10/15/2018

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Vestibular Rehabilitation

Carly Mattson, PT, DPT, OCS

Vestibular Rehabilitation

I have no financial relationships to disclose.

Disclosure

Vestibular Rehabilitation

Upon completion of this lecture, participants will

• understand the anatomy and physiology of the vestibular

system and how it relates to concussion management.

• understand the basic vestibular evaluation and treatment

relevant to post concussion patients.

• Be familiar with the research supporting vestibular therapy

for patients post concussion.

Objectives

Alarms raised over rising

concussion rates among young

female soccer playersMore dangerous than football?

Girls are being knocked out of

games — and classrooms —

more often. Reasons and

solutions are elusive.

By Joe Christensen Star Tribune

NOVEMBER 2, 2017 — 10:31AM

The Truth

About

Concussions

By Samantha Costa,

Staff Writer |Nov. 10

U.S. News and World

Report

Repetitive hits, concussions, and a

mother’s long goodbye to youth football

By Julie DiCaro September 12

Washington Post

1 In 5 Teens Reports A Concussion

Diagnosis

September 26, 201711:42 AM ET

NPR

GRETA JOCHEM

Playing Tackle

Football Before

12 Is Tied to

Brain Problems

Later

By KEN BELSON

New York Times

SEPT. 19, 2017

Study: CTE Found

In Nearly All

Donated NFL

Player Brains

NPR

Tom Goldman

July 25, 2017

Vestibular Rehabilitation

80% of concussions recover in 10-14 days.

How can we facilitate the recovery for the

remaining 20%?

McCrory, 2017

Consensus Recommendations 2017

Research has supported treatments such as:

- Psychological interventions

- Vestibular rehabilitation

- Cervical spine management

- Guided physical exercise

McCrory, 2017

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Cluster of Symptoms for Vestibulo-

Ocular Impairments

Dizziness

Nausea

Balance Problems

Headache

Sensitivity to visual motion - busy environments

etc.

Blurred vision (when moving head)

Mucha, 2014

Rehabilitation Role in Concussion

Management

“A combination of cervical and

vestibular physiotherapy

decreased time to medical

clearance to return to sport in

youth and young adults with

persistent symptoms of

dizziness, neck pain and/or

headaches following a sport-

related concussion.” Schneider,

2014

Review of the Literature

- Almost 50% of athletes following a sport related concussion report

dizziness (Kontos et al 2012).

- Dizziness at the time of injury is a risk factor for prolonged recovery

(Lau et al 2011).

- Dizziness, as a subacute symptom, is associated with post concussion

syndrome. (Yang, 2009)

Review of the Literature

- “Vestibular complaints are the most frequent sequelae of mTBI.

Vestibular physical therapy has been established as the most

important treatment modality for this group of patients.” (Gotshall,

2011)

- “Vestibular and ocular motor impairments and symptoms have been

documented in patients with sport related concussions.” (Mucha,

2014)

- “Sixty one percent of patients reported symptom provocation after at

least 1 VOMS item.” (Mucha, 2014)

Vestibular System in the Inner Ear

http://drsethevans.com/2014/01/27/ho

w-does-your-ear-work/

Vestibular System

• One of three balance systems in the body:– Vision– Somatosensory– Vestibular

• Peripheral Vestibular System– Semicircular canals– Otoliths: utricle and saccule– Vestibular ganglia– Vestibular nerve

• Central Vestibular System– Vestibular Nuclei– Cerebellum– Cortex– Thalamus

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Vestibular System

Two Functional Units

- Vestibulo-ocular system- Maintains visual stability during head movement

- Impairment produces:

- Dizziness, visual instability

- Vestibulo-spinal system- Maintains postural control

- Impairment produces:

- Poor balance Mucha, 2014

Vestibular System Function

Emory Course

Materials

Balance System and Concussion

Balance impairments resolve quickly compared to other

symptoms following a concussion (Catena, 2011).

Ability to utilize and process vestibular information

needed for balance may be affected in concussed

individuals (Guskewitz, 2001).

