Concussion Management

Vestibular Rehabilitation CARLY MATTSON, PT, DPT

DisclosureCarly Mattson, PT, DPT

TRIA Spring Conference 2015

I have no financial relationships to disclose

Objectives

Understand why the vestibular system is important to athletes

Summarize general vestibular problems that can arise post

concussion

Perform the basic vestibular and ocular motor examination for

patients post-concussion

Explain what indicates a positive finding on the vestibular

examination

Summarize the literature support for vestibular screening and

treatment for patients post-concussion

Why are we talking about this

today?

There are 300,000 sport related concussions per year in the U.S. -

age 15 24

(Gessel, 2007)

Football had the highest rate of concussion when comparing rates

and patterns across 20 different sports

Majority of concussions happened in football 47% (n of study = 1,936)

(Marar, 2012)

Vestibular System

80% of concussions should get better in 7 10 days

(Consensus Statement Zurich, 2012)

How can we help the remaining 20% get back to baseline?

Lets talk about the vestibular and ocular motor system.

Why check for vestibular system when evaluating

concussion?

1. Headache (71%)

2. Feeling slowed down (58%)

3. Difficulty concentrating (57%)

4. Dizziness (55%)

5. Fogginess (53%)

6. Fatigue (50%)

7. Visual blurring / double vision (49%)

8. Light sensitivity (47%)

9. Memory dysfunction (43%)

10. Balance problems (43%)Lovell, Collins et al. 2004

Review of Literature

ENG of 309 whiplash patients show frequent vestibular abnormalities,

abnormal calorics in 57%, and abnormal rotational tests in 51%.

Toglia, 1976

Vestibular complaints are the most frequent sequelae of mTBI.

Vestibular physical therapy has been established as the most

important treatment modality for this group of patients. Gotshall,

2011

A Review of the Literature

A combination of cervical and vestibular physiotherapy decreased

time to medical clearance to return to sport in youth and young

adults with persistent symptoms of dizziness, neck pain and/or

headaches following a sport-related concussion. Schneider, 2014

Vestibular and ocular motor impairments and symptoms have

been documented in patients with sport related concussions. Sixty

one percent of patients reported symptom provocation after at

least 1 VOMS item. Mucha, 2014

How is the vestibular system involved

when participating in sports?

http://cbssports.com/i

mages/blogs/nelson-

extension14.jpg

http://www1.pictures.zimbio.com

What does the Vestibular System

do?

Senses linear and angular speed

Senses rotational movements of head

Senses linear movements of the head

Senses head position in space

Vestibular System:One of the three balance

system in your body:

- Vision

- Somatosensory

Peripheral Vestibular System:

- Semicircular canals

- Otoliths: Utricle and

Saccule

- Vestibular Ganglia

- Vestibular Nerve

Central Vestibular System:

- Vestibular Nuclei

- Cerebellum

- Cortex

- Thalamushttp://en.wikipedia.org/wiki/Vestibular_system ,

http://www.nimh.nih.go

v/

Vestibular System in Inner Ear

http://drsethevans.com/2014/01/27/how-does-your-ear-work/

Peripheral Vestibular System

Otoliths:

Utricle senses head

tilt

Saccule senses

linear acceleration

of the head

Semicircular Canals

senses rotation of the head

Scicurious.scientopia.org

Vestibular System Function

Emory Course

Materials

www.neuroanatomy.wic.edu

Vestibular Impairments post

Concussion

VOR impairment

Visual Motion Sensitivity

BPPV (incidence in younger athletic population is low)

Cluster of Symptoms for Vestibular

Impairments

Dizziness

Nausea

Balance problems

Headache

Sensitivity to visual motion busy environments etc.

Blurred vision (when moving head)

Vestibular Exam:

VOR x 1: Assessment of peripheral vestibular labyrinth /

any of the central pathways

Treatment: Head eye coordination exercise using

various targets

http://en.wikipedia.org/wiki/Vestibulo-

ocular_reflexYoutube.com

Measuring VOR

Head Thrust test

Head shake Nystagmus test

Clinical DVA

Computerized DVA

Head movement with stationary target test

Measuring VOR

http://cp.neurology.

org/

Resourcesonbalance.c

om

VOR x 1 - Lab

Target at comfortable distance in front of patient.

