9/6/2017. Physical Therapist Role in Management of Concussions. Areas where Physical Therapy Can Help. What is the Vestibular System?

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1 Physical Therapist Role in Management of Concussions The APTA recognizes that physical therapists are part of the multidisciplinary team of licensed healthcare providers that assist in concussion management, which includes: Examination and evaluation to establish a diagnosis Treatment through implementation of a plan of care Monitoring of progress Making return to participation decisions by using best available evidence and standards of care. Education and prevention to minimize risk and increase awareness. (Linder, 2014) Areas where Physical Therapy Can Help Vestibular Dizziness Imbalance Orthopedic Neck pain (primary) Other injuries incurred during the traumatic event What is the Vestibular System? Vestibular system give sensory input about motion, equilibrium, & spacial orientation Functions of the Vestibular System Vestibular Ocular Reflex (VOR) Allows gaze stabilization with head/body movement Vestibulocollic Reflex (VCR) Initiates righting reactions for head on neck Vestibulospinal Reflex (VSR) Provides balance/stability with movement of the trunk How are concussion symptoms linked to the vestibular system? VOR - Gaze instability/oculomotor deficits Blurred vision, headaches, dizziness, motion sensitivity, visual motion sensitivity VCR Cervical instability Headache, neck pain, dizziness with head movement VSR Postural instability Imbalance, clumsy, falls 1

2 Vestibular Assessment Oculomotor and convergence screening Spontaneous and Gaze Nystagmus Gross ROM and Strength Screen Head Thrust Test (VOR) VOR Cancellation Dynamic Visual Acuity Test (DVA) Cervical spine ROM and special tests Balance and Gait Testing Exertional Assessment BPPV testing if history calls for it (c/o room spinning) Head Thrust Test / Head Impulse Test Picture: PT Treatment Based on Symptoms Vestibular dizziness, balance, headaches Ocular headaches, decreased tolerance for close work/school work, eye strain Referral to Vision OD or OT Manual headaches, neck pain and any impaired strength Progressive Aerobic Activity deconditioning or exercise intolerance Dual task Training incorporating attention, cognition, concentration with balance and exertion activities Vestibular Treatments VOR Retraining Dizziness and nausea is normal and expected Eyes move equal and opposite head Symptoms should improve in minutes (not hours) Metronome used to help maintain speed VOR x 1 Gaze fixed on a stable target while head or body move Perform horizontal ( no ) and vertical ( yes ) Static position with head moving eyes on target Bouncing on ball or trampoline eyes on target VOR Retraining Continued VOR x 2 - Gaze fixed on moving target while head or body move More difficult than 2 objects moving used frequently in sports Tracking a ball or player while moving in the other direction VOR cancellation - Gaze fixed on a target moving together with head Holding an object and spinning or moving Vestibular Treatments Continued Balance Static Feet together -> Tandem -> Single leg Eyes Open -> Eyes Closed Firm -> Foam Dynamic - Any static position plus additional activity Head turning and nodding Ball Toss D2 pattern pick up objects from floor to waist/overhead 2

3 Vestibular Treatments Continued Habituation Walking with head turns Walking with ball toss hand to hand (horizontal and vertical) Walking while putting down and picking up objects Turning (half turns and full turns) Walking forward ½ turn, walking backward ½ turn Any normal activity that is symptomatic Visual Stimulation Visual Add saccades Add pursuits Add noise Vestibular Balance Without Fixation With Fixation Counting moving dots Turns / Movement Cervical Spine Pain and Dizziness Cervical stabilization exercises Cervical stretching Scapular stability Postural correction and strengthening Manual therapy Exertion May be performed while symptoms are still present Find activity that with min to no increase in daily symptoms (<3/10 increase) Start with light cardio Progress to strength Wait to add/try jogging/running, agility and plyometrics until VOR improves Occupational Therapy in TBI Evaluate current level of brain function Identify limiting factors that impede daily independence Re-train brain skills with graded interventions as appropriate to further progress independence and reduce symptoms What are your patient s goal(s)? Self-reported goals and factors that limit independence Client-centered intervention that engages them to help remediate deficits Home exercise programs that are consistently modified to patient progress each week OT Evaluation ADL Scale King-Devick MOCA CISS Self-Perception Cohen Stress Scale Mayo-Portland Adaptability Inventory-4 COPM 3

4 Cognitive Remediation Requires patience and time Complete success cannot be made overnight Using mental manipulation and functional activities to improve overall brain function Altering the chemical makeup and electrical activity in your brain Conducting new pathways to complete tasks Cognitive Remediation Continued Attention Executive Functioning Memory Visuospatial Relations Visual Skills Compensatory Techniques Functional Vision Deficits External Techniques Voice recorders Calendars/Journals Timers Assistive Technology Applications Lists Internal Techniques - Visualization and pre-planning tasks - Chunking (words, phrases, numbers) - Association - Mnemonics - Pairing - Chaining Fixation (and/or visual attention*) Pursuits Saccades Accommodation Vergence Movements Photophobia Lateral field cut or homonymous hemianopsia Visual-perceptual abilities (Functional Vision Deficits continued) Strabismus Amblyopia Ptosis Cranial Nerve Palsy 3 rd cannot move inward or up 4 th vertical misalignment 6 th difficulty with lateral movements Vision Intervention Identify deficits Improve eye teaming and binocular vision Reduce symptoms with activities and Daily HEP Return to independence 4

5 Busy Backgrounds Metronome B Pursuits and Saccades (All Planes) Goal beats per minute Near and far bpm Speed and accuracy to reduce symptoms Home Exercise Program Psychological effects from mtbi Follow the B Eye Jumps Hart Chart Column Jumps Attention Process Training Goal: 3-5 times a day and at least 2 times a day Use Metronome for grading* Sensory Re-Integration* Depression and Anxiety are common due to: Prolonged recovery Significant life status change Difficulty processing information Sensory Processing What is sensory defensiveness? Overstimulation of Central Nervous System What makes the patient defensive? Intervention Neuro-Optometry, OT, and PT Team Work Similar Focus - Same Vision Collaboration of Optometric Efficiency with Cognition and Perceptual-Motor Skills Collaborative use of prisms to help with balance retraining 5

6 Contact Us Questions? Joe Kardine, OTR/L Jenny Rexon, PT, DPT Jefferson Comprehensive Concussion Center Main Phone: Rehab Phone: References Ahn, SK, Jeon, SY, Kim, JP, Park, JJ, et al. Clinical Characteristics and Treatment of Benign Paroxysmal Positional Vertigo After Traumatic Brain Injury. The Journal of Trauma Injury, Infection, and Critical Care. 2011;70(2): Differential Diagnosis for Vertigo. Available at: September 1, 2017 Linder S, Alberts J, Euype S. Implementation of a Multi-disciplinary Concussion Care Path. Presentation presented at the APTA Combined Sections Meeting; 2014; Las Vegas, NV. 6