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Concussion Visuo-vestibular Rehab
Lenore Herget DPT MEd
Massachusetts General Hospital
Sports Medicine Physical Therapy
Disclosures
I have no financial relationship with any
commercial entity producing health-care
related products andor services
(Alsalaheen B JNPT 2010)
Who benefits from Concussion rehab
Type of athlete
Cervical spine sx
Visual sx
Vestibular sx
Balance dysfunction ndash unresolving
Gender and Age not a factor
When do you begin treatment
Duration of rehabilitation
OUTLINE
Physical Therapy Assessment and Management
Taking a good history
Multi-System Approach Assess and Treat
Medical (will not be addressed in this lecture)
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
History
Let their story guide your exam
Basics of the injury
Sport position played and MOI
On-field sx (Dizzy HA Vision Aural)
Removal from play
Management since injury
Current symptoms MSK Neck pain
Disequilibrium Imbalance
Visual disturbances
Vestibular+ (Describe your dizziness)
lightheadedness
spinninghead moving
motion sickness
disequilibrium vs sensation in head
Aural fullnesspressuretinnitusloss
Emotional mood changes Parents do you see changes in your child
Multi-System Approach Assess and Treat
MSK Cervicogenic
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam MSK
Cervicogenic Dysfunction
MOI and structures involved (whiplash facet fx-fall
onto head)
Ro more complex c-spine injuries
Assess basic core strength periscapular lumbopelvic
and other MSK injuries involved in incident
Assess for Cervicogenic dysfunction
Cervicogenic HA
Cervicogenic Dizziness
Diagnosis of exclusion (difficult to treat)
Can be stand alone dx andor in combination with concussion sx
Headneck injury with HA and dizziness when all other causes of HA and dizziness are ruled out
Patient description
Occipital headband (oculo-frontal-temporal)
Typically generalized pressure aching
Limitations in cervical ROM (flex ext rot)
Typically unilateral
If full ROM and no neck pain but + for HAhelliplikely not cervicogenic
(Hall 2010)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Referred pain
Brain itself is not sensitive to pain (bdquopain sensitive‟ structures meninges vessels and extracranial structures neck eyes TMJ)
C1-C2 refers pain to oculo-fronto-temporal regions
C2 nerve root compression vs irritation contributes to
suboccipital aching and dysesthesias radiating to posterior
scalp and ear
C2 n root undergoes most stretchstrain dt uarr rotation at
C1-C2
C2 nerve root isnt protected by facets and pedicles like
other spinal nerves (it lies exposed on vertebral arch)
Synapses with trigeminal nerve so pain pathway from
C2 nerve irritation can travel along the trigeminal nerve
pathway
(Thurnberg 2001)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Trigeminocervical nucleus
Convergence of cervical and trigeminal nociceptive afferents
Structures include Articular muscular and neural
structures of c-spine from CO-C3
Upper portion of vertebral artery
TMJ
CN V VII IX X
Pain from trigeminal nerve may be interpreted as coming from neck and vise versa
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Examine
Muscle Palpation
Suboccipitals palpate while rotating
Splenius Capitis palpate just posterior to
mastoid and resist ipsilateral rotation
Upper cervical mobility (C1-2) FlexRotation test
Cervicogenic HA and C1-2 dysfunction correlate
Nml 45 deg B lt33 deg = C1-2 hypo
ProprioceptionHead position
Patient sits 35rdquo from target with head mounted laser
Find target with EO then close eyes and move head maximally
Patient attempts to return head toward center target
(Thurnberg 2001)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Sports Concussion Exam MSK
Cervicogenic Dizziness
Upper c-spine complex proprioceptive system with
connections to visual and vestibular systems
Doesnrsquot send appropriate signals dt damaged muscle spindles
Can be mechanoreceptor dysfunction or posttraumatic
vertebro-basilar circulatory insufficiency
Diagnosis of exclusion (difficult to treat)
Headneck injury with dizziness when all other causes of
dizziness are ruled out
Swivel chair test
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion PT Intervention
MSK C-Spine and Balance
darr balance from afferent efferent or integration malfunction
If any afferent signal is altered (cervical pain and
reduced range of motion can impair signal due to poor
proprioception)
Concussions disrupt the BS ability to integrate and
interpret the afferent signals
Efferent signal problems may occur due to delay from
poor central integration or from VS tract dysfunction
resulting in untimely ineffective balance reactions
Sports Concussion PT Intervention
MSK C-Spine and Balance
Challenge the somatosensory system
Most people are visually dominant for balance with an overreliance on vision and under-utilization of somatosensory and vestibular inputs for balance
Train by downplaying visual reliance
Posturography= most accurate way to measure
and affect visual dependency ($$)
Virtual reality may prove to do this as well
Use unstable surfaces to increase challenge
Cheap effective clinical way to limit vision Eyes closed
Dark room
Vaseline over glasses
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Visual Disturbance
Ocular issues after concussion are common
(poor eye tracking)
Characteristics HA eye strain
blurriness diplopia oscillopsia
frontal HA difficulty attending
Vision therapy goals
Improve brains ability to control eye alignment movement focus and visual processing
Visual skills are reinforced through repetition and integrated with cognitivemotor skills until automatic
Sports Concussion Exam
Visual Disturbance Oculomotor Control
Concussions can directly impair oculomotor function
The 3 nerves (CN III IV and VI) that innervate the eye muscles
exit the brain stem travel along base of skull join behind the eye
and enter orbit
The nerves are susceptible to injury anywhere along the route
from BS to eye muscles
Sports Concussion Exam
Visual Disturbance Observation (head tilt ptosis Ocular misalignment)
Observe initial head position but correct to neutral to perform exam
Visual Fields
EOMsSmooth pursuits (H-test)Gaze Holding
Saccades (vertical and horizontal)
Antisaccades (voluntary top-down cognitive control)
Static visual acuity (Snellen eye chart monocular binocular)
Convergence and Accommodation
Sports Concussion Exam
Visual Disturbance Acuity Accommodation and Vergence
Static Visual Acuity
Measure each eye individually then togetherhellipdistance and near
Variability btwn distance and near may indicate accommodative dysf
If acuity better monocularly than binocularly likely accommodative dysf
Ensure binocular vision compensates for monocular difference
Accommodative dysfunction
Difficult for eyes to shift focus between nearfar targets
Lag between stimulus to accommodation and accommodative response
Can simply be fatigue of repeated accommodative stimulationhellipdaily life
Vergence dysfunction
Disconjugate eye movements resulting in inability of eyes to accurately fixate and stabilize retinal image
Convergence Insufficiency is higher in children with ADHDhellip
Sports Concussion Exam
Visual Disturbance Convergence
Single image viewing with 2 eyes
Perform 3x and record (14 pt font)
Provides depth perception
Near Point
Nml NPC lt10cm
Athlete lt6 cm
Sports Concussion Exam
Visual Disturbance Convergence
Exophoria Practice effect
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Disclosures
I have no financial relationship with any
commercial entity producing health-care
related products andor services
(Alsalaheen B JNPT 2010)
Who benefits from Concussion rehab
Type of athlete
Cervical spine sx
Visual sx
Vestibular sx
Balance dysfunction ndash unresolving
Gender and Age not a factor
When do you begin treatment
Duration of rehabilitation
OUTLINE
Physical Therapy Assessment and Management
Taking a good history
Multi-System Approach Assess and Treat
Medical (will not be addressed in this lecture)
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
History
Let their story guide your exam
Basics of the injury
Sport position played and MOI
On-field sx (Dizzy HA Vision Aural)
Removal from play
Management since injury
Current symptoms MSK Neck pain
Disequilibrium Imbalance
Visual disturbances
Vestibular+ (Describe your dizziness)
lightheadedness
spinninghead moving
motion sickness
disequilibrium vs sensation in head
Aural fullnesspressuretinnitusloss
Emotional mood changes Parents do you see changes in your child
Multi-System Approach Assess and Treat
MSK Cervicogenic
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam MSK
Cervicogenic Dysfunction
MOI and structures involved (whiplash facet fx-fall
onto head)
Ro more complex c-spine injuries
Assess basic core strength periscapular lumbopelvic
and other MSK injuries involved in incident
Assess for Cervicogenic dysfunction
Cervicogenic HA
Cervicogenic Dizziness
Diagnosis of exclusion (difficult to treat)
Can be stand alone dx andor in combination with concussion sx
Headneck injury with HA and dizziness when all other causes of HA and dizziness are ruled out
Patient description
Occipital headband (oculo-frontal-temporal)
Typically generalized pressure aching
Limitations in cervical ROM (flex ext rot)
Typically unilateral
If full ROM and no neck pain but + for HAhelliplikely not cervicogenic
(Hall 2010)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Referred pain
Brain itself is not sensitive to pain (bdquopain sensitive‟ structures meninges vessels and extracranial structures neck eyes TMJ)
C1-C2 refers pain to oculo-fronto-temporal regions
C2 nerve root compression vs irritation contributes to
suboccipital aching and dysesthesias radiating to posterior
scalp and ear
C2 n root undergoes most stretchstrain dt uarr rotation at
C1-C2
C2 nerve root isnt protected by facets and pedicles like
other spinal nerves (it lies exposed on vertebral arch)
Synapses with trigeminal nerve so pain pathway from
C2 nerve irritation can travel along the trigeminal nerve
pathway
(Thurnberg 2001)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Trigeminocervical nucleus
Convergence of cervical and trigeminal nociceptive afferents
Structures include Articular muscular and neural
structures of c-spine from CO-C3
Upper portion of vertebral artery
TMJ
CN V VII IX X
Pain from trigeminal nerve may be interpreted as coming from neck and vise versa
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Examine
Muscle Palpation
Suboccipitals palpate while rotating
Splenius Capitis palpate just posterior to
mastoid and resist ipsilateral rotation
Upper cervical mobility (C1-2) FlexRotation test
Cervicogenic HA and C1-2 dysfunction correlate
Nml 45 deg B lt33 deg = C1-2 hypo
ProprioceptionHead position
Patient sits 35rdquo from target with head mounted laser
Find target with EO then close eyes and move head maximally
Patient attempts to return head toward center target
(Thurnberg 2001)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Sports Concussion Exam MSK
Cervicogenic Dizziness
Upper c-spine complex proprioceptive system with
connections to visual and vestibular systems
Doesnrsquot send appropriate signals dt damaged muscle spindles
Can be mechanoreceptor dysfunction or posttraumatic
vertebro-basilar circulatory insufficiency
Diagnosis of exclusion (difficult to treat)
Headneck injury with dizziness when all other causes of
dizziness are ruled out
Swivel chair test
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion PT Intervention
MSK C-Spine and Balance
darr balance from afferent efferent or integration malfunction
If any afferent signal is altered (cervical pain and
reduced range of motion can impair signal due to poor
proprioception)
Concussions disrupt the BS ability to integrate and
interpret the afferent signals
Efferent signal problems may occur due to delay from
poor central integration or from VS tract dysfunction
resulting in untimely ineffective balance reactions
Sports Concussion PT Intervention
MSK C-Spine and Balance
Challenge the somatosensory system
Most people are visually dominant for balance with an overreliance on vision and under-utilization of somatosensory and vestibular inputs for balance
Train by downplaying visual reliance
Posturography= most accurate way to measure
and affect visual dependency ($$)
Virtual reality may prove to do this as well
Use unstable surfaces to increase challenge
Cheap effective clinical way to limit vision Eyes closed
Dark room
Vaseline over glasses
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Visual Disturbance
Ocular issues after concussion are common
(poor eye tracking)
Characteristics HA eye strain
