The Role of Physical Therapy in Post Concussion Management. Cook Children s Sports Medicine Symposium Ryan Blankenship, PT, SCS Non Disclosure No conflicts of interest. 1
Course Objectives Participants will be able to perform Vestibular Ocular Reflex testing to help identify students with Vestibular dysfunction after concussion. Participants will be able to describe tests to assess visual function after concussion. Participants will be able to demonstrate 2 basic vestibular rehab exercises and give 2 ways of progressing those exercises. Symptoms of Concussion: General. Headaches Dizziness Nausea/Vomiting Fatigue Sleep Disturbance Irritability 2
What Role Does Physical Therapy play in Concussion Management? Management of headaches Management of visual issues Management of vestibular issues Physical Therapy and Headache Management Try to determine cause of the headache. When do the headaches start? Are there certain triggers? Is the patient having neck pain with the headaches? Are the headaches related to exertion? (Dysautonomia) When Your Child Has a Headache. Digital image. Hispanically Speaking News. N.p., n.d. Web. 28 June 2015. 3
Cervicogenic headaches Typically start at the end of the day Are usually posture related Start at the back of the skull and come forward Typically have some segmental dysfunction related to them. "Kids bad posture." Team Valley Wellness. N.p., n.d. Web. 2 July 2015. Treatment of Cervical Headaches Posture correction Stretching Manual segmental mobilizations 4
What Role Does Physical Therapy play in Concussion Management? Management of headaches Management of visual issues Management of vestibular issues How do we help Vestibular issues or dizziness? What kind of dizziness is the patient having? Are they feeling unsteady or off balance? Disequilibrium Are they feeling woozy or faint? Lightheadedness Do they feel like the room is spinning? Vertigo Do they report the perception of movement in stationary objects? Oscillopsia Gc dizzy. Digital image. Mycerebellarstrokerecovery. N.p., n.d. Web. 28 June 2015. 5
Why do concussions cause dizziness? Cause is often Multifactorial: Peripheral: BPPV Damage to inner ear Central: Difficulty with gaze stabilization and integration of visual/vestibular systems. Changes in oculomotor function including convergence, accomodation, and pursuit/saccades. Vestibular system and balance Semicircular canals detect rotational movements Saccule and Utricle detect linear movements. Otoconia crystals get displaced during linear acceleration, which in turn deflects hair cells and produces a sensory signal. Utricle detects front and back movement Saccule detects up/down movement. Vestibular System 1. Digital image. Scicurious Scientopia. N.p., n.d. Web. 28 June 2015. 6
Testing for Vestibular dysfunction BPPV (Dix Hallpike maneuver) VOR (Vestibulo Ocular Reflex) DVA (Dynamic Visual Acuity) BESS (Balance Error Scoring System) Dix Hallpike Maneuver "Dix Hallpike Test/sin458595.fig4.jpg." Medscape. N.p., n.d. Web. 30 June 2015. 7
Vestibulo ocular reflex Dynamic Visual Acuity Test 8
BESS test Treating Vestibular Dysfunction Gaze Stabilization Exercises Balance and Posture Exercises Canalith Repositioning as needed (for BPPV) 9
Gaze stabilization exercises VOR 1: Gaze stabilization on a fixed target VOR2: Gaze stable on moving target moving in the opposite direction of head movement. Progress from a stable surface to an unstable surface. Progress from static position to performing the exercises while walking. Balance and Posture Exercises Tandem stance (eyes open, eyes closed) Tandem stance compliant surface (eyes open, eyes closed) Single leg stance (eyes open, eyes closed) Single leg stance compliant surface (eyes open, eyes, closed) Dynamic exercises walking with head movement as someone throws a ball to you. 10
