Concussion and Dizziness: Application of Vestibular Rehab ... · Cardiovascular endurance limited...

Concussion and Dizziness:

Application of Vestibular Rehab

Across the LifespanPart 2

Hollie Elwood, PT, DPT

Kate Evans, PT, DPT

Objectives

Utilize case studies to:

▪ Demonstrate progressions of vestibular, balance, and

habituation training

▪ Identify treatment considerations with PCS population

▪ Identify factors and barriers that may influence treatment

and outcomes

▪ Acknowledge application of technology to aide treatment

sessions, testing, and HEP

Case Study 1

History / Background InfoInitial Evaluation 3/11/19▪ 23 y/o female referred to Physical Therapy for PCS ▪ Injury on10/29/18

▪ MVA - she was rear-ended ▪ No LOC or posttraumatic amnesia▪ Head, neck, and shoulder pain

▪ Developed concussion symptoms 2 days later▪ She consulted with her PCP who recommended she remain out of work from her per diem

job as a data entry clerk. She was non-compliant with this recommendation

▪ Prior PT▪ She had started PT at another clinic 2x/week, still symptomatic.

▪ Referred to Cantu Concussion Center ▪ Had finished OT through the Concussion Center prior to starting PT

▪ Symptoms: ▪ Headaches – “like a crown” – frontal and parietal▪ Exercise intolerance: difficulty with yoga ▪ Reports shoulder and neck pain have resolved. No imaging of neck. Denies

numbness/tingling ▪ Denies balance disturbances in day to day life

Functional Limitations 3/11

▪ Dizziness with head turns 4-5/10

▪ Headaches and dizziness with computer screen use

▪ Difficulty on stairs due to increased dizziness and “feeling sick”

4-5/10

▪ Difficulty controlling headaches limiting overall activity level up

to 5/10

▪ Decreased exercise tolerance

▪ Early on, difficulty driving due to dizziness. Initially required

rides but able to drive within a few days of concussion

Objective 3/11

▪ BESS Test: 13 errors

▪ Vestibular:

▪ Saccadic eye movements and eye strain with smooth pursuits

▪ Slow, self-selected pace with VOR x 1

▪ 1 point increase in HA, nausea, dizziness with VOR

▪ 2 point increase in dizziness, 1 point with headache and nausea with visual motion sensitivity

▪ Positional testing (-)

▪ Cervical Screen

▪ Tenderness to palpation

▪ Decreased deep neck flexor endurance

▪ Decreased postural strength

Bess Test

Bess Test: IE 3/11

▪ Leg Tested: R

Firm Surface Foam Surface

▪ Double Leg Stance 0 0

▪ SLS on non dominant foot 4 5

▪ Tandem stance with non dominate 2 2

foot in rear

▪ Total Errors each surface: 6 7

▪ Total BESS score: 13

VOMS: IE 3/11

Headache Dizziness Nausea Fogginess Comments

Baseline Symptoms 4 3 3 1

Smooth Pursuit 5-4 3 3 1 Saccadic, eye strain

Saccades (Horizontal) 4 3 3 1 WNL

Saccades (Vertical) 4 3 3 1 Correction x1 up

Convergence (near point) 4 3 3 1 Score #1: 5 cm

Score #2: 5 cm

Score #3: 5 cm

VOR Horizontal 5 4 4 1 Slow self selected pace

VOR Vertical 5 4 4 1 Slow self selected pace

Visual Motion Sensitivity 5 5 4 1

Cervical Exam 3/11

Palpation:

▪ (+) mild tenderness to palpation at upper cervical spine and suboccipitals

ROM

• WNL all directions

Special Tests:

• Transverse and Alar Ligament Testing (-) for laxity

• Vertebral Artery/ Quadrant Testing (-)

Postural Strength:

▪ Rhomboids 4/5, Mid Trap 4/5, Lower Trap 4-/5

▪ Deep neck flexor endurance: 7 seconds

Plan

▪ Symptom Management

▪ Oculomotor training

▪ Habituation training

▪ Balance training

▪ Postural Strengthening

▪ Frequency: 1x per week

Treatment Considerations

▪ Do not allow patient’s symptoms to increase by >2 points on

0-10 scale. Educate patient to monitor this at home as well.

