Transcript 2nd-year-vcu-presentation-handouts-2

CONCUSSION: The Good the
Bad, and the Ugly
Cristin Bealzey, PT, DPT, CBIS
Sheltering Arms – Total Concussion Care
Learning Objectives
• Identify common symptoms and the physiology associated
with concussion injury
• Identify each interdisciplinary team members role in
concussion management.
• Identify the core components of concussion management.
• Identify the physical therapist role in concussion
management.
• Identify common red flags that warrant referral to
alternative healthcare professionals.
• Identify the key components to a return to play protocol
which fully test the vestibular system and increase the
likelihood of complete concussion recovery prior to return
to play.
Who am I?
• Graduated from JMU with degree in Athletic
Training 2003
• Graduated from VCU PT school with DPT in 2006
• 10 years clinical experience – 5 years experience
at Children’s Hospital of Richmond, including 5
years of concussion treatment
• Started with Sheltering Arms in October 2012
• Lead Concussion Clinician for Total Concussion
Care Program at Sheltering Arms.
Concussion
OVERVIEW
Why Concussion?
• Long neglected population
• CONSTANTLY evolving and developing area of
practice
• It is an injury that covers a wide spectrum of patient
populations
• Effects can be debilitating and with proper
intervention can improve patient function and
return to prior functional levels
• Wide spread media attention
Definition
Concussion
 Complex pathophysiologic process
affecting the brain
 Induced by traumatic biomechanical
forces 2o direct or indirect forces to the
head.
 Constellation of physical, cognitive,
emotional or sleep-related symptoms,
+/- LOC.
 Neuroimaging typically normal
 Duration of symptoms is highly variable
- from several minutes to days, weeks,
months, or longer in some cases
*Center for Disease Control and Prevention: Heads up: Brain injury in your practice, Updated 2007
* West TA , Marion DW, Current Recommendations for the Diagnosis and Treatment of Concussion in Sport: A Comparison of
Three New Guidelines, Journal of Neurotrauma 31:159-168, January 15, 2014.
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Definition
Postconcussion Syndrome (PCS)
 collection of symptoms that occur after a
concussion, symptoms that persist longer than 3
weeks*
 Two clinical criteria
– International Classification of Diseases (ICD-10)
– DSM-IV
*Willer B, Leddy JJ. Management of concussion and post-concussion syndrome. Curr Treat Options Neurol 2006;8:415-426.
*Collins M, Lovett M, et al. Examining concussion rates and return to play in high school football playerswearing newer
helmet technology: A threee-year prospective cohort study. Neurosurgery 2006;58:275-286.
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DSM-IV-TR Criteria for Postconcussional Disorder
A. A history of head trauma that has caused significant cerebral concussion.
B. Evidence from neuropsychological testing or quantified cognitive assessment of difficulty
in attention (concentrating, shifting focus of attention, performing simultaneous
cognitive tasks), or memory (learning or recalling information).
C. Three (or more) of the following occur shortly after the trauma and last at least 3 months:
1.
Becoming fatigued easily
2.
Disordered sleep
3.
Headache
4.
Vertigo or dizziness
5.
Irritability or aggression with little or no provocation
6.
Anxiety, depression, or affective lability
7.
Changes in personality (eg, social or sexual inappropriateness)
8.
Apathy or lack of spontaneity
D. The symptoms in criteria B and C have their onset following head trauma or else
represent a substantial worsening of preexisting symptoms.
E. The disturbance causes significant impairment in social or occupational functioning and
represents a significant decline from a previous level of functioning. In school-aged
children, the impairment may be manifested by a significant worsening in school or
academic performance dating from the trauma.
F. The symptoms do not meet criteria for dementia due to head trauma and are not better
accounted for by another mental disorder (eg, amnestic disorder due to head trauma,
personality change due to head trauma).
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ICD-10 Criteria: Postconcussion Syndrome
 History of TBI
 Presence of 3 or more of the following 8
symptoms:
(1) headache
(2) dizziness
(3) fatigue
(4) irritability
(5) insomnia
(6) concentration
(7) memory difficulty
(8) intolerance of stress, emotion, or alcohol
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Synonyms
Mild TBI (mTBI) – WHO, ACRM
Concussion & Sports concussion – AAN
Mild CHI – American Academy of Pediatrics
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Epidemiology
Incidence rate
 Majority of TBI are mTBI or concussions (75-85%)
 Annual rate of mTBI is 130-546 per 100,000 persons
 Approximately 300,000 sports-related concussions occur in
the United States every year
Public health & cost
 Estimated annual cost (direct and indirect) in U.S = $12 -17
billion
 Negative effect on psychological well being and health
related quality of life (HRQOL)
 Higher family burden and emotional distress
(http://www.cdc.gov/injury/about/focus-tbi.html)
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Impact of Concussion
225,000 new persons each year show
LONG TERM deficits as a result of mTBI
(Meaney 2011)
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Age-Specific Considerations
 70.5% of sports & recreation-related TBI ED
visits were among persons aged 10-19 years.
 This age group requires clear guidelines for:
– activity modifications
– academic accommodations
 Goal: Return to previous levels of activity
 However, with athletes in particular, it is essential
to take them through a progressive, stepwise return
to play protocol to ensure safe return to play.