Target is stationary and head moves 30 degrees side to side, and

then up/down

Try to keep target in focus and NOT becoming blurry

Abnormal = dizziness, and blurry vision

Vestibular Exam:

VOR Cancellation: over-riding of VOR

This can be used to assess visual motion sensitivity

Increased awareness of normal visual motion

Symptom provocation created by moving crowds, busy environments

Ex: supermarket, school hallway, hockey game

Treatment: Ball toss, Lunges with medicine ball tracking

VOR Cancellation - Lab

Move head, body, and target side to side, and then up/down

Target is at comfortable distance in front of patient

Want to cancel out background, and be able to focus on target

Abnormal dizziness, blurry vision

BPPV

Occurs less often in athletic population

Otoconia (calcium carbonate crystals) from the otolith

detach and move into one of the semicircular canals

causing the sensation of head rotation = vertigo

www.imgarcade.com

http://www.imgarcade.com/

BPPV Screening:

Dix- Hall Pike Test (Posterior

Canal) Roll Test (horizontal canal)

www.physio-pedia.com

BPPV

Clinical Pearls for this diagnosis:

Duration of symptoms less than 1 minute (typically)

Occurs when head is in certain positions

Sense of vertigo vs. dizziness

Vertigo = room is spinning rotational component to symptom

Subjective complaints of BPPV:

Dizziness caused by getting out of bed, rolling in bed, looking up, or

lying down

Treatment: Canalith Repositioning Maneuver

Cluster of Symptoms for Ocular

Motor Impairments

Blurred vision

Double vision

Headache

Difficulty reading

Impaired eye movements

Poor visual concentration

Mucha, 2014

Literature Review

Ocular Motor Impairment found in patients post mild TBI

Convergence insufficiency = 55%

Saccadic dysfunction = 30%

Smooth pursuit impairment = 60%

Capo- Aponte, 2012

Ocular-motor Exam:

Saccades

Function: ability to look at one target, and then quickly at

another

Generated in region of the pons (horizontal) / midbrain (vertical /

torsional)

Abnormal findings

over / undershooting (cerebellar / brainstem lesion)

More than 3 saccades to get to target

Slow speed

abnormal findings = central problem

Treatment: 2-target exercise, clock exercise

Saccades - Lab

Hold target or finger tip about 15 degrees to one side of the nose,

and then to the other side of the nose.

Do in horizontal and vertical direction

Can also use one target and nose as the second target

Looking for number of eye movements in takes for the patients eyes to

reach the target.

Normal is 2 or less

If you can clearly pick up trajectory of eye movement from one target

to the next = going too slow!

Ocular-motor Exam:

Smooth Pursuit

Function: Ability to smoothly follow target with eyes

Sensitive in identifying pathologies involving CNS

Cortex, Basal ganglion region, Brainstem, Cerebellum, Oculomotor nucleus

Abnormal findings

asymmetric eye movement

saccadic movement/ not smooth movement while tracking (age is a factor)

Abnormal finding = central problem

Treatment: 9 point pattern, online computer exercise

Smooth Pursuit Eye Movement -

Lab

Have patient follow the target slowly horizontally 30 degrees to left

and right and then vertically 30 degrees up/down

Key is to move finger or target at correct speed about 20 degrees

per second

Abnormal smooth pursuit = jerky eye movement (saccadic

intrusions)

Ocular-motor Exam: Convergence

Function: ability to turn eyes inward to focus on a target

Near-point convergence break cut off (6 cm)

recovery cut off (10 cm)

Test patient 3 times!! to see if fatigue is a factor

Abnormal findings

Break point is greater than 6 cm

Recovery point is greater than 10 cm

Abnormal finding = central problem

Treatment: Brock string, Pencil Push-Ups

Convergence - Lab

Hold a target in your hand about 2 feet away from the patients

face. Ask him/her to focus on the target while moving it toward the

patients nose.

The eyes should converge and the pupils should constrict

Stop the test and measure when the patient develops double vision

NOT BLURRED VISION

Greater than 6 cm from nose = abnormal

Recovery point greater than 10 cm from nose = abnormal

When do you refer your athletes to vestibular therapy?

- Look for positive tests on VOMS assessment

- Be on the look out for persistent and prolonged signs / symptoms that relate to the vestibular or ocular motor systems.

Dizziness

Fogginess

Space and motion discomfort

Blurred / double vision

Imbalance

Headache

Poor visual concentration

Remember 80% of these symptoms should resolve two weeks post concussion, so referral should be after 2 weeks.

www.upmc.edu

Management Team:

Its TEAM WORK!!!Physician

ATC

Coach / Parents

PTSchool

administrator

Optometrist

Neuropsychologist

References: Giza, Christopher C., and David A. Hovda. "The Neurometabolic Cascade of

Concussion."Journal of Athletic Training 36.3 (2001): 228-35.

