Symptom screening tools do not elaborate on subcategories of ‘dizziness’. Concussed individuals may minimize symptom reports for a variety of reasons, may not describe abnormal sensations as dizziness, and brain injury impairs accurate self-assessment (McCrea M 2004). Careful questioning is required to draw out symptom details of this invisible injury. The symptoms of dizziness do not identify a structure, but rather an impaired sensory process.
SENSORY CONFLICT AND MALADAPTED RESPONSE
Sensory conflict is the miss-match of two or more sensory inputs to each other and to predictions based on memory of prior experience. That includes memory of the environment, the action, consequence, and effects of Earth’s gravity (Laquaniti F 2013, Asslander L 2016). Motion sickness is a common example of sensory conflict. Resolving conflict among sensory systems in healthy individuals requires the ability to shift or weight the use of one system over another, matching environmental demands while maintaining or recovering a normal sense of equilibrium (Peterka 2002). Amusement park rides capitalize on altering the environment visually as well as by defying gravity, producing temporary disorientation. Walking in the dark denies adequate visual information, requiring a shift to vestibular and somatosensory cues. Walking over uneven ground reduces reliable somatosensory information. Traveling in the dark over uneven ground in an unfamiliar environment can be quite disorienting if vestibular references are inaccurate or inefficient. Responses to unresolved sensory conflict vary from mild discomfort to autonomic “fight flight or freeze” reactions, nausea, misbehavior, and exhaustion (Lee H 2014).
Maladapted responses to chronically damaged, inefficient or missing vestibular inputs may present in numerous ways. Examples include avoiding crowds, restricted driving, muscle guarding or clenching to stabilize the head and body, or eyestrain from visual dependence for balance in absence of integrated multimodal sensory inputs. Timing and spatial perceptual errors will become more obvious as activities increase in speed and complexity, because visual and somatosensory neural transmissions are slower than vestibular conduction speeds, making compensation less efficient (Morris L 2014).
Whether acute or chronic, the effort to resolve the sensory conflict of dizziness causes brain fatigue and general exhaustion. The resulting delayed recovery contributes to further perceptual and cognitive errors (Franke LM 2012, Howell DR 2015).
VESTIBULAR INJURY AND CONSEQUENCES
The vestibular system is particularly vulnerable to concussive head forces because of its vast representative network at every level of the brain, and its sensory organs of the inner ears housed within the bony labyrinths of the temporal bones. The vestibular sensory system processes head station, acceleration and angular velocity data from the inner ears, integrates body motion, visual motion, eye response to head motion, and perception of Earth’s gravity. Thus it contributes the perception of weight and three-dimensional context to visual and somatosensory cues about self and the environment (Laquaniti F 2013). Navigation, gaze stability, balance, coordination, postural stability, control of heart rate and blood pressure, memory and emotional control
all depend to some degree on vestibular function (Brandt T 2005, Kristjansson E 2009, Franke LM 2012, Morris L 2014).
Central Vestibular Injury
The central vestibular system is the primary integrator of multisensory data from sensorimotor and behavioral areas (Bronstein 2016). Concussion’s neural injury and metabolic pathology disturb sensory integration at cortical and subcortical levels (Gattu R 2016). Disruption may involve the vestibular-ocular system, the vestibular-somatosensory systems (notably confounded by abnormal input and response from the cervical spine), vestibular-autonomic connections, vestibular cortex, or any combination (Furman JM 2000, Morris L 2014, Arshad Q 2017).
Diffusion Tensor magnetic resonance tractography (DTI) identifies the vestibular network as a rope ladder shape crossing the midline at every level from brainstem to cortex, including through the corpus callosum (Kirsch V 2016). Vestibular pathways are also two-way information tracts direct to the cerebellum, medulla and spinal cord, instigating and modulating neck, trunk and limb responses to head position and motion through the vestibulo-spinal system (Pan T 2015). This area is vulnerable to traction, torsion and compression during whiplash injuries to the cervical spine (Kristjansson E 2009).