▪ Allow for rest break if 2 point symptoms increase, may

continue when symptoms reduce

Day 1 HEP 3/11

▪ VOR x1 seated, self-selected pace

▪ Seated head turns

▪ Symptom management:

▪ Self SOR

▪ Stretching for upper traps, levator scap, scalenes, SCM

▪ Use of cryohelmet

▪ Two point scale

Cervical Stretching

1st Follow up 3/21

▪ Subjective: “I am feeling much better than the past two weeks.”

▪ Vestibular Training:

▪ UBE

▪ Sitting/standing as tolerated VOR x1 on solid surface

▪ Seated VOR cancellation at 50 bpm with use of metronome

▪ Standing horizontal and vertical head turns on solid surface

1st Follow up: Balance Training 3/21

▪ EC on airex narrow BOS

▪ Tandem Stance SS

▪ Airex: Rows with theraband

▪ Airex: Shoulder extensions with theraband

1st Follow up: Symptom Management

▪ Modifications PRN: standing > sitting

▪ Monitor ability to recover

▪ Educate patient on self-assessment of symptoms

▪ Cervical Stretching and self SOR

▪ Manual therapy

▪ SOR, cervical spine mobilizations, STM

Vestibular Progressions 4/3-5/3

▪ Improved tolerance for self-selected pace

▪ Use of metronome

▪ Able to progress speed of VOR to 120-140 bpm

▪ Able to progress to standing VOR

Habituation Progressions 4/3-5/3

▪ Walking with head turns

▪ Head turns on airex

▪ Walking with 360 degree turns

▪ Walking with quick pivot turns

▪ Ball toss > 180 degree pivot turn > ball toss to trampoline

Exercise Progressions – Video 1

Postural Strength Progressions

▪ Rows

▪ I,T,Y

▪ Chin tucks > chin tuck with lifts

▪ Lat Pulldown

Reassessment

Objective 4/12

▪ BESS Test: 9 errors

▪ VOMs:

▪ Symptom-free at start of test

▪ 1 point increase in HA with VOR x 1 @ 120 bpm (horizontal) and

140 bpm (vertical)

▪ Cervical Screen

▪ Resolved tenderness to palpation

▪ Deep neck flexor endurance 15 seconds

▪ Improved postural strength

▪ Symptoms: Headache 1-2/10, Dizziness 1-2/10 at worst

Reassessment: 4 weeks 4/12

Bess Test

Leg Tested: R




▪ 1 Point ^ in HA

▪ Tandem stance with non dominant 0 2 foot in rear



Reassessment: 4 weeks 4/12

VOMS

Headache Dizziness Nausea Fogginess Comments

Baseline Symptoms 0 0 0 0

Smooth Pursuit 0 0 0 0 WNL

Saccades (Horizontal) 1 0 0 0 WNL

Saccades (Vertical) 0 0 0 0 Correction x1 up

Convergence (near point) 0 0 0 0 Score #1: 7 cm

Score #2: 6 cm

Score #3: 7 cm

VOR Horizontal 0-1 0 0 0 120 bpm

VOR Vertical 0-1 0 0 140 bpm

Visual Motion Sensitivity 0 0 0 0

Cervical Exam 4/12

Palpation:

▪ Resolved tenderness to palpation at upper cervical spine and suboccipitals

ROM

• WNL all directions

Special Tests:



Postural Strength:

▪ Rhomboids 4+/5, Mid Trap 4+/5, Lower Trap 4-/5

▪ Deep neck flexor endurance: 15 seconds

Ongoing Functional Limitations 4/12

▪ 1-2/10 dizziness walking in a circular motion ie. spiral staircase

▪ 1-2/10 dizziness with repetitive head turns

▪ 1-2/10 increase in sx during therapy sessions, immediate

resolution of symptoms

▪ 1-2/10 symptom increase with yoga positions

Progressions: 4/12- 5/3

▪ Walking ball toss

▪ UE D2 with squat on foam ▪ Walking with 360 and 180 degree turns▪ Downward dog > high plank

▪ Figure 8 on foam ▪ Modified burpees▪ Walking VOR x1

▪ Walking / lunge with UE D2 ▪ VOR x 2 ▪ Elliptical

▪ Continuing with manual therapy for symptom management▪ Only requiring seconds to recover Plan:

▪ Progressed HEP▪ Advised to f/u in 2 weeks


Discharge 5/17

▪ VOMS: completed symptom free

▪ BESS score: 4 errors total

▪ Able to perform all habituation activities symptom free

▪ Cervical exam: WNL

▪ Symptom free in daily life for two weeks including work and

exercise

▪ Able to go away on road trip with friends without symptoms

Barriers to Progress

▪ Symptom management

▪ Difficulty controlling headaches early on

▪ Emotional

▪ “Invisible Injury”

