Evaluation & Treatment of Post-Concussive Vestibular Dysfunction

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1 Evaluation & Treatment of Post-Concussive Vestibular Dysfunction Gretchen A. Mueller, PT, DPT Cincinnati Children s Hospital Medical Center Pediatric Balance Center May 9, 2015

2 Vestibular System

3 Case Study: Emily 14 year old soccer player Suffered concussion 4 weeks ago Fielded a punt from a goalie, hitting front of head PMH: One prior concussion 9 months ago Elbowed in head while going for header Anxiety, depression

4 Case Study: Emily PCSI: 60 Higher symptom scale scores with: Dizziness Blurry vision Difficulty balancing Feeling clumsy

5 Case Study: Emily Symptoms worsen with: Driving in car Bending down to pick things up Light walking activities (outside) Lying down to go to sleep

6 Post Concussion Symptom Inventory (PCSI)

7 Dizziness Spinning i.e. true vertigo Lightheadedness Nausea Sensation of motion (i.e. floating )

8 Dizziness Migraine-associated dizziness Episodic vertigo May or may not be a positional component Periods of unsteadiness Headache Spatial disorientation Constant feeling of unsteadiness Drifting to one side while walking Shifting weight while standing still

9 Motion Sensitivity Motion Sensitivity Test Quantifies motion-provoked dizziness 16 changes in body/head position Athlete identifies If dizziness is provoked Rating of dizziness (compared to baseline) How long the dizziness lasts

10 Motion Sensitivity Motion Sensitivity Quotient Mild: 0-10% Moderate: 11-30% Severe: > 30%

11 Motion Sensitivity Emily s symptoms were provoked by 11/16 position changes

12 Motion Sensitivity

13 Visual Problems Blurriness Double vision Difficulty focusing Headaches Eye strain Difficulty with or avoidance of reading

14 Visual Problems Symptoms with reading Horizontal deficits Symptoms when looking up (at the board) and down (at the desk) Vertical deficits Symptoms while running and trying to focus on a target i.e. ball, goal Gaze stabilization

15 Oculomotor Exam Ocular alignment Of both eyes Of each eye individually Presence of nystagmus Spontaneous Peripheral lesion: Horizontal and direction-fixed Central lesion: Vertical or torsional and directionchanging

16 Oculomotor Exam Smooth Pursuits Lack of smooth tracking is abnormal finding Gaze-evoked Nystagmus Repeat smooth pursuits in horizontal and vertical directions, this time maintaining the target steady 30 degrees from midline Nystagmus or corrective saccade to midline is an abnormal finding Indicates central deficit

17 Oculomotor Exam Vestibulo-Ocular Reflex (VOR) Slow head rotations approximately 2 Hz (cycles per second) Task is to maintain visual fixation on a target Nystagmus or corrective saccade with head turns is an abnormal response Due to excessive retinal slip

18 Oculomotor Exam Head Thrust Test While performing VOR testing, quickly (and unpredictably) turn head 10 degrees from midline Slowly return to center Perform in each direction 3 times Perform in horizontal and/or vertical plane Corrective saccade to midline is abnormal finding

19 Oculomotor Exam VOR deficiency Inability to keep eyes stable in space during rapid head movements

20 Oculomotor Results Symmetrical eye alignment No spontaneous nystagmus No gaze-evoked nystagmus Smooth pursuits WNL all planes Normal saccades VOR WNL horizontal plane Abnormal HTT with corrective saccades 2/3 trials with rightward turns, 1/3 trials with leftward turns

21 Dynamic Vision Testing Static Visual Acuity Perception Time Testing Gaze Stabilization Test Dynamic Visual Acuity

22 Dynamic Vision Testing Gaze Stabilization Test (GST) Measures the head velocities at which the individual demonstrates an acceptable dynamic visual acuity At what head velocity can the patient stabilize gaze for function? Velocities indicate amount of dynamic visual impairment with ADLs including walking, running, and driving