Objective balance impairments recovery in most athletes

by 3 -5 days post concussion (Mucha, 2014).

What Does the Vestibular System Do?

• Senses linear and angular

speed

• Senses rotational movement

of the head

• Senses linear movement of

the head

• Senses head position in space

Vestibular Impairments Post Concussion

Central Impairment● VOR impairment

● Visual Motion Sensitivity

Peripheral Impairment ● BPPV

VOR (Vestibular Ocular Reflex)

Reflex that provides the ability to maintain focus on a

stationary target while moving the head without loss of

focus or dizziness

Stabilizes vision while head moves

Examples of use of VOR:

- Walking - head can move around 100 degrees/second

- ADLs - head can move around 120 degrees/second

- Running - head can move around 550 degrees/second

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VOR (Vestibular Ocular Reflex)

3 components to reflex arc

- Peripheral sensory

function - semicircular

canals

- Central processing

- Motor output - eye

muscles http://en.wikipedia.org/wiki/Vesti

bulo-ocular_reflex

VOR (Vestibular Ocular Reflex)

Abnormal VOR can occur post concussion

- Patient is not able to maintain focus on an

object while moving head - Symptoms:

- Blurry vision

- Dizzy sensation

VOR (Vestibular Ocular Reflex)

Measuring VOR

- Head thrust

- Head Shake Nystagmus

- Clinical DVA

- Computerized DVA

- Head movement with stationary target test

VOR (Vestibular Ocular Reflex)

Rehabilitation for VOR

Head eye coordination exercises using various targets

VOR Cancellation

• VOR Cancellation:

“over-riding” of VOR

• Ability to shift direction

of gaze along with head

movement

• Inhibition of eye

movement as a result

of head movement

VOR Cancellation

This can be used to assess visual motion sensitivity

- Increased awareness of normal visual motion

- Symptom provocation created by moving crowds, busy environments

Ex: supermarket, school hallway, hockey game

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VOR Cancellation

Treatment for VOR Cancellation

BPPV

Occurs less often in a young,

athletic population

Otoconia (calcium carbonate

crystals) from the otolith detach

and move into one of the

semicircular canals

Stimulation of semicircular canal

causes the sensation of head

rotation/vertigo

BPPV

Clinical Pearls:

- Duration of symptoms less than 1 minute (typically)

- Symptoms occur when head is in certain positions – not all

of the time

- Associated with nystagmus pattern in the eyes

- Subjective complaints of dizziness:

- Dizziness caused by changes in head position

- getting out of bed

- rolling in bed

- looking up/down

- lying down

BPPV

Clinical Pearls

Sense of Vertigo vs. Dizziness

- Vertigo = room is spinning – rotational

component to symptom

- Sense of vertigo is often quite strong

BPPV

Testing - Dix Hallpike

Tests for anterior and posterior canal

involvement

- Begin testing with patient in long sitting

position

- Their head is rotated 45 degrees towards

the side being tested

- Patient quickly lies down to supine position

with their head still rotated to 45 degrees

and their neck extended 30 degrees below

the horizontal

- Should maintain position for at least 30

seconds, and look for upbeat or downbeat

torsional nystagmus

BPPV

Treatment - Canalithic Repositioning Maneuver

- For posterior and anterior canal

Start in long sitting with head rotated 45 degrees to

affected side

Then quickly lie supine with head extended 30 degrees

and rotated 45 degrees to affected side

- maintain position for at least 45 seconds

Rotate head to opposite side 45 degrees – while

maintaining 30 degrees of extension

- Maintain position for at least 45 seconds

Roll onto side with head looking into the armpit of the

bottom arm

- Maintain position for at least 45 seconds

Return to seated position

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Cluster of Symptoms for Ocular Motor