▪ Frustration with sx

Factors Influencing Positive Outcome

▪ Age

▪ Motivation

▪ Support system

▪ Job – accommodating, low stress

▪ Compliance with HEP/ symptom management

▪ Self-management - empowering

Case Study 2

History / Background InfoInitial Evaluation – Early October 2018

▪ 48 y.o male

▪ Police officer

▪ Hx of 10-12 concussions with & without LOC

▪ 12/17/17 most recent – washing cruiser, slipped on ice, hit head on cruiser

▪ Fireworks in vision

▪ Neck, hip, shoulder pain

▪ Worked rest of day

▪ PCP next day – DX concussion

▪ Recommended time off of work

▪ Out of work recently for foot injury therefore continued working

▪ Loaded gun found in recycling (home)

▪ Out of work per sergeant

▪ Neurologist, P.T, O.T, Speech elsewhere – for a few months, still symptomatic

▪ Cantu Concussion Center for second opinion, referred to P.T (eventually O.T & Speech;

neuropsych testing also done)

PLOF

▪ Police officer

▪ Lives with wife (who is expecting their first child in November)

▪ Has 2 dogs

▪ Like to go fishing (boat)

▪ Likes to bike and swim

▪ Back pain exacerbated easily - used to be avid weight lifter and

hockey player

▪ Hx of anxiety and depression but very pleasant and motivated

Functional Limitations/ SymptomsInitial Eval

▪ <50% of his normal function

▪ Cardiovascular endurance limited and causes dizziness

▪ Biking causes dizziness and he can have symptoms until the following day if he overdoes it

▪ Fast head movements cause increased dizziness

▪ Anxiety, depression, irritability

▪ Sensitivity to sound, ringing in ears

▪ Headaches, eye pain/strain

▪ Fatigue, poor activity tolerance

▪ Impaired participation in work

▪ Impaired participation in community life

▪ Impaired instrumental activities of daily living

▪ Impaired activities of daily living (functional mobility)

▪ Impaired rest and sleep

▪ Impaired participation in leisure tasks (fishing, swimming, social events with friends)

Treatment Considerations

▪ Do not allow patient’s symptoms to increase by >2 points on

0-10 scale. Educate patient to monitor this at home as well.

▪ Allow for rest break if 2 point symptoms increase, may

continue when symptoms reduce

Cervical

▪ Minimal decreased cervical ROM with poor tissue quality and

tenderness to palpation

▪ Decreased postural strength & cervical endurance

Vestibular

▪ Impaired VOR – 110 bpm on metronome (VOMS)

▪ Impaired visual motion sensitivity (VOMS)

▪ (-) Positional Testing

Balance

▪ Impaired with NBOS, especially on compliant surface

(BESS – 40 errors)

JPE testing WNL

Objective Findings SummaryInitial Eval

C-Spine ExamInitial Eval

ROM

• Flexion: 45*

• Extension: 15*

• Lateral Flexion: 20* B

• Lateral Rotation: 70* B

Special Tests:



Strength:

• Postural strength: sh extension & mid traps 4/5; lower traps 4-/5. Poor

postural awareness. Poor cervical endurance

Palpation:

• Significant increased densities of cerv and thoracic postural muscles and

suboccipitals

VOMS TestInitial Eval

Headache Dizziness Nausea Fogginess

Baseline Symptoms 1 4-5 0 4

▪ Smooth Pursuit

▪ Saccades (Horizontal)

▪ Saccades (Vertical)

▪ Convergence (near point) Score #1: 5 cm

Score #2: 5 cm

Score #3: 5 cm

▪ VOR Horizontal 7

▪ VOR Vertical 7

▪ Visual Motion Sensitivity 7

▪ Comments: Increased sx as noted otherwise unchanged. Reports increased pressure

in head throughout. VOR slowed – determined appropriate HEP speed is 110 bpm on

metronome.