23 Dynamic Vision Testing Gaze Stabilization Test (GST) Velocities at which individual must be able to move head and simultaneously stabilize gaze for function: Walking: horizontal 36 deg/sec vertical 32 deg/sec Running: horizontal 62 deg/sec vertical 87 deg/sec Driving (at 30 mph): 84 deg/sec Competitive sports: 120 deg/sec

24 Dynamic Vision Testing Gaze Stabilization Test (GST)

25 Dynamic Vision Testing Dynamic Visual Acuity (DVA) Measurement of visual acuity during selfgenerated head movements (fixed velocity) What is the extent of acuity loss during active head movement? Measures difference between static and dynamic visual acuity Compares performance Rightward vs. leftward head turns Upward vs. downward head turns

26 Dynamic Vision Testing Dynamic Visual Acuity (DVA)

27 Dynamic Vision Screening DVA Screening Establish static visual acuity using Snellen eye chart Have the individual read to the lowest line that they can until they cannot correctly identify all the letters on a given line (note the line where this occurs)

28 Dynamic Vision Screening DVA Screening (cont) Stand behind the individual and firmly grasp the individual s head, moving the head side to side at a frequency of 2 Hz (2 complete side to side cycles per second) Have the individual read to the lowest line they can until they cannot correctly identify all the letters on a given line (note the line where this occurs)

29 Dynamic Vision Screening DVA is abnormal if the acuity degrades by 3 or more lines (head moving vs. head static)

30 Balance Problems Unsteadiness Near-falls Falls Clumsiness Difficulty in areas of low light Difficulty on uneven or angulated surfaces

31 Balance Assessment Computerized Dynamic Posturography i.e. Sensory Organization Test

32 Balance Assessment Sensory Organization Test

33 Balance Assessment Sensory Organization Test (SOT) Systematically eliminates useful visual and/ or support surface information Creates sensory conflicts situations Calibrated "sway referencing" Surround and/or support surface move in response to athlete s sway Eyes open or eyes closed

34 Balance Assessment Sensory Organization Test (SOT) Is the athlete able to: Make effective use of individual sensory systems? Isolate vestibular control?

35 Balance Assessment

36 Balance Assessment

37 Vestibular Balance Screening Romberg Observe athlete s sway when standing with eyes open (eyes on visual target 3 ft. away) vs. eyes closed Arms crossed against chest Shoes off Goal is 30 seconds Repeat on uneven surface i.e. foam pad

38 Vestibular Balance Screening Romberg Stop test (and record time) if patient moves feet, changes arm position, or opens eyes during closed eyes portion of test Moderate sway or stepping reactions prior to 30 second mark is abnormal finding

39 VESTIBULAR TREATMENT STRATEGIES

40 Habituation Habituate brain to position changes identified on MST which provoke dizziness

41 Habituation Habituation Why? Who? How? Asymmetrical vestibular function leads to sensory mismatch causing provocation of symptoms Athletes with motion sensitivity due to head movements or position changes Use results from MSQ and habituate patient to symptom provoking positions or movements

42 Motion Sensitivity: Criteria for D/C

43 Adaptation/Gaze Stabilization Promote adaptation of an uncompensated VOR Restore dynamic gaze stability and dynamic visual acuity

44 Adaptation/Gaze Stabilization Adaptation Why? Who? How? Facilitate long term changes to the neuronal response to head movement Athletes who complain of dizziness with head motion, vertigo, blurry vision, and double vision VOR X1 & X2 exercises

45 Adaptation/Gaze Stabilization X1 Actively rotate head 30 degrees (horizontal or vertical) while maintaining focus on a stationary target Athlete MUST move head as fast as he/she can WITHOUT the target getting blurry Otherwise they are not improving gaze stabilization, only performing habituation to cervical movement

46 Adaptation/Gaze Stabilization Duration Speed Background Distraction Position Distance Target Size Frequency Cognitive Task

47 Adapatation/Gaze Stabilization

48 Adaptation/Gaze Stabilization

49 Adaptation/Gaze Stabilization The athlete MUST demonstrate adequate performance with VOR X1 exercises before being progressed to X2 exercises

50 Adaptation/Gaze Stabilization X2 Actively rotate head 30 degrees (horizontal/ vertical) while focusing on a target moving in the opposite direction Use same progressions utilized with X1 exercises