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 disorder after concussion. Journal of Neurologic Physical Therapy, 34, 87-93.

McCrory, P, Meeuwisse, WH., Aubry, M., Cantu, B., Dvorak, J., Echemendia, RJ., Engebretsen, L., Johnston, K., Kutcher, J., Raftery, M., Sills, A., Benson, BW>, Davis, GA., Ellenbogen, RG., Guskiewicz, K., Herring, SA., Iverson, GL., Jordan, BD., Kissick, J., McCrea, M., Mclntosh, AS., Maddocks, D., Makdissi, M., Purcell, L., Putukian, M., Schneider, K., Tator, CH., & Turner, M. Concensus statement on concussion in sport; the 4th international conference on concussion in sport held in Zurich, November 2012. BJSM 2013; 47, 250-258.

Guerriero, Rejean M., Mark R. Proctor, Rebekah Mannix, and William P. Meehan, III. "Epidemiology, Trends, Assessment and Management of Sport-related Concussion in United States High Schools." Current Opinions in Pediatrics 24 (2012): 1-6. Print.

Collins M, Lovell MR, Iverson GL, Ide T, Maroon J. Examining concussion rates and return to play in high school football players wearing newer helmet technology: a three-year prospective cohort study. Neurosurgery. Feb 2006;58(2):275-286; discussion 275-286.

Mihalik, JP, Stump, JE, Collins, MW, Lovell, MR, Field, M and Maroon, JC. Posttraumatic migraine characteristics in athletes following sports-related concussion. Neurosurgery. 102: 850-855. 2005

Lau BC, Collins MW, Lovell MR. Sensitivity and specificity of subacute computerized neurocognitive testing and symptom evaluation in predicting outcomes after sports-related concussion. Am J Sports Med. Jun 2011;39(6):1209-1216.

Schubert MC. Clinical assessment of the ocular motor systems. Vestibular SIG Newsletter , Spring 2010.

Gill-Body, Kathleen M. "Current Concepts in the Management of Patients With Vestibular Dysfunction." PT Magazine 8.12 (2001): 40-57.

Alsalaheen BA, Whitney SL, Mucha A, Morris LO, Furman, JM, Sparto, PJ. Exercise Prescription Patterns in Patient Treated with Vestibular Rehabilitation After Concussion. Physiotherapy Research International. 2012, July.

Whitney SL, Marchetti GF, Morris LO. Usefulness of the dizziness handicap inventory in the screening for benign paroxysmal positional vertigo. Otol Neurotol. 2005 Sep;26(5):1027-33.

Guerraz, M, Yardley, Bertholon, P, Pollak, L, Rudge, P, Gresty, MA., and Bronstein AM. Visual Vertigo: symptom assessment, spatial orientation and postural control. Brain. 2001. 124, 1646-1656.

http://www.upmc.com/Services/sports-medicine/services/concussion/about-concussions/Pages/symptoms.aspx

Herdman, SJ. (2007) Vestibular Rehabilitation. Philadelphia. F.A. Davis Company.

Toglia, J. U. (1976). Acute flexion-extension injury of the neck. Electronystagmographic study of 309 patients. Neurology, 26(9), 808-814.

Capo- Aponte, J. E. (2012). Effectiveness of Computerized Oculomotor Vision Screening in a Military Population: Pilot Study. Military Medicine

Schneider, K. (2013). Cervicovestibular rehabilitation in sport-related concussion: a randomisedcontrolled trial. Br J Sports Med.

Gotshall, K. (2011). Vestibular rehabilitation after mild traumatic brain injury with vestibular pathology. NeuroRehabilitation, 29(2), 167-171.

http://www.upmc.com/Services/sports-medicine/services/concussion/about-concussions/Pages/symptoms.aspx

Emory Vestibular Competency Course materials

Miller, M. (2014). The Cervical Spine: Physical Therapy Patient Management Utilizing Current Evidence. Current Concepts, 3rd edition, 1-49

Mucha, A et al. (2014). A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions. Am J

Sports Med, 42(10)

Marar, M. "Epidemiology of concussions among United States high school athletes in 20 sports." American Journal of Sports Medicine 240.4 (2012): 747-55.

Gessel, Luke. "Concussions Among United States High School and Collegiate Athletes." Journal of

Athletic Training 42.4 (2007): 495-503.

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