10/11/2017. Disclosure: I have no actual or potential conflict of interest in relation to this program/presentation

Transcription

1 Vestibular Rehabilitation: Beyond BPPV Treatment Options for Challenging Vestibular Disorders Kathy L. Joy Vestibular Rehabilitation Program Director Disclosure: I have no actual or potential conflict of interest in relation to this program/presentation Workshop Overview Concussion Pathophysiology Criteria for post concussive symptoms Diagnostic algorithm: one way to think about PCD Physiologic vs. Vestibulo- ocular vs cervicogenic Vestibular Rehab Treatment ideas Migraine associated Vertigo Definitions and criteria Treatment strategies Chronic subjective Dizziness (CSD) / Persistent Perceptual Postural Dizziness 1 1

2 Vestibular PT Repositioning Maneuvers Eye Exercises/oculomotor training Gaze Stability Training Visual motion exercises Balance retraining: Grounding Manual work and strengthening Cspine Fitness Clinical Vestibular Exam Oculomotor Function: What can we do in the clinic to test Ocular alignment Smooth pursuit Saccades Vergence Clinical Exam Vestibulo-ocular reflex: VOR: Head thrust, Head shaking nystagmus Gaze Stability VOR: Dynamic visual acuity (Snellen Chart, LogMar) VOR cancellation 2

3 Review of Vestibular System Peripheral Vestibular System: semicircular canals, otoliths and the eighth cranial nerve Clinical Vestibular Examination Positional Testing Dix-Hallpike Test 3

4 Canalith-Repositioning: posterior canal BPPV Furman J NEJM, 341(21), 1999 Furman J NEJM, 341(21), 1999 Furman J NEJM, 341(21), 1999 Clinical Examination Vestibulospinal Function Balance Exam Gait Examination/Dynamic Postural Control Velocity timed measures Head movements, eyes closed, base of support, foam, quick turns Consider Cognitive Activities and Dualtask training Concussion 4

5 Concussion: Definitions American Academy of Neurology Summary Statement: A trauma induced alteration in mental status that may or may not involve loss of conciousness Confusion and amnesia are the hallmarks of concussion Due to biomechanical forces affecting the brain Concussion: Definition Complex pathophysiologic process induced by traumatic forces secondary to direct or indirect forces to the head that disrupts the function of the brain. Center for Disease Control and Prevention A blow or jolt to the head that: May or not involve LOC Typically associated with normal structural neuroimaging findings Disrupts brain function Results in variety of physical, cognitive, emotional and/or sleep-related symptoms Concussion: Definition DoD/ VA Normal Structural imaging LOC 0-30 minutes Alteration of consciousness, mental state for a moment up to 24 hours Post traumatic amnesia for 0-1 day. Glascow Coma Scale

6 Commonalities Secondary to biomechanical trauma May or may not have LOC Normal structural imaging Neuropathic changes with functional disturbance rather than structural changes Generally symptoms resolve quickly (3-5 days) Pathophysiology Initial injury Axonal Shearing Disruption of neuronal membranes Release of Glutamate K+ efflux/ Ca+ influx Altered cellular environment Neurometabolic Cascade Christopher C. Giza and David A. Hovda. The Neurometabolic Cascade of Concussion. J Athl Train Jul-Sep; 36(3):

7 Pathophysiology NA/K pump works overtime Increased energy demand Increased glycolosis/ lactic acid Decreased cerebral bloodflow Decreased Metabolism Metabolic crisis Signs and Symptoms Multifactorial Somatic Emotional Cognitive Sleep Disturbance Diagnostic Testing/ Imaging Brain CT or MRI contributes little to concussion evaluation but should be employed whenever suspicion of an intra-cerebral structural lesion exists otherwise they are insensitive Examples of such situations may include prolonged disturbance of conscious state, focal neurological deficit or worsening symptoms. 7