blurriness diplopia oscillopsia
frontal HA difficulty attending
Vision therapy goals
Improve brains ability to control eye alignment movement focus and visual processing
Visual skills are reinforced through repetition and integrated with cognitivemotor skills until automatic
Sports Concussion Exam
Visual Disturbance Oculomotor Control
Concussions can directly impair oculomotor function
The 3 nerves (CN III IV and VI) that innervate the eye muscles
exit the brain stem travel along base of skull join behind the eye
and enter orbit
The nerves are susceptible to injury anywhere along the route
from BS to eye muscles
Sports Concussion Exam
Visual Disturbance Observation (head tilt ptosis Ocular misalignment)
Observe initial head position but correct to neutral to perform exam
Visual Fields
EOMsSmooth pursuits (H-test)Gaze Holding
Saccades (vertical and horizontal)
Antisaccades (voluntary top-down cognitive control)
Static visual acuity (Snellen eye chart monocular binocular)
Convergence and Accommodation
Sports Concussion Exam
Visual Disturbance Acuity Accommodation and Vergence
Static Visual Acuity
Measure each eye individually then togetherhellipdistance and near
Variability btwn distance and near may indicate accommodative dysf
If acuity better monocularly than binocularly likely accommodative dysf
Ensure binocular vision compensates for monocular difference
Accommodative dysfunction
Difficult for eyes to shift focus between nearfar targets
Lag between stimulus to accommodation and accommodative response
Can simply be fatigue of repeated accommodative stimulationhellipdaily life
Vergence dysfunction
Disconjugate eye movements resulting in inability of eyes to accurately fixate and stabilize retinal image
Convergence Insufficiency is higher in children with ADHDhellip
Sports Concussion Exam
Visual Disturbance Convergence
Single image viewing with 2 eyes
Perform 3x and record (14 pt font)
Provides depth perception
Near Point
Nml NPC lt10cm
Athlete lt6 cm
Sports Concussion Exam
Visual Disturbance Convergence
Exophoria Practice effect
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
(Alsalaheen B JNPT 2010)
Who benefits from Concussion rehab
Type of athlete
Cervical spine sx
Visual sx
Vestibular sx
Balance dysfunction ndash unresolving
Gender and Age not a factor
When do you begin treatment
Duration of rehabilitation
OUTLINE
Physical Therapy Assessment and Management
Taking a good history
Multi-System Approach Assess and Treat
Medical (will not be addressed in this lecture)
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
History
Let their story guide your exam
Basics of the injury
Sport position played and MOI
On-field sx (Dizzy HA Vision Aural)
Removal from play
Management since injury
Current symptoms MSK Neck pain
Disequilibrium Imbalance
Visual disturbances
Vestibular+ (Describe your dizziness)
lightheadedness
spinninghead moving
motion sickness
disequilibrium vs sensation in head
Aural fullnesspressuretinnitusloss
Emotional mood changes Parents do you see changes in your child
Multi-System Approach Assess and Treat
MSK Cervicogenic
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam MSK
Cervicogenic Dysfunction
MOI and structures involved (whiplash facet fx-fall
onto head)
Ro more complex c-spine injuries
Assess basic core strength periscapular lumbopelvic
and other MSK injuries involved in incident
Assess for Cervicogenic dysfunction
Cervicogenic HA
Cervicogenic Dizziness
Diagnosis of exclusion (difficult to treat)
Can be stand alone dx andor in combination with concussion sx
Headneck injury with HA and dizziness when all other causes of HA and dizziness are ruled out
Patient description
Occipital headband (oculo-frontal-temporal)
Typically generalized pressure aching
Limitations in cervical ROM (flex ext rot)
Typically unilateral
If full ROM and no neck pain but + for HAhelliplikely not cervicogenic
(Hall 2010)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Referred pain
Brain itself is not sensitive to pain (bdquopain sensitive‟ structures meninges vessels and extracranial structures neck eyes TMJ)
C1-C2 refers pain to oculo-fronto-temporal regions
C2 nerve root compression vs irritation contributes to
suboccipital aching and dysesthesias radiating to posterior
scalp and ear
C2 n root undergoes most stretchstrain dt uarr rotation at
C1-C2
C2 nerve root isnt protected by facets and pedicles like
other spinal nerves (it lies exposed on vertebral arch)
Synapses with trigeminal nerve so pain pathway from
C2 nerve irritation can travel along the trigeminal nerve
pathway
(Thurnberg 2001)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Trigeminocervical nucleus
Convergence of cervical and trigeminal nociceptive afferents
Structures include Articular muscular and neural
structures of c-spine from CO-C3
Upper portion of vertebral artery
TMJ
CN V VII IX X
Pain from trigeminal nerve may be interpreted as coming from neck and vise versa
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Examine
Muscle Palpation
Suboccipitals palpate while rotating
Splenius Capitis palpate just posterior to
mastoid and resist ipsilateral rotation
Upper cervical mobility (C1-2) FlexRotation test
Cervicogenic HA and C1-2 dysfunction correlate
Nml 45 deg B lt33 deg = C1-2 hypo
ProprioceptionHead position
Patient sits 35rdquo from target with head mounted laser
Find target with EO then close eyes and move head maximally
Patient attempts to return head toward center target
(Thurnberg 2001)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Sports Concussion Exam MSK
Cervicogenic Dizziness
Upper c-spine complex proprioceptive system with
connections to visual and vestibular systems
Doesnrsquot send appropriate signals dt damaged muscle spindles
Can be mechanoreceptor dysfunction or posttraumatic
vertebro-basilar circulatory insufficiency
Diagnosis of exclusion (difficult to treat)
Headneck injury with dizziness when all other causes of
dizziness are ruled out
Swivel chair test
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion PT Intervention
MSK C-Spine and Balance
darr balance from afferent efferent or integration malfunction
If any afferent signal is altered (cervical pain and
reduced range of motion can impair signal due to poor
proprioception)
Concussions disrupt the BS ability to integrate and
interpret the afferent signals
Efferent signal problems may occur due to delay from
poor central integration or from VS tract dysfunction
resulting in untimely ineffective balance reactions
Sports Concussion PT Intervention
MSK C-Spine and Balance
Challenge the somatosensory system
Most people are visually dominant for balance with an overreliance on vision and under-utilization of somatosensory and vestibular inputs for balance
Train by downplaying visual reliance
Posturography= most accurate way to measure
and affect visual dependency ($$)
Virtual reality may prove to do this as well
Use unstable surfaces to increase challenge
Cheap effective clinical way to limit vision Eyes closed
Dark room
Vaseline over glasses
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Visual Disturbance
Ocular issues after concussion are common
(poor eye tracking)
Characteristics HA eye strain
blurriness diplopia oscillopsia
frontal HA difficulty attending
Vision therapy goals
Improve brains ability to control eye alignment movement focus and visual processing
Visual skills are reinforced through repetition and integrated with cognitivemotor skills until automatic
Sports Concussion Exam
Visual Disturbance Oculomotor Control
Concussions can directly impair oculomotor function
The 3 nerves (CN III IV and VI) that innervate the eye muscles
exit the brain stem travel along base of skull join behind the eye
and enter orbit
The nerves are susceptible to injury anywhere along the route
from BS to eye muscles
Sports Concussion Exam
Visual Disturbance Observation (head tilt ptosis Ocular misalignment)
Observe initial head position but correct to neutral to perform exam
Visual Fields
EOMsSmooth pursuits (H-test)Gaze Holding
Saccades (vertical and horizontal)
Antisaccades (voluntary top-down cognitive control)
Static visual acuity (Snellen eye chart monocular binocular)
Convergence and Accommodation
Sports Concussion Exam
Visual Disturbance Acuity Accommodation and Vergence
Static Visual Acuity
Measure each eye individually then togetherhellipdistance and near
Variability btwn distance and near may indicate accommodative dysf
If acuity better monocularly than binocularly likely accommodative dysf
Ensure binocular vision compensates for monocular difference
Accommodative dysfunction
Difficult for eyes to shift focus between nearfar targets
Lag between stimulus to accommodation and accommodative response
Can simply be fatigue of repeated accommodative stimulationhellipdaily life
Vergence dysfunction
Disconjugate eye movements resulting in inability of eyes to accurately fixate and stabilize retinal image
Convergence Insufficiency is higher in children with ADHDhellip
Sports Concussion Exam
Visual Disturbance Convergence
Single image viewing with 2 eyes
Perform 3x and record (14 pt font)
Provides depth perception
Near Point
Nml NPC lt10cm
Athlete lt6 cm
Sports Concussion Exam
Visual Disturbance Convergence
Exophoria Practice effect
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
OUTLINE
Physical Therapy Assessment and Management
Taking a good history
Multi-System Approach Assess and Treat
Medical (will not be addressed in this lecture)
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
History
Let their story guide your exam
Basics of the injury
Sport position played and MOI
On-field sx (Dizzy HA Vision Aural)
Removal from play
Management since injury
Current symptoms MSK Neck pain
Disequilibrium Imbalance
Visual disturbances
Vestibular+ (Describe your dizziness)
lightheadedness
spinninghead moving
motion sickness
disequilibrium vs sensation in head
Aural fullnesspressuretinnitusloss
Emotional mood changes Parents do you see changes in your child
Multi-System Approach Assess and Treat
MSK Cervicogenic
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam MSK
Cervicogenic Dysfunction
MOI and structures involved (whiplash facet fx-fall
onto head)
Ro more complex c-spine injuries
Assess basic core strength periscapular lumbopelvic
and other MSK injuries involved in incident
Assess for Cervicogenic dysfunction
Cervicogenic HA
Cervicogenic Dizziness
Diagnosis of exclusion (difficult to treat)
Can be stand alone dx andor in combination with concussion sx
Headneck injury with HA and dizziness when all other causes of HA and dizziness are ruled out
Patient description
Occipital headband (oculo-frontal-temporal)
Typically generalized pressure aching
Limitations in cervical ROM (flex ext rot)
Typically unilateral
If full ROM and no neck pain but + for HAhelliplikely not cervicogenic
(Hall 2010)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Referred pain
Brain itself is not sensitive to pain (bdquopain sensitive‟ structures meninges vessels and extracranial structures neck eyes TMJ)
C1-C2 refers pain to oculo-fronto-temporal regions
C2 nerve root compression vs irritation contributes to
suboccipital aching and dysesthesias radiating to posterior
scalp and ear
C2 n root undergoes most stretchstrain dt uarr rotation at
C1-C2
C2 nerve root isnt protected by facets and pedicles like
other spinal nerves (it lies exposed on vertebral arch)
Synapses with trigeminal nerve so pain pathway from
C2 nerve irritation can travel along the trigeminal nerve
pathway
(Thurnberg 2001)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Trigeminocervical nucleus
Convergence of cervical and trigeminal nociceptive afferents
Structures include Articular muscular and neural
structures of c-spine from CO-C3
Upper portion of vertebral artery
TMJ
CN V VII IX X
Pain from trigeminal nerve may be interpreted as coming from neck and vise versa
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Examine
Muscle Palpation
Suboccipitals palpate while rotating
Splenius Capitis palpate just posterior to
mastoid and resist ipsilateral rotation
Upper cervical mobility (C1-2) FlexRotation test
Cervicogenic HA and C1-2 dysfunction correlate
Nml 45 deg B lt33 deg = C1-2 hypo
ProprioceptionHead position
Patient sits 35rdquo from target with head mounted laser
Find target with EO then close eyes and move head maximally
Patient attempts to return head toward center target
(Thurnberg 2001)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Sports Concussion Exam MSK
Cervicogenic Dizziness
Upper c-spine complex proprioceptive system with
connections to visual and vestibular systems
Doesnrsquot send appropriate signals dt damaged muscle spindles
