3/23/2016
Evidenced Based
Practice Update in
Concussion
Management
B E CK Y B LIS S , P T, DP T, C/ N DT
C E R T I F I C AT E I N V E S T I B U L A R R E H A B I L I TAT I ON A P TA
A D VA N C E D V E S T I B U L A R C E R T I F I C AT E , A P TA
C O M P R E H E N SI V E C O N C U S S I O N C E R T I F I C AT E , A P TA
I MPA C T T R A I NED P HY SIC AL T H ER AP I ST
Objectives
• To become familiar with common visual and vestibular deficits
following concussion
• To review evidenced based practice and new protocols as well as
theories behind concussion rehabilitation
• To understand the role of visual and vestibular baseline tests in the
management and identification of potential prolonged recovery
Concussion 101…..
Concussion or mild traumatic brain injury (MTBI) is a pathophysiological
process affecting the brain induced by direct or indirect biomechanical
forces.
• Common features include the following:
• Rapid onset of usually short-lived neurological impairment, which
typically resolves spontaneously.
• Acute clinical symptoms that usually reflect a functional disturbance
rather than structural injury.
• A range of clinical symptoms that may or may not involve loss of
consciousness (LOC).
• Routine neuroimaging studies are typically normal.
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Metabolic Crisis
Pathophysiology
Initial
Injury
Axonal
Stretching
Disruption of
Neural
Membranes
Potassium
efflux
Calcium
Influx
Na/K
pump
works
overtime
Increased
energy
(glucose)
required
Increase
in
Demand
Decrease
in ATP
(energy)
Metabolic
Crisis
Axonal
Swelling
Lack of
Perfusion
Diffuse
Axonal
Injury
NCAA Concussion Statistics
Rates (per 10,000 exposures)
M. Wrestling
10.92
M. Ice Hockey
7.91
W. Ice Hockey
7.50
M. Football
6.71
W. Soccer
6.31
W. Basketball
5.95
W. Lacrosse
5.21
W. Field Hockey 4.02
M. Basketball
3.89
W. Volleyball
3.57
Avg for all athletes
4.47
Competition
12.81 (53%)
Practice
2.57
Actual # of Concussions Sustained
Football
3417
W. Soccer
1113
W. Basketball
998
M. Basketball
773
M. Wrestling
617
From APTA website, Oct 2015
2009/10-2013/14 academic years
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Post Concussion Syndrome vs.
Symptoms… The BIG Debate
• Symptoms include:
• ****Chronic persistent Headaches
• Fatigue/Sleep disturbances
• ****“Fogginess”
• Personality changes (irritability, depression)
• Sensitivity to light or sounds
• ****Dizziness when standing quickly
• Academic functioning: Short term memory deficits, difficulty with problem solving,
concentration, and processing speed.
• Can be very disabling for the individual and their families
• Typically defined as having concussion symptoms that last for greater than a
month after the initial head injury but WHO vs CDC have different criteria
currently
****Assessment for Vestibular Therapy warranted?
Second Impact Syndrome
• Rare fatal phenomenon involving a 2nd head injury before resolution of 1st
• 1st concussion could have been mins, days or weeks prior
• 2nd blow only have to be “minor”
• Sudden collapse and rapid neurological decline
• Results in severe death and/or impairment
• Thought to be caused by subdural hemorrhage and/or dysautoregulation of the
cerebral vasculature causing hyperemic brain swelling and elevated ICP
• Adolescents and young adults
Role of Athletic Trainers in Concussion
Management
• As licensed medical professionals, athletic trainers receive
comprehensive didactic and clinical training in concussion
management.
• They are typically the first providers to identify and evaluate injured
persons and are integral in the post injury management and returnto-play (RTP) decision-making process
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Role of Pre-season Preparation
• Risk Factors
• Education
• Baseline Concussion Testing
• Emergency Procedure Protocol
ImPACT Testing
New Developments…..
• Looking at baseline vestibular and oculomotor scores using VOMs
• Reliability and Associated Risk Factors for Performance on the
Vestibular/Ocular Motor Screening (VOMS) Tool in Healthy
Collegiate Athletes.
• Kontos AP, et al. Am J Sports Med. 2016.
• The VOMS possesses internal consistency and an acceptable false-positive rate
among healthy Division I collegiate student-athletes.
• Female sex and a history of motion sickness were risk factors for VOMS scores
above clinical cutoff levels among healthy collegiate student-athletes.
