Use of Ves(bular Therapy in the Concussed Athlete R. Robert Franks, D.O., FAOASM Director Sports Concussion Program Rothman Ins(tute OMED 2013 Las Vegas, Nevada October 1, 2013 Objec(ves •  To discuss ves(bular history clues in the office treatment of the concussed athlete •  To discuss the ves(bular physical examina(on clues in the office treatment of the concussed athlete •  To discuss ves(bular treatment modali(es and return to play criteria Introduc(on •  Most common head injury in athle(cs. •  Fewer than 10 percent result in loss of consciousness. •  Es(mated 2.25 million concussions uniden(fied each year. 1
Introduc(on •  At risk sports include football, boxing, hockey, wrestling, gymnas(cs, lacrosse, soccer, cheerleading and basketball. •  Once a concussion has occurred, a player is 4 to 6 (mes more likely to sustain a second concussion. Before Exam Begins •  Watch athlete walk to exam room •  CT Scan if done •  Computerized Neurocogni(ve Test Baseline and any post-­‐tests •  SCAT2 or BESS Scores •  PPE of athlete with complete concussion history •  Phone number of your ATC at your athlete’s school Key Historical Ques(ons •  Do they have a pressure headache and does it get worse with school or exer(on? •  Do they get dizzy with movement? •  Do they get fa(gued at a certain point in the day? •  Are they more sensi(ve to light/noise? 2
UPMC Symptom Categoriza(on •  Cervicogenic –  Dysfunc(on to the cervical spine UPMC Symptom Categoriza(on •  Cogni(ve Symptoms – A`en(on Problems – Dysfunc(on – Fogginess – Fa(gue – Cogni(ve Slowing UPMC Symptom Categoriza(on •  Emo(onality – More emo(onal – Sadness – Nervousness – Irritability 3
UPMC Symptom Categoriza(on •  Sleep Disturbance – Difficulty falling asleep – Sleeping less than usual UPMC Symptom Categoriza(on •  Ves(bular – Ability of ophthalmologic and neurological systems and body (eyes, brain, and body) to work together UPMC Symptom Categoriza(on •  Ocular – Ability of ophthalmologic system to work appropriately – Are vergence and divergence appropriate 4
Ves(bular Examina(on •  Anatomy –  Central Ves(bular System •  Ves(bular Nuclei •  Cerebellum •  Autonomic Nervous System •  Thalamus •  Cerebral Cortex Ves(bular Examina(on •  Anatomy –  Peripheral Ves(bular System •  Semicircular Canals •  Otoliths – Utricle and Saccule •  Ves(bular Ganglia •  Ves(bular Nerve Ves(bular Examina(on •  2 systems affected –  Ves(bular Ocular Reflex System (VOR) •  Stabilizes vision while head moves –  Ves(bular Spinal Reflex (VSR) •  Balance control 5
Ves(bular Examina(on •  Aural Symptoms –  Can occur status post concussion –  Tinnitus, fullness or hearing changes usually have worse prognos(c recovery –  Cause may be a mixed central and peripheral ves(bular disturbance that allows for slower and ogen incomplete recovery Ves(bular Examina(on •  Dizziness Status Post Concussion –  Inner Ear •  Benign Paroxysmal Ver(go •  Labyrinthine Concussion •  Perilympha(c Fistula Ves(bular Examina(on •  Dizziness Status Post Concussion –  Central •  Post Trauma(c Migraine Related Dizziness •  Brainstem Concussion •  Autonomic Dysregula(on/Postural Hypotension •  Ocular Motor Abnormali(es •  Seizure 6
Ves(bular Examina(on •  Causes of Dizziness Status Post Concussion – Cervicogenic Dizziness Ves(bular Examina(on •  Ocular Motor Tes(ng –  Gaze holding/fixa(on –  Pursuits –  Saccades –  Optokine(c Nystagmus –  Convergence –  Alignment –  Ves(bulo Ocular Reflex (VOR) Ves(bular Examina(on •  Ocular Motor Tes(ng –  1. Gaze Fixa(on •  Maintain eye fixa(on on target without drig •  Tested in neutral and up to 9 planes and in light and dark •  Look for rebound nystagmus –  Eye movement to direc(on of last movement ager return to center 7
Ves(bular Examina(on •  Ocular Motor Tes(ng –  2. Smooth Pursuits •  Eyes follow a target –  3. Saccades •  Quick movement of eyes between targets –  4. Convergence •  Ability to focus on near target •  Watch for convergence spasm Ves(bular Examina(on •  Ocular Motor Tes(ng –  5. Ocular Alignment •  Look for misalignment – strabismus or lazy eye •  Tes(ng –  Cover/Uncover Test –  Cross Cover Test –  Maddox Rod Ves(bular Examina(on •  Ocular Motor Tes(ng –  6. Ves(bulo-­‐Ocular Reflex (VOR) •  Ability to focus on sta(onary object while moving head without blurriness or dizziness •  Tes(ng –  Head Thrust Test –  Clinical Dynamic Visual Acuity Test –  Head Shake Nystagmus Test 8
