Alarms raised over rising concussion rates among young female soccer players. solutions are elusive. By Joe Christensen Star Tribune

Transcription

1 Disclosure I have no financial relationships to disclose. Vestibular Rehabilitation Vestibular Rehabilitation Carly Mattson, PT, DPT, OCS Objectives Alarms raised over rising concussion rates among young female soccer players Repetitive hits, concussions, and a mother s long goodbye to youth football By Julie DiCaro September 12 Washington Post Playing Tackle Football Before 12 Is Tied to Brain Problems Later Upon completion of this lecture, participants will More dangerous than football? Girls are being knocked out of games and classrooms By KEN BELSON New York Times more often. Reasons and SEPT. 19, 2017 Vestibular system and how it relates Rehabilitation to concussion management. understand the anatomy and physiology of the vestibular understand the basic vestibular evaluation and treatment relevant to post concussion patients. Be familiar with the research supporting vestibular therapy for patients post concussion. solutions are elusive. By Joe Christensen Star Tribune NOVEMBER 2, :31AM The Truth About Concussions By Samantha Costa, Staff Writer Nov. 10 U.S. News and World Report 1 In 5 Teens Reports A Concussion Diagnosis September 26, :42 AM ET NPR Study: CTE Found In Nearly All Donated NFL Player Brains NPR Tom Goldman July 25, 2017 GRETA JOCHEM Vestibular Rehabilitation Consensus Recommendations % of concussions recover in days. How can we facilitate the recovery for the remaining 20%? Research has supported treatments such as: - Psychological interventions - Vestibular rehabilitation - Cervical spine management - Guided physical exercise McCrory, 2017 McCrory,

2 Cluster of Symptoms for Vestibulo- Ocular Impairments Dizziness Nausea Balance Problems Headache Sensitivity to visual motion - busy environments etc. Blurred vision (when moving head) 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 sportrelated concussion. Schneider, 2014 Mucha, 2014 Review of the Literature 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) - 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 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 w-does-your-ear-work/ Central Vestibular System Vestibular Nuclei Cerebellum Cortex Thalamus 2

3 Vestibular System Vestibular System Function 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 Emory Course Materials Balance System and Concussion What Does the Vestibular System Do? 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). 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 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 3

4 3 components to reflex arc - Peripheral sensory function - semicircular canals - Central processing - Motor output - eye muscles bulo-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 Measuring VOR - Head thrust - Head Shake Nystagmus - Clinical DVA - Computerized DVA - Head movement with stationary target test Rehabilitation for VOR Head eye coordination exercises using various targets VOR Cancellation VOR Cancellation VOR Cancellation: over-riding of VOR Ability to shift direction of gaze along with head movement 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 Inhibition of eye movement as a result of head movement 4

5 VOR Cancellation Treatment for VOR Cancellation 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 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 Clinical Pearls Sense of Vertigo vs. Dizziness - Vertigo = room is spinning rotational component to symptom - Sense of vertigo is often quite strong 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 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 5

6 Cluster of Symptoms for Ocular Motor Impairments Frequency of Ocular Motor Impairments Post Concussion Blurred vision Double vision Headache Difficulty reading Impaired eye movement Poor visual concentration Accommodative Impairments 65% Convergence Insufficiency 55% Saccadic Impairment 30% Smooth Pursuit Impairment 60% Ocular Misalignment 55% Mucha, 2014 Capo-Aponte, 2012 Ocular Motor Exam - Convergence Ocular Motor Exam - Saccades 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 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 6

7 Desensitization Team work! 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 Giza, Christopher C., and David A. Hovda. "The Neurometabolic Cascade of Concussion."Journal of Athletic Training 36.3 (2001): 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, 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 4 th international conference on concussion in sport held in Zurich, November BJSM 2013; 47, 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): ; discussion Mihalik, JP, Stump, JE, Collins, MW, Lovell, MR, Field, M and Maroon, JC. Posttraumatic migraine characteristics in athletes following sports-related concussion. Neurosurgery. 102: 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 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): Schubert MC. Clinical assessment of the ocular motor systems. Vestibular SIG Newsletter, Spring Gill-Body, Kathleen M. "Current Concepts in the Management of Patients With Vestibular Dysfunction." PT Magazine 8.12 (2001): 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 Sep;26(5): Guerraz, M, Yardley, Bertholon, P, Pollak, L, Rudge, P, Gresty, MA., and Bronstein AM. Visual Vertigo: symptom assessment, spatial orientation and postural control. Brain , 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), 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), Image Citations Vestibular rehabilitation picture - What does the vestibular system do picture - Vestibular system picture - ttp://en.wikipedia.org/wiki/vestibular_system Head Thrust picture - Dynamic visual acuity test picture - Resourcesonbalance.com picture - 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 (2012): Gessel, Luke. "Concussions Among United States High School and Collegiate Athletes." Journal of Athletic Training 42.4 (2007): Yang CC et. Al (2009). Early clinical characteristics of patients with persistent post-concussion symptoms: a prospective study. Brain injury. 23(4): BPPPV roll test picture - Saccades picture - Smooth pursuits picture - VOR cancellation slide: Team work slide: or&usg=afrqezedfcopdaftbt- NsIc9ff1oMpb6jA&sa=X&ved=0ahUKEwi1gPPnsZ3dAhXB6YMKHZayBkcQ4lYIKygD&biw=1517&bih=646&dpr=0.9#imgdii=8MOaU1fTFhsqWM:&imgrc=lhipv3G7GpRViM: 7