17
51
• Pe
rip
her
ally
, in
ner
ear
co
mm
un
icat
es
(aff
eren
t si
gnal
) ab
ou
t h
ead
m
oti
on
wit
h
vest
ibu
lar
nu
clei
,
cen
tral
ly
• V
esti
b-o
cula
r tr
acts
asc
end
(e
ffer
ent
sign
al)
for
gaze
sta
bili
ty
(sta
bili
ze v
isio
n
wh
ile h
ead
mo
ves)
• V
esti
b-s
pin
al
trac
ts d
esce
nd
(e
ffer
ent
sign
al)
for
spat
ial
awar
enes
s an
d
b
alan
ce
52
Sum
mar
y: V
isio
n T
erm
ino
logy
(t
hat
will
be
dis
cuss
ed)
Term
D
efi
nit
ion
A
sso
ciat
ed S
ymp
tom
if a
bn
orm
al
Acc
om
mo
dat
ion
Ab
ility
to
mai
nta
in c
lear
imag
e an
d
chan
ge f
ocu
s b
etw
een
nea
r/fa
r
ob
ject
s
Co
nst
ant/
inte
rmit
ten
t b
lur
Am
plit
ud
e o
f ac
com
mo
dat
ion
C
lose
st p
oin
t o
f cl
ear
visi
on
Fusi
on
Si
ngl
e im
age
view
ing
wit
h b
oth
eyes
Het
ero
tro
pia
M
anif
est
mis
-alig
nm
en
t o
f ey
es
wh
en lo
oki
ng
at b
oth
eye
s (f
usi
on
allo
wed
)
Het
ero
ph
ori
a M
anif
est
mis
-alig
nm
en
t o
f ey
es
wh
en b
lock
ing
on
e ey
e (d
isru
pti
ng
fusi
on
)
Ver
gen
ce
Dis
jun
ctiv
e ey
e m
ove
men
ts t
o t
rack
an o
bje
ct o
n z
-axi
s –
dep
th
per
cep
tio
n
Co
nst
ant/
inte
rmit
ten
t ey
e st
rain
,
dip
lop
ia (
dis
ap
pea
rs w
ith
mo
no
cula
r vi
sio
n)
Nea
r p
oin
t o
f ve
rgen
ce
Clo
sest
po
int
of
bin
ocu
lar
fusi
on
–
sin
gle
ob
ject
53
Sum
mar
y: V
isio
n T
erm
ino
logy
V
ers
ion
s (2
D, x
/y a
xis,
co
nju
nct
ive
) D
esc
rip
tio
n
Exam
A
bn
orm
al r
esp
on
se
Fixa
tio
n Ey
es f
ixed
on
a t
arge
t to
mai
nta
in
imag
e o
n f
ove
a M
ain
tain
ste
ady
gaze
on
ta
rget
fo
r 1
0”
wit
ho
ut
ocu
lar
dri
ft, i
nst
abili
ty
Ocu
lar
dri
ft
Gaz
e in
stab
ility
N
ysta
gmu
s
Sacc
ades
R
apid
eye
mo
vem
ents
to
red
irec
t lin
e o
f si
ght
fro
m o
ne
ob
ject
to
an
oth
er
Hea
d s
till,
fo
llow
slo
wly
m
ovi
ng
(60
deg
/sec
) ta
rget
at
40
cm d
ista
nce
Ab
sen
ce o
f sm
oo
th e
ye
mo
vem
ent
Smo
oth
Pu
rsu
its
Slo
w, c
on
tin
uo
us
eye
mo
vem
ent
to
follo
w a
slo
wly
mo
vin
g o
bje
ct
Hea
d s
till,
rap
id e
ye
mo
vem
ent
fro
m o
ne
targ
et t
o t
he
oth
er a
t 4
0cm
dis
tan
ce, t
arge
ts
20
cm a
par
t H
ori
zon
tal,
vert
ical
Dys
met
rias
– o
ver/
un
der
sho
ot
targ
et
Del
ayed
init
iati
on
H
ead
mo
vem
ent
Dec
reas
ed s
pee
d
Ve
rge
nce
(3D
, z a
xis,
d
isju
nct
ive
) D
esc
rip
tio
n
Exam
A
bn
orm
al r
esp
on
se
Nea
r p
oin
t o
f ve
rgen
ce
Dis
jun
ctiv
e ey
e m
ove
men
ts t
o t
rack
an
ob
ject
on
z-a
xis
– d
epth
p
erce
pti
on
Mai
nta
in f
ocu
s o
n t
arge
t as
it m
ove
s to
war
d
pat
ien
ts n
ose
. M
easu
re:
Wh
ere
fusi
on
bre
aks
Wh
ere
fusi
on
rec
ove
rs
Eye
dev
iati
on
s
Rep
ort
ed d
iplo
pia
an
d/o
r d
evia
tio
n o
f o
ne/
bo
th e
yes
>10
cm a
way
fro
m n
ose
54
Migraine Assessment Tool
1. Did the headaches start within 2 weeks of a head injury, trauma, or medical illness? YES NO (If no, proceed to next question.)