Ves(bular Examina(on •  Dizziness and Mo(on Dysfunc(on –  Feeling of unease with fluid s(muli –  Inability to seamlessly maneuver –  Increased awareness of normal mo(on –  Ogen coexists with migraine (migraine induced dizziness) or anxiety (migraine anxiety related dizziness) Ves(bular Examina(on •  Dizziness and Mo(on Dysfunc(on –  Tes(ng •  VOR Cancella(on •  DHI – Dizziness Handicap Inventory •  CTSIB – Clinical Test of Sensory Integra(on on Balance (Foam and Dome) Ves(bular Examina(on •  Balance Dysfunc(on –  Pa(ent inability to hold self up or maintain posture voluntarily in a plane 9
Ves(bular Examina(on •  Balance Dysfunc(on –  Balance Tes(ng •  Pa(ent self report (Ac(vity Specific Confidence Scale or Falls Efficacy Scale) •  BPPV Tes(ng •  Tes(ng Plaiorm (i.e. Biosway) •  Balance Error Scoring System (BESS) •  Computerized Dynamic Posturography Ves(bular Examina(on •  Balance Dysfunc(on –  Balance Tes(ng •  Dynamic Gait Index •  Func(onal Gait Assessment •  HiMAT (High Level Mobility Assessment Tool) •  Dual Cogni(ve Task Paradigms •  Five Time Sit to Stand •  Timed Up and Go Test (TUG) Ves(bular Physician Examina(on Ves(bular Tes(ng 1. Smooth Pursuit – Extra-­‐ocular Muscle Tes(ng 10
Ves(bular Physician Examina(on Ves(bular Tes(ng 2. Saccades Tes(ng •  Point to Point Discrimina(on in horizontal and ver(cal planes (Fingers 12 inches apart and pa(ent looks between them for 15 seconds.) •  Look for latency of onset, speed, accuracy and conjugate movement. Test failure is delayed, inaccurate saccades or disconjugate eye movement. Ves(bular Physician Examina(on Ves(bular Tes(ng 3.  Ves(bulo-­‐Ocular Reflex (VOR) – Gaze Stability •  Ability to focus on sta(onary object while moving head without blurriness or dizziness •  Do with examiner finger sta(onary and pa(ent moving head side to side while fixa(ng on sta(onary finger •  Test in horizontal and ver(cal plane for 15 seconds •  Look for inability to hold focus Ves(bular Physician Examina(on Ves(bular Tes(ng 4. Fixa(on Suppression Test – Response to optokine(c s(umla(on – Pa(ent focus on thumb as moves side to side following own thumb – Look for inability to follow fixated object 11
Ves(bular Physician Examina(on Ves(bular Tes(ng 5. Near Point Convergence Dysfunc(on Test – Focus on wri(ng on pen 6 cm from nose bridge – Look for diplopia at greater than 6 cm Ves(bular Physician Examina(on Ves(bular Tes(ng 6. Test of Near Point Accommoda(on -­‐ Cover one eye -­‐ Bring object to face -­‐ Should accommodate – see clear at 15 cm -­‐ Can fa(gue system by bringing closer Balance Assessment •  BESS –  3 Tests 6 different balance condi(ons las(ng 20 seconds –  Stance sejngs – double leg, single leg, and tandem done on three surfaces – stable/firm and unstable/foam. –  Score determined by amount of errors recorded during different balance condi(ons – one point for each error –  Increased error reflect increased problems with balance and coordina(on post concussion 12
Ves(bular Therapy •  Helps with dizziness, ver(go, balance, and vision/visual discrimina(on associated with concussion •  Uses current PT and OT maneuvers •  May be used alone or as adjunct therapy Ves(bular Therapy •  Mean dura(on of ves(bular therapy in significant concussions can be as long as 33 days Ves(bular Therapy •  5 Main Categories of Exercise – Eye-­‐Head Coordina(on • Involve movement of head and/or eyes for purpose of VOR gain adapta(on, symptom habitua(on or oculomotor re-­‐educa(on 13
Ves(bular Therapy •  5 Main Categories of Exercise –  Eye-­‐Head Coordina(on • Exercises ο VOR x 1 ο VOR Cancella(on ο Smooth Pursuits ο An(cipatory Gaze Shigs ο Imagined Target ο Saccades Ves(bular Therapy •  5 Main Categories of Exercise –  Sijng Balance Exercises •  Maintain balance while sijng upright, weight shiging side to side or bouncing Ves(bular Therapy •  5 Main Categories of Exercise –  Standing Sta(c Balance Exercises •  Pa(ent stands with feet in place while upright or weight shiging •  Can be asked to stand on one leg, stand on a rocker board, or stand with one foot on a step •  Includes the sit to stand exercise 14
Ves(bular Therapy •  5 Main Categories of Exercise –  Standing Dynamic Balance Exercises •  Pa(ent stands and moves without walking •  Pa(ent may march in place, step forward, step backward, step to the side, step up and down, or turn around Ves(bular Therapy •  5 Main Categories of Exercise –  Ambula(on Exercise •  Pa(ent walks forward, backward, on stairs, with turns and prac(ces braiding, skipping, jogging, and running Ves(bular Therapy •  5 Main Categories of Exercise –  10 modifiers to describe exercise characteris(cs •  Posture •  Surface •  Size of base support •  Posi(on of trunk •  Posi(on of arms 15