51 Gaze Stabilization: Criteria for D/C

52 Dynamic Visual Acuity: Criteria for D/C

53 Balance Exercises Balance Exercises Why? Who? How? Develop effective sensory and motor strategies to maintain upright posture Athletes who report unsteadiness, difficulties on uneven surfaces, or in areas of low light Balance exercises in multiple functional positions

54 Balance Exercises Sitting Compliant surface Foam pad Therapy ball Weight shifting Bouncing

55 Balance Exercises Static standing Even surface Compliant surface Foam pad Rockerboard Eyes open Eyes closed BOSU Feet apart Feet together Single leg stance Tandem stance

56 Balance Exercises

57 Balance Exercises Dynamic standing Even surface Compliant surface Foam pad Pillow Eyes open Eyes closed Marching in place Stepping Pivoting Forward/backward, Left/right, Up/down

58 Balance Exercises Ambulation Walking Stairs Skipping Jogging Running Forwards or backwards Ascending or descending With head turns

59 Vestibular Balance Control: Criteria for D/C

60 Vestibular Balance Control: Criteria for D/C

61 Criteria for Discharge Dizziness: Negligible baseline dizziness Motion Sensitivity Quotient: < 2% MSQ Balance Complete SOT without abnormal sway or loss of balance

62 Criteria for Discharge Dynamic Visual Acuity: No more than 0.20 LogMar loss of dynamic visual acuity with head turns Gaze Stabilization: Maintain gaze stability at a speed of 120 deg or greater with head turns

63 References Hain T. Neurophysiology of vestibular rehabilitation. NeuroRehabilitation. 2011; 29: Whitney SL & Sparto PJ. Principles of vestibular physical therapy rehabilitation. NeuroRehabilitation. 2011; 29: Gottshall K. Vestibular rehabilitation after mild traumatic brain injury with vestibular pathology. NeuroRehabilitation. 2011; 29: Slattery EL, Sinks BC, & Goebel JA. Vestibular tests for rehabilitation: Applications and interpretation. Neurorehabilitation. 2011; 29: Whitney SL, Marchetti GF, Pritcher M et al. Gaze stabilization and gait performance in vestibular dysfunction. Gait & Posture. 2009; 29:

64 References Alsaheen B, Mucha A, Morris L, et al. Vestibular rehabilitation for dizziness and balance disorders after concussion. JNPT. 2010; 34: Alsalaheen B, Whitney S, Mucha A, et al. Exercise prescription patterns in patients treated with vestibular rehabilitation after concussion. Physiother. Res. Int. 2012; 2: Gottshall K, Drake A, Gray N, et al. Objective vestibular tests as outcome measure in head injury patients. The Laryngoscope. 2003; 113: Gottshall K, Moore R, and Hoffer M. Vestibular rehabilitation for migraineassociated dizziness. International Tinnitus Journal. 2005; 11: Hoffer M, Balough B, and Gottshall K. Posttraumtic balance disorders. International Tinnitus Journal. 2007; 13: Hoffer M, Donaldson C, Gottshall K, et al. Blunt and blast head trauma: Different entities. International Tinnitus Journal. 2009; 15:

65 References Mucha A, Collins MW, Elbin RJ et al. A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions: Preliminary Findings. American Journal of Sports Medicine. 2014; 42(10): Honaker J, Criber R, Patterson JN et al. Gaze stabilization test asymmetry score as an indicator of previous concussion in a cohort of collegiate football players. Clinical Journal of sports Medicine Jul 24. Schneider KJ, Meeuwisse WH, Nettel Aguirre A et al. Cervicovestibular rehabilitation in sports-related concussion: a randomisec controlled trial. British Journal of sports Medicine. 2014; 48: Valovich McLeod TC, Hale TD. Vestibular and balance issues following sports-related concussion. Brain Injury. 2014; 7: Diaz DS. Management of athletes with postconcussion syndrome. Semin Speech Lang. 2014; 35(3):

66 References Collins M, Kontos A, Reynolds E et al. A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion. Knee Surg Sports Traumatol Arthrosc. 2014; 22:

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