2. Do you have any brain abnormality, like tumors or hydrocephalus?
YES NO (If no, proceed to next question.)
3. Do you have a headache everyday or take over-the-counter or prescription pain or headache medications (eg, Excedrin) more than 4 days per week?
YES NO (If no, proceed to next question.) 4. Do you have an intermittent or constant headache? Constant Intermittent (If intermittent, proceed to the next question.) 5. How long does each individual headache episode last? <2 hours .2 hours (If .2 hours, proceed to next question.) 6. Do you have any of the following neurological symptoms immediately before or during your headache episodes:
Visual scotoma (blind or black spots in the vision) Visual hallucination (zigzag or wavy lines, colored lights or balls, shimmering patterns) Weakness or numbness on one side of your body
If YES, diagnose MIGRAINE. No further questions needed. If NO, proceed with question 7. 7. Do you have at least 2 of the following symptoms with your headache?
Pain is on one side of the head during a headache episode Pain feels like throbbing or pulsing sensation Pain limits, restricts, or interferes with routine activities Pain is made worse by performing routine activities, such as stair climbing
NO (STOP! No diagnosis of migraine) YES (If yes, proceed to next question.) 8. Do you have at least 1 of the following symptoms with your headache?
Nausea or vomiting Markedly increased sensitivity to BOTH normal room lighting AND conversational speech (You need to turn down or off lights, close curtains or blinds, turn down or off radio or television, or need to retreat to dark, quiet room.)
If YES, then diagnose MIGRAINE
55
Qu
ick
and
Eas
y d
iffe
ren
tial
Migraine
Anxiety
Cervicogenic
On
set
Cri
sis
w/m
igra
ine
feat
ure
s St
ress
M
edic
al c
risi
s Tr
aum
a
Trig
ger
Mig
rain
e tr
igge
rs
Envi
ron
men
tal
Cer
vica
l lo
adin
g
Sx r
elat
ed t
o d
izzi
nes
s Se
nso
ry h
yper
sen
siti
vity
D
isti
nct
ver
tigo
an
d/o
r H
A
Vag
ue
diz
zin
ess
Fl
oat
ing
Dis
con
ne
ct
Effe
ct o
n li
fe
Seve
re e
pis
od
es
Dis
ablin
g m
oti
on
se
nsi
tivi
ty
Vis
ual
mo
tio
n in
tole
ran
ce
Bal
ance
inse
curi
ties
Fe
ar/a
void
ance
Nec
k d
ysfu
nct
ion
Ob
ject
ive
fin
din
gs
Nys
tagm
us
Mild
cer
vica
l fin
din
gs
C
ervi
cal r
elat
ed
Trea
tmen
t Li
fest
yle
chan
ges
Med
s H
abit
uat
ion
/vis
ual
m
oti
on
tra
inin
g
M
anu
al
Mo
tor
con
tro
l P
ost
ura
l re-
ed
stre
ngt
h
Slid
e cr
edit
to
:
Jan
ene
M. H
olm
ber
g, P
T, D
PT,
NC
S
R
ob
Lan
del
, PT,
DP
T, O
CS,
CSC
S, F
AP
TA
Lau
ra M
orr
is, P
T, N
CS
(H
olm
ber
, Lan
del
, Mor
ri; C
SM 2
016
)
56
Referrals
• Physical/Vestibular Therapist - concussion specialist:– Dizziness and/or headaches when movement is introduced– Space and motion discomfort– Imbalance with higher level demands– Any visual or vestibular related symptoms with need to
return to activity/sport
• Vision specialist: – Ocular misalignment (tropias); always refer any vertical
misalignment– Visual acuity poorer than 20/40 in either/both eyes– Moderate to severe Convergence Insufficiency (>20cm)– Pursuit and Saccade abnormalities, refer to either a PT (if
mild) or Vision specialist (if moderate to severe) – Nystgamus > 3-4 beats at end range or at rest – Restricted visual fields– Asymmetry in pupil size/shape or response– If slow to recover, may need additional evaluation/exercises
(prisms, etc)
• Mental health services: – The more involved in a sport, the more the child is identified
as an athlete, the greater the psychological effects