Symptoms of vestibular disruption often begin with dizziness. The inability to sort sensory input caused by neural disruption at sub cortical levels pushes processing to a cortical level, creating a significantly increased metabolic demand and contributing to pervasive brain fatigue. Increased metabolic demand co-occurring with reduced blood perfusion initially creates vulnerability to a second injury from impact or exertion (Franke LM 2012). When further insult is experienced the neural crisis is extended (Vagnozzi R 2010)
Peripheral Vestibular Injury
The peripheral vestibular organs can be damaged by concussive forces to the ear injuring membranes and hair cells, creating inflammation resulting in endolymphatic hydrops, labyrinthitis, perforation (fistula) or by dislodging calcite crystals from the utricle of the otolith (Morris L 2014). Loose calcite crystals may float into a semicircular canal, causing abnormal fluid turbulence during head motion. The distorted perception of motion is Benign Paroxysmal Positional Vertigo (BPPV), and can be quite frightening. Nearly 30% of post concussive dizziness is attributed to BPPV (Hoffer ME 2004). Initial brief episodes of dizziness and imbalance may devolve into lasting vague discomfort and other impairments if not treated. New symptoms will develop from the brain’s attempt to adapt and compensate for abnormal sensory spatial and motion information.
Vestibular Injury Impact on Vision
Visual disruption after mTBI is more often a problem with the oculomotor system and/or visual processing than visual acuity (Heitger MH 2009). Direct vestibular connections to the oculomotor nuclei create the fastest central reflex in humans, the vestibulo-ocular reflex (VOR). By calibrating eye motion precisely to head motion and direction, an image is maintained on the retina for clear vision despite head motion. Together with
the cervico-ocular reflex and the optokinetic reflex, the VOR is an important component of gaze stabilization. Interference in accurate and precise perception of head position may disrupt the VOR resulting in blurred vision and uncoordinated voluntary eye motions of smooth pursuits, vergence and saccades (Bronstein 2016). Clients’/patients’ whose VOR is impaired find it difficult to read using print, or see objects in the environment as stable when turning, walking or running.
Ocular reflexes generated from the vestibular system also support stable vision when the environment is moving. When disrupted, symptoms include headache, eyestrain and fatigue, inability to tolerate scrolling print on a computer monitor, and nausea from the sensory conflict between visual perception and perceived head position and motion. Impairments in eye control worsen as speed increases, and with fatigue during sustained activity such as is required to attend school or work (Gottshall KR 2010, Murray NG 2014).
Accurate visual processing depends on intact vestibular information. Astronauts on the International Space Station maintain semicircular canal function, but lose otolith function in a 0g environment. In experiments they made timing errors when reaching for a vertically propelled ball (constant speed in absence of gravity acceleration). Errors persisted longer than 14 days, suggesting difficulty in learning to override ingrained prior memory of Earth’s gravitational effects (Laquaniti F 2013). When sensory integration is damaged, visual processing deficits have been identified long after a concussive event (Brosseau-Lachaine O 2008, Heitger MH 2009)
Visual processing alone is also not sufficient to determine self verses environmental motion. In the absence of accurate or adequate vestibular function, and in concert with oculomotor deficiencies, over-reliance on vision may develop into visual motion hypersensitivity (VMH), or visual vertigo (Winkler PA 2009, Pavlou 2010) Individuals with VMH may not be able to differentiate self motion from environmental motion, may see stationary objects as moving, have difficulty reading, and report dizziness. They are likely to self-limit exposure to aggravating stimuli (busy environments, travel, crowds), affecting their lives, fitness, psychological health, and relationships.
Vestibular injury Effect on Balance
Balance is a complex expression of motor control, timing, reflexes, predictions, learned patterns, intent and constant updating and grading of information in response to sensory inputs, to arrange the body relative to gravity to achieve a desired task. The central vestibular system dictates eye, neck, trunk and extremity responses based on head position with movement input from the peripheral vestibular organs of the inner ears and proprioception from the high cervical spine (Kristjansson E 2009, Horak 2010, Bronstein 2016). Balance and equilibrium impairments are measurable immediately after concussion. Unaddressed balance impairments may persist and even worsen over time (Franke LM 2012, Murray NG 2014, Pan T 2015). When vestibular function is inadequate, inaccurate or absent, reliance on remaining sensory systems will increase. Returning to activity after mTBI, no matter how graded, without addressing vestibular impairment invites development of less efficient movement.