Can be mechanoreceptor dysfunction or posttraumatic
vertebro-basilar circulatory insufficiency
Diagnosis of exclusion (difficult to treat)
Headneck injury with dizziness when all other causes of
dizziness are ruled out
Swivel chair test
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion PT Intervention
MSK C-Spine and Balance
darr balance from afferent efferent or integration malfunction
If any afferent signal is altered (cervical pain and
reduced range of motion can impair signal due to poor
proprioception)
Concussions disrupt the BS ability to integrate and
interpret the afferent signals
Efferent signal problems may occur due to delay from
poor central integration or from VS tract dysfunction
resulting in untimely ineffective balance reactions
Sports Concussion PT Intervention
MSK C-Spine and Balance
Challenge the somatosensory system
Most people are visually dominant for balance with an overreliance on vision and under-utilization of somatosensory and vestibular inputs for balance
Train by downplaying visual reliance
Posturography= most accurate way to measure
and affect visual dependency ($$)
Virtual reality may prove to do this as well
Use unstable surfaces to increase challenge
Cheap effective clinical way to limit vision Eyes closed
Dark room
Vaseline over glasses
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Visual Disturbance
Ocular issues after concussion are common
(poor eye tracking)
Characteristics HA eye strain
blurriness diplopia oscillopsia
frontal HA difficulty attending
Vision therapy goals
Improve brains ability to control eye alignment movement focus and visual processing
Visual skills are reinforced through repetition and integrated with cognitivemotor skills until automatic
Sports Concussion Exam
Visual Disturbance Oculomotor Control
Concussions can directly impair oculomotor function
The 3 nerves (CN III IV and VI) that innervate the eye muscles
exit the brain stem travel along base of skull join behind the eye
and enter orbit
The nerves are susceptible to injury anywhere along the route
from BS to eye muscles
Sports Concussion Exam
Visual Disturbance Observation (head tilt ptosis Ocular misalignment)
Observe initial head position but correct to neutral to perform exam
Visual Fields
EOMsSmooth pursuits (H-test)Gaze Holding
Saccades (vertical and horizontal)
Antisaccades (voluntary top-down cognitive control)
Static visual acuity (Snellen eye chart monocular binocular)
Convergence and Accommodation
Sports Concussion Exam
Visual Disturbance Acuity Accommodation and Vergence
Static Visual Acuity
Measure each eye individually then togetherhellipdistance and near
Variability btwn distance and near may indicate accommodative dysf
If acuity better monocularly than binocularly likely accommodative dysf
Ensure binocular vision compensates for monocular difference
Accommodative dysfunction
Difficult for eyes to shift focus between nearfar targets
Lag between stimulus to accommodation and accommodative response
Can simply be fatigue of repeated accommodative stimulationhellipdaily life
Vergence dysfunction
Disconjugate eye movements resulting in inability of eyes to accurately fixate and stabilize retinal image
Convergence Insufficiency is higher in children with ADHDhellip
Sports Concussion Exam
Visual Disturbance Convergence
Single image viewing with 2 eyes
Perform 3x and record (14 pt font)
Provides depth perception
Near Point
Nml NPC lt10cm
Athlete lt6 cm
Sports Concussion Exam
Visual Disturbance Convergence
Exophoria Practice effect
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
History
Let their story guide your exam
Basics of the injury
Sport position played and MOI
On-field sx (Dizzy HA Vision Aural)
Removal from play
Management since injury
Current symptoms MSK Neck pain
Disequilibrium Imbalance
Visual disturbances
Vestibular+ (Describe your dizziness)
lightheadedness
spinninghead moving
motion sickness
disequilibrium vs sensation in head
Aural fullnesspressuretinnitusloss
Emotional mood changes Parents do you see changes in your child
Multi-System Approach Assess and Treat
MSK Cervicogenic
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam MSK
Cervicogenic Dysfunction
MOI and structures involved (whiplash facet fx-fall
onto head)
Ro more complex c-spine injuries
Assess basic core strength periscapular lumbopelvic
and other MSK injuries involved in incident
Assess for Cervicogenic dysfunction
Cervicogenic HA
Cervicogenic Dizziness
Diagnosis of exclusion (difficult to treat)
Can be stand alone dx andor in combination with concussion sx
Headneck injury with HA and dizziness when all other causes of HA and dizziness are ruled out
Patient description
Occipital headband (oculo-frontal-temporal)
Typically generalized pressure aching
Limitations in cervical ROM (flex ext rot)
Typically unilateral
If full ROM and no neck pain but + for HAhelliplikely not cervicogenic
(Hall 2010)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Referred pain
Brain itself is not sensitive to pain (bdquopain sensitive‟ structures meninges vessels and extracranial structures neck eyes TMJ)
C1-C2 refers pain to oculo-fronto-temporal regions
C2 nerve root compression vs irritation contributes to
suboccipital aching and dysesthesias radiating to posterior
scalp and ear
C2 n root undergoes most stretchstrain dt uarr rotation at
C1-C2
C2 nerve root isnt protected by facets and pedicles like
other spinal nerves (it lies exposed on vertebral arch)
Synapses with trigeminal nerve so pain pathway from
C2 nerve irritation can travel along the trigeminal nerve
pathway
(Thurnberg 2001)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Trigeminocervical nucleus
Convergence of cervical and trigeminal nociceptive afferents
Structures include Articular muscular and neural
structures of c-spine from CO-C3
Upper portion of vertebral artery
TMJ
CN V VII IX X
Pain from trigeminal nerve may be interpreted as coming from neck and vise versa
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Examine
Muscle Palpation
Suboccipitals palpate while rotating
Splenius Capitis palpate just posterior to
mastoid and resist ipsilateral rotation
Upper cervical mobility (C1-2) FlexRotation test
Cervicogenic HA and C1-2 dysfunction correlate
Nml 45 deg B lt33 deg = C1-2 hypo
ProprioceptionHead position
Patient sits 35rdquo from target with head mounted laser
Find target with EO then close eyes and move head maximally
Patient attempts to return head toward center target
(Thurnberg 2001)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Sports Concussion Exam MSK
Cervicogenic Dizziness
Upper c-spine complex proprioceptive system with
connections to visual and vestibular systems
Doesnrsquot send appropriate signals dt damaged muscle spindles
Can be mechanoreceptor dysfunction or posttraumatic
vertebro-basilar circulatory insufficiency
Diagnosis of exclusion (difficult to treat)
Headneck injury with dizziness when all other causes of
dizziness are ruled out
Swivel chair test
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion PT Intervention
MSK C-Spine and Balance
darr balance from afferent efferent or integration malfunction
If any afferent signal is altered (cervical pain and
reduced range of motion can impair signal due to poor
proprioception)
Concussions disrupt the BS ability to integrate and
interpret the afferent signals
Efferent signal problems may occur due to delay from
poor central integration or from VS tract dysfunction
resulting in untimely ineffective balance reactions
Sports Concussion PT Intervention
MSK C-Spine and Balance
Challenge the somatosensory system
Most people are visually dominant for balance with an overreliance on vision and under-utilization of somatosensory and vestibular inputs for balance
Train by downplaying visual reliance
Posturography= most accurate way to measure
and affect visual dependency ($$)
Virtual reality may prove to do this as well
Use unstable surfaces to increase challenge
Cheap effective clinical way to limit vision Eyes closed
Dark room
Vaseline over glasses
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Visual Disturbance
Ocular issues after concussion are common
(poor eye tracking)
Characteristics HA eye strain
blurriness diplopia oscillopsia
frontal HA difficulty attending
Vision therapy goals
Improve brains ability to control eye alignment movement focus and visual processing
Visual skills are reinforced through repetition and integrated with cognitivemotor skills until automatic
Sports Concussion Exam
Visual Disturbance Oculomotor Control
Concussions can directly impair oculomotor function
The 3 nerves (CN III IV and VI) that innervate the eye muscles
exit the brain stem travel along base of skull join behind the eye
and enter orbit
The nerves are susceptible to injury anywhere along the route
from BS to eye muscles
Sports Concussion Exam
Visual Disturbance Observation (head tilt ptosis Ocular misalignment)
Observe initial head position but correct to neutral to perform exam
Visual Fields
EOMsSmooth pursuits (H-test)Gaze Holding
Saccades (vertical and horizontal)
Antisaccades (voluntary top-down cognitive control)
Static visual acuity (Snellen eye chart monocular binocular)
Convergence and Accommodation
Sports Concussion Exam
Visual Disturbance Acuity Accommodation and Vergence
Static Visual Acuity
Measure each eye individually then togetherhellipdistance and near
Variability btwn distance and near may indicate accommodative dysf
If acuity better monocularly than binocularly likely accommodative dysf
Ensure binocular vision compensates for monocular difference
Accommodative dysfunction
Difficult for eyes to shift focus between nearfar targets
Lag between stimulus to accommodation and accommodative response
Can simply be fatigue of repeated accommodative stimulationhellipdaily life
Vergence dysfunction
Disconjugate eye movements resulting in inability of eyes to accurately fixate and stabilize retinal image
Convergence Insufficiency is higher in children with ADHDhellip
Sports Concussion Exam
Visual Disturbance Convergence
Single image viewing with 2 eyes
Perform 3x and record (14 pt font)
Provides depth perception
Near Point
Nml NPC lt10cm
Athlete lt6 cm
Sports Concussion Exam
Visual Disturbance Convergence
Exophoria Practice effect
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Multi-System Approach Assess and Treat
MSK Cervicogenic
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam MSK
Cervicogenic Dysfunction
MOI and structures involved (whiplash facet fx-fall
onto head)
Ro more complex c-spine injuries
Assess basic core strength periscapular lumbopelvic
and other MSK injuries involved in incident
Assess for Cervicogenic dysfunction
Cervicogenic HA
Cervicogenic Dizziness
Diagnosis of exclusion (difficult to treat)
Can be stand alone dx andor in combination with concussion sx
Headneck injury with HA and dizziness when all other causes of HA and dizziness are ruled out
Patient description
Occipital headband (oculo-frontal-temporal)
Typically generalized pressure aching
Limitations in cervical ROM (flex ext rot)
Typically unilateral
If full ROM and no neck pain but + for HAhelliplikely not cervicogenic
(Hall 2010)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Referred pain
Brain itself is not sensitive to pain (bdquopain sensitive‟ structures meninges vessels and extracranial structures neck eyes TMJ)
C1-C2 refers pain to oculo-fronto-temporal regions
C2 nerve root compression vs irritation contributes to
suboccipital aching and dysesthesias radiating to posterior
scalp and ear
C2 n root undergoes most stretchstrain dt uarr rotation at
C1-C2
C2 nerve root isnt protected by facets and pedicles like
other spinal nerves (it lies exposed on vertebral arch)
Synapses with trigeminal nerve so pain pathway from
C2 nerve irritation can travel along the trigeminal nerve
pathway
(Thurnberg 2001)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Trigeminocervical nucleus
Convergence of cervical and trigeminal nociceptive afferents
Structures include Articular muscular and neural
structures of c-spine from CO-C3
Upper portion of vertebral artery
TMJ
CN V VII IX X
Pain from trigeminal nerve may be interpreted as coming from neck and vise versa
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Examine
Muscle Palpation
Suboccipitals palpate while rotating
Splenius Capitis palpate just posterior to
mastoid and resist ipsilateral rotation
Upper cervical mobility (C1-2) FlexRotation test
Cervicogenic HA and C1-2 dysfunction correlate
Nml 45 deg B lt33 deg = C1-2 hypo
ProprioceptionHead position
Patient sits 35rdquo from target with head mounted laser
Find target with EO then close eyes and move head maximally
Patient attempts to return head toward center target