8 Diagnostic Testing/ Imaging fmri demonstrates activation patterns that correlate with symptom severity and recovery in concussion. Reveals local blood flow and metabolic changes in real time when asked to do a cognitive activity Post-concussion syndrome (PCS) Diagnosed by clinical criteria ICD 10 code: Must have 3 or more of the following symptoms: headache, dizziness, fatigue, irritability, insomnia, concentration difficulty, or memory difficulty Post- concussive symptoms can affect > 20-30% of patients with mild TBI. (World Health Organization s International Classification of Diseases, or ICD-10) What about Protracted Recovery? Factors that may influence Did not rest initially Previous Concussions Co-morbid physical conditions Migraines, seizures, vertigo, neck pain Co-morbid psych condition Anxiety, depression, sleep disorder, substance abuse Developmental History Learning Disability, ADHD Medications 8

9 Tests and inventories Sideline tests: SCAT; Maddocks Score; BESS test Other tests/inventories: looking at subjective symptoms Rivermead, PCS Symptom scale, Balance Error Scoring System (BESS) Post-Concussion Symptom Scales 9

10 Active Rehabilitation At this stage in recovery, vestibular symptoms, residual neck injury, exercise intolerance/dysautonomia and memory issues respond better to active rehab through targeted strategies rather than strict rest. Vestibular therapy Aerobic exercise at subsymptom threshold Speech therapy for working memory and executive functioning» Vidal PG;Speicialized PT, LLC; CH, NJ PCD Algorithm Physiologic PCD Vestibulo-ocular PCD Cervicogenic PCD Physiologic PCD Determined by use of the graded treadmill test Buffalo Concussion Treadmill test: BCCT Start at 3.3mph, 0% incline and increase incline by 1% every minute Monitor heart rate and BP and VAS every 1-2 minutes 10

11 Physiologic PCD Whatever the HR was at the point when symptoms increased, exercise at 80% of that heart rate Physiologic PCD 20 80% THR x 2 wks If tolerated, THR by 5-10 bpm and repeat every 2 weeks PCD Algorithm Leddy J et al; Brain Inj, 2015; 29(2):

12 Vestibulo-ocular PCD Peripheral BPPV to vestibular deficit Central Migraine Anxiety Autonomic issues Oculomotor deficits Vestibulo-ocular PCD Vestibular Migraine Autonomic Dysregulation Relates back to physiologic PCD Anxiety CSD PTSD Vestibulo-ocular PCD Oculomotor dysfunction Saccadic/pursuit abnormalities Convergence insufficienty Convergence spasm Gaze stabilization 12

13 Vergence The simultaneous movement of both eyes in opposite direction to obtain/maintain singular binocular vision. Normal is 2-3 inches. Proven to demonstrate impairment when Sx report is negative. Deficitis: Difficulty reading/focusing Trouble taking notes or watching lecture Blurred vision Pulling sensation around eyes Eye strain 13

14 Convergence Insufficiency Patient cannot converge to near targets Testing: looking for when patient sees two images. Deficitis: Difficulty reading/focusing Trouble taking notes or watching lecture Blurred vision Pulling sensation around eyes Eye strain Brock String wikipedia Convergence Spasm Excessive convergence. Remain converged and have pupillary constriction. Deficitis: Difficulty reading/focusing Trouble taking notes or watching lecture Blurred vision Pulling sensation around eyes Eye strain These deficits can cause fatigue, headaches and dizziness 14

15 Vestibulo ocular PCD Gaze Stability Deficits Motion Sensitivity vs. Central integration issues Clinical Tests of VOR: Gaze Stability X1 Viewing X2 Viewing VOR Cancellation (VORc) 15

16 Cervicogenic PCD Persistent concussion symptoms and impairments caused by dysfunction of the cervical spine somatosensory system Cervicogenic Dizziness 46 Cervicogenic PCD Careful examination of cervical spine, posture and gait Symptoms: Neck Pain, Stiffness/restricted ROM Fatigue Dizziness Spatial Disorientation, feel out of it Symptoms worsen as the day progresses Specific headaches Cervicogenic PCD Treadmill Test Goals of Rehab: Reduce pain Restore normal somatosensory output and connections to vestibular and oculomotor systems 16

17 Patient presentation Symptoms of dizziness and instability/imbalance are aggravated by head movements Have to determine if the symptoms are due to stimulation of the vestibular or cervical system. 49 Cervicogenic Dizziness exam Stress testing for instability VBI testing AROM Posture Soft tissue involvement Head/neck torsion test Cervical kinesthetic sense 50 Cervical Vertigo : Exam Differentiating between neck and vestibular Vestibular Rehabilitation; Herdman, 2007; 3 rd edition 17