THE MULTIFACETED COSTS OF MTBI WITH VESTIBULAR INJURY
Individuals with post concussion syndrome or post concussion disorders represent a significant number of people in light of the total number of mTBI’s per year. There is not yet a reliable treatment intervention to stop or change the acute cascade of disruptive neural processes after mTBI. Current management guidelines recommend initial rest from all activity, then graded return to activity while monitoring symptoms during the natural course of healing (McCrory P 2013). However, symptoms are not reliable indicators of resolution stage of the neurophysiologic, hemodynamic, metabolic and micro-structural disruptions from mild traumatic brain injury. Multiple studies have demonstrated neural substrate abnormalities resolving from 30 days to four months in asymptomatic athletes (Signoretti S 2011, Yeo RA 2011).
When resolution of a concussion lasts longer than a week, disruptions at school and work can become onerous, or even insurmountable. Over time, the cost of post concussion disorders may be measured in lost opportunities, lost income, medical expense, behavioral changes, social-relational and emotional disturbances, and physiologic energy depletion. These effects are not limited to the concussed individual, but may extend to family members, caregivers, workplaces, teachers and school administrators, and social networks.
NEURO-VESTIBULAR REHABILITATION IMPROVES SENSORY
Evaluation for Functional Deficits
As part of a multidisciplinary team, Physical Therapists with highly specialized training and a neurological rehabilitation background provide vestibular rehabilitation (VR). A complex evaluation is required to identify a patient’s functional deficits (Alsalaheen BA 2013). Tools such as the Balance Error Scoring System (BESS) , commonly used as part of concussion screening for athletes and military personnel, are not specific enough to inform treatment direction. A series of validated testing tools are combined to best identify specific deficits in gravity perception, postural stability, gait, oculomotor function, tolerance to exercise exertion, and sensory weighting from one system to another (Scherer MR 2009, Alsalaheen BA 2013, Morris L 2014). Underlying dysfunctions, timing, balance, and cognitive errors, may be revealed under increasingly stressful or demanding test conditions. Performance during dual-task activities, requiring a higher level of cognitive and sensorimotor processing, is significantly impaired in concussed athletes and worsens after return to activity (Roberts JC 2011).
Vestibular Rehabilitation Goals
Treatment begins with extensive education for patients and their relevant intimates. The first functional task in mTBI recovery treatment is to match sensory inputs, ideally beginning as soon as dizziness is reported. Specialized activities are designed and prescribed specifically to address an individual’s identified needs. Feedback from appropriate sensory systems, error signals, task specificity and proper dosing of challenges are required to encourage healthy neurobehavioral adaptation and reorganization. Co-existing impairments must be identified as they complicate and lengthen the rehabilitation process (Hoffer ME 2004, Shumway-Cook 2007, Scherer
MR 2009, Alsalaheen BA 2010, Morris L 2014).
Benefits of VR include recalibration of sensory systems, improved postural stability and gait, improved oculomotor function and gaze stability, and reduced symptoms of dizziness. More than 85% of dizzy patients improve with such specialized care. Studies demonstrating improvements have looked at patients with vestibular disease, BPPV both traumatic and idiopathic, mTBI, migraine, imbalance, and visual motion hypersensitivity. Success has been documented no matter how long after injury the person enters care (Hoffer ME 2004, Gottshall KR 2010, Alsalaheen BA 2013, Broglio SP 2015, Gottshall KR 2015, Whitney SL 2016).
EARLY INTERVENTION RECOMMENDED BY SCIENCE AND EXPERTS IN THE FIELD.
Reducing brain energy demands by reducing dizziness early paves the way for quicker and more robust recovery from mTBI. BPPV is a mechanical problem and should be treated and resolved immediately. Stroke research has demonstrated positive structural changes in neural axons when task specific training is introduced between day 1 and 3 after onset (Lee KH 2013). In the Statements of Agreement from the Targeted Evaluation and Active Management Approaches to Treating Concussion Meeting (Collins MW 2016), 38 specialists in the care of mTBI concluded that intervention on the first day was indicated and would produce more desirable and expedient outcomes .