• Results support a comprehensive baseline evaluation approach that includes an
assessment of premorbid vestibular and oculomotor symptoms.
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Risk Factors
• Several risk factors contribute to an athlete’s concussion recovery.
• Assessing the athlete’s concussion history can provide valuable
information; specifically, the number of concussions, the severity of
each concussion, and how close in time the concussions occurred to each
other.
• Additionally, assessing concussion symptoms (number, severity, and
duration), the age of the athlete, and any pre-existing conditions (e.g.,
history of migraines, headaches, ADD/ADHD, Learning Disability,
Depression, Anxiety) before the season begins can help with managing a
concussion if it ever occurs.
What is YOUR State’s Law?
• All 50 states have a Concussion Law
• Who can return individuals to play?
• In the states of KS
• Kansas law requires a physician’s signature (MD/DO) to "Return to Play.“
• http://www.kansasconcussion.org
ImPACT Testing
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Risk Factors
• Several risk factors contribute to an athlete’s concussion recovery.
• Assessing the athlete’s concussion history can provide valuable
information; specifically, the number of concussions, the severity of
each concussion, and how close in time the concussions occurred to each
other.
• Additionally, assessing concussion symptoms (number, severity, and
duration), the age of the athlete, and any pre-existing conditions (e.g.,
history of migraines, headaches, ADD/ADHD, Learning Disability,
Depression, Anxiety) before the season begins can help with managing a
concussion if it ever occurs.
Sideline Assessments ?????
• SCAT 3
• Child SCAT 3
• SCAT 2 (mobile app)
• Sideline Impact Test (mobile app)
• NFL Sideline Tool
• SAC
• King- Devick Test
Return to Play Protocol… stay tuned may be
changing
http://blogs.bmj.com/bjsm/files/2013/11/RTP1.jpg
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Typical Recovery
• 85-90% Concussions show signs of recovery in first 7-10 days
• 80% of Concussions fully recovered in 3-4 weeks
• What about the rest?
• Early identification of impairments aids in return to activity/sport without
prolonged sequelae
Predictors of Prolonged Recovery?
Published in the Journal of Pediatrics 2013:
“Symptoms Severity Predicts Prolonged Recovery after Sport-Related
Concussion, but Age and Amnesia Do Not”
Boston Children’s and University of Pittsburgh Medical Center studied a
total of 182 patients that presented to their clinics within three weeks of
injury.
*****We need to listen to the initial symptoms (especially headaches,
dizziness and fogginess) described versus considering sex, age, loss of
consciousness, and amnesia when discussing length of recovery
Symptomatic Recovery Period
• Reassurance/Education
• No exercise (24-48 hours only?)
• Decreased school activity/hours (based on symptoms)
• Do not want decompensation
• Role of added stressors?
• Each case is individual, no 2 concussions are the same
• PATIENT EDUCATION!!!
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Multidisciplinary Approach
From withdrawal to return to play:
• Coach
• Athletic Trainer
• Sports Medicine Doctor
• Neuropsychologist
• Neurologist
• Vestibular Therapist (PT/OT)
• Vision Therapist
• Neuro-otologist
• Counselor
UPMC Concussion Trajectories
Conceptual Framework…. UPMC
Ocular
Cognitive/
Fatigue
PostTraumatic
Migraine
Concussion
Anxiety/Mood
Vestibular
Cervical
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Not a perfect World
• Subtypes RARELY occur in isolation and often overlap
• The KEY is finding the “driving“ subtype(s) to start
management
Vestibular
Concussion
Anxiety/Mood
PostTraumatic
Migraine
Medical History is Key!
• Migraines
• Prior Concussions
• Visual Impairment
• Cervical Injury/Impairment
• Learning Disabilities
• Mood Disturbances
Clinical Pattern Recognition in Concussion
• What are your patient’s symptoms?