18 Treatment and Management Soft tissue mobilizations/release Postural corrections Active and Passive mobility Retrain kinesthetic sense Joint repositioning exercises Strength and conditioning 52 Cervico Ocular Exercise Stand or sit tall Awareness of the middle of feet Keep eyes on a target Rotate trunk under a stable head while keeping eyes on target Continue for 2-5 minutes, resting if needed 53 Cervical myofascial therapy Suboccipitals SCM Paraoral: masseter, temporalis, pterygoids 54 18

19 Suboccipital Muscles The Sternocleidomastoid SCM Self Compress and Stretch Neckandbackexercises.com 19

20 Self Trigger Point Therapy Neckandbackexercises.com Temporalis Compress and Stretch Seated Postural Correction Neckandbackexercises.com 60 20

21 Chin Tuck Exercise 61 Vestibular PT Eye Exercises/oculomotor training Gaze Stability Training Eye-head Motion Balance retraining Manual work and strengthening Cspine Cervical kinesthetic training Coordination Conditioning/Fitness Exercise Progression General rule is no exacerbation of concussion sx with any activities. 21

22 General Treatment Considerations for concussion Anxiety/Depression Symptoms with exertion Oculomotor Issues Sleep Dysfunction Visual Vertigo Migraine Migraine Migraine is a neurological event Often occurs with headache Range from no pain to severe pain with ischemic damage Most common non-pain form of migraine is visual visual but can be other symptoms- including dizziness Migraine and Dizziness Studies 22

23 Proposed Definition for Vestibular Migraine: Definite Episodes of at least moderate severity Current or prior history of migraine One or more of these migrainous symptoms during at least two attacks of vertigo: migrainous headache, phonophobia, photophobia, visual or other aura Other cause ruled out Proposed Definition for Vestibular Migraine: Probable Episodes of at least moderate severity One of the following: Current or prior history of migraine Migrainous symptoms during vestibular symptoms Response to migraine meds in 50% Migrainous precipitants of vertigo in greater than 50% of attacks Other causes ruled out Vestibular Migraine Prevention: Behavioral Dietary changes Reduce Stress Aerobic Exercise Tai Chi Regular meals Stable sleep schedule Avoid Nicotine Hormone Replacement 23

24 Vestibular Migraine vs Menieres Disease Migraine Spontaneous episodes Unilateral tinnitus and fluctuating hearing Unlikely permanent progressive hearing loss Mild ENG findings Duration of vertigo seconds to days Meniere s Spontaneous episodes Unilateral tinnitus and fluctuating hearing Likely permanent progressive hearing loss Mild to significant ENG findings including asymmetry Duration of vertigo > 10 minutes and < 24 hours Psychological Symptoms with Dizziness Studies/ Evidence Psychological Symptoms with Dizziness Vestibular disorder: physical symptoms can develop some depression and anxiety Predisposition of psych issues without vestibular disorder - symptoms are second to heart palpitations and panic Provocation from stress reaction which triggers vestibular event 24

25 Psychological Symptoms with Dizziness Perpetuation: capturing and causing symptoms to continue even though the original source of dizziness is resolved Chronic Subjective Dizziness A proposed specific clinical syndrome of which the cardinal feature is persistent dizziness not explained by an active medical condition (Staab JE; et al Arch Otolaryngology Head Neck surgery 2007; 133:170-6 Persistent, Postural, Perceptual Dizziness Chronic Subjective Dizziness Typically associated with other disorders: Migraine, PCD, lightheadedness, anxiety 25

26 Chronic Subjective Dizziness Presentation: Persistent Dizziness > 3 months; will confirm that it is 24/7, extremely sensitive to visual motion and self motion Symptoms increase with complex environments and visual tasks Model of CSD Classifications of CSD Otogenic Psychogenic Interactive 26

27 Treatment Approach for CSD Smaller studies have had reasonable success with 3 pronged approach Medications Cognitive / Behavioral Therapy Vestibular and Balance Rehab Therapy Thank You 27