– Perceived mood state is just as important to an athlete re RTP as clinical readiness
– Can be helpful for anxiety, insomnia, depression (CBT, mindfulness, etc)
– Pre-injury somatasization (psychosocial measurement)
• Cardiac lab
– Abnormally high resting HR
57
– Abnormal result on exercise testing (symptomatic and post- exercise clinical measures)
• Neuro-endocrine– Pituitary deficiencies exist at higher rates in concussions– Straightforward testing and replacements may be effective
and appropriate– Sx include: changes to hair/skin/weight, mental fogginess,
fatigue, decreased exercise capacity
58
K+
GlutamateGlucose
Cerebral Blood Flow
59
Vestibular/Ocular-MotorScreeningforConcussion(adaptedfromUPMC‘VOMS’)
Vestibular-Ocular Motor Test
Dizzy (0-10)
HA
(0-10)
Nausea (0-10)
Foggy (0-10)
Comments
Baseline Pursuits -2trials,Htest
Saccades(10ea,
3feetaway/apart) -horizontal -vertical
NPC (3trials,14ptfonttarget)
______cm ______cm ______cm
VOR(180bpm,40
degofcenter) -horizontal -vertical
VORc (visual motion) -50bpm -160degarcofmotion
60
Convergence Insufficiency Symptom Survey Name _____________________________________ DATE __/__/__
Clinician instructions: Read the following subject instructions and then each item exactly as written. If subject responds with “yes” - please qualify with frequency choices. Do not give examples. Subject instructions: Please answer the following questions about how your eyes feel when reading or doing close work.
Never (not very often)
Infrequently
Sometimes Fairly often Always
1. Do your eyes feel tired when reading or doing close work?
2. Do your eyes feel uncomfortable when reading or doing close work?
3. Do you have headaches when reading or doing close work?
4. Do you feel sleepy when reading or doing close work?
5. Do you lose concentration when reading or doing close work?
6. Do you have trouble remembering what you have read?
7. Do you have double vision when reading or doing close work?
8. Do you see the words move, jump, swim or appear to float on the page when reading or doing close work?
9. Do you feel like you read slowly?
10. Do your eyes ever hurt when reading or doing close work?
11. Do your eyes ever feel sore when reading or doing close work?
12. Do you feel a "pulling" feeling around your eyes when reading or doing close work?
13. Do you notice the words blurring or coming in and out of focus when reading or doing close work?
14. Do you lose your place while reading or doing close work?
15. Do you have to re-read the same line of words when reading?
__x 0 __ x 1 __ x 2 __ x 3 __ x 4 TOTAL SCORE ___________
61
62
The Dizziness Handicap Inventory ( DHI )
P1. Does looking up increase your problem? o Yes o Sometimes o No
E2. Because of your problem, do you feel frustrated? o Yes o Sometimes o No
F3. Because of your problem, do you restrict your travel for business or recreation? o Yes o Sometimes o No
P4. Does walking down the aisle of a supermarket increase your problems? o Yes o Sometimes o No
F5. Because of your problem, do you have difficulty getting into or out of bed? o Yes o Sometimes o No
F6. Does your problem significantly restrict your participation in social activities, such as going out to dinner, going to the movies, dancing, or going to parties?
o Yes o Sometimes o No
F7. Because of your problem, do you have difficulty reading? o Yes o Sometimes o No
P8. Does performing more ambitious activities such as sports, dancing, household chores (sweeping or putting dishes away) increase your problems?