BESS TestInitial Eval

Leg Tested: L

Surface Firm Surface Foam




foot in rear



Vestibular Positional TestingInitial Eval

▪ Pt reporting that he gets short (20s) spinning dizziness when

moving head quickly

▪ Dix Hallpike, Roll test, Deep extension Testing all (-) for

nystagmus

JPE Testing

Initial Eval

▪ Horizontal: 4.5o

▪ Vertical: 4.5o

Pain/ Symptoms

Initial Eval

▪ Headaches: parietal lobes 5/10 generally; 7/10 worst; 1/10 best

▪ Minimal neck pain: generally 2/10

▪ Episodic back pain, none currently

▪ Dizziness: 4-5/10 generally; 8/10 worst

▪ Fogginess: 4-5/10 generally; 8/10 worst

Plan

▪ Symptom Management

▪ Oculomotor training

▪ Habituation training

▪ Balance training

▪ Postural Strengthening

▪ Frequency: 1x per week

Day 1-2 HEP

Education:

▪ Importance of symptom management

▪ Self management strategies

▪ Causes of concussion sx

HEP

▪ Stretches: UT, LS, suboccipitals, SCM

▪ Vestibular:

▪ Head turns horizontal and vertical

▪ Basic VOR

▪ Use metronome for HEP - 110 bpm (180 bpm is WNL)

▪ Other self management: foam roll/ towel roll pec stretch; SOR with

tennis balls; self TPR with trigger point cane (or cane)

▪ Written instructions, pictures given

SubjectiveNext few sessions - end of October - early November

• Feels 85% of his normal function• HA improving

• Construction – head down for 5 hours• Tinnitus and dizziness next day

• Biking – 10 mile ride• Remembered to take breaks for sx management

• Back pain

• Starting Cognitive therapy soon

• Wife due to have baby Nov 28

Therapy ProgressionNext Few Sessions - Early November

Manual: C-spine, T-spine, Peri-Scap muscles

Cardiovascular

• Bike – recumbent; 5-7 minutes sessions, first 1x, then 2x next session

• Elliptical – more vestibular involvement; Gaze stable focused on target. Started with 2-3 minutes; then increased to 5 minutes next session

Vestibular

• Standing on foam balance static; head turns horizontal and vertical

• Semi tandem on foam static; head turns horizontal and vertical

• Tandem balance; wobble board balance with rows

Exercise Comments

• Able to tolerate increased biking time and addition of elliptical. More conversational with therapist and able to move head around more with session.

• Additional rests req to accommodate sx. Rests 5-10 minutes between exercises, with stretching, trigger point cane, cryohelmet.

D/C Manual Work Cardiovascular

• Continued with bike and elliptical• Elliptical – progressed by having patient look around while on elliptical • Addition of UBE for added vestibular / visual stimulation

Vestibular / Habituation• FT and tandem balance on foam – increase speed of head turns; had pt perform

dual task while doing this (state names of hockey teams)• Rainbow rings reaches (OT Tool)

• Solid surface tandem• Foam surface tandem• Standing on ½ foam roller flat side up eyes tracking rings

• Standing on balance board with tricep push down – tracking with eyes• Counting backwards from 100 by 2’s with balance on BOSU• Step up to BOSU – with dual tasking (naming sports teams)• Single leg reaching to 3 cones, visual trackingExercise Comments• Additional rests req to accommodate sx. Rests 5-10 minutes between exercises,

with stretching, Additional rests req to accommodate sx. Stretching, trigger point cane, cryohelmet.

Therapy ProgressionNext Few Sessions - Mid November


Re-Evaluation Mid-Late November

▪ Feels 85-90% of his normal function

▪ General baseline sx 2/10 for fogginess, dizziness, HA

▪ VOR @ 130 bpm with metronome (HEP)

▪ Shoveled 2 hours and biked – dizziness increased to 5/10 today

▪ Symptom management – difficult

▪ Delayed onset of symptoms

Functional Limitations/ SymptomsMid-Late November

▪ Cardiovascular endurance / biking limited and causes dizziness

▪ Improving, now can do 10 miles on bike with rests for symptoms management

▪ Fast head movements cause increased dizziness

▪ Improving

▪ Anxiety, depression, irritability

▪ Improving and focusing on stress management / relaxation technique in HEP

▪ Sensitivity to sound, ringing in ears

▪ Headaches, eye pain/strain

▪ Improving, focusing on symptom management

▪ Fatigue, poor activity tolerance

▪ Improving, still requires rests for symptoms management

▪ Impaired participation in work

▪ Still unable to work as police officer

▪ Impaired participation in community life

▪ Able to go shopping, out for walks now

▪ Impaired rest and sleep

▪ Improving

▪ Impaired participation in leisure tasks

▪ Able to do more with friends, fishing still difficult

Cervical

▪ ROM, tissue quality, and tenderness to palpation improving

▪ Postural strength & cervical endurance improving

Vestibular

▪ VOR improving – 130 bpm on metronome (VOMS)

Balance

▪ Improving – less errors with NBOS / compliant surface

(BESS – 21 errors)

Objective Findings SummaryMid-Late November

ROM

• Flexion: 65*

• Extension: 35*

• Lateral Flexion: 45* B

• Lateral Rotation: 90* B

Strength:

• Postural strength: sh extension & mid traps 4/5; lower traps 4/5.

