concussions in the workplace & vestibular … handouts/rims 16/clm019/clm019...concussions in...

Concussions in the Workplace &

Vestibular RehabilitationCLM019

Speakers:

• Melissa Bloom, PT, DPT, NCS, Physical Therapist, Physio

Learning Objectives

At the end of this session, you will:

• Explain the reasoning for vestibular deficits post concussion

• Describe symptoms post concussion which can be

addressed with vestibular rehabilitation

• Discuss several assessment tools and treatments used in

vestibular rehabilitation

• Describe the benefits of physical therapy for clients with

dizziness, vertigo, or balance symptoms post concussion

Concussions

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Concussions• Often with misconceptions regarding extent and nature

• Gaps in knowledge on diagnosis, pathology, function, and optimal treatment course

• Synonymous with Mild Traumatic Brain Injury (mTBI)1

• Recent increase in media attention on sequella of repeated and unnoticed concussion

1Http://www.cdc.gov/concussion/headsup/pdf/Facts_for_Physicians_booklet-a.pdf

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Mechanism of injury• Mechanical trauma to the brain

as a result of acceleration/deceleration forces

o Direct blow to the head, face or neck

o Direct blow elsewhere on the body with an impulsive force transmitted to the head

• May or may not involve LOC (4-10%)

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Concussion

• Often under diagnosed secondary to its’ inability to be seen on diagnostic imagingo 95% of patients with concussion have normal CT scans 1

o 70% of patients with concussions have normal MRIs 2

1 Jagoda AS, Cantrill SV, Wears RL, et al. Clinical policy: neuroimaging and decision making inadult mild traumatic brain injury in the acute setting. Ann Emerg Med. 2002;40(2):231-249.

2 Hughes DG, Jackson A, Mason DL, Berry E, Hollis S, Yates DW. Abnormalities on magnetic resonance imaging seen acutely following

mild traumatic brain injury: correlation with neuropsychological tests and delayed recovery. Neuroradiology. 2004;46(7):550-558..

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What causes a concussion?

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• Mechanical Forces to the

moving brain causes sheering

of nerves

• Allows abnormal nerve firing

• This is followed but a period of

abnormal brain functioning

(Toledo et al, 2012) Figure 3

These neuro-metabolic changes lead to…

Swelling in the nerve axon

Decreased ability to of nerves to transmit signals (action potentials)

Decreased transmission of signals and decreased processing of nerve signals

Decreased overall functioning and ability complete daily and work related tasks

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Pathophysiology review

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• Cascade leading to neuronal dysfunction and symptoms

• Secondary to the nature of the changes there are diffuse

areas affected simultaneously

• Produces a constellation of symptoms and signs

involving physical, cognitive, emotional, and somatic

dysfunction

• Leads to increased fatigue and tiredness

• Symptoms are often “invisible” and diffuse

(Giza et al 2001)

Typical symptoms

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Headache

Dizziness

Impaired gait and balance

Motion sensitivity

Impaired memory, concentration, and attention

Fatigue

Sleep dysfunction

Headaches & concussion• Headache is a common symptom post concussion

• Occurrence in 40-86%

• Commonly overlooked symptom

• Presence of PTH

• Known decrease in neuro psychological performance

• Increase severity of symptoms

• May exacerbate neuro-cognitive impairment after injury

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Vestibular Anatomy

Dizziness and imbalance

• Those post concussion often complain of persistent dizziness and imbalance

• Vestibular rehabilitation has been demonstrated to address symptoms and regaining independence

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Dizziness and concussion• Reported in 23-81% of cases in the first days after injury

• Persistent dizziness varies from 1.2- 32.5% from 6 months to 5 years after injury

• Can occur with various levels of severity of concussion

• Griffiths, M. V. (1979). The incidence of auditory and vestibular concussion following minor head injury. The Journal of Laryngology & Otology, 93(03), 253-265.

• Masson, F., Maurette, P., Salmi, L. R., Dartigues, J. F., Vecsey, J., Destaillats, J. M., & Erny, P. (1996). Prevalence of impairments 5 years after a head injury, and their relationship with disabilities and outcome. Brain Injury, 10(7), 487-498.

• Maskell, F., Chiarelli, P., & Isles, R. (2006). Dizziness after traumatic brain injury: overview and measurement in the clinical setting. Brain Injury, 20(3), 293-305.