Ves(bular Therapy •  5 Main Categories of Exercise –  10 modifiers to describe exercise characteris(cs •  Direc(on of head movements •  Direc(on of whole body movements •  Visual input •  Presence or absence of a dual cogni(ve task •  Special circumstances Ves(bular Therapy •  5 Main Categories of Exercise –  Exercises are recorded in frequency and dura(on Ves(bular Therapy •  Most commonly prescribed exercises –  Eye-­‐head coordina(on – 95% •  VOR x 1 •  VOR Cancella(on •  Convergence 16
Ves(bular Therapy •  Most commonly prescribed exercises –  Sta(c Balance – 88% •  Standing upright on level and foam surfaces •  Single leg stance •  Weight shiging exercises in various direc(ons •  Sit to stand Ves(bular Therapy •  Most commonly prescribed exercises –  Ambula(on – 76% •  Forward •  Backward •  Walking with turns Ves(bular Therapy •  Maneuvers –  Gaze Stability Training –  Eye and Head Mo(on Training –  Binocular Vision Exercises • 
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Dot Card Brock String Pencil Push Ups Two Targets –  Oculo-­‐motor Exercises •  Increases coordina(on between eyes, brain and ves(bular system 17
Ves(bular Therapy •  Maneuvers –  Epley Maneuver •  Treats posi(onal ver(go –  Balance Retraining •  Improves balance by having brain use all systems affec(ng balance –  Mo(on Tolerance Exercises •  Retrains brain to adapt to specific movements without dizziness –  Exer(onal Tolerance Ac(vity • 
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Bike Treadmill Resistance Training Sports Specific Ac(vity Ves(bular Therapy •  Maneuvers – Cervicogenic Rehabilita(on • Manual Therapy • ROM • Strength Training • Injec(on • OMT • Acupuncture Ves(bular Therapy •  Maneuvers – Exer(onal Tolerance Ac(vity • Bike • Ellip(cal Walker • Stair Stepper • Treadmill • Resistance Training • Sports Specific Ac(vity 18
Return to Play •  Never return a player who s(ll has concussive symptoms. •  Pa(ent requires physical and cogni(ve rest •  This includes ac(vi(es that require concentra(on and a`en(on –  School Work –  Video Games –  Text Messaging •  If symptoms have resolved with rest, test pa(ent with exer(on. Return to Play •  Player should proceed stepwise. •  If post-­‐concussive symptoms recur, the athlete should drop back to previous asymptoma(c level and a`empt progression again in 24 hours. •  Should not be taking any pharmacological agents that may effect or change symptoms of concussion. •  Should have neuropsychological tes(ng return to baseline Return to Play •  No ac(vity –  Complete rest –  Recovery Phase •  Once asymptoma(c for 24 hours, proceed to step 2 19
Return to Play •  Light aerobic exercise –  Walking –  Swimming –  Sta(onary Cycling •  All Less Than 70 % MPHR •  No Resistance Training •  – Increase HR Return to Play •  Sport-­‐specific training –  Ska(ng drills in ice hockey –  Running in soccer –  No head impact ac(vi(es –  Add movement Return to Play •  Noncontact training drills –  Progression to more complex training drills •  Passing drills in football •  Passing drills in hockey •  May begin progressive resistance training –  Exercise, coordina(on, and cogni(ve load 20
Return to Play •  Full-­‐contact training ager medical clearance –  Restore confidence and assess func(onal skills by coaching staff •  Return to game play Return to Play •  No child or adolescent athlete, including the collegiate athlete, no ma`er the skill level, should return to play on the same day. •  Some NFL studies have shown no risk of recurrence or sequelae with same day RTP in presence of physicians with experience and rapid neurocogni(ve assessment. –  However, full clinical and cogni(ve recovery must occur before considera(on of RTP References •  McCrory, P., Et Al. “Summary and Agreement Statement of the 3rd Interna(onal Conference on Concussion in Sport, Zurich 2008.” Clinical Journal of Sports Medicine. 19: 185-­‐195. May 2009. •  McCrory, P., Et Al. “Summary and Agreement Statement of the 2nd Interna(onal Conference on Concussion in Sport, Prague 2004.” Clinical Journal of Sports Medicine. 15: 48-­‐55. March 2005. •  Aubry, M., Et Al. “Summary and Agreement Statement of the First Interna(onal Conference on Concussion in Sport, Vienna 2001.” Physician and Sports Medicine. 30: 57-­‐63. Feb 2002. •  Johnson, K. M., Et Al. “Evidence Based Review of Sport-­‐
Related Concussion.” Clinical Journal of Sport Medicine, 11:150-­‐9. 2001. 21
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