In their essays for The Players Tribune, Bryce Sandoval (‘Til It’s Gone, September 5, 2015) and Gabriel Landeskog (We Need to Talk About Concussions, Right Now, August 2, 2016) vividly recounted their experiences of concussions after being hit in the face with flying pucks. As a defenseman for the New Jersey Devils, Sandoval developed gradually worsening physical, perceptual and emotional dysfunction over two seasons. Night driving made him feeling as though he was floating. He misjudged puck location and trajectory and felt nauseous when turning repeatedly. Although he sought help from numerous specialists, he did not fully recover until experts in neurology and physical therapy experienced with the multisensory complications of concussion designed a novel rehabilitation program to recalibrate his vestibular, visual and somatosensory subsystems. Landeskog, as a forward and newly anointed captain for the Colorado Avalanche, pushed himself to return to play immediately, underreporting his symptoms out of loyalty and commitment to his teammates. He developed severe light sensitivity and migraines. Fortunately he had immediate access to highly skilled care, and was force-marched through the rest and rehabilitation required to recover 100%. But he made note of the lack of such care for non-professionals and children, highlighting the need to improve all aspects of concussion recognition and management for everyone, immediately.
CONSEQUENCES OF MISSED DIAGNOSES AND DELAYED CARE
Vestibular disruption following mild traumatic brain injury underlies many symptoms and impairments. The Department of Defense (VA/Dod 2016), Colorado Department of Labor and Employment (Worker’s Compensation 2012), and the Colorado Department of Education (McAvoy K 2014) have
Alsalaheen BA, Mucha A, Morris LO, Whitney SL, Furman JM, Camiolo-Reddy CE, Collins MW, Lovell MR, Sparto PJ (2010). “Vestibular rehabilitation for dizziness and balance disorders after concussion.” J Neurol Phys Ther 34(2): 87-93.
Alsalaheen BA, W.hitney SL, Mucha A, Morris LO, Furman JM, Sparto PJ (2013). “Exercise prescription patterns in patients treated with vestibular rehabilitation after concussion.” Physiotherapy Research International 18(2): 100-108.
Arshad Q, Roberts RE, Ahmad H, Lobo R, Patel M, Han T, Sharp DJ, Seemungal BM (2017). “Patients with chronic dizziness following traumatic head injury typically have multiple diagnoses involving combined peripheral and central vestibular dysfunction.” Clin Neurol Neurosurg 155: 17-19.
Assländer L, Peterka RJ (2016). “Sensory reweighting dynamics following removal and addition of visual and proprioceptive cues.” J Neurophysiol 116(2): 272-285.
Brandt T, Schautzer F, Hamilton DA, Bruning R, Markoitsch HJ, Kalla R, Darlington C, Smith P, Strupp M (2005). “Vestibular loss causes hippocampal atrophy and impaired spatial memory in humans.” Brain 128(Pt 11): 2732-2741.
Broglio SP, Collins MW, Williams RM, Mucha A, Kontos A. (2015). “Current and emerging rehabilitation for concussion: A review of the evidence. .” Clinics in sports medicine 34(2): 213-231.
Bronstein AM (2016). “Multisensory integration in balance control.” Handbook of Clinical Neurology 137: 57-66.
Brosseau-Lachaine O, Gagnon I, Forget R, Faubert J. (2008). “Mild traumatic brain injury induces prolonged visual processing deficits in children.” Brain Inj 22(9): 657-668.
CDC (2003). Report to Congress on Mild Traumatic Brain Injury in the United States: steps to prevent a serious public health problem. Atlanta, GA, National Center for Injury Prevention and Control
Chamelian L, Feinstein A. (2004). “Dizziness following traumatic brain injury is an independent predictor of failure to return to work.” Arch Phys Med Rehabil 85: 1662-1666.
Collins MW, et. al. (2016). “Statements of Agreement from the Targeted Evaluation and Active Mangement (TEAM) Approaches to Treating Concussion Meeting, Pittsburgh, Oct 15-16, 2015.” Neurosurgery 79(6): 912-929.
Faul M, Xu L, Walk MM, Coronado VG. (2010). Traumatic Brain Injury in the United States: Emergency Department visits, hospitalizations, and deaths, 2002-2006. National Centers for Injury Prevention and Control; Centers for Disease Control and Prevention. Atlant, GA.
Franke LM, Walker WC, Cifu DX, Ochs AL, Lew HL (2012). “ Sensoryintegrative dysfunction underlying vestibular disorders after traumatic brain injury.” J Rehabil Res Dev 49(7): 985-994.
Furman JM, Whitney S. (2000). “Central causes of dizziness.” Phys Ther 80(2): 179-187.