(Thurnberg 2001)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Sports Concussion Exam MSK
Cervicogenic Dizziness
Upper c-spine complex proprioceptive system with
connections to visual and vestibular systems
Doesnrsquot send appropriate signals dt damaged muscle spindles
Can be mechanoreceptor dysfunction or posttraumatic
vertebro-basilar circulatory insufficiency
Diagnosis of exclusion (difficult to treat)
Headneck injury with dizziness when all other causes of
dizziness are ruled out
Swivel chair test
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion PT Intervention
MSK C-Spine and Balance
darr balance from afferent efferent or integration malfunction
If any afferent signal is altered (cervical pain and
reduced range of motion can impair signal due to poor
proprioception)
Concussions disrupt the BS ability to integrate and
interpret the afferent signals
Efferent signal problems may occur due to delay from
poor central integration or from VS tract dysfunction
resulting in untimely ineffective balance reactions
Sports Concussion PT Intervention
MSK C-Spine and Balance
Challenge the somatosensory system
Most people are visually dominant for balance with an overreliance on vision and under-utilization of somatosensory and vestibular inputs for balance
Train by downplaying visual reliance
Posturography= most accurate way to measure
and affect visual dependency ($$)
Virtual reality may prove to do this as well
Use unstable surfaces to increase challenge
Cheap effective clinical way to limit vision Eyes closed
Dark room
Vaseline over glasses
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Visual Disturbance
Ocular issues after concussion are common
(poor eye tracking)
Characteristics HA eye strain
blurriness diplopia oscillopsia
frontal HA difficulty attending
Vision therapy goals
Improve brains ability to control eye alignment movement focus and visual processing
Visual skills are reinforced through repetition and integrated with cognitivemotor skills until automatic
Sports Concussion Exam
Visual Disturbance Oculomotor Control
Concussions can directly impair oculomotor function
The 3 nerves (CN III IV and VI) that innervate the eye muscles
exit the brain stem travel along base of skull join behind the eye
and enter orbit
The nerves are susceptible to injury anywhere along the route
from BS to eye muscles
Sports Concussion Exam
Visual Disturbance Observation (head tilt ptosis Ocular misalignment)
Observe initial head position but correct to neutral to perform exam
Visual Fields
EOMsSmooth pursuits (H-test)Gaze Holding
Saccades (vertical and horizontal)
Antisaccades (voluntary top-down cognitive control)
Static visual acuity (Snellen eye chart monocular binocular)
Convergence and Accommodation
Sports Concussion Exam
Visual Disturbance Acuity Accommodation and Vergence
Static Visual Acuity
Measure each eye individually then togetherhellipdistance and near
Variability btwn distance and near may indicate accommodative dysf
If acuity better monocularly than binocularly likely accommodative dysf
Ensure binocular vision compensates for monocular difference
Accommodative dysfunction
Difficult for eyes to shift focus between nearfar targets
Lag between stimulus to accommodation and accommodative response
Can simply be fatigue of repeated accommodative stimulationhellipdaily life
Vergence dysfunction
Disconjugate eye movements resulting in inability of eyes to accurately fixate and stabilize retinal image
Convergence Insufficiency is higher in children with ADHDhellip
Sports Concussion Exam
Visual Disturbance Convergence
Single image viewing with 2 eyes
Perform 3x and record (14 pt font)
Provides depth perception
Near Point
Nml NPC lt10cm
Athlete lt6 cm
Sports Concussion Exam
Visual Disturbance Convergence
Exophoria Practice effect
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Sports Concussion Exam MSK
Cervicogenic Dysfunction
MOI and structures involved (whiplash facet fx-fall
onto head)
Ro more complex c-spine injuries
Assess basic core strength periscapular lumbopelvic
and other MSK injuries involved in incident
Assess for Cervicogenic dysfunction
Cervicogenic HA
Cervicogenic Dizziness
Diagnosis of exclusion (difficult to treat)
Can be stand alone dx andor in combination with concussion sx
Headneck injury with HA and dizziness when all other causes of HA and dizziness are ruled out
Patient description
Occipital headband (oculo-frontal-temporal)
Typically generalized pressure aching
Limitations in cervical ROM (flex ext rot)
Typically unilateral
If full ROM and no neck pain but + for HAhelliplikely not cervicogenic
(Hall 2010)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Referred pain
Brain itself is not sensitive to pain (bdquopain sensitive‟ structures meninges vessels and extracranial structures neck eyes TMJ)
C1-C2 refers pain to oculo-fronto-temporal regions
C2 nerve root compression vs irritation contributes to
suboccipital aching and dysesthesias radiating to posterior
scalp and ear
C2 n root undergoes most stretchstrain dt uarr rotation at
C1-C2
C2 nerve root isnt protected by facets and pedicles like
other spinal nerves (it lies exposed on vertebral arch)
Synapses with trigeminal nerve so pain pathway from
C2 nerve irritation can travel along the trigeminal nerve
pathway
(Thurnberg 2001)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Trigeminocervical nucleus
Convergence of cervical and trigeminal nociceptive afferents
Structures include Articular muscular and neural
structures of c-spine from CO-C3
Upper portion of vertebral artery
TMJ
CN V VII IX X
Pain from trigeminal nerve may be interpreted as coming from neck and vise versa
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Examine
Muscle Palpation
Suboccipitals palpate while rotating
Splenius Capitis palpate just posterior to
mastoid and resist ipsilateral rotation
Upper cervical mobility (C1-2) FlexRotation test
Cervicogenic HA and C1-2 dysfunction correlate
Nml 45 deg B lt33 deg = C1-2 hypo
ProprioceptionHead position
Patient sits 35rdquo from target with head mounted laser
Find target with EO then close eyes and move head maximally
Patient attempts to return head toward center target
(Thurnberg 2001)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Sports Concussion Exam MSK
Cervicogenic Dizziness
Upper c-spine complex proprioceptive system with
connections to visual and vestibular systems
Doesnrsquot send appropriate signals dt damaged muscle spindles
Can be mechanoreceptor dysfunction or posttraumatic
vertebro-basilar circulatory insufficiency
Diagnosis of exclusion (difficult to treat)
Headneck injury with dizziness when all other causes of
dizziness are ruled out
Swivel chair test
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion PT Intervention
MSK C-Spine and Balance
darr balance from afferent efferent or integration malfunction
If any afferent signal is altered (cervical pain and
reduced range of motion can impair signal due to poor
proprioception)
Concussions disrupt the BS ability to integrate and
interpret the afferent signals
Efferent signal problems may occur due to delay from
poor central integration or from VS tract dysfunction
resulting in untimely ineffective balance reactions
Sports Concussion PT Intervention
MSK C-Spine and Balance
Challenge the somatosensory system
Most people are visually dominant for balance with an overreliance on vision and under-utilization of somatosensory and vestibular inputs for balance
Train by downplaying visual reliance
Posturography= most accurate way to measure
and affect visual dependency ($$)
Virtual reality may prove to do this as well
Use unstable surfaces to increase challenge
Cheap effective clinical way to limit vision Eyes closed
Dark room
Vaseline over glasses
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Visual Disturbance
Ocular issues after concussion are common
(poor eye tracking)
Characteristics HA eye strain
blurriness diplopia oscillopsia
frontal HA difficulty attending
Vision therapy goals
Improve brains ability to control eye alignment movement focus and visual processing
Visual skills are reinforced through repetition and integrated with cognitivemotor skills until automatic
Sports Concussion Exam
Visual Disturbance Oculomotor Control
Concussions can directly impair oculomotor function
The 3 nerves (CN III IV and VI) that innervate the eye muscles
exit the brain stem travel along base of skull join behind the eye
and enter orbit
The nerves are susceptible to injury anywhere along the route
from BS to eye muscles
Sports Concussion Exam
Visual Disturbance Observation (head tilt ptosis Ocular misalignment)
Observe initial head position but correct to neutral to perform exam
Visual Fields
EOMsSmooth pursuits (H-test)Gaze Holding
Saccades (vertical and horizontal)
Antisaccades (voluntary top-down cognitive control)
Static visual acuity (Snellen eye chart monocular binocular)
Convergence and Accommodation
Sports Concussion Exam
Visual Disturbance Acuity Accommodation and Vergence
Static Visual Acuity
Measure each eye individually then togetherhellipdistance and near
Variability btwn distance and near may indicate accommodative dysf
If acuity better monocularly than binocularly likely accommodative dysf
Ensure binocular vision compensates for monocular difference
Accommodative dysfunction
Difficult for eyes to shift focus between nearfar targets
Lag between stimulus to accommodation and accommodative response
Can simply be fatigue of repeated accommodative stimulationhellipdaily life
Vergence dysfunction
Disconjugate eye movements resulting in inability of eyes to accurately fixate and stabilize retinal image
Convergence Insufficiency is higher in children with ADHDhellip
Sports Concussion Exam
Visual Disturbance Convergence
Single image viewing with 2 eyes
Perform 3x and record (14 pt font)
Provides depth perception
Near Point
Nml NPC lt10cm
Athlete lt6 cm
Sports Concussion Exam
Visual Disturbance Convergence
Exophoria Practice effect
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Diagnosis of exclusion (difficult to treat)
Can be stand alone dx andor in combination with concussion sx
Headneck injury with HA and dizziness when all other causes of HA and dizziness are ruled out
Patient description
Occipital headband (oculo-frontal-temporal)
Typically generalized pressure aching
Limitations in cervical ROM (flex ext rot)
Typically unilateral
If full ROM and no neck pain but + for HAhelliplikely not cervicogenic
(Hall 2010)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Referred pain
Brain itself is not sensitive to pain (bdquopain sensitive‟ structures meninges vessels and extracranial structures neck eyes TMJ)
C1-C2 refers pain to oculo-fronto-temporal regions
C2 nerve root compression vs irritation contributes to
suboccipital aching and dysesthesias radiating to posterior
scalp and ear
C2 n root undergoes most stretchstrain dt uarr rotation at
C1-C2
C2 nerve root isnt protected by facets and pedicles like
other spinal nerves (it lies exposed on vertebral arch)
Synapses with trigeminal nerve so pain pathway from
C2 nerve irritation can travel along the trigeminal nerve
pathway
(Thurnberg 2001)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Trigeminocervical nucleus
Convergence of cervical and trigeminal nociceptive afferents
Structures include Articular muscular and neural
structures of c-spine from CO-C3
Upper portion of vertebral artery
TMJ
CN V VII IX X
Pain from trigeminal nerve may be interpreted as coming from neck and vise versa
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Examine
Muscle Palpation
Suboccipitals palpate while rotating
Splenius Capitis palpate just posterior to
mastoid and resist ipsilateral rotation
Upper cervical mobility (C1-2) FlexRotation test
Cervicogenic HA and C1-2 dysfunction correlate
Nml 45 deg B lt33 deg = C1-2 hypo
ProprioceptionHead position
Patient sits 35rdquo from target with head mounted laser
Find target with EO then close eyes and move head maximally
Patient attempts to return head toward center target
(Thurnberg 2001)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Sports Concussion Exam MSK
Cervicogenic Dizziness
Upper c-spine complex proprioceptive system with
connections to visual and vestibular systems
Doesnrsquot send appropriate signals dt damaged muscle spindles
Can be mechanoreceptor dysfunction or posttraumatic
vertebro-basilar circulatory insufficiency
Diagnosis of exclusion (difficult to treat)
Headneck injury with dizziness when all other causes of
dizziness are ruled out
Swivel chair test
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion PT Intervention
MSK C-Spine and Balance