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Closer Look at the Injury
• http://www.youtube.com/watch?v=YYs50Xjp8
kM&feature=player_detailpage
• http://www.youtube.com/watch?v=6K3PIgX8c
3g&feature=player_detailpage
• http://www.youtube.com/watch?v=Tyv4du7B
TOc
• https://www.youtube.com/watch?v=Sno_0Jd8
GuA&nohtml5=False
Pathophysiology of Concussion
 Metabolic crisis, resulting
in an ↑ in energy demand
with a ↓ in blood flow as a
result of concussion.
 May also be diffuse
shearing of the axons due
to the movement of the
brain within the skull
 It is important during this
time of the crisis to not get
hit again as well as to not
stress the brain
– Cognitive and physical rest
in the early stages of
recovery.
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Rest? ??
• Recent study in Journal of Pediatrics from 11/14 looked at the benefits for
strict rest after concussion
• Randomized controlled trial
– 99 pts age 11-22 that presented to ED within 24 hours of concussion
– Completed neurocognitive, balance and symptom assessment in ED
– Randomized to:
• Intervention group – strict rest for 5 days and
• Control group – usual care, 1-2 days of rest and then gradual step wise return to previous
activities
– Results
• Intervention group had less attendance for school and after school at days 2 and 5
• No clinically significant difference on neurocognitive and balance assessments
• Intervention group reported more daily postconcussive symptoms ( over 10 days total
score 187.9 vs. 131.9) and slower symptom resolution
– Conclusion
• Recommending strict rest after concussion for 5 days added NO benefit to concussion
recovery as compared to the usual care
Symptoms & Symptom Management
 Concussion
management & recovery
– Focused on symptom
management throughout
 Symptoms
– Predictors of outcomes
and overall prognosis.
 Early stages of
concussion recovery
– Monitor symptom
progression, resolution
and variability.
Concussion Symptoms
(Lovell 2006)
COGNITIVE
SYMPTOMS
fogginess, difficulty
concentrating,
memory deficits,
cognitive fatigue
SLEEP ALTERATIONS
SOMATIC
SYMPTOMS
difficulty falling
asleep, fragmented
sleep, too
much/little sleep
Headache, dizziness,
nausea, light/sound
sensitivity
MOOD DISRUPTION
irritability, feeling
sad, anxiety
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What Affects Recovery?
 Adolescents more vulnerable
 STRESS!!!!
 Past Medical History
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Previous concussions
Migraines
Visual impairments
ADHD/Learning disability
Mood disorders
 Symptoms at time of injury
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Dizziness*
Amnesia
LOC
Fogginess
(Lau et al 2011)
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Age
Exertion
Gender
Migraine
Repetitive concussion
Acute markers of TBI: LOC,
amnesia, confusion
Subacute symptoms
-Memory problems &
fogginess
-Anxiety & noise
sensitivity
Prognosis and Recovery with Concussion
 Concussion recovery can be highly variable
– Treatment is time sensitive secondary to the scope of functioning
 People post-concussion report that everything is affected
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Ability to sleep
Ability to think clearly
Ability to concentrate
Ability to interact with a variety of environments
 According to research
 Old research (Collins et al 2006, Neurosurgery)
 80% of all concussion recovery within 21 days
 New research (Henry LC et al, 2016, Neurosurgery)
 When the recommended "comprehensive" approach is used for
concussion assessment, recovery time for SRC is approximately 3
to 4 weeks, which is longer than the commonly reported 7 to 14
days
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Clinical Trajectories
• Previous concussions
• Migraine
• LD/ADHD
• Sex
• Age
• Motion Sensitivity/Ocular
history
Risk Factors
Concussion Clinical
Trajectories
• Vestibular
• Ocular
• Cognitive
• Migraine
• Anxiety/Mood
• Cervical
• Medication management
• Vestibular Therapy
• Vision therapy
• Exercise prescription
Treatment and
Rehab Pathways
It takes a village…
Parents
Community
Pediatrician
Physician
Specialists
School
Teacher
Student
Athlete
Medical
Psychologist,
Neuropsychologist
Counselor
Physical Therapist
Athletic Trainer
Coach
Approach to Concussion Treatment
Interdisciplinary/Multimodal
Primary care/Pediatrician/ER initial diagnosis
ATC for sideline assessment and RTP
PT – Vestibular/Cervical eval & rehab, RTP protocol
Medical psychologist – neurocognitive testing and
supportive counseling/psychotherapy
Medical management
No FDA approved medications
“start low, go slow”
Ongoing research but still limited evidence
Weekly team conferences
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Concussion
CURRENT SIDELINE
ASSESSMENTS
Sideline Assessments
• According to the Consensus Statement on Concussion
In Sport, sideline assessment is an essential component
of treatment of concussion.
• Sideline assessments should be performed
immediately following any needed first aid assessment.