Gattu R, A. F., Cacace AT, Hall CD, Munane OD, Haacke EM (2016). “Vestibular, balance, microvascular and white matter neuroimaging characteristics of blast injuries adn mild traumatic brain injury: Four case reports.” Brain Inj 30(12): 1501-1514.
Gottshall KR, Hoffer M. (2010). “Tracking recovery of vestibular function in individuals with blast-induced head trauma using vestibular-visual-cognitive interaction tests.” J Neurol Phys Ther 34(2): 94-97.
Gottshall KR, Sessoms PH. (2015). “Improvements in dizziness and imbalance results from using a multi disciplinary and multi sensory approach to vestibular Physical Therapy: a case study.” Frontiers in Systems Neuroscience(06 August).
Gurley JM, Hujsak BD, Kelly JL (2013). “Vestibular rehabilitation following mild traumatic brain injury.” NeuroRehabilitation 32(3): 519-528.
Harmon KG, et. al. (2013). “American Medical Society for Sports Medicine Position Statement: concussion in sport.” Br J Sports Med 47: 15-26.
Heitger MH, Jones RD, Macleod AD, Snell DL, Frampton CM, Anderson TJ (2009). “Impaired eye movements in post concussion syndrome indicate suboptimal brain function beyond the influence of depression , malingering, or intellectual ability.” Brain 132(10): 2850-2870.
Hoffer ME, Gottshall K, Moor R, Balough BJ, Wester D. (2004). “Characterizing and treating dizziness after mild head trauma.” Oto Neurotol 25(2): 135-138.
Horak, F. B. (2010). “Postural compensation for vestibular loss and implications for rehabilitation.” Restor Neurol Neurosci 28(1): 57-68.
Howell DR, Osternig LR, Chou LS (2015). “Return to activity after concussion affects dual-task gait balance control recovery.” Med Sci Sports Exerc 47(4): 673-680.
Kelly JC, Efland H, Barth JT (2012). “Mild traumatic brain injury: Lessons learned from clinical, sports and combat concussions.” Rehabil Res Pract 2012: 371970.
Kirsch V, Keeser D, Hergenroeder T, Erat O, Erti-Wagner B, Brandt T, Dieterich M (2016). “Structural and functional connectivity mapping of the vestibular circuitry from human brainstem to cortex.” Brain Struct Funct 221(3): 1291-1308.
Kisilevski V, Podoshin L, Ben-David J, Soustiel JF, Teszier CB, Hafner H, ChistyakovA (2001). “Results of oto vestibular tests in mild head injuries.” International Tinnitus Journal 7(2): 118-121.
Kristjansson E, Treleaven J (2009). “Sensorimotor function and dizziness in neck pain: implications for assessment and management.” J Orthop Sports Phys Ther 39(5): 364-377.
Langlois JA, R.utland-Brown W, Wald MM (2006). “The epidemiology and impact of traumatic brain injury: a brief overview.” J Head Trauma Rehabil 21(5): 375-378.
Laquaniti F, Bosco G, Indovina I, La Scaleia B, Maffei V, Moscatelli A, Zago M (2013). “Visual gravitational motion and the vestibular system in humans.” Frontiers in Integrative Neuroscience 26(12).
Lau BC, Kontos A. Collins MW, Mucha A, Lovell MR. (2011). “Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players?” Am J Sports Med 39(11): 2311-2318.
Lee H, Kim H (2014). “Autonomic dysfunction in chronic persistent dizziness.” J Neurol Sci 344(1-2): 165-170.
Lee KH, Kim JH, Choi DH, Lee J (2013). “Effect of task specific training on functional recovery and corticospinal tract plasticity after stroke.” Restor Neurol Neurosci 31: 773-785.
McAvoy K, Werther K. (2014). Concussion Management Guidelines. Denver, CO, Colorado Department of Education.
McCrea M, Hammeke T, Olsen G, Leo P, Guskiewicz K (2004). “Unreported concussion in high school football players: implications for prevention.” Clinical Journal of Sport Medicine 14(1): 1317.
McCrory P, Meeuwisse WH, Aubry M, et al (2013). “Concensus statement on concusison in sport: the 4th International Conference on Concussion in Sport, Zurich, November 2012.” British J Sport Med 47(5): 250-258.
Miranda N, Campbell H (2015). A Thinking Map to Guide the Differential Diagnosis of Dizziness. Brain Injury Summit: A Meeting of teh Minds. Vail, CO.
