Evaluation & Treatment of Post-Concussive Vestibular Dysfunction Gretchen A. Mueller, PT, DPT Cincinnati Children s Hospital Medical Center Pediatric Balance Center May 9, 2015
Vestibular System
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
Case Study: Emily PCSI: 60 Higher symptom scale scores with: Dizziness Blurry vision Difficulty balancing Feeling clumsy
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
Post Concussion Symptom Inventory (PCSI)
Dizziness Spinning i.e. true vertigo Lightheadedness Nausea Sensation of motion (i.e. floating )
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
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
Motion Sensitivity Motion Sensitivity Quotient Mild: 0-10% Moderate: 11-30% Severe: > 30%
Motion Sensitivity Emily s symptoms were provoked by 11/16 position changes
Motion Sensitivity
Visual Problems Blurriness Double vision Difficulty focusing Headaches Eye strain Difficulty with or avoidance of reading
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
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
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
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
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
Oculomotor Exam VOR deficiency Inability to keep eyes stable in space during rapid head movements
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
Dynamic Vision Testing Static Visual Acuity Perception Time Testing Gaze Stabilization Test Dynamic Visual Acuity
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
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
Dynamic Vision Testing Gaze Stabilization Test (GST)
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
Dynamic Vision Testing Dynamic Visual Acuity (DVA)
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)
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)
Dynamic Vision Screening DVA is abnormal if the acuity degrades by 3 or more lines (head moving vs. head static)
Balance Problems Unsteadiness Near-falls Falls Clumsiness Difficulty in areas of low light Difficulty on uneven or angulated surfaces
Balance Assessment Computerized Dynamic Posturography i.e. Sensory Organization Test
Balance Assessment Sensory Organization Test
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
Balance Assessment Sensory Organization Test (SOT) Is the athlete able to: Make effective use of individual sensory systems? Isolate vestibular control?
Balance Assessment
Balance Assessment
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
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
VESTIBULAR TREATMENT STRATEGIES
Habituation Habituate brain to position changes identified on MST which provoke dizziness
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
Motion Sensitivity: Criteria for D/C
Adaptation/Gaze Stabilization Promote adaptation of an uncompensated VOR Restore dynamic gaze stability and dynamic visual acuity
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
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
Adaptation/Gaze Stabilization Duration Speed Background Distraction Position Distance Target Size Frequency Cognitive Task
Adapatation/Gaze Stabilization
Adaptation/Gaze Stabilization
Adaptation/Gaze Stabilization The athlete MUST demonstrate adequate performance with VOR X1 exercises before being progressed to X2 exercises
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
Gaze Stabilization: Criteria for D/C
Dynamic Visual Acuity: Criteria for D/C
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
Balance Exercises Sitting Compliant surface Foam pad Therapy ball Weight shifting Bouncing
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
Balance Exercises
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
Balance Exercises Ambulation Walking Stairs Skipping Jogging Running Forwards or backwards Ascending or descending With head turns
Vestibular Balance Control: Criteria for D/C
Vestibular Balance Control: Criteria for D/C
Criteria for Discharge Dizziness: Negligible baseline dizziness Motion Sensitivity Quotient: < 2% MSQ Balance Complete SOT without abnormal sway or loss of balance
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
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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: 235-246.