• Some examples include the following:
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King Devick Test
SCAT-3
SAC
Military Acute Concussion Evaluation
Balance Error Scoring System (BESS)
Clinical Reaction Time
King Devick Test
• Remove from play sideline assessment
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–
–
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Parents or coaches can administer
2 minute test
Athlete must read single digit numbers across cards or an iPAD
Any deviation from baseline score results in recommendation for
remove from play for further evaluation by a licensed professional
– Screens for:
•
•
•
•
•
Saccades (eye movements)
Attention
Concentration
Speech/Language
Other areas of brain function
• Vision testing is additive to the sideline assessment of sports –
related concussion
Progressively get harder with each card
King Devick Cards
Sport Concussion Assessment Tool – 3rd
Edition (SCAT-3)
•Standardized assessment
-SCAT-3 for ages >13 years old
-Child SCAT-3: ages 5-12
-Designed to be done by a medical professional
-8 items
• Comprised of the following categories
– Symptom score
– Cognitive assessment
– Neck evaluation
– Balance Assessment
– Coordination Examination
– Delayed recall
•According to the Consensus Statement on Concussion In Sport:
– It appears that the SCAT -3 is comprehensive as a sideline assessment to
address medical history, a neurological examination including a thorough
assessment of mental status, cognitive functioning, gait, and balance
Balance Error Scoring System (BESS)
• Full version and modified
• Full includes conditions for both eyes open (EO)
and eyes closed (EC): modified just EC
• 3 foot positions
– Feet together
– Tandem stance
– Single leg stance (SLS)
• Firm vs. Foam Surface
• # of errors counted for each trial of 20 seconds
BESS Test
• BESS test designed specifically for concussed athletes – accurate
only within 1-3 days post injury (Broglio 2009, Peterson 2003)
• Recent systematic review determined that the BESS has moderate
to good reliability to assess static balance. However it also
determined that is better at determining large balance changes and
not as accurate at detecting subtle changes. (Bell et al, 2011)
TYPICAL MEDICAL MANAGEMENT
 Sideline testing: MD vs.  Imaging
– CT scan/MRI (Functional
ATC
MRI)
– Symptom management
– Typically negative
– Balance Testing
 Cognitive Rest
– Neurocognitive testing
 Computer-based testing
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–
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Cogsport
ANAM
Concussion Vital Signs
ImPACT*
 MD/ER visit
– How long? 2 weeks?
Until symptoms go away?
 Medications
– OTC, prescription
 School Accommodations
 Referral to PT
Concussion
MEDICAL MANAGEMENT
Assessment & Diagnosis
Concussion
History
Comorbidities
Complicating
Factors
Symptoms
Multidimensional
Assessment
Balance
Postural
Stability
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Cognition
(Echemendia RJ, et al. Br J Sports Med 2013)
Assessment & Diagnosis
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HPI and PE
Post-Concussion Symptom Scale (Pardini et al. 2004)
Clinical testing – balance, VOR, endurance
Neurocognitive assessment
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(Pardini D, et al. Br J Sports Med 2004)
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Post-Concussion Symptom Scale
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Sleep cycle dysfunction
•
Trouble falling asleep
•
Too much/little sleep
•
Fragmented sleep
Somatic Symptoms
Headache
Dizziness/ balance
Nausea
Light /noise sensitivity
Tired, low energy
Blurred vision
•
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•
•
•
•
•
•
Mood Disruption
Irritability
Sadness
Anxiety/nervousness
Emotional lability
(Pardini D, et al. Br J Sports Med 2004)
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Cognitive symptoms
Concentration
Memory
Fogginess
Cognitive
fatigue/slowing
Approach to Concussion Treatment
 Individualized management
standardized concussion grading scales  neurocognitive
testing & comprehensive symptom evaluation
 Cornerstones of treatment:
– Cognitive & physical rest
– Education
– Therapy
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Somatic Symptoms
Sleep cycle dysfunction
•
Trouble falling asleep
•
Too much/little sleep
•
Fragmented sleep
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•
Somatic Symptoms
Headache
Dizziness/ balance
Nausea
Light /noise sensitivity
Tired, low energy
Blurred vision
•
•
•
•
•
•
•
•
Mood Disruption
Irritability
Sadness
Anxiety/nervousness
Emotional lability
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Cognitive symptoms
Concentration
Memory
Fogginess
Cognitive
fatigue/slowing
Somatic Symptoms
POST-TRAUMATIC HEADACHE (PTH)
 Most common reported symptom of concussion = 85%
 International Classification of Headache Disorders
 Secondary headache
 Types:
– Cervicogenic
– Fatigue-related HA
– MSK : myosfascial/tension
– Nerve injury (Greater occipital nerve)
– Post-traumatic migraine
– Rebound HA : medication induced
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Somatic Symptoms
 Myofascial/Musculoskeletal/Tension headache
– Medications : NSAIDs, analgesics, muscle relaxants
– Trigger point injections
– Greater occipital nerve blocks
– PT : myofascial release, muscle energy techniques,
massage, modalities, TENS
– Acupuncture
– Relaxation and meditation techniques
– Biofeedback & behavior modification
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Somatic Symptoms
 Migraine
– Abortives
 Sumatriptan (Imitrex) 25-100mg/dose, max 200
mg/day, oral/inhaled
 Rizatriptan (Maxalt) 5-10mg/dose, max 20 mg/day
– Prevention/Treatment
 Antidepressants
– Amitriptyline (Elavil) 30-50 mg
– Escitalopram (Celexa) 20-40 mg
– Sertaline (Zoloft) 25-100 mg
– Venlafaxine (Effexor) 25-100 mg, XR 37.5 – 150 mg
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Somatic Symptoms
 Migraine
 Anticonvulsants
– Topiramate (Topamax) - 25 mg/day x 1week, 25
