Predictors of Protracted Recovery
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1 CONCUSSION MANAGEMENT SPECIALIST ON LINE CURRICULUM Protracted Recovery and Clinical Rehabilitation All rights reserved. Sports Medicine Concepts Concussion Management Specialist Program 1 Predictors of Protracted Recovery Significant: amnesia, balance abnormalities, tinnitus & visual impairments at 20 min. 87% probability: headache & amnesia at 5 min 73% probability: headache, dizziness & balance abnormalities at 20 min Friday, September 15, Protracted Recovery Theories CBF Disconnect Post Concussion signs and symptoms that do not resolve with rest within 7 10 days may be due to reduced cerebral blood flow resulting from initial injury Vestibular Disorders Vestibular impairments common following concussion may delay recovery Sports Medicine Concepts, Inc Friday, September 15, All Rights Reserved 1
2 Indications for Clinical Rehabilitation Clinical Rehabilitation should be considered in the management of concussed individuals who do not recover with rest in 7 10 days Friday, September 15, The CBF Disconnect Reestablish CBF Leddy Article In patients with lingering S/S proper exercise prescription can result in improvement Sports Medicine Concepts 5 Medically Supervised X Cise Rx Step Wise RTP Physical and Cognitive Progression Sub Symptom Progression Sports Medicine Concepts, Inc Friday, September 15, All Rights Reserved 2
3 Vestibular System Small Sensory Organs of the Inner Ear Utricle Saccule Semicircular canals Connections to Brain stem Cerebellum Cerebral Cortex Ocular System Postural Muscles Sports Medicine Sports Concepts, Medicine IncConcepts, Inc Friday, September 15, Vestibular System Provides information regarding head movements and position Maintain balance and visual control Friday, September 15, Why The Vestibular System? 1. Headache (71%) 2. Feeling slowed down (58%) 3. Difficulty concentrating (57%) 4. Dizziness (55%) 5. Fogginess (53%) 6. Fatigue (50%) 7. Visual blurring/dbl vision (49%) 8. Light sensitivity (47%) 9. Memory dysfunction (43% 10. Balance problems (43%) Lovell et al, 2004 Protracted recovery Younger athletes Female athletes ADD Rx Friday, September 15, All Rights Reserved 3
4 2 Distinct Functional Units Vestibulo Ocular System VOMR Maintains visual stability during head movements Eye position in orbit Head position in space Eye position in space Dizziness Visual instability Sports Medicine Concepts, Inc Friday, September 15, Distinct Functional Units Vestibulo Spinal System Vestibulo Spinal Reflex (VSR) Balance Control Most active when vision and somatosensation are reduced Sports Medicine Concepts, Inc Friday, September 15, Vestibular System Injury Distinct Functional Units Possible to have injury to one system without impairment of the other Sports Medicine Concepts, Inc Friday, September 15, All Rights Reserved 4
5 Vestibular System Injury Signs and Symptoms of Acute signs and symptoms typical of vestibular system involvement may not be accurate indicator of VS injury Balance impairment reported in 40% of concussed athletes within first week Recover within 3 5 days Sports Medicine Concepts, Inc Friday, September 15, Implications Protracted recovery Post traumatic Benign paroxysmal positional vertigo Co existing Labyrinthine concussion Post traumatic migraine related dizziness Central vestibular dysfunction/brainstem concussion Return to play Treatable Rehab techniques Time Friday, September 15, More Predictive Subjective Symptoms Dizziness Impaired balance (particularly in the dark) Blurred vision Motion discomfort Height phobia Difficulty in busy visual environments Sports Medicine Concepts, Inc Friday, September 15, All Rights Reserved 5
6 Space and Motion Discomfort Space and Motion Discomfort (SMD) Jacob et al, 1993 Visual Vertigo Bronstein, 1005 Chronic Subjective Dizziness Staab, 2004 Uneasiness created by situational stimuli Moving crowds, supermarkets, malls, staircases, heights Heightened awareness of normal motion Coexists with migraine and/or anxiety Seems to be responsive to medication, vestibular therapy, & behavior therapy Whitney et al, 2005; Jacob et al, 2001 Or Time? Friday, September 15, Aural Symptoms May indicate labyrinthine injury Changes in hearing Tinnitus, particularly lateralizing Pressure/fullness in ear(s)] Tend to be associated with protracted recovery Referral to Otology or Otoneurology Friday, September 15, Dizziness Handicap Inventory Somewhat more objective measure of 25 item subjective self rating Each item answered yes, no, or sometimes Score: Yes = 4 No = 0 Sometimes = 2 Higher score reflects higher disability Materials section: Jacobson and Newman, 1990 Some modifications to questions required for younger athletes Friday, September 15, All Rights Reserved 6