Postural awareness improving, cervical endurance improving

Palpation:

• Quality of cerv and thoracic postural muscles and suboccipitals –

improving, less tenderness to palpation

C-Spine ExamMid-Late November

BESS TestMid-Late November

Leg Tested: L

Surface Firm Foam

Double Leg Stance 0 0

▪ SLS on non dominate foot 5 10


foot in rear


▪ Total BESS score: 21 (was 40 on IE)

VOMSMid-Late November

Headache Dizziness Nausea Fogginess

▪ Baseline Symptoms 0 5 0 5

▪ Smooth Pursuit

▪ Saccades (Horizontal)

▪ Saccades (Vertical)

▪ Convergence (near point) Score #1: 5 cm Score #2: 5 cm Score #3: 5 cm

▪ VOR Horizontal 6

▪ VOR Vertical 5

▪ Visual Motion Sensitivity 8

▪ Comments: Increased pressure in head. Baseline sx elevated. Less symptom exacerbation with VOR today. <1 minute to recover back to baseline. VOR @130 bpm

Pain/ SymptomsMid-Late November

▪ Headaches: parietal lobes 2/10 generally; 5/10 worst; 0-1/10 best

▪ Minimal neck pain: generally 0/10

▪ Episodic back pain 2/10 generally; 5/10 worst

▪ Dizziness: 2/10 generally; 5/10 worst

▪ Fogginess: 2/10 generally; 5/10 worst

HEP & Plan

Mid-Late November

Recommendations for home/ HEP:

• Take rests more frequently even if you do not have sx during activities.

• Continue self symptom management • Use ice pack, stress management, stretches, tennis balls, trigger point

cane

• Reaching tasks with visual tracking

• Dual tasking

• VOR x1, x2, continue use of metronome to track progress at home

• Throwing and catching

• Continue balance work on compliant surfaces, EO, EC, head turns, VOR, etc

• Mentally prepare for birth of child and beginning cognitive therapy

Therapy plan: decrease sessions to 1x/ month or every few weeks to allow him to prioritize new baby and cognitive therapy

LIFE CHANGING EVENT – BABY IS BORN

Two Months Go By...

DH Returns to Therapy January

▪ 2 month absence from rehab

▪ Has not been doing P.T exercises

▪ Symptoms significantly elevated

▪ Stressful delivery, wife required C-section, still recovering

▪ NICU stay

▪ Sleep deprived / stressed

▪ Onset of visual disturbances, migraines

▪ Immediately after birth of daughter, felt he lost all progress, took > 1

month for him to start feeling better

Functional Limitations/ SymptomsJanuary

▪ Sensory overload

▪ Fatigue

▪ Dizziness

▪ Fogginess

▪ Headaches

▪ Walking up stairs

▪ Fast head turns

▪ Physical exertion causes increased symptoms

▪ Difficulty caring for new born daughter

▪ Difficulty performing household duties

▪ Tried to start resuming his bike riding 4 miles - a few times a

week

▪ Started cognitive therapy, upset with his cognitive status

Cervical – unchanged from November re-eval

Vestibular

▪ VOR improved – 160 bpm; sx decrease ~ 1 min (VOMS)

Balance

▪ Regressed since November re-eval but better than IE - errors

with NBOS / compliant surface (BESS – 36 errors)

▪ Difficulty with walking with head turns & eyes closed (FGA)

Objective Findings SummaryJanuary

VOMSJanuary

Headache Dizziness Nausea Fogginess ▪ Baseline Sx 0 3 0 0 ▪ Smooth Pursuit ▪ Saccades (Horizontal) - spikes dizziness but goes down in 10 sec ▪ Saccades (Vertical)▪ Convergence (near point)

Score #1: 5 cm Score #2: 5 cm Score #3: 5 cm

▪ VOR Horizontal 5 ▪ VOR Vertical ▪ Visual Motion Sensitivity - spikes dizziness but goes down in 10 sec

Comments: VOR @ 160 bpm today. Increased symptoms with test resolve within 1 minute.