mg BID, increase 25 mg/day weekly
– Valproic acid – 250 mg BID
– Gabapentin – 300 mg/d, inc to TID prn, non-FDA
approved indication
 Beta blockers – propranolol
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Somatic Symptoms
 Rebound headache
– Increased incidence in patients with chronic PTH
– Most common: opioids, butalbital-containing
combination analgesics & ASA/APAP/caffeine
combinations
– Opiates : risk of transformation from episodic HA to
chronic, greater in men & use 8 days/month
– APAP greater risk than NSAIDS & triptans
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Somatic Symptoms
 Concussion “supplements”
- Chronic supplementation (3-6 months) may decrease
frequency & severity of primary HA, not studied in PTH
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Alpha lipoic acid – 400-600 mg/d
Coenzyme Q-10 = 300 mg/d
Magnesium oxide = 500 mg/d
Omega-3 fish oils = 3-4 gm/d
Vitamin B2 (riboflavin) – 200-400mg/d
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Somatic Symptoms
DIZZINESS
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

Dysfunction of the vestibular system
as many as 80%
independent risk factor for failure to return to work
Correlation with other post-concussive sx:
– PTH, may contribute to dizziness  manage HA, + VT
– Anxiety: esp visual vertigo = space & motion discomfort
 anxiolytic + VT, more research needed
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Sleep Cycle Dysregulation
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Somatic Symptoms
Headache
Dizziness/ balance
Nausea
Light /noise sensitivity
Tired, low energy
Blurred vision
Sleep cycle dysfunction
•
Trouble falling asleep
•
Too much/little sleep
•
Fragmented sleep
•
•
•
•
•
•
•
•
Mood Disruption
Irritability
Sadness
Anxiety/nervousness
Emotional lability
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Cognitive symptoms
Concentration
Memory
Fogginess
Cognitive
fatigue/slowing
Sleep Cycle Dysregulation
Etiology in TBI
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Anxiety-depression
Environmental – stimuli from music, phone, tv etc
Neurophysiologic injury
Pain
Pharmacologic effects
h/o sleep disorder
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Sleep Cycle Dysregulation
Adverse Effects
 ↓ QOL
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↑risk of accidents
↑rate of chronic pain
Difficulty concentrating
Mood changes
Independent risk factor for poor physical and
mental health (Walsh JK, J Clin Psychiatry 2004)
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Sleep Cycle Dysregulation
TREATMENT
Nonpharmacologic
Pharmacologic
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Sleep Cycle Dysregulation
 Nonpharmacologic Rx
– Proper sleep hygiene
 no electronics (TV, computer, phone, music)
at bedtime
 avoid caffeine, EtOH, nicotine 4-6 hrs before
bedtime
 consistent bedtime & wake-up schedule
 no daytime naps
 sleep restriction 7-9 hrs
– Relaxation tx
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Sleep Cycle Dysregulation
 Pharmacologic Rx
– Melatonin : 3-5 mg
– Anti-depressants
 Amitriptyline : titrate, 30 mg
 Trazodone : 100 mg
– Non- benzodiazepine hypnotics – short term x 1 week, to
reset cycle
 Zolpidem (Ambien) 5-10 mg, 12.5 mg XR
 Ezopiclone (Lunesta) 2-3 mg
– Zaleplon (Sonata) 5-10 mg
– Anti-histamines
 Hydroxyzine (Vistaril ): Kids 12.5-25 mg, adults 50-100
mg
- Benzodiazepines : caution
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Cognitive Symptoms
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•
•
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•
Somatic Symptoms
Headache
Dizziness/ balance
Nausea
Light /noise sensitivity
Tired, low energy
Blurred vision
Sleep cycle dysfunction
•
Trouble falling asleep
•
Too much/little sleep
•
Fragmented sleep
•
•
•
•
•
•
•
•
Mood Disruption
Irritability
Sadness
Anxiety/nervousness
Emotional lability
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Cognitive symptoms
Concentration
Memory
Fogginess
Cognitive
fatigue/slowing
Cognitive Symptoms
 Neurocognitive testing → objective data utilizing
reliable & valid tests
 Moderate to severe TBI, cognitive deficits improve
with neurostimulants
 In postconcussion syndrome
– No RCT
– Anecdotal reports of benefit
– More widely used
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Cognitive Symptoms
 Pharmacologic Rx
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Amantadine : 100 mg BID
Methylphenidate : 10-60 mg/day, divided 2-3 x/day
Atomoxetine : 40 mg/day
Modafinil: 100-200/day
 Speech Tx: learning compensatory strategies
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Mood Disruption
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Somatic Symptoms
Headache
Dizziness/ balance
Nausea
Light /noise sensitivity
Tired, low energy
Blurred vision
Sleep cycle dysfunction
•
Trouble falling asleep
•
Too much/little sleep
•
Fragmented sleep
•
•
•
•
•
•
•
•
Mood Disruption
Irritability
Sadness
Anxiety/nervousness
Emotional lability
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Cognitive symptoms
Concentration
Memory
Fogginess
Cognitive
fatigue/slowing
Mood Disruption
 Emotional disturbances
– frustration, anxiety - from prolonged cognitive, somatic and
sleep-related symptoms
– isolation - cognitive & physical rest, limitations on activities
(school, work, athletics)
– PTSD
 Worsen perception of cognitive impairment and pain
 Interfere with recovery
 Rx:
– Medical psychologist &/or psychiatrist referral
– SSRI, TCA
• no RCTs in concussion treatment
• caution in adolescents:
suicide risk
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Concussion
PSYCHOLOGY
MANAGEMENT/RETURN TO LEARN
Concussion Management: Clinical
Psych/Neuropsych
 Assessment
 Academic Accommodations
 Management of complex persistent
symptoms
 Guidelines for return-to-learn
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Initial Assessment
 Computer-administration of Neurocognitive
Screening (e.g., ImPACT, CNS Vital Systems, etc.)