7 Balance Inquiry Subjective Falls since concussion? Staggering, veering or near falls? Imbalance in the dark/getting out of bed? Motion sickness (particularly in the car?) Looking up? Quick head movements? Turning over in bed? Bending over? Lying down? Vestibular Screening Examinations Form Materials section Friday, September 15, Balance Error Score (BESS) Friday, September 15, Balance Error Scoring System Types of Errors Lift hands off illiac crest Opening eyes Step, stumble of fall Moving hip into>30 degrees abduction Lifting forefoot or heel Remaining out of testing position > 5sec Calculation of BESS Score Adding one error point for each error during the 6 20s tests Friday, September 15, All Rights Reserved 7
8 BESS Score Card SCORE CARD: (# of errors) Double Leg Stance (feet together) Single Leg Stance (non dominant foot) Tandem Stance (non dominant foot back) TOTAL SCORES: BESS TOTAL FIRM Surface FOAM Surface Sports Medicine Concepts, Inc Friday, September 15, Normative BESS Scores BESS Norms Firm Surface Foam Surface Dbl Leg Stance.009 +/ /.90 Single Leg Stance / / 2.80 Tandem Stance.91 +/ / 2.62 Surface Total / / 5.13 BESS Total Score / 7.34 Sports Medicine Concepts, Inc Friday, September 15, BESS as Rehab Foam Surface Increased tactile surface theorized to increase proprioception Tandem Walking Friday, September 15, All Rights Reserved 8
9 Physical Exam Ocular Motor Smooth pursuits Saccades Convergence Nystagmus Vestibulo Ocular VOR Vision Therapy? Expensive Insurance? Effectiveness? Friday, September 15, Pursuits Movements At about 40 cm, head fixed. Do they pass through full range? Do they move smoothly is there evidence of nystagmus? Do they move synchronously? Friday, September 15, Saccades Quickly move from point to point. Look for patient to overshoot or undershoot target. King DevickTest Sports Medicine Concepts, Inc Friday, September 15, All Rights Reserved 9
10 Convergence 10 cm or less from nose to target Discomfort Headache Pain in eyes Sports Medicine Concepts, Inc Friday, September 15, Vestibulo Ocular Reflex Side to side movement at comfortable speed with eyes fixed on target Dizziness Nystagmus Unsteadiness Motion sickness Sports Medicine Concepts, Inc Friday, September 15, SMC Enhanced VOM Screen Provides easy opportunity to record wealth of vestibular information Record Symptom Onset with Baseline Symptoms Balance Screen BESS Sports Medicine Concepts, Inc Friday, September 15, All Rights Reserved 10
11 Early Management of Balance Abnormalities Friday, September 15, Visually Conflicting Environments Treadmill Wii Sports Medicine Concepts, Inc Friday, September 15, Management of Vestibular Dysfunction Hallpike Dix Maneuver Observe for side lying or positional nystagmus/dizziness Friday, September 15, All Rights Reserved 11
12 Canalith Repositioning Maneuver Benign paraxymal positional vertigo (BPPV) Start on affected side Hold s, watch for nystagmus Turn 45deg to affected side Turn 45deg to unaffected side Wait 30sec after nystagmus/dizziness subsides Friday, September 15, Canalith Reposition Maneuver Moves otoliths out of SCC Broken free via impact Friday, September 15, Canalith Reposition Maneuver Head up/vertical head position for next 48 hours Soft collar may help maintain vertical head position May require multiple tx 80 90% cure rate? Contraindications Ongoing CNS disease, including stroke Unstable heart disease High grade carotid stenosis Severe neck disease Friday, September 15, All Rights Reserved 12
13 Get Them OUT of the Clinic Pursuits Saccades Convergence Computer Free! School s like that! Easy on i Pad, tablet, etc Slippery Slope On set of depression VOR: Sports specific rehab include: free throws ground balls/pass Max protect Friday, September 15, Pharm X and Modifying Conditions Pharmaceutical and prescription med profile review should be intricate part of your on going assessment Depression ADD/ADHD Sleep disorders Anxiety Sports Medicine Concepts, Inc Friday, September 15, All Rights Reserved 13
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