What Role Does Physical Therapy play in Concussion Management? Management of headaches Management of visual issues Management of vestibular issues Visual Symptoms http://www.denvervt.com/wp content/uploads/2013/04/seeing double.png 11
Visual Symptoms: Ocular Motor Complaints Losing place when reading Skipping lines or words Letters jump around on the page Difficulty following moving objects Difficulty focusing from one task to another Eyes burning or watering http://bryanking.net/wp content/uploads/2010/12/diplopia 300x225.jpg Specific Visual impairments and concussion: What do we test? Saccades Pursuits Near point convergence 12
Testing Saccades Look from one target to another on command Test in 3 fields (superior, middle, and inferior) King Devick Test King Devick Test "Stacks Image 1070." King Devick Test. N.p., n.d. Web. 30 June 2015. 13
Pursuits Testing Follow target Move in H, X, and O patterns Testing Vergence Convergence Break Point 2 4 inches Divergence Recovery Point 6 8 inches 14
Treating visual dysfunction: Exercises for smooth pursuits Follow the flashlight or laser pointer. Pass ball back and forth from hand to hand Tracing on dry erase board As exercises get easier incorporate balance challenges with exercises. Treating visual dysfunction: Exercises for saccades Moving from one target to another and tapping the target. Numbered post it notes on wall. Sorting lettered blocks Hart Charts 15
Hart Chart: Exercise for saccades "HC image." Hart Chart Decoding. N.p., n.d. Web. 30 June 2015. Treating visual dysfunction: Exercises for accommodation Using Hart chart near and far Identifying numbers on targets moving towards and away from patient 16
Treating visual dysfunction: Exercises for convergence Use activities that are bilateral and emphasize crossing midline. Clapping hands together Fingertips together Golf tee into straw exercise What Role Does Physical Therapy play in Concussion Management? Management of headaches Management of visual issues Management of vestibular issues 17
How Much is Enough? "Nap Time." Dakiniland Files Wordpress. N.p., n.d. Web. 30 June 2015. References Alsalaheen, B.A., Mucha, A., Morris, L. o., Whitney, S.L., Furman, J. M., Camiolo Reddy, C. E., & Sparto, P.J. (2010). Vestibular rehabilitation for dizziness and balance disorders after concussion. Journal of Neurologic Physical Therapy, 34(2), 87 93 Finn, Christina, MS, OTR/L. Post Concussion Syndrome Assessment and Treatment. Education Resources, Inc. Galetta, K. M., Barrett,, J., Allen, M., Madda, F., Delicata, D., Tennant, A. T., & Balcer, L. J. (2011). The King Devick test as a determinant of head trauma and concussion in boxers and MMA fighters. Neurology, 76(17), pp. 1456 1462. Heitger, M. H., Jones, R. D., Macleod, A. D., Snell, D. L., Frampton, C.M., & Anderson, T.J. (2009). Impaired eye movements in postconcussion syndrome indicate suboptimal brain function beyond the influence of depression, malingering, or intellectual ability. Brain, awp 181. 18
References continued Leddy, John J. MD, Harkeet Sandhu, MD, Vikram Sodhi, MD, John G. Baker, PhD, & Barry Willer, PhD: Rehabilitation of Concussion and Post concussion Syndrome. Sports Health April 2012, Vol 4. no.2. pp.147 154. Leddy, John J., MD, John G. Baker, PhD, Karl Kozlowski, PhD, Leslie Bisson, MD, and Barry Willer, PhD: Reliability of Graded Exercise Test for Assessing Recovery From Concussion. Clinical Journal of Sport Medicine. Vol 21, No. 2, March 2011, pp. 89 94. McCrory P, Meeuwisse WH, Aubry M, et al, Br J Sports Med 2013; 47:250 258. Consensus Statement on Concussion in Sport: the 4 th International Conference on Concussion in Sport held in Zurich, November 2012. Thiagarajan, P., & Ciuffreda, K.J. (2014). Effect of oculomotor rehabilitation on vergence responsivity in mild traumatic brain injury. Journal of rehabilitation research and development, 50, 1223 1240. 19