darr balance from afferent efferent or integration malfunction
If any afferent signal is altered (cervical pain and
reduced range of motion can impair signal due to poor
proprioception)
Concussions disrupt the BS ability to integrate and
interpret the afferent signals
Efferent signal problems may occur due to delay from
poor central integration or from VS tract dysfunction
resulting in untimely ineffective balance reactions
Sports Concussion PT Intervention
MSK C-Spine and Balance
Challenge the somatosensory system
Most people are visually dominant for balance with an overreliance on vision and under-utilization of somatosensory and vestibular inputs for balance
Train by downplaying visual reliance
Posturography= most accurate way to measure
and affect visual dependency ($$)
Virtual reality may prove to do this as well
Use unstable surfaces to increase challenge
Cheap effective clinical way to limit vision Eyes closed
Dark room
Vaseline over glasses
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Visual Disturbance
Ocular issues after concussion are common
(poor eye tracking)
Characteristics HA eye strain
blurriness diplopia oscillopsia
frontal HA difficulty attending
Vision therapy goals
Improve brains ability to control eye alignment movement focus and visual processing
Visual skills are reinforced through repetition and integrated with cognitivemotor skills until automatic
Sports Concussion Exam
Visual Disturbance Oculomotor Control
Concussions can directly impair oculomotor function
The 3 nerves (CN III IV and VI) that innervate the eye muscles
exit the brain stem travel along base of skull join behind the eye
and enter orbit
The nerves are susceptible to injury anywhere along the route
from BS to eye muscles
Sports Concussion Exam
Visual Disturbance Observation (head tilt ptosis Ocular misalignment)
Observe initial head position but correct to neutral to perform exam
Visual Fields
EOMsSmooth pursuits (H-test)Gaze Holding
Saccades (vertical and horizontal)
Antisaccades (voluntary top-down cognitive control)
Static visual acuity (Snellen eye chart monocular binocular)
Convergence and Accommodation
Sports Concussion Exam
Visual Disturbance Acuity Accommodation and Vergence
Static Visual Acuity
Measure each eye individually then togetherhellipdistance and near
Variability btwn distance and near may indicate accommodative dysf
If acuity better monocularly than binocularly likely accommodative dysf
Ensure binocular vision compensates for monocular difference
Accommodative dysfunction
Difficult for eyes to shift focus between nearfar targets
Lag between stimulus to accommodation and accommodative response
Can simply be fatigue of repeated accommodative stimulationhellipdaily life
Vergence dysfunction
Disconjugate eye movements resulting in inability of eyes to accurately fixate and stabilize retinal image
Convergence Insufficiency is higher in children with ADHDhellip
Sports Concussion Exam
Visual Disturbance Convergence
Single image viewing with 2 eyes
Perform 3x and record (14 pt font)
Provides depth perception
Near Point
Nml NPC lt10cm
Athlete lt6 cm
Sports Concussion Exam
Visual Disturbance Convergence
Exophoria Practice effect
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Referred pain
Brain itself is not sensitive to pain (bdquopain sensitive‟ structures meninges vessels and extracranial structures neck eyes TMJ)
C1-C2 refers pain to oculo-fronto-temporal regions
C2 nerve root compression vs irritation contributes to
suboccipital aching and dysesthesias radiating to posterior
scalp and ear
C2 n root undergoes most stretchstrain dt uarr rotation at
C1-C2
C2 nerve root isnt protected by facets and pedicles like
other spinal nerves (it lies exposed on vertebral arch)
Synapses with trigeminal nerve so pain pathway from
C2 nerve irritation can travel along the trigeminal nerve
pathway
(Thurnberg 2001)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Trigeminocervical nucleus
Convergence of cervical and trigeminal nociceptive afferents
Structures include Articular muscular and neural
structures of c-spine from CO-C3
Upper portion of vertebral artery
TMJ
CN V VII IX X
Pain from trigeminal nerve may be interpreted as coming from neck and vise versa
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Examine
Muscle Palpation
Suboccipitals palpate while rotating
Splenius Capitis palpate just posterior to
mastoid and resist ipsilateral rotation
Upper cervical mobility (C1-2) FlexRotation test
Cervicogenic HA and C1-2 dysfunction correlate
Nml 45 deg B lt33 deg = C1-2 hypo
ProprioceptionHead position
Patient sits 35rdquo from target with head mounted laser
Find target with EO then close eyes and move head maximally
Patient attempts to return head toward center target
(Thurnberg 2001)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Sports Concussion Exam MSK
Cervicogenic Dizziness
Upper c-spine complex proprioceptive system with
connections to visual and vestibular systems
Doesnrsquot send appropriate signals dt damaged muscle spindles
Can be mechanoreceptor dysfunction or posttraumatic
vertebro-basilar circulatory insufficiency
Diagnosis of exclusion (difficult to treat)
Headneck injury with dizziness when all other causes of
dizziness are ruled out
Swivel chair test
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion PT Intervention
MSK C-Spine and Balance
darr balance from afferent efferent or integration malfunction
If any afferent signal is altered (cervical pain and
reduced range of motion can impair signal due to poor
proprioception)
Concussions disrupt the BS ability to integrate and
interpret the afferent signals
Efferent signal problems may occur due to delay from
poor central integration or from VS tract dysfunction
resulting in untimely ineffective balance reactions
Sports Concussion PT Intervention
MSK C-Spine and Balance
Challenge the somatosensory system
Most people are visually dominant for balance with an overreliance on vision and under-utilization of somatosensory and vestibular inputs for balance
Train by downplaying visual reliance
Posturography= most accurate way to measure
and affect visual dependency ($$)
Virtual reality may prove to do this as well
Use unstable surfaces to increase challenge
Cheap effective clinical way to limit vision Eyes closed
Dark room
Vaseline over glasses
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Visual Disturbance
Ocular issues after concussion are common
(poor eye tracking)
Characteristics HA eye strain
blurriness diplopia oscillopsia
frontal HA difficulty attending
Vision therapy goals
Improve brains ability to control eye alignment movement focus and visual processing
Visual skills are reinforced through repetition and integrated with cognitivemotor skills until automatic
Sports Concussion Exam
Visual Disturbance Oculomotor Control
Concussions can directly impair oculomotor function
The 3 nerves (CN III IV and VI) that innervate the eye muscles
exit the brain stem travel along base of skull join behind the eye
and enter orbit
The nerves are susceptible to injury anywhere along the route
from BS to eye muscles
Sports Concussion Exam
Visual Disturbance Observation (head tilt ptosis Ocular misalignment)
Observe initial head position but correct to neutral to perform exam
Visual Fields
EOMsSmooth pursuits (H-test)Gaze Holding
Saccades (vertical and horizontal)
Antisaccades (voluntary top-down cognitive control)
Static visual acuity (Snellen eye chart monocular binocular)
Convergence and Accommodation
Sports Concussion Exam
Visual Disturbance Acuity Accommodation and Vergence
Static Visual Acuity
Measure each eye individually then togetherhellipdistance and near
Variability btwn distance and near may indicate accommodative dysf
If acuity better monocularly than binocularly likely accommodative dysf
Ensure binocular vision compensates for monocular difference
Accommodative dysfunction
Difficult for eyes to shift focus between nearfar targets
Lag between stimulus to accommodation and accommodative response
Can simply be fatigue of repeated accommodative stimulationhellipdaily life
Vergence dysfunction
Disconjugate eye movements resulting in inability of eyes to accurately fixate and stabilize retinal image
Convergence Insufficiency is higher in children with ADHDhellip
Sports Concussion Exam
Visual Disturbance Convergence
Single image viewing with 2 eyes
Perform 3x and record (14 pt font)
Provides depth perception
Near Point
Nml NPC lt10cm
Athlete lt6 cm
Sports Concussion Exam
Visual Disturbance Convergence
Exophoria Practice effect
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Trigeminocervical nucleus
Convergence of cervical and trigeminal nociceptive afferents
Structures include Articular muscular and neural
structures of c-spine from CO-C3
Upper portion of vertebral artery
TMJ
CN V VII IX X
Pain from trigeminal nerve may be interpreted as coming from neck and vise versa
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Examine
Muscle Palpation
Suboccipitals palpate while rotating
Splenius Capitis palpate just posterior to
mastoid and resist ipsilateral rotation
Upper cervical mobility (C1-2) FlexRotation test
Cervicogenic HA and C1-2 dysfunction correlate
Nml 45 deg B lt33 deg = C1-2 hypo
ProprioceptionHead position
Patient sits 35rdquo from target with head mounted laser
Find target with EO then close eyes and move head maximally
Patient attempts to return head toward center target
(Thurnberg 2001)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Sports Concussion Exam MSK
Cervicogenic Dizziness
Upper c-spine complex proprioceptive system with
connections to visual and vestibular systems
Doesnrsquot send appropriate signals dt damaged muscle spindles
Can be mechanoreceptor dysfunction or posttraumatic
vertebro-basilar circulatory insufficiency
Diagnosis of exclusion (difficult to treat)
Headneck injury with dizziness when all other causes of
dizziness are ruled out
Swivel chair test
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion PT Intervention
MSK C-Spine and Balance
darr balance from afferent efferent or integration malfunction
If any afferent signal is altered (cervical pain and
reduced range of motion can impair signal due to poor
proprioception)
Concussions disrupt the BS ability to integrate and
interpret the afferent signals
Efferent signal problems may occur due to delay from
poor central integration or from VS tract dysfunction
resulting in untimely ineffective balance reactions
Sports Concussion PT Intervention
MSK C-Spine and Balance
Challenge the somatosensory system
Most people are visually dominant for balance with an overreliance on vision and under-utilization of somatosensory and vestibular inputs for balance
Train by downplaying visual reliance
Posturography= most accurate way to measure
and affect visual dependency ($$)
Virtual reality may prove to do this as well
Use unstable surfaces to increase challenge
Cheap effective clinical way to limit vision Eyes closed
Dark room
Vaseline over glasses
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Visual Disturbance
Ocular issues after concussion are common
(poor eye tracking)
Characteristics HA eye strain
blurriness diplopia oscillopsia
frontal HA difficulty attending
Vision therapy goals
Improve brains ability to control eye alignment movement focus and visual processing
Visual skills are reinforced through repetition and integrated with cognitivemotor skills until automatic
Sports Concussion Exam
Visual Disturbance Oculomotor Control
Concussions can directly impair oculomotor function
The 3 nerves (CN III IV and VI) that innervate the eye muscles
exit the brain stem travel along base of skull join behind the eye
and enter orbit
The nerves are susceptible to injury anywhere along the route
from BS to eye muscles
Sports Concussion Exam
Visual Disturbance Observation (head tilt ptosis Ocular misalignment)
Observe initial head position but correct to neutral to perform exam
Visual Fields
EOMsSmooth pursuits (H-test)Gaze Holding
Saccades (vertical and horizontal)
Antisaccades (voluntary top-down cognitive control)
Static visual acuity (Snellen eye chart monocular binocular)
Convergence and Accommodation
Sports Concussion Exam
Visual Disturbance Acuity Accommodation and Vergence
Static Visual Acuity
Measure each eye individually then togetherhellipdistance and near
Variability btwn distance and near may indicate accommodative dysf
If acuity better monocularly than binocularly likely accommodative dysf
Ensure binocular vision compensates for monocular difference
Accommodative dysfunction
Difficult for eyes to shift focus between nearfar targets
Lag between stimulus to accommodation and accommodative response