 Diagnostic clinical interview
 Targeted questions regarding symptom onset,
duration, severity, and factors that exacerbate,
maintain, and alleviate symptoms.
 Detailed history: medical, psychosocial,
education/intellectual
 Functional impact of symptoms (e.g., Now I can’t do
_____ because of ______); how symptoms manifest in
daily living.
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Initial Assessment
 Results (Briefly review and interpret along
with reported symptoms, timelines, literature,
etc.)
 Feedback with EDUCATION and EXPECTATIONS
 Discuss some of the findings, normalize, provide
clear expectations to reduce unnecessary
stress/catastrophizing.
 Variability is normal…
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Additional Assessment
Additional measures (when necessary?)
When a patient is reporting symptoms beyond a
typical recovery window for their
age/demographic, and symptoms are of clinical
significance such that they impede
functioning/daily activities.
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Academic Accommodations
 Common Accommodations: Proactive Rest,
Reduced work (prioritized and structured
plan when necessary); Tinted lenses;
reduced computer time; structured reading
breaks
 Factors to consider: Deficits, Symptoms,
Healing/recovery curve, catch-up work,
additional stressors.
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Management of Complex Persistent Symptoms
 Referrals and collaboration:
 Involvement of other physicians/professionals as necessary
(e.g., PM&R, Neurologist, Ophthalmologist, Physical
Therapist, Psychiatrist, School Psychologist, Social Worker,
Case Manager, etc.).
 With or without a documented remarkable
psychological/psychiatric history, individuals who have
sustained a concussion and continue to experience
problematic symptoms can benefit from psychologicallybased interventions.
 Stress reduces the brain’s capacities to heal. Stress can
impact sleep hygiene, appetite, and general self-care which
can all impact the duration of symptom resolution.
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Management of Persistent Symptoms
 Stress Reduction/Coping Skill Training
 Diaphragmatic Breathing
 Progressive Muscle Relaxation
 Compensatory Strategy Training (using a notebook
and/or calendar, adding structure to support
prioritization and recommended limitations e.g.,
proactive rest).
 Mindfulness-based interventions (e.g., meditation)
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Guidelines for Return-to-Learn
 Rest is crucial in first few days; return to
cognitive activity has been gaining attention as
prolonged rest can be counterproductive. (see
Kirkwood, 2012, McCrea, AACN 2014, Iverson
– 2014).
 Structured return-to-learn is typically advisable
within one to two weeks of the injury…
 Homebound education – conservatively
recommended with caution…can be helpful for
select cases.
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Neurocognitive Testing
• Neurocognitive screenings (both computerized and paper versions)
were developed out of a need to better way to assess impairments
as related to concussion and to assist with diagnosis.
• Studies also suggest that up to 50% of athletes experience
concussion symptoms per year, but only 10% report having an
injury.
• Some examples of computer-based neurocognitive testing are;
– Cogsport,
– Headminders (CRI),
– ANAM,
– Concussion Vital Signs
– ImPACT.
*It is also recommended and helpful to be able to make academic
accommodations based on the findings of this testing to help the
patients better manage school environments successfully.
Neurocognitive Testing
• Studies have looked at the sensitivity of using balance
testing, a symptom checklist and neurocognitive testing
individually in detecting concussion; they were 62%, 68%
and 79%.
– Used together, their sensitivity was determined to be 90%
(Broglio SP M. S., 2007).
• Resolution of hyperactivity on functional MRI correlates
with recovery on ImPACT (Lovell MR, 2007).
• When computerized neurocognitive testing is utilized,
athletes are less likely to return to play within a week,
compared to those with whom it was not utilized – 13.6%
vs. 32.9% (Meehan W., 2010).
• **Take home – Just one of the many tools that should be
used.**
ImPACT
• Computerized neurocognitive screen
• Baseline Testing recommended every 2 years
• Assesses the following:
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Symptoms with a checklist
Attention span
Working memory
Sustained and selective response time
Response variability
Non-verbal problem solving
Reaction time
Concussion
PHYSICAL THERAPY
MANAGEMENT
Concussion
VESTIBULAR AND OCULOMOTOR
IMPAIRMENTS
Impairments
 Oculomotor Dysfunction
 Vestibular Impairments
 Balance Impairments
 Cervical Impairments
 Autonomic dysfunction/
physiologic impairments
Physical Therapy Intervention
 Concussion therapy is focused on symptom
reporting and targeting interventions to noted
impairments.