BESS/ FGAJanuary

BESS Test

Leg Tested: L




▪ Tandem stance with non dominant 5 10

foot in rear


▪ Total BESS score: 36 (was 21 on 11/21)

FGA: 21/30

▪ Most difficulty with walking with head turns & eyes closed

Needed to give detailed, clear; not overwhelming; start small to

show progress & motivate him

▪ Single leg balance on pillow eyes open

▪ Semi tandem on solid surface eyes closed

▪ Resume biking as much as tolerated

▪ Resume neck stretches

▪ VOR - resume doing at home to tolerance - instructions on how to

perform given, reminded to use metronome

▪ Resume chin tucks and prone I’s

▪ Stress management at home

▪ Encourage accepting family help and support

HEPNext Few Sessions - End of January-Mid February

▪ “Back on track” with exercises

▪ Jogging with daughter in stroller

▪ “Threw out” his back when snow blowing

▪ Spent one session teaching core stabilization and stretching;

manual work to alleviate back pain

▪ “One step forward, two steps back”

Subjective/ Therapy ProgressionNext Few Sessions - Early February

▪ Fall during 10 mile bike ride (ice)▪ Increased dizziness, tinnitus, pressure in head, HA in temple▪ Vision changes, “flashes, electric “▪ Advised to follow up with Cantu Concussion Center

▪ Recovered in 1 week▪ Felt “normal” one day for first time since concussion, “bouts of

mental clarity”

SubjectiveNext Few Sessions - mid February-March

Cardiovascular

▪ Continue with bike, elliptical, UBE

Vestibular/ Habituation

▪ Seated on ball holding ball – moving ball side to side with visual tracking

▪ Standing rows on wobble board

▪ Walking with head turns horizontal, vertical, VOR horizontal, vertical

▪ Walking with ball toss; with visual tracking

▪ Walking – take 3 steps, bounce ball on ground, 3 steps ball press overhead; with

visual tracking

▪ Walking – moving ball side to side with visual tracking

▪ Walking backwards

▪ Seated on ball – marches while lifting ball overhead with visual tracking

▪ Step up to BOSU 1 UE assist for balance

▪ Tandem rebounder throws with soccer ball

Exercise comments: progressing vestibular challenges to make exercises more

functional with walking. Less need for rest, 2-5 minutes now. Stretching, trigger point

cane, cryohelmet.

Therapy ProgressionNext Few Sessions - mid February-March


Cardiovascular

▪ Continue biking, with symptom management. ▪ If unable to bike, interval jogging with stroller, rests as needed

Vestibular/ Habituation

▪ Progress VOR x1, x2, while doing balance exercises. Continue use of metronome to track progress

▪ How to progress balance (ie surface, VOR, head turns, EC, busy back drop, dual task, walking)

▪ VOR with walking▪ Walking with high knees looking up and down▪ Step ups looking up and down▪ Walking with ball pass from hand to hand

HEP ProgressionNext Few Sessions - March

Re-evaluationEnd of March

▪ Recovered from back pain

▪ Advancing vestibular exercises

▪ Progressing cardiovascular exercise

▪ At home doing more biking and jogging with daughter

▪ In therapy, tolerating biking and elliptical again. UBE for vestibular stimulation

▪ Progressing postural strengthening; postural strength and awareness improving

▪ Requires less rest: 1-2 min vs 5-10 min previously

▪ Reports symptoms “spike” and then resolve quickly

▪ Baseline sx: mild dizziness, feeling “off”, mild HA

▪ FGA scores improving 21/30 > 24/30

Functional LimitationsRe-evaluation End of March

▪ Sensory overload▪ Improving

▪ Fatigue▪ Daughter on better sleep schedule so this is improving

▪ Dizziness▪ Baseline dizziness improving 2/10

▪ Fogginess▪ Baseline fogginess improving 2/10

▪ Headaches ▪ Baseline headaches improving 2/10

▪ Walking up stairs▪ Improving, no symptoms unless experiencing flare up

▪ Fast head turns▪ Still problematic but slight improvements

▪ Physical exertion causes increased symptoms▪ Improving – able to bike, jog with stroller

▪ Difficulty caring for new born daughter▪ Getting into more of a schedule, improving