• Oculomotor
• Vestibular
• Cervical
• Cognitive
• Post Traumatic Migraine
• Anxiety/Mood
• Exertional
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Common Symptoms in Ocular Deficits
• Difficulty focusing/ prolonged reading
• Double vision
• Blurry vision
• Eye strain
• Headaches
• Pulling around eyes
• Sensitivity to light
Oculomotor Dysfunction Following mTBI
mTBI
• Convergence Insufficiency
55%
Control
5%
• Saccadic Impairment
30%
0%
• Pursuit Impairment
60%
0%
• Ocular misalignment
55%
5%
45%
5%
(vertical phoria)
• Ocular misalignment
(horizontal phoria)
• Accommodative dysfunction 65%
15%
Capo-Aponte et al. Military Medicine 2012
Oculomotor System
• Purpose: to produce eye movements to direct the fovea toward the
target of interest
• 6 extraocular muscles rotate the eye
• Divided into 3 pairs with complementary actions
• 3 cranial nerves control the eye muscles
• CNIII (oculomotor): Medial rectus, superior rectus, inferior rectus and inferior
oblique
• CN IV (Trochlear): Superior oblique
• CN VI (Abducens): Lateral rectus
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Visual Assessment
• Visual acuity
• Extra-ocular movements
• Pursuit eye movements
• Saccades
• Vergence
• Accommodation
• Gaze holding ( nystagmus)
• Ocular alignment
Ocular Motor findings –
Post Concussion:
Pursuits:
• “Saccadic” pursuits or
“Saccadic Intrusions”
• Symptomatic w/ pursuit
Saccades:
• Hypometric Saccades
• Slowed Saccades
• Symptomatic with saccades
eye movements
movements
Atypical to Concussions: overshoots!
Abnormal Smooth Pursuits
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Fast Speed Smooth Pursuits
Vergence System Issues
• Convergence: Ability of eyes to turn inward to focus on a near
target
• Vergence Testing: Patient fixates on target brought in along the
mid-sagittal plane toward the nose
• Near Point of Convergence: when target becomes double
• Normal NPC < 6 cm from tip of nose
• (Scheiman 2003)
• Abnormalities in Vergence
• Convergence Insufficiency =reduced vergence response (≥ 6 cm from tip
of nose)
• Convergence Spasm = Increased vergence response
Convergence
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Convergence ls Linked to Neurocognitive
Functioning
• Methods: A total of 78 athletes (mean age, 14.31 6 2.77 years) who were seen a mean 5.79 6 5.63
days after an SRC were dministered 3 trials of an NPC assessment, along with neurocognitive
(Immediate Post-Concussion Assessment and Cognitive Testing [ImPACT]) and symptom
assessments. Patients were divided into normal NPC (NPC 5 cm; n = 45) and CI (NPC .5 cm; n = 33)
groups. Intraclass correlation coefficients (ICCs) and repeated-measures analyses of variance
(ANOVAs) assessed the consistency of NPC across the 3 trials. The ANOVAs were employed to
examine differences on neurocognitive composites and symptoms between the normal NPC and
CI groups. Stepwise regressions (controlling for age and symptom scores on the Post-Concussion
Symptom Scale [PCSS]) were conducted to evaluate the predictive utility of the NPC distance for
neurocognitive impairment.
• Results: Groups did not differ on demographic or injury characteristics. NPC differed between trial
1 and trials 2 (P = .02) and 3 (P = .01) for the CI group but not the normal NPC group. Internal
consistency was high across NPC measurements (ICC range, 0.95-0.98). Patients with CI
performed worse on verbal memory (P = .02), visual motor speed (P = .02), and reaction time (P =
.001, h2 = .13) and had greater total symptom scores (P = .02) after the injury. Results of
hierarchical regression revealed that the NPC distance contributed significantly to the model for
reaction time (P\.001).
• Conclusion: CI was common (~42%) in athletes evaluated within 1 month after an SRC. Athletes
with CI had worse neurocognitive impairment and higher symptom scores than did those with
normal NPC. Clinicians should consider routinely screening for NPC as part of a comprehensive
concussion evaluation to help inform treatment recommendations, academic accommodations,
and referrals for vision therapy.