Impairments

Blurred vision

Double vision

Headache

Difficulty reading

Impaired eye movement

Poor visual concentration

Mucha, 2014

Frequency of Ocular Motor Impairments

Post Concussion

• Accommodative Impairments – 65%

• Convergence Insufficiency – 55%

• Saccadic Impairment – 30%

• Smooth Pursuit Impairment – 60%

• Ocular Misalignment – 55%

Capo-Aponte,

2012

Ocular Motor Exam - Convergence

Function: ability to turn eyes inward to

focus on a target

Abnormal findings

- Break point is greater than 6 cm

- Recovery point is greater than 10 cm

Ocular Motor Exam - Saccades

Function: ability to look at one target,

and then quickly at another

Abnormal findings

- over / undershooting

- More than 3 saccades to get to

target

- Slow speed

Ocular Motor Exam - Smooth

Pursuits

Function: Ability to smoothly follow

target with eyes

Abnormal findings:

- asymmetric eye movement

- saccadic movement/ not

smooth movement while

tracking (age is a factor)

Rehabilitation Prescription

• Individually tailored, progressive interventions

• Ok with symptom reproduction during exercise treatment

– Symptoms should feel familiar but can get heightened during

exercise session

– Observe to ensure symptoms return to baseline

• Educating patient that symptom reproduction does not cause

further harm

• Set a symptom score threshold – i.e. 2 levels above baseline

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Desensitization

• Habituation of vestibular system

• Start: head movement and visual/vestibular stimulation in

controlled environment = minimal head movement and

environmental stimulation

– Gradually progress head movements and environmental stimuli

• Work into modified school or work environment

• Work into unrestricted school or work environment

• Work into modified recreational/sport environment

• Work into unrestricted recreation/sport environment

• Tolerate normal school/work/recreation/sport routine

Team work!

References

•Giza, Christopher C., and David A. Hovda. "The Neurometabolic Cascade of Concussion."Journal of Athletic Training 36.3 (2001): 228-35.

•Alsalaheen, BA., Mucha, A., Morris, LO., Whitney, SL., Furman, JM., Camiolo-Reddy, CE., Collins, MW., Lovell, MR., & Sparto, PJ. (2010). Vestibular rehabilitation

for dizziness and balance disorder after concussion. Journal of Neurologic Physical Therapy, 34, 87-93.

•McCrory, P, Meeuwisse, WH., Aubry, M., Cantu, B., Dvorak, J., Echemendia, RJ., Engebretsen, L., Johnston, K., Kutcher, J., Raftery, M., Sills, A., Benson, BW>,

Davis, GA., Ellenbogen, RG., Guskiewicz, K., Herring, SA., Iverson, GL., Jordan, BD., Kissick, J., McCrea, M., Mclntosh, AS., Maddocks, D., Makdissi, M.,

Purcell, L., Putukian, M., Schneider, K., Tator, CH., & Turner, M. “Concensus statement on concussion in sport; the 4th international conference on

concussion in sport held in Zurich, November 2012. “ BJSM 2013; 47, 250-258.

•Guerriero, Rejean M., Mark R. Proctor, Rebekah Mannix, and William P. Meehan, III. "Epidemiology, Trends, Assessment and Management of Sport-related

Concussion in United States High Schools." Current Opinions in Pediatrics 24 (2012): 1-6. Print.

•Collins M, Lovell MR, Iverson GL, Ide T, Maroon J. Examining concussion rates and return to play in high school football players wearing newer helmet

technology: a three-year prospective cohort study. Neurosurgery. Feb 2006;58(2):275-286; discussion 275-286.

•Mihalik, JP, Stump, JE, Collins, MW, Lovell, MR, Field, M and Maroon, JC. Posttraumatic migraine characteristics in athletes following sports-related concussion.

Neurosurgery. 102: 850-855. 2005

•Scheiman, M, Gallaway, Michael, Frantz, KA, Peters, RJ, Hatch, S, Cuff, M, and Mitchell GL. Near point of Convergence: Test Procedure, Target Selection and

Normative Data. Optometry and Vision Science. 80. 3. 214-225.