▪ Difficulty performing household duties▪ Wife going back to work soon, this is improving but still a challenge

▪ Started cognitive therapy, stressed with his cognitive status ▪ This is his most frustrating impairment/ F/L

▪ Head down position – still difficult

▪ Fell – slipped on water▪ Back pain with radicular sx

▪ Advised to follow up with Cantu Concussion Center and

Interventional Spine Specialist

▪ Stress at home

▪ Daughter is off sleeping schedule

▪ 2 deaths in the family

▪ Finances

▪ Friends – think he should be better by now

▪ Frustration with continued sx; some depression

SubjectiveNext Few Sessions - April-Early May

Cardiovascular

▪ Continue bike and elliptical

Vestibular

▪ ½ kneeling chop and lift with head turns

▪ Prone over ball I’s

▪ Quad bird dogs

▪ Tandem rebounder throws

▪ Biodex weight shifting, maze control, catching game – began on solid surface then

addition of foam surface for additional visual and vestibular challenge

▪ Wii Fit: bowling – while on balance board; frisbee while standing on on foot; tandem on

foam; etc

Core stabilization

▪ For back pain, taught self traction

Exercise Comments Requires increased rests due to exacerbation of sx. Stretching,

trigger point cane, cryohelmet. Rec he consults with interventional spine for back pain.

Therapy ProgressionNext Few Sessions - April-Early May


Cardiovascular

▪ Continue biking, with symptom management.

▪ If unable to bike, interval jogging with stroller, rests as needed

Vestibular

▪ Progress VOR x1, x2, while doing balance exercises. Continue use of metronome to

track progress

▪ How to progress balance (ie surface, VOR, head turns, EC, busy back drop, dual task)

▪ VOR with walking

▪ Walking with high knees looking up and down

▪ Step ups looking up and down

▪ Walking with ball pass from hand to hand

Stress Management

▪ Meditation, deep breathing

▪ Discussed importance of open communication with wife

▪ Accept help from family

▪ Try to increase “normal” activities - go shopping, go to dinner with wife, spend time with

friends, etc

HEP ProgressionNext Few Sessions – April-May

▪ Doing better – 85-90% normal function, motivated and compliant

with HEP

▪ Decreasing therapy frequency▪ Bi-weekly, bi-monthly

▪ Continued sx management

▪ Trying to increase “normal” activities – home, social

▪ Cantu Concussion Center follow up – recommend trial of HEP

▪ He is thinking about joining a gym – exercise in a “normal” setting

▪ Review of machines @ gym and how to add vestibular

challenges

▪ Head turns, visual tracking, conversation/ looking at friend, dual

task, perform on unsteady surface or challenging foot position

Therapy ProgressionNext Few Sessions – May-June

Cervical

▪ WFL at this time

Vestibular

▪ Tinnitus at baseline. VOMS now WNL aside from slowed VOR

(160 bpm, 180 bpm is normal)

Balance

▪ Much improved, mild impairment NBOS / compliant surface

(BESS)

▪ Gait with EC and head turns still somewhat challenging (FGA)

Objective Findings SummaryD/C Status - June

BESSD/C Status - June

Leg Tested: L



▪ SLS on non dominate foot 4 5


foot in rear


▪ Total BESS score: 16 (was 36 in January)

D/C Plan

▪ Has been in therapy >1.5 years (total) – difficult to achieve sense of

normalcy

▪ Encourage return to “normal” activities

▪ Gym with friends (normal exercise vs rehab)

▪ Walks with daughter and wife

▪ Outings with friends, etc.

▪ Independent with HEP, compliant and motivated

▪ Given therapist’s email and was advised to reach out as needed

▪ Work

▪ Has not yet returned

▪ Continue to be followed by Cantu Concussion Center to determine plan

for return to work


Symptom Management

▪ Previous therapies – no sx management▪ Use 2 point symptom management scale. Slowly increase intensity only to

tolerance

▪ Delayed onset of sx▪ Take more rests, even if not symptomatic

▪ “No pain no gain” mentality▪ Start with less intensity, increase only if tolerated.