Can simply be fatigue of repeated accommodative stimulationhellipdaily life
Vergence dysfunction
Disconjugate eye movements resulting in inability of eyes to accurately fixate and stabilize retinal image
Convergence Insufficiency is higher in children with ADHDhellip
Sports Concussion Exam
Visual Disturbance Convergence
Single image viewing with 2 eyes
Perform 3x and record (14 pt font)
Provides depth perception
Near Point
Nml NPC lt10cm
Athlete lt6 cm
Sports Concussion Exam
Visual Disturbance Convergence
Exophoria Practice effect
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Examine
Muscle Palpation
Suboccipitals palpate while rotating
Splenius Capitis palpate just posterior to
mastoid and resist ipsilateral rotation
Upper cervical mobility (C1-2) FlexRotation test
Cervicogenic HA and C1-2 dysfunction correlate
Nml 45 deg B lt33 deg = C1-2 hypo
ProprioceptionHead position
Patient sits 35rdquo from target with head mounted laser
Find target with EO then close eyes and move head maximally
Patient attempts to return head toward center target
(Thurnberg 2001)
Sports Concussion Exam MSK
Cervicogenic Dysfunction
Sports Concussion Exam MSK
Cervicogenic Dizziness
Upper c-spine complex proprioceptive system with
connections to visual and vestibular systems
Doesnrsquot send appropriate signals dt damaged muscle spindles
Can be mechanoreceptor dysfunction or posttraumatic
vertebro-basilar circulatory insufficiency
Diagnosis of exclusion (difficult to treat)
Headneck injury with dizziness when all other causes of
dizziness are ruled out
Swivel chair test
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion PT Intervention
MSK C-Spine and Balance
darr balance from afferent efferent or integration malfunction
If any afferent signal is altered (cervical pain and
reduced range of motion can impair signal due to poor
proprioception)
Concussions disrupt the BS ability to integrate and
interpret the afferent signals
Efferent signal problems may occur due to delay from
poor central integration or from VS tract dysfunction
resulting in untimely ineffective balance reactions
Sports Concussion PT Intervention
MSK C-Spine and Balance
Challenge the somatosensory system
Most people are visually dominant for balance with an overreliance on vision and under-utilization of somatosensory and vestibular inputs for balance
Train by downplaying visual reliance
Posturography= most accurate way to measure
and affect visual dependency ($$)
Virtual reality may prove to do this as well
Use unstable surfaces to increase challenge
Cheap effective clinical way to limit vision Eyes closed
Dark room
Vaseline over glasses
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Visual Disturbance
Ocular issues after concussion are common
(poor eye tracking)
Characteristics HA eye strain
blurriness diplopia oscillopsia
frontal HA difficulty attending
Vision therapy goals
Improve brains ability to control eye alignment movement focus and visual processing
Visual skills are reinforced through repetition and integrated with cognitivemotor skills until automatic
Sports Concussion Exam
Visual Disturbance Oculomotor Control
Concussions can directly impair oculomotor function
The 3 nerves (CN III IV and VI) that innervate the eye muscles
exit the brain stem travel along base of skull join behind the eye
and enter orbit
The nerves are susceptible to injury anywhere along the route
from BS to eye muscles
Sports Concussion Exam
Visual Disturbance Observation (head tilt ptosis Ocular misalignment)
Observe initial head position but correct to neutral to perform exam
Visual Fields
EOMsSmooth pursuits (H-test)Gaze Holding
Saccades (vertical and horizontal)
Antisaccades (voluntary top-down cognitive control)
Static visual acuity (Snellen eye chart monocular binocular)
Convergence and Accommodation
Sports Concussion Exam
Visual Disturbance Acuity Accommodation and Vergence
Static Visual Acuity
Measure each eye individually then togetherhellipdistance and near
Variability btwn distance and near may indicate accommodative dysf
If acuity better monocularly than binocularly likely accommodative dysf
Ensure binocular vision compensates for monocular difference
Accommodative dysfunction
Difficult for eyes to shift focus between nearfar targets
Lag between stimulus to accommodation and accommodative response
Can simply be fatigue of repeated accommodative stimulationhellipdaily life
Vergence dysfunction
Disconjugate eye movements resulting in inability of eyes to accurately fixate and stabilize retinal image
Convergence Insufficiency is higher in children with ADHDhellip
Sports Concussion Exam
Visual Disturbance Convergence
Single image viewing with 2 eyes
Perform 3x and record (14 pt font)
Provides depth perception
Near Point
Nml NPC lt10cm
Athlete lt6 cm
Sports Concussion Exam
Visual Disturbance Convergence
Exophoria Practice effect
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Sports Concussion Exam MSK
Cervicogenic Dizziness
Upper c-spine complex proprioceptive system with
connections to visual and vestibular systems
Doesnrsquot send appropriate signals dt damaged muscle spindles
Can be mechanoreceptor dysfunction or posttraumatic
vertebro-basilar circulatory insufficiency
Diagnosis of exclusion (difficult to treat)
Headneck injury with dizziness when all other causes of
dizziness are ruled out
Swivel chair test
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion PT Intervention
MSK C-Spine and Balance
darr balance from afferent efferent or integration malfunction
If any afferent signal is altered (cervical pain and
reduced range of motion can impair signal due to poor
proprioception)
Concussions disrupt the BS ability to integrate and
interpret the afferent signals
Efferent signal problems may occur due to delay from
poor central integration or from VS tract dysfunction
resulting in untimely ineffective balance reactions
Sports Concussion PT Intervention
MSK C-Spine and Balance
Challenge the somatosensory system
Most people are visually dominant for balance with an overreliance on vision and under-utilization of somatosensory and vestibular inputs for balance
Train by downplaying visual reliance
Posturography= most accurate way to measure
and affect visual dependency ($$)
Virtual reality may prove to do this as well
Use unstable surfaces to increase challenge
Cheap effective clinical way to limit vision Eyes closed
Dark room
Vaseline over glasses
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Visual Disturbance
Ocular issues after concussion are common
(poor eye tracking)
Characteristics HA eye strain
blurriness diplopia oscillopsia
frontal HA difficulty attending
Vision therapy goals
Improve brains ability to control eye alignment movement focus and visual processing
Visual skills are reinforced through repetition and integrated with cognitivemotor skills until automatic
Sports Concussion Exam
Visual Disturbance Oculomotor Control
Concussions can directly impair oculomotor function
The 3 nerves (CN III IV and VI) that innervate the eye muscles
exit the brain stem travel along base of skull join behind the eye
and enter orbit
The nerves are susceptible to injury anywhere along the route
from BS to eye muscles
Sports Concussion Exam
Visual Disturbance Observation (head tilt ptosis Ocular misalignment)
Observe initial head position but correct to neutral to perform exam
Visual Fields
EOMsSmooth pursuits (H-test)Gaze Holding
Saccades (vertical and horizontal)
Antisaccades (voluntary top-down cognitive control)
Static visual acuity (Snellen eye chart monocular binocular)
Convergence and Accommodation
Sports Concussion Exam
Visual Disturbance Acuity Accommodation and Vergence
Static Visual Acuity
Measure each eye individually then togetherhellipdistance and near
Variability btwn distance and near may indicate accommodative dysf
If acuity better monocularly than binocularly likely accommodative dysf
Ensure binocular vision compensates for monocular difference
Accommodative dysfunction
Difficult for eyes to shift focus between nearfar targets
Lag between stimulus to accommodation and accommodative response
Can simply be fatigue of repeated accommodative stimulationhellipdaily life
Vergence dysfunction
Disconjugate eye movements resulting in inability of eyes to accurately fixate and stabilize retinal image
Convergence Insufficiency is higher in children with ADHDhellip
Sports Concussion Exam
Visual Disturbance Convergence
Single image viewing with 2 eyes
Perform 3x and record (14 pt font)
Provides depth perception
Near Point
Nml NPC lt10cm
Athlete lt6 cm
Sports Concussion Exam
Visual Disturbance Convergence
Exophoria Practice effect
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion PT Intervention
MSK C-Spine and Balance
darr balance from afferent efferent or integration malfunction
If any afferent signal is altered (cervical pain and
reduced range of motion can impair signal due to poor
proprioception)
Concussions disrupt the BS ability to integrate and
interpret the afferent signals
Efferent signal problems may occur due to delay from
poor central integration or from VS tract dysfunction
resulting in untimely ineffective balance reactions
Sports Concussion PT Intervention
MSK C-Spine and Balance
Challenge the somatosensory system
Most people are visually dominant for balance with an overreliance on vision and under-utilization of somatosensory and vestibular inputs for balance
Train by downplaying visual reliance
Posturography= most accurate way to measure
and affect visual dependency ($$)
Virtual reality may prove to do this as well
Use unstable surfaces to increase challenge
Cheap effective clinical way to limit vision Eyes closed
Dark room
Vaseline over glasses
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Visual Disturbance
Ocular issues after concussion are common
(poor eye tracking)
Characteristics HA eye strain
blurriness diplopia oscillopsia
frontal HA difficulty attending
Vision therapy goals
Improve brains ability to control eye alignment movement focus and visual processing
Visual skills are reinforced through repetition and integrated with cognitivemotor skills until automatic
Sports Concussion Exam
Visual Disturbance Oculomotor Control
Concussions can directly impair oculomotor function
The 3 nerves (CN III IV and VI) that innervate the eye muscles
exit the brain stem travel along base of skull join behind the eye
and enter orbit
The nerves are susceptible to injury anywhere along the route
from BS to eye muscles
Sports Concussion Exam
Visual Disturbance Observation (head tilt ptosis Ocular misalignment)
Observe initial head position but correct to neutral to perform exam
Visual Fields
EOMsSmooth pursuits (H-test)Gaze Holding
Saccades (vertical and horizontal)
Antisaccades (voluntary top-down cognitive control)
Static visual acuity (Snellen eye chart monocular binocular)
Convergence and Accommodation
Sports Concussion Exam
Visual Disturbance Acuity Accommodation and Vergence
Static Visual Acuity
Measure each eye individually then togetherhellipdistance and near
Variability btwn distance and near may indicate accommodative dysf
If acuity better monocularly than binocularly likely accommodative dysf
Ensure binocular vision compensates for monocular difference
Accommodative dysfunction
Difficult for eyes to shift focus between nearfar targets
Lag between stimulus to accommodation and accommodative response
Can simply be fatigue of repeated accommodative stimulationhellipdaily life
Vergence dysfunction
Disconjugate eye movements resulting in inability of eyes to accurately fixate and stabilize retinal image
Convergence Insufficiency is higher in children with ADHDhellip
Sports Concussion Exam
Visual Disturbance Convergence
Single image viewing with 2 eyes
Perform 3x and record (14 pt font)
Provides depth perception
Near Point
Nml NPC lt10cm
Athlete lt6 cm
Sports Concussion Exam
Visual Disturbance Convergence
Exophoria Practice effect
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Sports Concussion PT Intervention
MSK C-Spine and Balance
darr balance from afferent efferent or integration malfunction
If any afferent signal is altered (cervical pain and
reduced range of motion can impair signal due to poor
proprioception)
Concussions disrupt the BS ability to integrate and
interpret the afferent signals
Efferent signal problems may occur due to delay from
poor central integration or from VS tract dysfunction
resulting in untimely ineffective balance reactions
Sports Concussion PT Intervention
MSK C-Spine and Balance
Challenge the somatosensory system
Most people are visually dominant for balance with an overreliance on vision and under-utilization of somatosensory and vestibular inputs for balance
Train by downplaying visual reliance