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May report “dizziness or vertigo”, but…

…may complain of an overall fogginess or non specific dizziness

Swimminess

Light headedness

Floating

Rocking

Disoriented

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Dizziness or vertigo

Unilateral weakness

BPPV

Decreased sensory

integration & processing of

sensory information

Vestibular causes

• Loss of vestibular hair cells or neurons

• Abnormal firing on one ear results in asymmetric signals to

the brain

• Asymmetric signals can result in :• Vertigo

• Dizziness

• Disequilibrium

• Postural instability

• Oscillopsia (blurred vision)

Vestibular Weakness

Vestibular weakness nystagmus

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Head Thrust Test

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•Difficulty getting to work

•Dizziness with turning, bending,

and moving head at work

•Dizziness with walking

•Dizziness with computer work

•Bending, reaching, and turning will

likely be imbalanced, inaccurate,

and unsafe

How this impacts work

• Positional vertigo caused by changes in head or body position

• A common form of vertigo, affecting at least 9 out of 100 older adults

• Can be accompanied with balance deficits

• Creates a true vertigo vs. dizziness or blurred vision

BPPV

Hain, TC. http://www.dizziness-and-hearing.com. 1 March 2016<https://encrypted-

tbn1.gstatic.com/images?q=tbn:ANd9GcTiXBSGzm6diw7tOaWiytj367cKDWO4MvFN82QNfGI1bdwtWrEjzw

BPPV Nystagmus

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•Difficulty with getting out of bed to

get to work

•Vertigo with turning, bending, and

looking up

•May have dizziness and imbalance

with walking

•Bending, reaching, and turning may

be imbalanced, inaccurate, and unsafe

•Nausea/vomiting with movement

common

How this impacts work

Sensory Input Central Processing Motor

Output

Visual

(Eyes)

Vestibular

(Ears)

Somatose

nsory

(Joints)

Central Processing

Centers of the

Brain

Motor Neurons

Dizziness

Balance

Central deficits or limitations of sensory integration

•Difficulty with getting to work, due

to dizziness and imbalance

•Dizziness and imbalance with

turning, bending, and moving head

at work

•Dizziness and imbalance with

walking

•Dizziness with computer work

•Upright standing and moving tasks

may be unsafe

How this impacts work

◦ Uneasiness created by situational

stimuli

Moving crowds, supermarkets, busy

patterns, etc

Heightened awareness of normal motion

(Jacob et al, 1993)

Space and motion discomfort

•Dizziness and instability with

walking in halls

•Difficulty with tasks in busy

environments

•Difficulty talking with coworkers

involving head turns

•Difficulty with computer tasks

How this impacts work

•Not uncommon after injury involving hitting head

•High presence of balance deficits after a sports related concussion

•Can be seen with multiple severity of injury

•LOC not necessary to have symptoms

Imbalance Post concussion

• Gait and mobility limitations are common abnormalities after neurologic injury

• Dysfunction can result in falls, disability, psychological problems, and secondary medical problems…and difficulty getting back to work

Gait

•Difficulty with getting to work

•Imbalance and safety concerns

with walking, reaching, bending,

turning

•Increased risk for falls and further

injury

How this impacts work

Vestibular Rehabilitation:

the basics

• Known benefits to multiple populations including concussion

• Used to address dizziness, vertigo, and imbalance

• Management can be challenging post concussion

Vestibular rehabilitation

• While there is a high incidence of dizziness & imbalance, vestibular rehabilitation is often under utilized in this population

• Vestibular rehabilitation has shown to be effective in this population although the time course may be longer than in peripheral vestibular disorders1

1. Shepard, N. T., Telian, S. A., Smith-Wheelock, M., & Raj, A. N. I. L. (1993). Vestibular and balance rehabilitation therapy. The Annals of otology, rhinology, and laryngology, 102(3 Pt 1), 198-205.