▪ Self management strategies: Ice/ cryohelmet, tennis balls for SOR, trigger

point cane, stretching, rests

Financial Stressors

▪ Equipment for home▪ Waited for tax returns to purchase equipment – used tennis balls for

soft tissue work; icepack to make a cryohelmet

▪ Other financial stressors

Occupational Stressors

▪ Police officer – workman’s comp. No part time work or light duty▪ Discussed with team (P.T, O.T, SLP, NP) likelihood of him returning

to work as a police officer. NP responsibility to clear him and

discuss alternative options for work


Home / Social Stressors

▪ New baby, wife – post partum; return to work▪ Meditation, stress management, open communication with wife

▪ Accept help from family members

▪ Invisible Injury – strain on family and friend relationships,

avoiding social interactions▪ Exit strategy when in social situations; “concussion kit”

▪ Concussion education handouts


Case ComparisonCommon Themes

▪ “Invisible Injury”

▪ Frustration with symptoms and limitations

▪ Difficulty with symptom management

Case ComparisonDifferences - Influence on Outcomes

▪ Case Study 1 had better outcomes overall than Case Study 2

due to several factors:

▪ Career

▪ Concussion History

▪ PMHx/ Comorbidities

▪ Psychosocial factors

▪ Finances

▪ Age

▪ Sex?

TechnologyVestibular Rehab

Used with case studies▪ Elliptical ▪ UBE ▪ Treadmill▪ Bike▪ Virtual Reality (Wii)▪ Biodex▪ Cryohelmet▪ Trigger Point Cane ▪ Polar Heart Rate Monitor▪ Cell phone

▪ Metronome App▪ Reminders, symptom tracking, timer, stop watch, etc.

Other▪ Filters, lenses, blue light blocking glasses

▪ Refer to O.T

▪ Frenzel Goggles – BPPV▪ Pool▪ App - Brain Kit: Task planner, sx tracking, balance

Special Considerations

Vestibular Impairment and Driving

▪ Our responsibility to ask about driving

▪ If we feel the patient is unsafe, discuss concerns with patient and

contact referring physician and PCP

▪ Document all discussions with patient

▪ Utilize programs such as the Keys to Independence Program to

determine safety and readiness for driving

Keys To Independence Program

Offered at Baker Ave Location. An Emerson occupational therapist/driver rehabilitation specialist (OT-DRS) is on-site to provide comprehensive driver assessment.

Address vision in OT first

Populations who may benefit:

▪ People with lower levels of cognitive or emotional reserve (in addition to the concussion)▪ Persons with disabilities, anxiety and depression, other psychiatric disorders, previous brain injury

or neurological disorder, and older adults with decreased mental flexibility due to aging, medication use, etc.

▪ These populations have a harder time compensating for concussion and PCS symptoms.▪ Driver evaluation and retraining can be very helpful for the individual to explore driving routes and

routines that are comfortable for them without causing increased symptoms and anxiety.▪ Refer those who may need boost in confidence and support/ encouragement - ie do not just refer

those who you think may failCost: ▪ $350 for the clinical eval (Emerson)▪ ~$200 for on-road assessment

For more Info: https://www.emersonhospital.org/clinical-services/physical-rehabilitation-sports-medicine/clinics-classes-groups/keys-to-independence-driver-assessment

Resources

▪ https://picclick.com/Cane-Massage-Trigger-Point-Hook-Acupressure-Back-Handheld-152452971629.html

▪ https://pixabay.com/photos/newborn-baby-feet-basket-young-1399155/▪ http://thesportjournal.org/article/advancements-in-concussion-prevention-

diagnosis-and-treatment/▪ https://www.amazon.com/Rolyan-Graded-Plastic-Motion-

Exerciser/dp/B071J4234K▪ http://w.ci-journal.net/index.php/ciej/article/download/827/1008?inline=1▪ https://www.flickr.com/photos/dgoomany/4976873174▪ https://www.medbridgeeducation.com

▪ http://www.nardellaclinic.com/assets/files/references/Visual-Perception.pdf

▪ http://www.skillworks.biz/Resources/Documents/JPE%20Target%20and%20Instructions.pdf

▪ https://www.walmart.com/ip/Catalyst-Cryo-Helmet-Brain-Cooling-System/454960365?wmlspartner=wlpa&selectedSellerId=16245&adid=22222222227142602076&wl0=&wl1=g&wl2=c&wl3=253388468331&wl4=pla-418077207356&wl5=9001863&wl6=&wl7=&wl8=&wl9=pla&wl10=120813241&wl11=online&wl12=454960365&veh=sem&gclid=EAIaIQobChMI3Om84s6m5AIVB56fCh2t1AAcEAQYBSABEgJsxPD_BwE

Thank you for your attention!

Date post:	09-Aug-2020
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