 Heavy emphasis on the vestibular system and cspine
 Physical therapists are uniquely qualified to
help manage and treat this population:
– Vestibular therapy
– Manual therapy for cervical impairments
– Exertional therapy for return to activity/play with
continued emphasis on testing the vestibular
system
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PT Evaluation
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Detailed history
Strength/ROM
Oculomotor exam
Vestibular testing
Balance
Gait
Education on concussion symptoms and
activity modifications
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Evaluation – Red Flags
 REFER TO NEUROLOGY IF YOU SEE ANY OF
THE BELOW AS A NEW SYMPTOM:
* visual field cuts
* hyper/hypo deviations with cover/uncover test
* dysconjugate eye movements
* significant memory loss – persistent
* significant one sided weakness
* seizures – new onset
 REFER TO ENT FOR:
* one sided hearing loss or significant ringing or aural
symptoms
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Evaluation – Red Flags
 REFER TO ORTHO OR NEED FOR FURTHER
WORK UP:
* for persistent neck complaints and/or report of
numbness or tingling
 REFER TO PM&R FOR BELOW:
* significant difficulty with sleep regulation
* persistent headaches
* significant difficulty with concentration
* guidance with school and/or work accommodations
* when issues are not resolving with PT for further
recommendations or specialist referrals
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PT (cont)…
 Exertional/Return to play
– Testing vs Rehab
– Graded exertional return to sport/activity
 5 stages; including aerobic, strength, stretching and dynamic
exercises
 Include head/body position changes to test the vestibular
system
 Include balance and dual tasking as needed
– When symptom free
» RTP decisions; collaborative effort
» Clear for activity
– If symptomatic
» Symptom exacerbation
» Establish thresholds
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Evaluation – Subjective
 There are four key areas to
investigate in the subjective
portion of the therapist’s
evaluation:
– (1) mechanism of injury
– (2) symptom reporting
and management
– (3) past medical history
– (4) pain
 Mechanism of Injury
Use of the clinical history
specific questions to obtain
this information.
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Evaluation - PMH
 Considerations: Research has shown that there are certain things
in a patient’s PMH that can affect overall recovery and indicate a
risk for prolonged recovery.
 The most pertinent factors at this time :
– previous history of concussion,
– personal or family history of migraine
– personal or family history of visual impairments
– personal or family history of anxiety and/or mood disorders
– personal and or family history of learning disabilities or ADHD.
– Clinical history questionnaire
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Evaluation: Symptom Reporting & Mgmt
 Symptom Reporting and Management
– Clinical history with questions specific to concussion
– Rivermead Post Concussion Questionnaire**
– Dizziness Handicap Inventory
– Activities Balance Confidence Scale**
– Post Concussion Symptom Scale
– Neck Disability Index
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Evaluation – Objective Portion
 The primary areas of focus in the
objective portion of the
concussion evaluation are:
(1) strength/ROM
(2) oculomotor screen
(3) vestibular testing
(4) balance testing/gait
(5) neurocognitive screening/testing
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Objective – Oculomotor Exam
Oculomotor exam
– Convergence/divergence
– smooth pursuits
– saccades
– gaze holding in 9 cardinal planes
– King Devick Test (assesses reading saccade
function) (Dhawan, Starling, et al.)
– VOMS
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Oculomotor Dysfunction
Ocular Motor Dysfunction following mTBI [blast-related]
(Capo-Aponte et. Al Military Medicine 2012)
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Objective – Vestibular Exam
 Vestibular Exam
– VOR x 1 viewing (active) first slow and then
faster (in all 3 planes, Pitch, roll and yaw)
– Dix Hallpike if indicated (based on symptom
reporting)
– Dynamic Visual Acuity
– Gaze Stabilization
– Motion Sensitivity Quotient (MSQ)
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Vestibular Exam – Supporting Evidence
• Studies found that impairments with gaze stability were present
for as long as 4 weeks post concussion even with interventions.
(Gottshall K, Drake A, Gray N, McDonald E, Hoffer ME. Objective vestibular tests as outcome measures in head
injury patients. Laryngoscope. Oct 2003; 113(10): 1746-1750.
• Another study found that there was evidence to support
meaningful improvement in target following and DVA after 8
weeks of vestibular therapy and 12 weeks for gaze stabilization
impairments
(Gottshall, K. Hoffer, Michael. Tracking Recovery of Vestibular Function in Individuals with blast induced head
trauma using Vestibular-Visual-Cognitive Interaction Tests. JNPT. June 2010)
• MSQ has been determined to have good sensitivity and
specificity for detecting motion-provoked dizziness.
– Patients reporting motion sensitivity following concussion should
be assessed with the use of the MSQ to determine which position
changes are symptom provoking.
(Akin et al. J Rehabilitation Research and Development. 2003) (Akin F.W., 2003)
Vestibular OcularMotor Screen
• Clinical assessment used at time of initial evaluation as well as on reevaluations/discharges as needed
• Symptoms measured at baseline and with testing:
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Headache
Dizziness
Nausea
Fogginess
• Testing
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Smooth pursuit
Saccades
Convergence
VOR x 1
Visual motion sensitivity (VOR cancellation)
Mucha, A., Collins, M.W., Elbin, R.J., Furman, J.M., Troutman- Enseki, C., DeWolf, R.M., Marchetti, G., Kontos, A.P.
A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions: Preliminary Findings.
American Journal of Sports Medicine. 2014 October; (42) 10.
Demonstration Video - 1
Demonstration Video - 2
Evidence-Based Practice: VOD
• Vestibular-ocular dysfunction (VOD) in acute sports
related concussion (SRC) and postconcussion syndrome
(PCS)
– Postconcussion syndrome defined here as those with
symptoms lasting > 1 month
• Findings:
– Median duration of symptoms
• Those with SRC and VOD: 40 days
• Those with SRC without VOD: 21 days
– Statistically significant increase in the adjusted odds of
developing PCS among patients with acute SRC who had
VOD than those without
Ellis, M. J., Cordingley, D., Vis, S. Reimer, K., Leiter, J., and Russell, K. Vestibulo-ocular dysfunction in
pediatric sports related concussion. Journal of Neurosurg Pediatrics. June 2015.