Dizziness & imbalance

Improve gaze stability

Improve postural stability

Improve activities of daily living

Promote mechanisms for central

adaptation and/or compensation

Decrease feelings of dizziness and

unsteadiness

Decrease fall risk

Goals of vestibular rehabilitation

•Improve gaze stability

•Improve postural stability

•Improve activities of daily living

•Promote mechanisms for central

adaptation and/or compensation

•Decrease feelings of dizziness

and unsteadiness

•Decrease fall risk

Dizziness, blurred vision

especially with head movement

Balance and job related

movement

Bathroom, hygiene, preparing for

work

Dizziness and balance for job

related tasks

Increase confidence and self

efficacy with ability to work

Increased safety in the work

place

Goals of vestibular rehabilitation: in relation to return to work

•Immediately after concussion, exertion and activity should be

limited

•Do not over load the system, watch for increasing symptoms

•Patients should be encouraged to increase daily mobility and

activities as long as symptoms do not increase

•Mild increase in symptoms is OK and expected but should

resolve quickly when movement stops

Intervention strategies

•Partial duty work may be OK if

symptoms don’t increase with work

task and balance is safe

•Increase of symptoms is a sign the

task is too demanding

•Modifying work to minimize visual

stimulation, head/body movements,

and dynamic standing tasks

How this impacts work

Gaze stabilization exercises

Adaptation exercises

Habituation and movement exercises

OKN stimulation

Somatosensory training

Dynamic balance and gait training

Canal Repositioning as needed

Vestibular rehabilitation post concussion

•Long term changes to “recalibrate”the way the brain utilizes the inner

ears sensory input

Purpose:•Decrease retinal slip/blurred vision

•Increase balance

•Decrease dizziness

•Central compensation

Gaze Stability/Adaptation exercises

Improved visual acuity with head movement (Herdman

2003)

Improved balance and decreased perception of disequilibrium (Herdman 1995)

Reduced dizziness (Enticott 2005)

Improved perception of unsteadiness, level of disability (DHI), and postural stability in chronic vestibular hypofunction (Giray 2009)

Evidence for adaptation exercises

•Able to move head without

getting dizzy

•Can walk without dizziness

•Increased balance with

movement

•Decreased perception of

impairments and disability!

How this impacts work

•A long-term reduction in the pathologic response to a specific

movement (noxious stimuli),brought about by repeated

exposed to the provocative stimulus

•Decreased and often asymmetrical vestibular function leads to

sensory mismatch, which leads to symptom provocation•High alert

•Repeated exposure to noxious stimuli decreases that

hypersensitivity

•Desensitization

•Exposure therapy

Habituation exercises

•Decrease intensity and duration of

symptoms with movement

•Increase ability to perform functional

activities, such as bathing and dressing,

household chores, work activities

Goals/purpose of habituation

•Patients who are avoiding particular

movements or activities

•Patients who present with anxiety with

movement or motion

Those who typically respond well to Habituation Exercises…

•Able to walk, bend, and move

without dizziness

•Increased balance and stability

•Greater ability to perform

functional movements required at

work

How this impacts work

Canal repositioning for BPPV

Hain, TC. http://www.dizziness-and-hearing.com. 1 March 2016<http://www.dizziness-and-balance.com/disorders/bppv/epley/epley.html

•Able to get out of bed without

vertigo

•Able to reach overhead, pick

objects off the floor, and move head

at work without vertigo

•Safer walking and balance with all

upright movement

•Resolution of nausea/vomiting

How this impacts work

•Goals of treatment:

•Decreased visual dependence for balance (Pavlou 2011)

•Improve tolerance of visual stimulation

•Decrease motion intolerance

•Improve dynamic balance and balance confidence (Rendon 2012)

Visual motion sensitivity training

•Movements in the visual field to induce optokinetic nystagmus and

promote increased sensory stimulation to the visual centers in the brain

Optokinetic Stimulation (OKS)

•Disco Ball

•Train

•You Tube

•Hallways with busy

walls or heavy foot

traffic

Treatment ideas

•More likely to be able to drive to

work

•Able to tolerate walking in halls at

work

•Able to communicate with

coworkers while looking at them

without dizziness

•Able to tolerate computer work

•Increased walking & balance

stability

How this impacts work

•Bringing in other sensory input

(beyond the vestibular system) to help

system integrate and better sensory

information

•Good for increased body awareness

for those with constant “floaty”symptoms (likely due to a sensory

mismatch)

•Utilize other sensory systems to

decrease symptoms and increase

awareness of body position

Somatosensory retraining

•Tolerate standing and balance

tasks including walking

•Better able to participate due to

decreased constant dizziness

•Increased safety with standing

and walking

How this impacts work

•Function focused

•Task specific

•Must be challenging

•If symptoms allow, high

amounts of intense training

Balance & Gait

•Safe and efficient performance of

work related movement

•Safe walking in work environment

•Decreased risk for falls and further

injury

How this impacts work

•Symptom free at rest

•Symptom free following exertion

•Dizziness with walking, bending,

thinking, driving, using computer?

•Balance, safety, and fall risk

Return to work

•Concussions can result in a number of symptoms that can

often be overlooked secondary to the lack of objective

medical measures and “invisible” nature of injury

•Numerous studies show an increase in dizziness and

imbalance after multiple intensities of concussion

•Dizziness and imbalance caused by concussion are both

addressable by Vestibular Rehabilitation

Wrap Up

Thank you!

Melissa S. Bloom, PT, DPT, NCS

Board Certified Specialist in Neurologic Physical Therapy

Tucker/Decatur

Physio

2799 Lawrenceville Hwy, Suite 205

Decatur, GA 30033

Ph: 770-491-0920

Melissa.bloom@myphysio.com