and control body balance while our head is in motion.
Vestibular and vision rehabilitation is reportedly a key factor in reducing symptoms of dizziness, balance problems, and vertigo (Cohen, 2013). Both diagnosis and monitoring of mTBI recovery are hindered by the absence of reliable biomarkers. Standard CT and MRI tests are often negative, suggesting that symptoms may be the result of both functional and metabolic neural alterations not well visualized with existing imaging technology.
RESEARCH FOCUS: mTBI BIOMARKERS
When, during a game, a concussion is suspected, the big question is "it is or it is not?". A series of conflicting interests and feelings come into play at that time. Currently, identification of concussion in the athlete relies heavily on self-reporting. It is a natural tendency for the athlete to minimize the symptoms and to continue to play, particularly if the symptoms are mild and the game a key game for the season. With the increased awareness of the short- and long-term potential damaging effects of concussion, the coach will often prefer an immediate withdrawal from the game and perhaps for several more days even if a concussion is only suspected. Most parents, of course, will be even more protective. An effective biomarker for concussion would allow to recognize if it occurred, ideally directly on the field if possible. If a mTBI actually occurred, a quantitative and objective evaluation of the severity of the injury is still lacking. It is also difficult to evaluate the recovery process to determine when the athlete can safely “return to think” and “return to play”. Questions and worries that are obviously present not only in sport but in any kind of accident or fall with suspected mTBI. The need for quantitative and reliable biomarkers is also evident considering that repetitive concussions without full recovery between them generate a cumulative effect with an exponential increase in the probability of long-term deficits, including irreversible brain degeneration.
Many of the symptoms associated with concussion are consistent with alterations in the function of the vestibular system, both as eye stabilization reflexes and postural control, as well as in some of the other oculomotor systems (saccadic, optokinetic, smooth pursuit, vergence, accommodation, blink, pupil light reflex and near response synergy).
Therefore, our 2013 UAB HSF-GEF proposal was to establish the UAB Vestibular and Oculomotor Research Clinic (VORClinic), with primary focus on Balance, Eye, And Mild traumatic brain injury (BEAM). This project has been conceptualized by a team of UAB/COA clinicians, vision scientists, and bioengineers interested in mild traumatic brain injury (mTBI) and other conditions that may affect the vestibular and oculomotor systems. A HSF-GEF grant for the amount of $175,000, to which many other UAB entities offered additional contributions, made this possible.
The Vestibular and Oculomotor Research Clinic, with its multidisciplinary team of clinicians and scientists is unique in Alabama and one of the few in the United States. The team is perfectly poised to perform ground-breaking research in the area of mTBI and other disorders affecting the vestibular, postural, and oculomotor systems.
The main unit is a Neuro Kinetics Inc. I-Portal-NOTC-Clinical system with a high-torque Barany chair assembly inside an enclosure system to achieve complete darkness. Eye tracking is at 100 Hz, binocular, with a video system mounted inside goggles, or electro-oculography, the latter more suitable for young children. The resolution of the cameras is enough to offer reliable pupil and torsional measures. An optokinetic stimulus system on the ceiling projects large patterns on the inside wall for optokinetic testing. A fast x-y mirror galvanometer laser system projects moving dots or bars for saccadic, smooth pursuit, visual suppression, and objective horizontal or vertical tests. Push buttons are available for the evaluation of visual and auditory reaction times. A highly advanced analysis software allows a rapid quantification of the data, which are also available in raw format for user-specific measures. The system offers all standard vestibular, optokinetic, smooth pursuit, and saccadic tasks, which can be easily customized in terms of dynamical profiles, duration, direction, step sizes, etc. In addition, we purchased a specialized mTBI/Concussion Research Software Package, which validation will be a primary focus of our mTBI research. Preliminary data indicate that this protocol is extremely sensitive in detecting mTBI and following the recovery process.
SECOND EYE TRACKING SYSTEM WITH HEAD ACCELEROMETERS
This second eye tracking system has the same specifications and software of the one associated with the main system, but with its own head accelerometric system mounted on the goggles. It allows passive or active head movements in all directions and clinical tests like air or water caloric tests,
Epley maneuver for benign paroxysmal positional vertigo and, associated with a head holder, head-stationary oculomotor tests.
Vestibular and visual contributions directly affect our equilibrium. The SMART Equitest Platform (Neurocom) is specifically designed to challenge the equilibrium of the subject by altering the visual surroundings and by moving the 18"x18" dual forceplate on which the subject is standing. By recording the vertical forces exerted by the patient's feet it is possible to evaluate the ability of the subject to react to these disturbances and to maintain proper equilibrium. A supporting system safely keeps the subject from falling.
VESTIBULAR EVOKED MYOGENIC POTENTIAL
In primates there is a vestigial interaction between the sacculus and the hearing system. Auditory clicks
cause both brief relaxations of the sternocleidomastoid muscle (part of the neck muscles) and an oculomotor response. This system allows the testing of the function of the sacculus, which is a gravity sensor and also driving the linear vestibular ocular reflex.
Concussion seems to alter the constriction of the pupil to light. We are evaluating if this simple instrument can be used both in the clinic and on the field as a quick and reliable indicator of concussion.
We are a unique group of researchers with a unique set of equipment and expertise aimed at developing and validating testing protocols to detect mTBIs both on the field and in the clinic and to monitor the recovery from the concussion. With this research we will offer tools to athletes, coaches, and parents to determine when the player can safely “return to think” and “return to play” to minimize the possibility of long-term complications. At the same time, by detecting when all results are back to normal, to minimize the time off from school and other activities, including games.
WHAT YOU CAN DO
The first thing is to be aware of what concussion is, its dangers, and how to avoid it. We added useful links in "TO LEARN MORE ABOUT CONCUSSION" below. If you, your friend or someone in your family has a suspected concussion, do not ignore it or think that it will go away. It might, as it might not. A concussion is not a demonstration of being a though player or some kind of a badge of honor. Its symptoms are the sign that the brain got hurt, a SERIOUS thing which, in some cases, could affect a life forever.
To be successful in our projects, we will need to recruit large populations of athletes both in contact and non-contact sports at different ages and with or without a history of concussion. We also plan long-term studies where we will follow athletes from elementary school to the end of their college to study the long-term effects of playing sport. We will work in close collaboration with the Children's of Alabama Concussion Clinic to test patients as soon as possible when a concussion has occurred and to follow their recovery. We are also developing a concussion awareness program and assistance with some Birmingham City schools. Although you will probably hear about these studies from your school, please check our main webpage when recruitments are open, what are the requirements to be enrolled and what compensation or other benefits, like a free complete eye exam and discounts on glasses, you would receive for participating in these studies. These are all painless tests and, if enrolled, you can withdraw from a study at any time, no questions asked. Feel free to contact Dr. Katherine Weise (firstname.lastname@example.org 205-934-8964) if interested in participating in these studies or just to know more about them.
TO LEARN MORE ABOUT CONCUSSION
The Concussion Clinic at Children's of Alabama
Center for Disease Control and Prevention: concussion
Center for Disease Control and Prevention: traumatic brain injury
Alabama Head Injury Foundation
Brain Trauma Foundation
US Army: tbi
Sport Legacy Institute
Sport Legacy Institute Community Educators (SLICE)
Alabama Department of Rehabilitation Services: tbi
The VORClinic is also open to UAB researches that are interested in including vestibular, oculomotor, and postural tests in their work. Please contact us!
Created by Claudio Busettini 11/21/2016