Vestibular Impairments
**Studies that have used the SOT to evaluate balance in
collegiate athletes and military personnel have consistently
demonstrated a primarily vestibular pattern of balance
impairment on sensory analysis in contrast to vision or
somatosensory based patterns**
Evidence-Based Practice: Objective Tests
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Objective Testing of Children with Dizziness and Balance Complaints Following Sports Related
concussions
42 pts –
– 25 girls and 17 boys
– Age range 8-18 – avg 13.9 +/- 2.4 years
Testing included SOT, VNG, bithermal caloric test, sinusoidal harmonic rotation chair test,
DVAT, cervical vestibular evoked myogenic potential (cVEMP) test and static subjective visual
vertical test
– *all performed by an audiologist
Avg time between initial concussion and vestibular testing 26 +/- 20 weeks
Only 4% of the 42 pts had completely normal vestibular and balance test battery
55% underwent DVAT testing and of those 57% were abnormal;
40% who had SOT testing were abnormal
25% abnormal VNG
Based on testing results –
***abnormal DVAT results seen in this study and in others may not reflect a direct injury
to the peripheral vestibular system from concussion but may instead result from
impairment of central integration of visual and vestibular stimuli at the central
integration of visual and vestibular stimuli at the level of the brainstem or cerebellum***.
Objective – Balance Testing and Gait
Considerations: Balance deficits are
often reported in the first week after
injury and typically are one of the first
things to recover.
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Balance Impairments

43% of athletes report balance
dysfunction as an early symptom
following sports related concussion
(Lovell 2004)
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Postural Control assessment should
be combined with other evaluative
measures to gain the highest
sensitivity to concussive injuries (Broglio,
2007)
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Balance dysfunction may resolve
more quickly than other symptoms
following concussion (Catena 2011)
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BESS test designed specifically for
concussed athletes – accurate only
within 1-3 days post injury (Broglio 2009,
Peterson 2003)
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Cervical Impairments
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ROM
Sensation
Palpation
Joint stability testing
Strength testing
Manual therapy as indicated
Cervical Proprioception testing and training
Cervicovestibular rehabilitation in sportrelated concussion: a RCT
• Persistent symptoms of dizziness, neck pain
and/or headaches post sports-related concussion
• Control group: postural education, ROM,
cognitive and physical rest until asymptomatic
then RTP
• Intervention group: cervical spine and vestibular
rehab
• Conclusion: intervention group was 3.91 times
more likely to be medically cleared by 8 weeks
Physiologic/Autonomic Dysfunction: When can
I exercise?
• Research has shown that the Balke Treadmill protocol
has been an effective tool to help identify symptom
reproduction in post concussion syndrome.
• It has also been rated for reliability for accurately
reproducing maximal heart rate and systolic blood
pressure of symptom reproduction in those with PCS.
• Based on these findings it is useful to determine sub
symptom threshold exercise prescription for those that
are still experiencing symptoms as well as determining
readiness to initiate the return to play/activity
protocol.
(Leddy et al. Clin J Sport Med. 2011)
Evidence-Based Practice: Physiological
Markers
• Some patients with PCS have difficulty tolerating return to exercise
– May have inability to pass exertional testing due to symptom onset
• Found to be a result of altered cerebral blood flow (CBF) regulation
due to reduced CO2 sensitivity
– Hypothesized to then cause symptoms of headache and dizziness at
threshold intensity
• Utilization of a progressive subthreshold exercise program
– Increased CO2 sensitivity to near normal levels
– Improved exercise tolerance with ability to exercise to exhaustion
without symptom onset
• Suggests that “return of normal control of exercise CBF and of
exercise tolerance could be objective physiological markers of
recovery for concussion, which has implications for establishing
prognosis and preventing premature return to sport, activity, or
military duty
Exercise
• Another study that looked at sub
symptom threshold exercise prescription
for treatment of post concussion
syndrome concluded that overall those
who participated in the exercise
rehabilitation program returned to full
daily functioning.
(Baker et al. Rehabilitation Research and Practice. 2012)
Concussion
EXAMPLES OF TREATMENT
Concussion
RETURN TO PLAY PROTOCOLS
Return to Play/Activity
 Symptom management continues even with
RTP
 Returning an athlete to play prior to full
resolution of the concussion can have negative
effects
– Research has shown that student athletes who
have engaged in high levels of activity in the weeks
following a concussion had increased symptoms,
worsened neurocognitive data, and significantly
longer recovery times (Majerske et al. J of Athletic Training
2008)
Return to Play/Activity
 The Return to Play protocol
– 5 stages,
– Largely based on the protocol that is being used
by University of Pittsburgh Medical Center
– Guidelines recommended by The 4th
International Conference on Concussion In
Sport.
Return to Play Criteria
 Symptom free at rest
 Clear oculomotor/Vestibular and balance
exam
 Symptom free with cognitive/physical
exertion
 Full day/schedule/load at school
 Off medications* *
 Normal neurocognitive data – both baseline
and post exertion for optimal clearance*
RTP: Exertion Therapy Post Concussion
• Patients should be symptom free for 24 hours prior to
progressing to the next stage (cannot complete two stages in
one day). If the patient reports symptoms during any stage,
terminate the activity; allow the patient to recover and rest
until symptom free.
