Transcript Warrior Recovery Center Physical Therapy

Physical Therapy
in the DoD
CDR Henry McMillan, PT, DPT
LCDR Alicia Souvignier, MPT, DPT, GCS
Objectives
Identify the common patient
presentations seen by PHS PTs working in
the DoD
 Be able to indentify key aspects of the
evaluation of a dizzy patient
 List 3 treatment techniques used to treat
dizziness

Indentification of mTBI
Incident in theatre results in Medivac to
CONUS
 After redeployment, troops inprocess
through the Soldier Readiness Center,
where history of concussion is identified
 Soldiers with possible residual symptoms
of concussion, are referred to the TBI
clinic.

DoD/Physical Therapy

Optimistic expectation for full recovery

Therapists incorporate assessment of the
Service Members goals and priorities
along with MTBI related symptoms
Areas of concern for a soldier who
has a history of concussion/mTBI
Vestibular Dysfunction
 Balance Complaints
 Post Traumatic Headache
 Temporomandibular Joint Dysfunction
 Attention and Dual-Task Deficits
 Fitness/ Activity intolerance
 Musculosketetal complaints

Guidelines for PT Referral
DHI Score > 11 (Yes to any F’s or P’s)
 Plus yes to one of the following:
◦ R/SR (Eyes Closed) less than 30 seconds(arms across chest)

◦ VOR x1 for less than one minute with onset
of symptoms
◦ Walking with HT increase symptoms, deviated
gait, LOB- (Museum Gait)
Guidelines for PT referral
◦ If the patient reports any of the following
 Difficulty with balance or dizziness that is affecting
their functional performance
 Unsteady while standing still or walking, in poor
lighting, or in crowds
 Difficulty with balance on uneven surfaces
 Intense spinning, lightheadedness, or unsteadiness
associated with exercise
Causes of Vertigo

Vestibular Lesions or hypofunction
◦ Unilateral- infection/neuritis, lesions, bppv
◦ Bilateral- ototoxic medications

Central processing
◦ Central lesions- brainstem, cerebellum
◦ Migranes
◦ Anxiety

Cervicogenic dizziness
◦ Vertebrobasilar insufficiency
◦ Altered proprioceptive signals
Evaluation

Subjective
◦
◦
◦
◦
MOI or idiopathic
Frequency/Intensity/duration
Vision/ Hearing deficits
Positional/activity induced
 Valsalva/ pressure changes
◦ Describe symptoms of dizziness
 Vertigo
 Imbalance
 Lightheadedness
Evaluation

Subjective
◦ Activity Level
 Recreational Sports
◦ Exercise Tolerance
 Unit Physical Training
◦ Behavioral Health
◦ Quality of Life
 DHI
 Family Participation
 Command/Unit Support
Vestibular Evaluation
Musculoskeletal Screen
 Positional Testing
 Oculomotor
 Balance

Oculomotor
Smooth Pursuit
 Saccadic
 VOR

Oculomotor

Vestibular Ocular Reflex
◦ Vestibular system sends information regarding
speed of movement to the visual system.
Allows us to keep focus while performing
functional head motions.
Test for VOR

Head Thrust Test
◦ Grasp patients head firmly
◦ Tilt patient’s head to 30 deg flex
◦ Move head back and forth slowly and instruct
patient to keep focus on target
◦ Provide a quick movement through a small
range and watch for patient’s ability to refocus
on target.
◦ Refixation saccade indicates decreased VOR
Test for VOR

Dynamic Visual Acuity
◦ Test visual acuity on a Snellen Chart
◦ Turn patients head vertical and horizontal
plane to the beat of a metronome at 2Hz
◦ Retest visual acuity while you are moving the
patient’s head.
◦ 3 lines loss is significant
Positional Testing

Dizziness caused by certain positions
◦ Spinning
◦ Use Frenzal goggles

Dix Hallpike
◦ BPPV

Motion Sensitivity Quotient
◦ Motion Sensitivity
Positional Testing

Dix Hallpike
◦ Long sitting, head turned 45 deg, drop down
with neck into about 30 deg of extension
Balance
Functional Gait Assessment
 Romberg/ Sharpened
 Neurocom or M-CTSIB

Treatment Approaches

Adaptation Exercises: adapting residual
vestibular function to make up for lost
function
◦ Example: Maintain visual fixation on object
while the head is moving

Substitution Exercises
◦ Doing exercises with and without visual cues

Habituation Exercises
◦ Repeated exposure to provocative stimulus,
for example motion sensitivity.
VOR Treatment - Adaptation
Walking head turns
 Tracking with eyes
 Tracking with head movements
 All of the above together
 Above exercises on varied surfaces

Motion Sensitivity Treatment
Brandt Daroff (picture)
 Positions identified from MSQ

Treatment of BPPV
Canalith Repositioning Technique
 Liberatory Maneuver

Postural Stability
Prioprio
 Neurocom Balance activities- SOT

◦ Foam
◦ Unstable surface
◦ Uneven terrain
Treatment Ideas
Foam bowling
 Bear claws
 Soccer Toss
 Wii
 Dance Revolution
 Discoball/strobe with balance

Goals for Physical Therapy
Return to Duty
 Goals for Civilian Life

Questions?