References

•Lau BC, Collins MW, Lovell MR. Sensitivity and specificity of subacute computerized neurocognitive testing and symptom evaluation in predicting outcomes after

sports-related concussion. Am J Sports Med. Jun 2011;39(6):1209-1216.

•Schubert MC. Clinical assessment of the ocular motor systems. Vestibular SIG Newsletter , Spring 2010.

•Gill-Body, Kathleen M. "Current Concepts in the Management of Patients With Vestibular Dysfunction." PT Magazine 8.12 (2001): 40-57.

•Alsalaheen BA, Whitney SL, Mucha A, Morris LO, Furman, JM, Sparto, PJ. Exercise Prescription Patterns in Patient Treated with Vestibular Rehabilitation After

Concussion. Physiotherapy Research International. 2012, July.

•Whitney SL, Marchetti GF, Morris LO. Usefulness of the dizziness handicap inventory in the screening for benign paroxysmal positional vertigo. Otol Neurotol.

2005 Sep;26(5):1027-33.

•Guerraz, M, Yardley, Bertholon, P, Pollak, L, Rudge, P, Gresty, MA., and Bronstein AM. Visual Vertigo: symptom assessment, spatial orientation and postural

control. Brain. 2001. 124, 1646-1656.

•http://www.upmc.com/Services/sports-medicine/services/concussion/about-concussions/Pages/symptoms.aspx

•Herdman, SJ. (2007) Vestibular Rehabilitation. Philadelphia. F.A. Davis Company.

•Toglia, J. U. (1976). Acute flexion-extension injury of the neck. Electronystagmographic study of 309 patients. Neurology, 26(9), 808-814.

•Capo- Aponte, J. E. (2012). Effectiveness of Computerized Oculomotor Vision Screening in a Military Population: Pilot Study. Military Medicine

•Schneider, K. (2013). Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. Br J Sports Med.

•Gotshall, K. (2011). Vestibular rehabilitation after mild traumatic brain injury with vestibular pathology. NeuroRehabilitation, 29(2), 167-171.

References

•Emory Vestibular Competency Course materials

•Miller, M. (2014). The Cervical Spine: Physical Therapy Patient Management Utilizing Current Evidence. Current Concepts, 3rd edition, 1-49

•Mucha, A et al. (2014). A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions. Am J Sports Med, 42(10)

• Marar, M. "Epidemiology of concussions among United States high school athletes in 20 sports." American Journal of Sports Medicine 240.4 (2012): 747-55.

•Gessel, Luke. "Concussions Among United States High School and Collegiate Athletes." Journal of

• Athletic Training 42.4 (2007): 495-503.

• Yang CC et. Al (2009). Early clinical characteristics of patients with persistent post-concussion symptoms: a prospective study. Brain injury. 23(4): 299-

306

References

Image CitationsVestibular rehabilitation picture - https://www.neura.edu.au/wp-content/uploads/2016/05/Ear.png

What does the vestibular system do picture - http://www.nbcsports.com/sites/nbcsports.com/files/2016/06/26/oly16_gym_kocianuneven_160626_1.jpg

Vestibular system picture - http://www.nimh.nih.gov; ttp://en.wikipedia.org/wiki/Vestibular_system

Head Thrust picture - http://cp.neurology.org

Dynamic visual acuity test picture - Resourcesonbalance.com

BPPV picture - http://www.mayoclinic.org/tests-procedures/canalith-repositioning-procedure/multimedia/img-20146069

BPPPV roll test picture - www.physio-pedia.com

Saccades picture - www.physio-pedia.com

Smooth pursuits picture - https://entokey.com/neuro-ophthalmology

VOR cancellation slide: http://www.inside.iastate.edu/article/2013/01/17/school,

https://www.google.com/search?safe=strict&biw=1366&bih=637&tbm=isch&sa=1&q=picture+of+supermarket&oq=picture+of+supermarket&gs_l=psy-ab.3,

https://www.google.com/search?safe=strict&biw=1366&bih=637&tbm=isch&sa=1&q=picture+of+crazy+pattern

Team work

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