Posturography= most accurate way to measure
and affect visual dependency ($$)
Virtual reality may prove to do this as well
Use unstable surfaces to increase challenge
Cheap effective clinical way to limit vision Eyes closed
Dark room
Vaseline over glasses
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Visual Disturbance
Ocular issues after concussion are common
(poor eye tracking)
Characteristics HA eye strain
blurriness diplopia oscillopsia
frontal HA difficulty attending
Vision therapy goals
Improve brains ability to control eye alignment movement focus and visual processing
Visual skills are reinforced through repetition and integrated with cognitivemotor skills until automatic
Sports Concussion Exam
Visual Disturbance Oculomotor Control
Concussions can directly impair oculomotor function
The 3 nerves (CN III IV and VI) that innervate the eye muscles
exit the brain stem travel along base of skull join behind the eye
and enter orbit
The nerves are susceptible to injury anywhere along the route
from BS to eye muscles
Sports Concussion Exam
Visual Disturbance Observation (head tilt ptosis Ocular misalignment)
Observe initial head position but correct to neutral to perform exam
Visual Fields
EOMsSmooth pursuits (H-test)Gaze Holding
Saccades (vertical and horizontal)
Antisaccades (voluntary top-down cognitive control)
Static visual acuity (Snellen eye chart monocular binocular)
Convergence and Accommodation
Sports Concussion Exam
Visual Disturbance Acuity Accommodation and Vergence
Static Visual Acuity
Measure each eye individually then togetherhellipdistance and near
Variability btwn distance and near may indicate accommodative dysf
If acuity better monocularly than binocularly likely accommodative dysf
Ensure binocular vision compensates for monocular difference
Accommodative dysfunction
Difficult for eyes to shift focus between nearfar targets
Lag between stimulus to accommodation and accommodative response
Can simply be fatigue of repeated accommodative stimulationhellipdaily life
Vergence dysfunction
Disconjugate eye movements resulting in inability of eyes to accurately fixate and stabilize retinal image
Convergence Insufficiency is higher in children with ADHDhellip
Sports Concussion Exam
Visual Disturbance Convergence
Single image viewing with 2 eyes
Perform 3x and record (14 pt font)
Provides depth perception
Near Point
Nml NPC lt10cm
Athlete lt6 cm
Sports Concussion Exam
Visual Disturbance Convergence
Exophoria Practice effect
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Sports Concussion PT Intervention
MSK C-Spine and Balance
Challenge the somatosensory system
Most people are visually dominant for balance with an overreliance on vision and under-utilization of somatosensory and vestibular inputs for balance
Train by downplaying visual reliance
Posturography= most accurate way to measure
and affect visual dependency ($$)
Virtual reality may prove to do this as well
Use unstable surfaces to increase challenge
Cheap effective clinical way to limit vision Eyes closed
Dark room
Vaseline over glasses
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Visual Disturbance
Ocular issues after concussion are common
(poor eye tracking)
Characteristics HA eye strain
blurriness diplopia oscillopsia
frontal HA difficulty attending
Vision therapy goals
Improve brains ability to control eye alignment movement focus and visual processing
Visual skills are reinforced through repetition and integrated with cognitivemotor skills until automatic
Sports Concussion Exam
Visual Disturbance Oculomotor Control
Concussions can directly impair oculomotor function
The 3 nerves (CN III IV and VI) that innervate the eye muscles
exit the brain stem travel along base of skull join behind the eye
and enter orbit
The nerves are susceptible to injury anywhere along the route
from BS to eye muscles
Sports Concussion Exam
Visual Disturbance Observation (head tilt ptosis Ocular misalignment)
Observe initial head position but correct to neutral to perform exam
Visual Fields
EOMsSmooth pursuits (H-test)Gaze Holding
Saccades (vertical and horizontal)
Antisaccades (voluntary top-down cognitive control)
Static visual acuity (Snellen eye chart monocular binocular)
Convergence and Accommodation
Sports Concussion Exam
Visual Disturbance Acuity Accommodation and Vergence
Static Visual Acuity
Measure each eye individually then togetherhellipdistance and near
Variability btwn distance and near may indicate accommodative dysf
If acuity better monocularly than binocularly likely accommodative dysf
Ensure binocular vision compensates for monocular difference
Accommodative dysfunction
Difficult for eyes to shift focus between nearfar targets
Lag between stimulus to accommodation and accommodative response
Can simply be fatigue of repeated accommodative stimulationhellipdaily life
Vergence dysfunction
Disconjugate eye movements resulting in inability of eyes to accurately fixate and stabilize retinal image
Convergence Insufficiency is higher in children with ADHDhellip
Sports Concussion Exam
Visual Disturbance Convergence
Single image viewing with 2 eyes
Perform 3x and record (14 pt font)
Provides depth perception
Near Point
Nml NPC lt10cm
Athlete lt6 cm
Sports Concussion Exam
Visual Disturbance Convergence
Exophoria Practice effect
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Visual Disturbance
Ocular issues after concussion are common
(poor eye tracking)
Characteristics HA eye strain
blurriness diplopia oscillopsia
frontal HA difficulty attending
Vision therapy goals
Improve brains ability to control eye alignment movement focus and visual processing
Visual skills are reinforced through repetition and integrated with cognitivemotor skills until automatic
Sports Concussion Exam
Visual Disturbance Oculomotor Control
Concussions can directly impair oculomotor function
The 3 nerves (CN III IV and VI) that innervate the eye muscles
exit the brain stem travel along base of skull join behind the eye
and enter orbit
The nerves are susceptible to injury anywhere along the route
from BS to eye muscles
Sports Concussion Exam
Visual Disturbance Observation (head tilt ptosis Ocular misalignment)
Observe initial head position but correct to neutral to perform exam
Visual Fields
EOMsSmooth pursuits (H-test)Gaze Holding
Saccades (vertical and horizontal)
Antisaccades (voluntary top-down cognitive control)
Static visual acuity (Snellen eye chart monocular binocular)
Convergence and Accommodation
Sports Concussion Exam
Visual Disturbance Acuity Accommodation and Vergence
Static Visual Acuity
Measure each eye individually then togetherhellipdistance and near
Variability btwn distance and near may indicate accommodative dysf
If acuity better monocularly than binocularly likely accommodative dysf
Ensure binocular vision compensates for monocular difference
Accommodative dysfunction
Difficult for eyes to shift focus between nearfar targets
Lag between stimulus to accommodation and accommodative response
Can simply be fatigue of repeated accommodative stimulationhellipdaily life
Vergence dysfunction
Disconjugate eye movements resulting in inability of eyes to accurately fixate and stabilize retinal image
Convergence Insufficiency is higher in children with ADHDhellip
Sports Concussion Exam
Visual Disturbance Convergence
Single image viewing with 2 eyes
Perform 3x and record (14 pt font)
Provides depth perception
Near Point
Nml NPC lt10cm
Athlete lt6 cm
Sports Concussion Exam
Visual Disturbance Convergence
Exophoria Practice effect
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Sports Concussion Exam
Visual Disturbance
Ocular issues after concussion are common
(poor eye tracking)
Characteristics HA eye strain
blurriness diplopia oscillopsia
frontal HA difficulty attending
Vision therapy goals
Improve brains ability to control eye alignment movement focus and visual processing
Visual skills are reinforced through repetition and integrated with cognitivemotor skills until automatic
Sports Concussion Exam
Visual Disturbance Oculomotor Control
Concussions can directly impair oculomotor function
The 3 nerves (CN III IV and VI) that innervate the eye muscles
exit the brain stem travel along base of skull join behind the eye
and enter orbit
The nerves are susceptible to injury anywhere along the route
from BS to eye muscles
Sports Concussion Exam
Visual Disturbance Observation (head tilt ptosis Ocular misalignment)
Observe initial head position but correct to neutral to perform exam
Visual Fields
EOMsSmooth pursuits (H-test)Gaze Holding
Saccades (vertical and horizontal)
Antisaccades (voluntary top-down cognitive control)
Static visual acuity (Snellen eye chart monocular binocular)
Convergence and Accommodation
Sports Concussion Exam
Visual Disturbance Acuity Accommodation and Vergence
Static Visual Acuity
Measure each eye individually then togetherhellipdistance and near
Variability btwn distance and near may indicate accommodative dysf
If acuity better monocularly than binocularly likely accommodative dysf
Ensure binocular vision compensates for monocular difference
Accommodative dysfunction
Difficult for eyes to shift focus between nearfar targets
Lag between stimulus to accommodation and accommodative response
Can simply be fatigue of repeated accommodative stimulationhellipdaily life
Vergence dysfunction
Disconjugate eye movements resulting in inability of eyes to accurately fixate and stabilize retinal image
Convergence Insufficiency is higher in children with ADHDhellip
Sports Concussion Exam
Visual Disturbance Convergence
Single image viewing with 2 eyes
Perform 3x and record (14 pt font)
Provides depth perception
Near Point
Nml NPC lt10cm
Athlete lt6 cm
Sports Concussion Exam
Visual Disturbance Convergence
Exophoria Practice effect
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Sports Concussion Exam
Visual Disturbance Oculomotor Control
Concussions can directly impair oculomotor function
The 3 nerves (CN III IV and VI) that innervate the eye muscles
exit the brain stem travel along base of skull join behind the eye
and enter orbit
The nerves are susceptible to injury anywhere along the route
from BS to eye muscles
Sports Concussion Exam
Visual Disturbance Observation (head tilt ptosis Ocular misalignment)
Observe initial head position but correct to neutral to perform exam
Visual Fields
EOMsSmooth pursuits (H-test)Gaze Holding
Saccades (vertical and horizontal)
Antisaccades (voluntary top-down cognitive control)
Static visual acuity (Snellen eye chart monocular binocular)
Convergence and Accommodation
Sports Concussion Exam
Visual Disturbance Acuity Accommodation and Vergence
Static Visual Acuity
Measure each eye individually then togetherhellipdistance and near
Variability btwn distance and near may indicate accommodative dysf
If acuity better monocularly than binocularly likely accommodative dysf
Ensure binocular vision compensates for monocular difference
Accommodative dysfunction
Difficult for eyes to shift focus between nearfar targets
Lag between stimulus to accommodation and accommodative response
Can simply be fatigue of repeated accommodative stimulationhellipdaily life
Vergence dysfunction
Disconjugate eye movements resulting in inability of eyes to accurately fixate and stabilize retinal image
Convergence Insufficiency is higher in children with ADHDhellip
Sports Concussion Exam
Visual Disturbance Convergence
Single image viewing with 2 eyes
Perform 3x and record (14 pt font)
Provides depth perception
Near Point
Nml NPC lt10cm
Athlete lt6 cm
Sports Concussion Exam
Visual Disturbance Convergence
Exophoria Practice effect
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Sports Concussion Exam
Visual Disturbance Observation (head tilt ptosis Ocular misalignment)
Observe initial head position but correct to neutral to perform exam
Visual Fields
EOMsSmooth pursuits (H-test)Gaze Holding
Saccades (vertical and horizontal)
Antisaccades (voluntary top-down cognitive control)
Static visual acuity (Snellen eye chart monocular binocular)
Convergence and Accommodation
Sports Concussion Exam
Visual Disturbance Acuity Accommodation and Vergence
Static Visual Acuity
Measure each eye individually then togetherhellipdistance and near
Variability btwn distance and near may indicate accommodative dysf
If acuity better monocularly than binocularly likely accommodative dysf
Ensure binocular vision compensates for monocular difference
Accommodative dysfunction
Difficult for eyes to shift focus between nearfar targets
Lag between stimulus to accommodation and accommodative response
Can simply be fatigue of repeated accommodative stimulationhellipdaily life
Vergence dysfunction
