concussion update: vestibular/ocular motoreval/rehab · concussion update: vestibular/ocular motor...
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Concussion Update:Vestibular/Ocular Motor Eval
+Rehab // Other UpdatesKevin Edward Elder, MD, FAAFP
Team Physician Pool, US Soccer
Team Physician Pool, US Ski Team
Adult and Pediatric Sports Medicine
BayCare Medical Group
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I HAVE NO DISCLOSURES
The shrug gesture in text (emoticon) form is
known as the shruggie and typed as:
¯\_(ツ)_/¯
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Vestibular/Ocular Motor Screening (VOMS test)
• Components of eval part of previous concussion evaluations
• Designed by researchers at UPMC under Dr. Micky Collins
• Vestibular ocular system responsible for integrating vision,
balance, and movements
• Vision issues, fogginess, and dizziness often associated with worse
outcomes, longer recovery from concussion
• This test increases accuracy of concussion diagnosis (90th%tile
according to their study)
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VOMS
• Types of concussions
– No longer classified as mild, moderate, severe, Grades etc…
– However may be different types based on symptoms
• Vestibular (balance issues)
• Ocular (vision problems)
• Mood and anxiety
• Migraine headaches
• Cervical
• *****Often manifestation of several categories
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VOMS
• Importance:
– Accuracy on field, in training room, in office
– Approximately 80% of those with concussions are
fully recovered by 3 weeks
– It may take months for the remaining 20% to
recover
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VOMS
• 5 Areas of the vestibular Ocular System
– Smooth pursuits (eyes following a moving object)
– Saccades (rapid eye movements)
– Horizontal vestibular ocular reflex (images stabilized during
head movement)
– Visual motion sensitivity (as it relates to inducing dizziness)
– Near-point-of-convergence testing (where eyes can hold
together without double vision)
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VOMS
• Learning to do the test resources:
– http://www.ncbi.nlm.nih.gov/pubmed/25106780
– A Brief Vestibular/Ocular Motor Screening (VOMS) assessment to
evaluate concussions: preliminary findings. Mucha A, Collins MW,
Elbin RJ, et al. Am J Sports Med. 2014 Oct;42(10): 2479-2486.
– Many others online
– Main point is that should be incorporating some of the VOMS into
concussion evaluation based on current knowledge- not just doing
SCAT3 and/or Impact etc.
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VOMS
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US Ski Team- Oslo + TrondheimFeb 2016
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VOM Rehab
• Think about anatomy of brain: CN II, IV, and
VI innervate eye muscles, exit brain stem,
travel along base of skull, join behind the eye
and enter the orbit
– Susceptible to injury anywhere along the route
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VOM Rehab• Vestibular System
– CNS processes input from visual, vestibular, and
somatosensory system to execute and coordinate
musculoskeletal responses
– Maintain balance in conjugation with info from visual and
proprioceptive inputs
– Maintain fixed gaze stabilization during head and body
movement
• Tilt a Hurl >30 yo
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VOM Rehab• Vision Behavioral Exercises
– 2-10 Visits with excellent prognosis
– Exercises to strengthen and increase endurance of
eye muscles and improve speed, coordination and
accuracy
– Patients may do HEP (smart phone apps, etc)
• www.visiontherapysolutions.net
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VOM Rehab
• Many studies showing benefit lack Level 1
evidence however challenging to develop
conditions with this diagnosis where there is a
control group, retrospective data collection
often, chronicity of concussion symptoms,
absence of standardized vestibular function test
battery, etc etc
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VOM Rehab
• Timing is Everything!!
– After initial period of restriction/limitation
– Ensure all visual-vestibular sx are gone before initiating
activities with head/eye movement (such as elliptical/jogging)
• Acutely exercising can decrease cognitive performance and
exacerbate symptoms
• Exercise delayed until after acute healing has occurred can increase
neurogenesis, neuroplasticity and visual processing
• What if symptoms lingering?