Vergence Dysfunction
Convergence Insufficiency
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Convergence
Insufficiency
Difficult Environments
Misalignment Issues
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Alternate Cross Cover Test
Misalignment Symptoms:
Areas Responsible For Binocular
Function
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Vestibular/Ocular System Deficits –
Present in Concussion
• Disruption of both static and dynamic balance contributing to postural instability
• Symptoms can be:
• Dizziness/Vertigo
• Motion Sensitivity/ Height Phobia
• Tinnitus
• Lightheadedness
• Blurred vision/Double vision/Trouble Focusing
• Photophobia
• Imbalance (especially in dark)
Dizziness Post Concussion
Causes of Vestibular Dysfunction
Type of TBI
Possible Manifestation
Comment
Labyrinthine
Concussion
Ataxia, imbalance, BPPV may be present
Most common vestibular injury
due to TBI
Skull Fracture
UVL or BVL (partial or complete)
Conductive hearing loss
May have mixed peripheral and central
lesions
Common with blows to the
occiput, temporal or parietal
regions
Hemorrhage into
Labyrinth
May create post traumatic hydrops
(Meniere’s type syndrome)
Damage to labyrinth, may create acute
vertigo and Unilateral hearing loss
Labyrinthine damage may present
with signs and symptoms similar
with acute peripheral vestibular
damage
Hemorrhage into
brainstem
Oculomotor signs, poor smooth pursuit,
vertigo, perception of tilt
Damage to vestibular and
oculomotor nuclei
Increased Intracranial
Pressure
Fluctuating hearing loss, ataxia, imbalance
May cause peri-lymphatic fistula
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Ears and the Brain… Connection
• Head movements are
detected by the cupula
and transmitted via
Vestibular Nerve to the
Brain. Which then
controls eye movement
to stabilize the gaze
• The ratio of eye to head
movement (GAIN) should
be 1:1. Abnormal gain
can cause symptoms of
blurry vision or vertigo
Central Processing Proprioceptive
Input
From: Armstrong B, McNair P, Taylor D. Head and neck position sense. Sports Med. 2008;38(2):101-117.
Motor Outputs
• VOR (Vestibular Ocular Reflex): generates eye movements, which
enables clear vision while head is in motion
• VSR (Vestibular Spinal Reflex): generates compensatory body movement
in order to maintain head and postural stability, thereby preventing falls
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Dynamic Visual Acuity (VOR)
Gottshall K, Drake A, Gray N, McDonald E, Hoffer ME. Objective vestibular tests as outcome measures in head
injury patients. Laryngoscope. Oct 2003;113(10):1746-1750.
http://www.eastneurology.com.au/images/BPPV%202.jpg
Migraine Related Dizziness (Jeong et al, 2010)
Meta-analysis (Furman et al, 2003) - 534 migrainers:
• Unilateral caloric reduction - 25 %
• Spontaneous nystagmus 10%
• Positional nystagmus - 20%
• Directional preponderance - 50%
• Abnormal postural stability - approx 30%
• Migraine-related dizziness may be the most common disorder presenting to
specialty clinics for dizziness,vertigo and disequilibrium (Neuhauser et. al, 2009)
• Hypersensitivity of the Vestibular System speculated
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Vestibular Migraine Complicated
• Hard to identify… may not report “true headache”
• 114 consecutive post concussive patients who were referred for balance/vestibular rehabilitation
• Significant improvements achieved in following standardized outcome measures of balance/vestibular
function:
• Activity-Specific Balance Confidence Scale
• Dizziness Handicap Inventory
• Gait Speed
• Computerized Dynamic Posturography – Sensory Organization Test
• Dynamic Gait Index
• Functional Gait Assessment
• 5Times Sit to Stand
(Alsalaheen 2010)
Visual Motion Sensitivity Issues
•
•
•
•
•
Vision is in the Brain – facilitated by the eyes
The visual world is a mental construction
Constructing a visual world requires energy and effort
½ of the cerebral cortex is devoted to the task
Visual processing accounts for 44% of the brain’s energy
consumption
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How Does this All Work?
• Spatial/ M Pathway
• Focal/P Pathway
• Proactive
• Reactive
• Lighting Fast
• Slower
• Subconscious
• Cortical/Higher Level Processing
• Movement
• Object Identification
• Spatial Localization
• Guidance of the Fine Motor
• Figure-Ground Segregation
• Spatial Localization
• Larger Impact on
balance/posture/function
• Secondary to Ambient Process in
Survival
• Anticipates change in preconscious
Binocular Occlusion
WARNING!!!
Pencil Push Ups
• Do NOT do in Acute Phase > Focal Binding
• If send home for practice make sure they have someone watching
them
• Optometrists do not send home pencil push ups because they lack
the neuro-cognitive link
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Focal Binding and Motor Skills
• Focal Binding compromises preconscious/proactive
relationship between magnocellular processing and motor
• Movement becomes conscious and isolates function (lack of
automaticity)
• No fluency because system is unable to anticipate
• May have intact peripheral field but no peripheral awareness
MAGNO and PARVO Balance
• Need to be able to use the spatial (magna) and focal (parvo) systems
together and switch back and forth easily between the 2 systems
• Neurological events affect the balance between the 2 systems
• An imbalance between the 2 processes results in information being
by the occipital cortex without spatial pre-programming = poor
anticipation/motor planning
How Does This Make You Feel?