Disconjugate eye movements resulting in inability of eyes to accurately fixate and stabilize retinal image
Convergence Insufficiency is higher in children with ADHDhellip
Sports Concussion Exam
Visual Disturbance Convergence
Single image viewing with 2 eyes
Perform 3x and record (14 pt font)
Provides depth perception
Near Point
Nml NPC lt10cm
Athlete lt6 cm
Sports Concussion Exam
Visual Disturbance Convergence
Exophoria Practice effect
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Sports Concussion Exam
Visual Disturbance Acuity Accommodation and Vergence
Static Visual Acuity
Measure each eye individually then togetherhellipdistance and near
Variability btwn distance and near may indicate accommodative dysf
If acuity better monocularly than binocularly likely accommodative dysf
Ensure binocular vision compensates for monocular difference
Accommodative dysfunction
Difficult for eyes to shift focus between nearfar targets
Lag between stimulus to accommodation and accommodative response
Can simply be fatigue of repeated accommodative stimulationhellipdaily life
Vergence dysfunction
Disconjugate eye movements resulting in inability of eyes to accurately fixate and stabilize retinal image
Convergence Insufficiency is higher in children with ADHDhellip
Sports Concussion Exam
Visual Disturbance Convergence
Single image viewing with 2 eyes
Perform 3x and record (14 pt font)
Provides depth perception
Near Point
Nml NPC lt10cm
Athlete lt6 cm
Sports Concussion Exam
Visual Disturbance Convergence
Exophoria Practice effect
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Sports Concussion Exam
Visual Disturbance Convergence
Single image viewing with 2 eyes
Perform 3x and record (14 pt font)
Provides depth perception
Near Point
Nml NPC lt10cm
Athlete lt6 cm
Sports Concussion Exam
Visual Disturbance Convergence
Exophoria Practice effect
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Sports Concussion Exam
Visual Disturbance Convergence
Exophoria Practice effect
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Sports Concussion PT Intervention
Vision Exercises
Visual Behavioral Exercises
2-10 visits with excellent prognosis
Smart phone apps HTS online
(wwwvisiontherapysolutionsnet)
good resources for home program
Referral to neuro-optometrist or neuro-
opthamologist if needed
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Treleaven 2008
Sports Concussion PT Intervention
Vision Exercises
Exercises to strengthen and uarr endurance of eye muscles and
improve speed coordination and accuracy
AccommodationConvergence
Hart Chart Five Fingers
Brocks Strings Two Fingers
PursuitsSaccades
Patterns mazes
Self targets progress by increasing space between targets
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Sports Concussion Exam
Vestibular Disturbance
Subjective Sx-Self Reports (DHI PCSS)
Balance (included with)
BESSTandem Gait
Computerized Dynamic Posturography
Vestibular
Dynamic Visual Acuity (compared to static-Snellen)
Gaze stability (VOR viewing)
Fukuda step test
VORc (Space and Motion Discomfort)
hellipor VOMS
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo
VOMS (Vestibular Oculomotor Screen)
85 pts 85 controls (12-18yr old)
6 days post injury +- 5d
α 91 internal consistencyreliability
VOR VORc and NPC most sensitive for
predicting concussed group vs control
(Mucha Collins Elbin AJSM In press)
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
New Data Validating Visuo-Vestibular
Screening UPMC ldquoVOMSrdquo Dizzy
(0-10)
HA
(0-10)
Nausea
(0-10)
Foggy
(0-10)
Comments
Baseline
Pursuits
-2 trials H test
Saccades (10ea)
-horizontal
-vertical
NPC (3 trials 14pt font target) ______cm
______cm
______cm
VOR (180bpm 40 deg of center)
-horizontal
-vertical
VORc (visual motion)
-50bpm
-160 deg arc of motion
(Mucha Collins Elbin AJSM In press)
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Sports Concussion PT Intervention
Vestibular
Goals of vestibular PT
Remediate dizziness and disequilibrium
Increase accuracy of sensory inputs
Desensitization to provocative stimuli
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Sports Concussion PT Intervention
Vestibular Exercises
Habituation bullDesensitization
bullSMD
bullNot for true vestibular system
impairments
Canalith repositioning bullBPPV
bullEpley Libertory Maneuver
Adaptation bullGaze stabilizationVOR
bullComputerized DVA
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Does Vestibular Rehabilitation Benefit the Athlete
Literature Review
Zurich 2012 updated guidelines include visuo-vestibular
Military Blast induced head trauma DVA Target AcquisitionFollowing Perception Time
Improves to normative values after 4 weeks PT
Elderly with vestibular pathology Great evidence showing effective for improving vestibular pathology
Decreasing fall risk
Athletic Concussions darr sxdizziness provoked by head movement busy environ
uarr balance function
Limitations in studies retrospective nature of data collection no control group chronicity of concussion sx absence of standardized vestibular function test battery (BUT WAIT)
Lacking Level 1 evidence howeverhellip
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Sports Concussion PT Intervention
Vestibular Exercises VORx1
Adaptation
VOR x 1 viewing (ldquosteady-camrdquo feature of brain)
Turn head 40degto R and 40degto L while eyes fixate on target
Head moves 180bpm
----------(slower to maintain clarity) --------------------
10-20 repetitions 2xday
Preferably glasses off
Horizontal and vertical
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Sports Concussion PT Intervention
Vestibular Exercises SMD
Habituation Gradual exposure to provocative stimuli
Down-regulate vision ndash decrease visual dependency
Mixture of gaze-stabilization protocol (VORx1) and balance exercise protocol ndash greater emphasis on suppressing abnormal visual input
Create a visual anchor (non-moving target) AND a visually dynamic targetdestabilizing input helps recalibrate ptrsquos oversensitivity to optic flow
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Sports Concussion PT Intervention
Vestibular Exercises
Adaptation
Gaze stabilityVORx1
exercises with
progressions
including SMD
(habituation)
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Multi-System Approach Assess and Treat
Musculoskeletal
Balance
VisualOcular Disturbance
Vestibular Dysfunction
Exertion and Sport Specific Training
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Sports Concussion Exam Exertion Considerationshellip
Ensure all visuo-vestibular sx are gone before initiating activities with headeye movement (ellipticaljogging)
Threshold
HDR to exercise (elevated RHR common after concussion)
Symptomatic response to exercise
Progression should be symptoms dependent sub-sx threshold
Timing is everything
Acutely exercising can decrease cognitive performance and the numberperformance of BDNP nt
Exercise delayed until acute healing has occurred can increase neurogenesis neuroplasticity and visual processing can improve cerebral blood flow and increase parasympathetic activity NO evidence shows rest gt3wks is beneficial
Consider cost of abrupt ending to years of extreme exercise
(Vidal et al 2012)
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Exertion and Sport Specific Training
A Sample Protocol
Relative cognitive and physical rest
Light aerobic exercise (15‟ low intensity)
Moderate aerobic activity 30‟ bike at 75 MHR
Heavy aerobic activity 30‟ bike at 75 MHR w30rdquo intervals at max effort at 10‟ 15‟ 20‟
Sport specific aerobic activity
15‟ low intensity (minimally distracting environment)
Sport specific activity 30‟ mod intensity w30rdquo intervals at max effort 10‟ 15‟ and 20‟
Non contact activity regular warm up and high intensity agility coordination activity
once cleared by physician
Full contact practice followed by games
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Sports Concussion PT Intervention
Exertion and Sport Specific Exercises
Functionalsport specific ways to
incorporate vestibular vision therapy
and traditional PT into concussion rehab
Ensure athlete can succeed with
challenges to multiple sensory motor
and cognitive systems
Examples from the military
ldquoSALUTErdquo ldquoRun roll aimrdquo ldquoIllinois
Agility Testrdquo ldquoCQ dutyrdquo
Tasks which challenge executive
function gaze stability pursuit
tracking dynamic stability exertion
etc
(Moore et al 2013)
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Thank you
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
References ndash available upon request
Gottshall K Hoffer M Tracking Recovery of Vestibular Function in Individuals with Blast-Induced Head Trauma Using Vestibular-Visual Cognitive Interaction Tests JNPT (34) June 2010
McCrory P Meeuwisse W Johnston K et al Consensus statement on concussion in sport the 3rd International Conference on Concussion in Sport J Athl Train 2009 44 (4) 434-48
Cantu RC When to disqualify an athlete after a concussion CUrr Sports Med Rep 2009 Jan-Feb 8(1) 6-7
Meehan WP III Bachur RG Sport-related concussion Pediatrics 2009 123 114-123 Shaw NA The neurophysiology of concussion Prog Neurobiol 2002 67281-244 Hillier SL Hollohan V Vestibular rehabilitation for unilateral peripheral vestibular dysfunction
Cochrane Database Syst Rev 2007(4)CD005397 Whitney SL Wrisley DM Brown KE Furman JM Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine Laryngoscope Sep 2000110(9)1528-1534
Brown KE Whitney SL Marchetti GF Wrisley DM Furman JM Physical therapy Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Iverson G Predicting slow recovery from sport-related concussion the new simple-complex distinction Clin J Sport Med Jan 200717(1)31-37
Kontos AP Elbin RJ Schatz P Covassin T Henry L Pardini J Collins MW A revised factor structure for the post-concussion symptom scale baseline and postconcussion factors Am J Sports Med 2012 Oct40(10)2375-84 Epub 2012 Aug 16
httpwwwsteelerscomnewsarticle-1Collins-Concussion-is-a-manageable-injury6d442f9d-d13f-4403-9a86-b6242afc7eb4
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Maples WC FIcklin TW Interrater and test-retest reliabiliity of pursuits and saccades J Am Optom
Assoc 1988 Jul59 (7) 549-52 Evans RW Migraine a question and answer review Med Clin NA 93245-62 2009 Thurnberg et al Influences on the fusimotor-muscle spindle system from chemosensitive nerve
endings in cervical facet joints in the cat possible implications for whiplash induced disorders Pain (2001) 91 15-22
Pikus HJ Phillips JM Headache 35621-9 1995 Hearn A Rivett DA Cervical SNAGs a biomechanical analysis Manual Therapy 7(2) 71-9 2002
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
Scheiman M Cooper J Mitchell GL et al A survey of treatment modalities for convergence insufficiency Optom Vis Sci 2002 79 (3)151-157
Hanes DA McCollum G Journal of Vestibular Research 2006 16 (3) 75-91 Alsalaheen BA Mucha A Morris LO et al Vestibular rehabilitation for dizziness and balance
disorders after concussion J Neurol Phys Ther 2010 Jun 34 (2) 87-93 Gaze Stabilization Exercises DizzinessandBalancecom httpwwwdizziness-and-
balancecomtreatmentrehabgaze Krebs D Vestibular Rehabilitation Useful But Not Universally So Otolaryngology-Head and Neck
Surgery 2003 128 (2) 240-250 Lee T amp Chee N Vestibular Rehabilitation for the Dizzy Patient Am Academy of Medicine 2005
34 289-294 Gottshall KR Hoffer ME Tracking recovery of vestibular function in individuals with blast-induced
head trauma using vestibular-visual-cognitive interaction tests J Neurol Phys Ther Jun 201034(2)94-97
Alsalaheen BA Mucha A Morris LO et al Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion Journal of Neurologic Physical Therapy 20103487-93
Rine RM et al Vestibular function testing using NIH toolbox Neurology 2012 in press Horak FB Jones-Rycewicz C Black FO Shumway-Cook A Effects of vestibular rehabilitation on
dizziness and imbalance Otolaryngol Head Neck Surg 1992 106175-80 HErdman SJ Clendaniel RA Mattox DE Holiday MJ Niparko JK Vestibular adaptation exercises
and recovery acute stage after acoustic neuroma resection Otolaryngol Head Neck Surg 1995 113 77-87
Herdman SJ Shubert MC Das VE Tusa RJ Recovery of dynamic visual acuity in unilateral vestibular hypofunction Arch Otolaryngol Head Neck Surgery 2003 129 819-24 Other
httpwwwneuroptorgspecial-interest-groupsvestibular-rehabilitationresources Times KR Vestibular Disorders Association httpvestibularorg Moore et al The Role of US Military Physical Therapists During Recent Combat Campaigns Phys
Ther 2013 93 (9)1259-1268) Vidal PG et al Rehabilitation Strategies for Prolonged Recovery in Pediatric and Adolescent
Concussion Pediatric Annals 2012 419
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