– No evidence rest > 3 weeks is beneficial
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VOM Rehab
• Bottom Line
– Big opportunity for PT to help athletes actively
recover from concussion
– May not be needed for every patient, but certainly
should be considered in any patient with protracted
symptoms and/or history of multiple concussions
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And now for Something Completely Different
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Misc Updates of Common Questions asked
• Helmets:
– No helmet can prevent concussions
• However Improperly fitted helmets is a risk factor for a
concussion with more symptoms and of longer duration
• Concussions of longer duration are more common in air-bladder
lined helmets in study of 4580 high school students
• Greenhill DA, Navo P, Zhao H et al. Inadequate Helmet Fit
Increases Concussion Severity in American High School Football
Players. Sports Health, May/June 2016; 8(3): 238-243.
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US Soccer MNT U23 -Provence, FR May 2015
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Misc Updates
• Medications
– None have any evidence of shortening concussion recovery
• Careful with administering too much ibuprofen- can cause rebound
HA/worsening
• Amantadine has one (small N=25) study showing giving it twice daily
100 mg to pts aged 13-19 who had not recovered at 3 weeks showed
decrease in reported symptoms however researchers state “results
should be viewed cautiously”
• **Consider Omega 3 FA’s/ Curcumin/ Resveratrol/ Melatonin
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Misc Updates• How Many Concussions are too many
• “I heard three strikes and you’re out”
• Bottom line is that there is not yet any solid data on this AT
ALL regarding some exact number. This is an individual
decision and discussion taking into account:
– Pre-existing conditions (ADD, migraine, depression, etc)
– Athlete’s goals
– Thorough, individualized process
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Misc Updates
• DO NOT make any decisions while the athlete still has
symptoms regarding eventual returning to given sport
• There is no evidence for a hard number
• Every athlete deserves an individual and thoughtful
evaluation if this is an issue
• It is also not appropriate for the pendulum to have swung
from “Rub some dirt on it” to widespread panic and
hysteria about all sports.
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References• 1. Bernhardt D, Young CC et al. Concussion Treatment & Management. Updated Sept 21, 2015.
http://emedicine.medscape.com/article/92095-treatment
• 2. Collins MW, Kontos AP, Reynolds E et al. A comprehensive, targeted approach to the clinical care of athletes
following sport-related concussion. Knee Surg Sports Traumatol Arthrosc. 2014;2222(2): 235-246.• 3. Greenhill DA, Navo P, Zhao H et al. Inadequate Helmet Fit Increases Concussion Severity in American High School Football Players. Sports
Health, May/June 2016; 8(3): 238-243.
• 4. Kostyun RO and Hafeez I. Protracted Recovery from a concussion: A focus on gender and treatment
interventions in an adolescent population. Sport Health. Jan/Feb 2015, p 52-57.
• 5. Leddy JJ, Sandhu H et al. Rehabilitation of concussion and post-concussion syndrome. Sport Health.
2012;4(2):147-154.
• 6. Matuszak JM, McVige J, Willer B, and Leddy J. A Practical concussion physical examination toolbox. Evidence-
Based Physical Examination for concussion. Sport Health. May/June 2016;8(3):2 260-269.
• 7. Meehan WP. Kids, Sports, and Concussions. (Praeger 2011).
• 8. Meehan WP, Mannix RC et al. Symptom severity predicts prolonged recovery after sport-related concussion,
but age and amnesia do not. J Pediatr. 2013;163(3): 721-725.
• 9. Mucha A, Collins MW, Elbin RJ, et al. A Brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions:
preliminary findings. Am J Sports Med. 2014 Oct;42(10): 2479-2486.
• 10. Pillarelli JF. Experts debate: How many concussions are too many for an athlete?
https://www.statnews.com/2016/01/11/concussions-counseling-experts-debate/
• 11. Vidal PG et al. Rehabilitation strategies for prolonged recovery in pediatric and adolescent concussion.
Pediatric Annals. 2012. 41:9
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Thank You!!