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How Do We Train This?
• All sensory systems working together!
Physical Therapy Concussion Eval: The
Whole Picture
• Subjective Questionnaires: DHI, ABC Scale, NDI, HIT-6
• Complete History of Event – LOC, direction of hit, amnesia, removal from play?, on-field symptoms
• Prior concussion(s), history of mood disorders / anxiety, ADHD, ADD, migraines, learning disabilities
• History of visual impairments
• Management since injury? (cognitive rest, days off school/work, medications, testing)
• Full past medical history
• Complete Vestibular/Ocular Evaluation
• Cervical Spine Evaluation
• Exertional Tolerance Exam
Concussion Exam Components
Exam:
Cervical Range of Motion
Cervical Ligamentous Integrity
General Extremity strength screening
Fine Motor/Coordination Assessment
(finger to nose, finger to object etc)
Joint Position Error Test
Cranial N. Exam
Ocular Motor Range of Motion
Smooth Pursuit
Saccades
Vestibular Ocular Reflex (horizontal and
vertical at different speeds)
Head Thrust Test
VOR Cancellation
Convergence
Ocular Alignment Testing
Optokinetic Nystagmus
Spontaneous Nystagmus
Fixed Gaze Nystagmus
Head Shaking Nystagmus
Dix Hallpike and Roll Test (rule out BPPV)
Vertebral Artery Test
Tragal Pressure/Valsalva for fistula/inner ear tear
Dynamic Visual Acuity (eye chart)
Romberg, Sharpened Romberg, Standing Foam
(modified CTSIB)
Dynamic Gait Index or Functional Gait
Assessment
Tandem walking
Single Leg Stance
BESS Test if applicable / HiMAT
Motion Sensitivity Quotient (if complaints of
motion evoked dizziness)
Modified Balke Protocol/ Buffalo Treadmill Test
(determine threshold for aerobic activities)
Vestibular Rehab
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Visual Acuity/Dynamic Visual Acuity
Visual acuity (VA) is acuteness or clearness of vision,
which is dependent on the sharpness of the retinal focus
within the eye and the sensitivity of the interpretative
faculty of the brain.
Visual Acuity – Static
Dynamic Visual Acuity - DVA
Computerized DVAT
• InVision
• The Dynamic Visual Acuity (DVA) Test
Quantifies the impact of vestibular ocular reflex (VOR) system
impairment on a patient's ability to perceive objects
accurately while moving the head at a given velocity on a
given axis.
• Gaze Stabilization Test (GST)
Quantifies the range of head movement velocities on a given
axis over which a patient is able to maintain an acceptable
level of visual acuity.
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Balance and Gait Assessment
• Romberg, Sharpened Romberg, Single Leg Stance
• Sensory Organization Test (Balance Master)
• Modified CTSIB
• BESS Test
• Dynamic Gait Index
• Functional Gait Assessment
• HiMAT (relatively new for higher level TBI)
• Computerized Posturography…. Neurocom
Buffalo Treadmill Test
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Use of Buffalo Concussion Treadmill Test
Differential Diagnosis of Exertional Symptoms
What We’ve Learned……
• It is more than just balance
• Vestibular/Ocular Component is missing Link
• On Field Markers that Predict Complicated Recovery?
• Outcomes are highly variable
• Vestibular-related symptoms (dizziness/fogginess) and migraine history/symptoms best predict protracted recoveries
• Effective sideline management is key-removal from play a must when symptoms occur
• Return to play prior to full recovery from concussion will result in worse outcome and less force causing re-injury.
• Neurocognitive testing is an effective tool to help quantify the injury and guide the management and RTP process.
• The “mild” injuries may become complicated and the “severe” injuries may become mild
• Proper Clinical management is best form of prevention
• Targeted clinical pathways for treatment and rehabilitation are being established
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Role of Vestibular/Ocular Rehab
Return to Play/Activity
• Does the patient have skewed/blurred vision while body in motion/head turning?
• Do they have continued headaches?
• Do visual tasks increase their symptoms?
• Critical missing link of full sensory integration of visual / vestibular / somatosensory system?
You Have To Train All Systems!
Where Do I Start?
• Ocular ?
• Vestibular?
• Cervical?
• Exertional/Fatigue?