The next session should return the patient to the same stage and
then repeat.
• If patient presents with baseline symptoms:
– ensure those symptoms remain at the same level
throughout the session
– complete each stage 3 times with same report before
progressing to the next stage.
Sport Specific Return to Play Guidelines
• Developed by Children’s Healthcare of Atlanta
– Based on the 7 stage RTP developed at the ICCS
• Football, gymnastics, cheerleading, wrestling,
soccer, basketball, lacrosse, baseball, softball,
and ice hockey
• Added a moderate activity step highlighted by
resistance training
• Included non-contact and light contact in a
sport specific fashion
(May, Marshall, Burns, et al.)
Concussion
CASE STUDIES
Patient Demographic Information
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24 year old female
Working in a church daycare center
Reported LOC
PMH:
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Migraine (single episode)
Night terrors
Depression (while in high school)
1 prior concussion 2-3 years previous which took 2 weeks
to heal per the patient’s report
• Social Hx: College student
– PM&R physician pulled her from summer school
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Initial PT Evaluation
• Initial Evaluation took place 20 days after concussion
• Subjective
– MVA: rear-ended
– Post Concussion Symptom Scale: 108 – High
– Dizziness Handicap Index: 78 – severe handicap
• Objective
– ROM: full UE ROM, limited cervical extension
– Oculomotor
– Vestibular
• HEP: initial exercises for habituation
• Referrals generated to PM&R and Medical Psychology at
this time
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PM&R Management
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Posttraumatic headache
Sleep dysregulation
Mood disorder
Continue outpatient physical therapy
Continue cognitive rest, minimizing TV and
computer use.
Medical Psychology Management
• Presenting concerns/problems
– Mood disruption
– Cognitive symptoms
– Sleep cycle dysfunction
• Relevant past medical history
• Treatment
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Supportive Psychotherapy
CBT – Behavioral Activation
CBT – systematic desensitization
CBT – sleep hygiene/behavioral modification
Mindfulness-based interventions (guided meditation)
Physical Therapy Management
• Interventions and course of care:
– Balance testing
– Oculomotor training
– Habituation and adaptation based training
– Vestibular training
– Therapeutic exercise
– Return to Play protocol
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Case study #2
• 15 year old female
• Competitive cheerleader, participates year round as a level 3
competitor
• Presented to PT about a week after she noticed symptoms including
headache and dizziness
• Subjective: No one incident caused her concussion, reported that
she “was elbowed in the nose a cajillion times a day in practice.”
– Noticed a week ago that “words were moving around” when she was
trying to read for school
• PMH:
– Family history of migraines
– Personal history anxiety
– No previous concussions
Case study #2
• Objective findings:
– Smooth pursuit: abnormal – 3/5 dizziness
– Saccades: abnormal – slight dizziness
– Convergence: WNL but with slight increase in
dizziness
– Active VOR x 1 in sitting, tested at self selected
pace: 5/5 dizziness in all planes, 20-30 reps
performed
– Abnormal SLS balance with EC on L LE with fall
Case study #2
• 20 visits over the course of 6 months to
complete plan of care with full symptom
resolution
• Patient followed by PM&R MD for medication
management
– Final clearance for RTP provided by MD
Case study #3
• 14 year old male
• Football player, does track in the spring
• Presented to PT 4 days post concussion – dizziness,
headache, and noise sensitivity at the time of injury
• Second concussion in 3 months
– Following his first concussion he was out of play x 3 weeks
– Most recent concussion was hit x 2 in the same game with
onset of dizziness and headache
• PMH
– Positive history of migraines
– Previous concussion: 1 in elementary school, one in July
2013 and current in October 2013
Case Study 1: PMH and Injury Information
• 13 year old male with onset of concussive
symptoms after riding roller coasters at King’s
Dominion in August 2015
– Two episodes of blacking out on coasters with
subsequent dizziness, headache
• History of concussion in February 2015 when he
was checked in an ice hockey game
– Approximately 3 week recovery for full return to
school
• Familial history of strabismus – both parents
Initial Evaluation
• Questionnaires:
– PCSS: 61
– DHI: 78
• VOMS:
– Abnormal smooth pursuit, saccades, convergence
– Abnormal VOR x 1 viewing and VMS
– Symptom increase across all areas of testing
• Decreased cervical ROM with increased turgor/pain
with lateral flexion
• HEP given for smooth pursuit, saccades, and
compensatory saccades
Follow up visits
• Motion Sensitivity Quotient testing revealed L
BPPV (posterior canal)
– Performed Epley to correct and educated on
activity modifications
• Next session – no spinning – felt much better
• Continued to advance over the course of visits
with intervention focused on oculomotor,
vestibular, and manual therapy intervention
The numbers
• 7 days from injury to initial evaluation with
initiation of vestibular rehab
• 28 days from initiation of vestibular rehab to
clearance with RTP recommendation
– 35 days from date of injury
• Final outcomes:
– DHI: 0
– PCSS: 1
• 11 visits total from 8/26/15 to 10/7/15
Summary
 Concussion & PCS are disabling conditions in the
general population and athletes alike
 Individualized approach to treatment
 Interdisciplinary management is necessary – PT
plays a large role in rehabilitation!
 Research is ongoing across all areas of
management and changing daily
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QUESTIONS??
• [email protected]
References
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