o Yes o Sometimes o No
E9. Because of your problem, are you afraid to leave your home without having without having someone accompany you?
o Yes o Sometimes o No
E10. Because of your problem have you been embarrassed in front of others? o Yes o Sometimes o No
P11. Do quick movements of your head increase your problem? o Yes o Sometimes o No
F12. Because of your problem, do you avoid heights? o Yes o Sometimes o No
P13. Does turning over in bed increase your problem? o Yes o Sometimes o No
F14. Because of your problem, is it difficult for you to do strenuous homework or yard work?
o Yes o Sometimes o No
E15. Because of your problem, are you afraid people may think you are intoxicated? o Yes o Sometimes o No
F16. Because of your problem, is it difficult for you to go for a walk by yourself? o Yes o Sometimes o No
P17. Does walking down a sidewalk increase your problem? o Yes o Sometimes o No
E18.Because of your problem, is it difficult for you to concentrate o Yes o Sometimes o No
F19. Because of your problem, is it difficult for you to walk around your house in the dark?
o Yes o Sometimes o No
63
DHI Scoring Instructions
The patient is asked to answer each question as it pertains to dizziness or unsteadiness problems, specifically considering their condition during the last month. Questions are designed to incorporate functional (F), physical (P), and emotional (E) impacts on disability.
To each item, the following scores can be assigned: No=0 Sometimes=2 Yes=4
Scores:Scores greater than 10 points should be referred to balance specialists for further evaluation.
16-34 Points (mild handicap) 36-52 Points (moderate handicap) 54+ Points (severe handicap)
E20. Because of your problem, are you afraid to stay home alone? o Yes o Sometimes o No
E21. Because of your problem, do you feel handicapped? o Yes o Sometimes o No
E22. Has the problem placed stress on your relationships with members of your family or friends?
o Yes o Sometimes o No
E23. Because of your problem, are you depressed? o Yes o Sometimes o No
F24. Does your problem interfere with your job or household responsibilities? o Yes o Sometimes o No
P25. Does bending over increase your problem? o Yes o Sometimes o No
Used with permission from GP Jacobson. Jacobson GP, Newman CW: The development of the Dizziness Handicap Inventory. Arch Otolaryngol Head Neck Surg1990;116: 424-427
64
from: J. Vestib Res. 2011;21(3):153-9.
Visual Vertigo Analogue Scale (Adapted from Longridge et al., 2002)
Indicate the amount of dizziness you experience in the following situations
by marking off the scales below. 0 represents no dizziness and 10 represents the most dizziness
Walking through a supermarket aisle
0 10
Being a passenger in a car
0 10
Being under fluorescent lights
0 10
Watching traffic at a busy intersection
0 10
Walking through a shopping mall
0 10
Going down an escalator
0 10
Watching a movie at the movie theatre
0 10
Walking over a patterned floor
0 10
Watching action television
0 10
65
66
Name: _____________________ Age/DOB: ______________ Date of Injury:____________
Post Concussion Symptom Scale
No symptoms"0"-------Moderate "3"---------Severe"6"
Time after Concussion
SYMPTOMS Days/Hrs ________ Days/Hrs ________ Days/Hrs ________
Headache 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6
Nausea 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6
Vomiting 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6
Balance problems 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6
Dizziness 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6
Fatigue 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6
Trouble falling to sleep 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6
Excessive sleep 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6
Loss of sleep 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6
Drowsiness 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6
Light sensitivity 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6
Noise sensitivity 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6
Irritability 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6
Sadness 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6
Nervousness 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6
More emotional 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6
Numbness 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6
Feeling "slow" 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6
Feeling "foggy" 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6
Difficulty concentrating 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6
Difficulty remembering 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6
Visual problems 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6
TOTAL SCORE _____ _____ _____
Use of the Post-Concussion Symptom Scale: The athlete should fill out the form, on his or her own, in
order to give a subjective value for each symptom. This form can be used with each encounter to track the
athlete’s progress towards the resolution of symptoms. Many athletes may have some of these reported
symptoms at a baseline, such as concentration difficulties in the patient with attention-deficit disorder or
sadness in an athlete with underlying depression, and must be taken into consideration when interpreting
the score. Athletes do not have to be at a total score of zero to return to play if they already have had some
symptoms prior to their concussion.
67