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Rehabilitation
Vision: saccades, convergence, ocular alignment, tracking
Vestibular: VOR, VSR, Balance, motion sensitivity
Cervical: ROM, manual, pain control, posture, proprioception
Exertional: Buffalo Treadmill Test > treatment
Train All Together!!!!
Concussion Rehab Focus
• Fine Motor Deficits/Reaction Time
• Vision
• Eye head coordination
• Headaches
• Fatigue
• Balance/Coordination
• Dual task performance
• Body Mechanics and Posture
• Safe return to activity
Convergence Exercises
• Pencil Push Ups (do not overtrain!)
• Brock String
• Arrow Chart/Dot Card
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Motor Control Exercises
Cervical Stabilization with Visual Feedback
Adaptation Exercises
• VOR x 1 and x 2 viewing exercises
• Progression:
•
•
•
•
•
Duration, goal up to 2 minutes continuous
Velocity
Patterned/Busy backgrounds
Position
Target Distance
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Vestibular Exercises
Vestibular Exercises
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Substitution
• Substitution of other strategies to replace the lost or impaired
function
• Eye tracking
• Oculomotor Exercises
• Saccades
• Eye head coordination exercises
• Remembered Targets
Cheap Dynavision……
Substitution Exercises
Using laser, eyes first then head, how
accurate, add compliant surface
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Cervical Proprioception with Oculomotor
Component
Saccades with Balance and Cervical
Proprioception
Cervical Proprioceptive Exercises
• Head Laser with Targets
• Combine with Saccades
• Eyes Closed awareness
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Vestibular Rehab Concussion
More exercise ideas
Agility Drills
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Progression
• Adaptation (if there is something to adapt)
• Substitution (this includes oculomotor component)
• Habituation
• Add balance component into all of above or separately
What About Visual Motion Sensitivity ?
Factors that may trigger or exacerbate
headaches
• Cervical spine injury
• Impaired sleep
• Higher level cognition
• Vision
• Hearing sensitivity
• Exercise
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Questions?
References
1. Center for Disease Control and Prevention. Concussion and mild TBI. http://www.cdc.gov/concussion/. Updated 2012.
Accessed 11/2012. Accessed 6/18, 2013.
2. Physical Therapist’s Role in Management of the Person with Concussion . http://www.apta.org/StateIssues/Concussions.
Updated 2012. Accessed 11 09, 2012.
3. Missouri 2011 HB 300. http://www.biamo.org/LegislativeIssues.aspx Updated 2012. Accessed 11 09, 2012.
4. 2011 Kan. Sess. Laws, Chap. 45. http://www.kslegislature.org/li_2012/b2011_12/measures/documents/hb2182_enrolled.pdf.
Updated 2012. Accessed 11 09, 2012.
5. Pardini D, Lovell MR, Collins MW, et al. The post-concussion symptoms scale (PCSS): a factor analysis. Br J Sports Med. 2004;
38:661-662.
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sport. Br J Sports Med. 2013;47(1):15-26. doi: 10.1136/bjsports-2012-091941; 10.1136/bjsports-2012-091941.
8. Jamault V, Duff E. Adolescent concussions: When to return to play. Nurse Pract. 2013;38(2):16-22; quiz 22-3. doi:
10.1097/01.NPR.0000425825.82811.ae; 10.1097/01.NPR.0000425825.82811.ae.
9. Purcell L. What are the most appropriate return-to-play guidelines for concussed child athletes? Br J Sports Med. 2009;43
Suppl 1:i51-5. doi: 10.1136/bjsm.2009.058214; 10.1136/bjsm.2009.058214.
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References
13. Alsalaheen BA, Whitney SL, Mucha A, Morris LO, Furman JM, Sparto PJ. Exercise prescription patterns in patients treated
with vestibular rehabilitation after concussion. Physiother Res Int. 2013;18(2):100-108. doi: 10.1002/pri.1532; 10.1002/pri.1532.
14. Harmon KG, Drezner JA, Gammons M, et al. American medical society for sports medicine position statement: Concussion
in sport. Br J Sports Med. 2013;47(1):15-26. doi: 10.1136/bjsports-2012-091941; 10.1136/bjsports-2012-091941.
15. Jamault V, Duff E. Adolescent concussions: When to return to play. Nurse Pract. 2013;38(2):16-22; quiz 22-3. doi:
10.1097/01.NPR.0000425825.82811.ae; 10.1097/01.NPR.0000425825.82811.ae.
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10.1097/JSM.0b013e3181c6c22c; 10.1097/JSM.0b013e3181c6c22c.
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