Morris L, Gottshall K (2014). Physical Therapy management of the patient with vestibular dysfunction from head trauma. Vestibular Rehabilitation. S. H. R. Clendaniel. Philadelphia, PA, FA Davis Company: 504-536.
Murray NG, Ambati N, Contreras MM, Salvatore AP, Reed-Jones RJ (2014). “Assessment of ocu-lomotor control and balance post-concussion: a preliminary study for a novel approach to concussion management.” Brain Inj 28(4): 496-503.
Pan T, Liao K, Roenigk K, Daly JJ, Walker MF. (2015). “Static and dynamic postural stability in veterans with combat-related mild traumatic brain injury.” Gait Posture 42(4): 550-557. Pavlou, M. (2010). “The use of optokinetic stimulation in vestibular rehabilitation.” J Neurol Phys Ther 34(2): 105-110.
Peterka, R. (2002). “Sensorimotor integration in human postural control.” J Neurophysiol 88(3): 1097-1118.
Roberts JC, Cohen HS, Sangi-Hghpeykar H (2011). “Vestibular disrorders and dual task performance: impairment when walking a straight path.” J Vestib Res 21(3): 167-174.
Saman Y, Bamiou D, Gleeson M, Dutia M (2012). “Interactions between stress and vestiular compensation – a review.” Frontiers in Neurology 3: 1-8.
Scherer MR, Schubert M. (2009). “Tramatic brain injury and vestibular pathology as a comorbid-ity after blast exposure.” Phys Ther 89: 980-992.
Signoretti S, Lazzarino G. Tavazzi B, Vagnozzi R (2011). “The pathophysiology of concussion.” Physical Medicine Rehabilitation 3(10 Suppl 2): S359-368.
Taylor CA, Greenspan AI, Xu L, Kresnow MJ. (2015). “Comparability of national estimates for Tramatic Brain Injury-related medical encounters.” J Head Trauma Rehabil 30(3): 150-159.
Terrio H, Brenner LA, Ivins BJ, Cho JM, Helmick K, Schwab K, Scally K, Bretthauer R, Warden D (2009). “Traumatic brain injury screening: preliminary findings in a U.S. Army Brigade Combat Team.” J Head Trauma Rehabil 24(1): 14-23.
VA/Dod (2016). Clinical Practice Guideline for the Management of Concussion-mild Traumatic Brain Injury.
Vagnozzi R, Signorelli S, Christofori L, et. al. (2010). “Assessment of metabolic brain damage and recovery following mild traumatic brain injury: a multicentre, proton magnetic resonance spectroscopic study in concussed patients.” Brain 133: 3232-3242.
Whitney SL, Alghadi AH, Anwer S (2016). “Recent evidence about the effectiveness of vestibular rehabilitation.” Curr Treat Options Neurol 18(3): 13.
Winkler PA, Ciuffreda KJ (2009). “Ocular fixation, vestibular dysfunction, and visual motion hypersensitivity.” Optometry 80(9): 502-512.
Worker’s Compensation Division (2012). Traumatic Brain Injury Medical Treatment Guidelines. Department of Labor and Employment. Denver, CO. 17, Exhibit 10.
Yeo RA, Gasparovic C, Merideth F, Ruhl D, doezema D, Mayer AR. (2011). “A longitudinal proton magnetic resonance spectroscopy study of mild traumatic brain injury.” J Neurotrauma 28(1): 1-11.
Heather Campbell is a physical therapist in the South East Denver area with 40 years experience in clinical care and education. She is currently consulting on development of a Neuro-vestibular program within a multidisciplinary setting for military veterans and retired athletes, serves as affiliate faculty for the Regis University Program in Physical Therapy, and is active in research.
With Melissa Winthers, Dr. Campbell has presented several programs for the Brain Injury Alliance of Colorado, and continues to develop and teach post-professional courses in vestibular and mild traumatic brain injury management.
Melissa J. Winthers is an attorney with Shapiro Winthers & McGraw P.C. in Denver, Colorado. She specializes in helping clients who have been hurt by negligence and have suffered life-altering injuries, especially traumatic brain injuries, put their lives back together. She works to help clients navigate the complex legal system and care network and receive fair compensation. Melissa has been awarded Super Lawyers’ Top 50 Women and Top 100 Attorneys in Colorado designations.