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Audrey Paslow PT, DPT, NCS

Chair, Eastern District, NYPTA

Chair, Leadership Committee, NYPTA

Concussion Management Treatment Strategies for the Physical Therapist

§ By the end of the day, you should be able to:

§ 1. Apply a multi-faceted evaluation approach to concussion management care.

§ 2. Summarize essential questions to ask during a patient interview.

§ 3. Determine treatment techniques appropriate for care of a patient across the continuum of recovery (return to work or play)

§ 4. Analyze the impact of health literacy on care of this population.

§ 5. Identify additional resources and tools that can be applied to practice.

§ Today's agenda:

§ 8:00 - Introduction

§ 8:15 - Pathophysiology and Statistics

§ 8:45 - Interdisciplinary care model -outlined

§ 8:40 - Break

§ 9:00 - Management Techniques: Cervical Spine

§ 10:00 - Management Techniques: Ocular and Vestibular

§ 11:00 - Management Techniques: Balance

§ 12:00 - Lunch

§ 1:15 - Management Techniques: Exertion

§ 2:00 - Health Literacy

§ 2:15 - Break

§ 2:30 - Breakout sessions/case studies

§ 4:00 - Session wrap up

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None to disclose

Graduate of Sage Colleges

Work at Ellis Medicine - outpatient clinic

SME/Adjunct Faculty at Excelsior College

Chair of Leadership Committee - NYPTA

Chair of Eastern District - NYPTA

NCS - Certified July 2017

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Section One: The Basics

Epidemiology

Pathophysiology

Basic Symptom Profile

Negative Prognostic Factors

Care Team Set Up -- Where do we fit in this continuum?

§ 1.8-3.6 million concussions occur annually (9)

§ Per CDC, concussion accounts for $12 billion annually in direct and indirect costs (9)

§ Uncertain if/how gender plays a role (7, 10, 12)

§ Normal (median) recovery timeline: 7-10 days for adults, 25-75 days for children (9, 12)

§ Adults: 10-30% experience delayed recovery (10, 12)

§ Children: 43-73% experience delayed recovery (12)

§ Persistent symptoms may not be as uncommon as we think (3)

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Source (17)

§ Almost 450,000 sports-related head injuries seen in the ER in 2009 (18)§ Was an increase of 95,000 from the prior year§ Number is likely much higher (18)

§ Concern: Returning to the field too soon§ May be at risk for a secondary head injury (second impact

syndrome) (20)§ May be at risk for a secondary bone and joint injury (3.39x higher)

(19)

§ A self-limiting condition that creates alterations in neurocognitive and/or neurological functioning, is both metabolic and physiologic (12,1)§ Neurotransmitter and ion disturbances (1) § Alterations in autonomic nervous system function, control of cerebral blood flow

(1)

§ Is a functional, not a structural injury (6)§ CT/MRI often unhelpful§ Creates a "spreading depression"

§ Unresolved symptoms may be both physiological and psychological in nature (6) § Up to us to help tease this out!

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POST CONCUSSION SYNDROME§ Definitions of this syndrome are not well agreed upon in clinical

practice (12)

§ Two main definitions: DSM-IV and WHO Criteria§ DSM-IV definition … must include:

§ Cognitive deficits in attention and memory

§ At least 3+ Symptoms (12)

§ WHO Criteria: 3+ symptoms that must be present within the first month post-injury (11, 12)

§ Issue: Definitions lack specificity, are confusing; many non-standard definitions exist as well (12)

Theory 1: Continued Metabolite Imbalance

Theory 2: Continued Axonal Dysfunction

Theory 3: Possible Psychological Factors

Theory 4: Altered Cerebral Blood Flow

Theory 5: Cervicogenic ComponentTheory 6: Altered oculomotor or vestibular function

WHO’S MOST AT RISK?

§ Intrinsic:§ A history of concussion

§ Extrinsic: § Type of sport

§ Technique

§ Officiating

§ Note…§ Helmets, headbands

§ Mouthguards….don’t lower this risk! (23)

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§ May be the brain…or something else! (1) § Whiplash can be concurrent injury due to

acceleration/deceleration (1)

§ Most common symptoms: § Headache (1, 2, 3, 6)§ Dizziness (2, 6)§ Nausea (2)§ Neck Pain (2) § Fatigue (3) § Forgetfulness (3) § Poor Concentration/Fogginess (3)§ Memory issues§ Sleep Disturbances

§ Medical history: § **History of concussion (3, 12)

§ Multiple co-morbidities (3)§ ADD/ADHD, LD (12, 23)

§ **Migraine headaches (23)

§ Female sex? (3, 12)

§ Age (Younger > Older) (12)

§ Mood disorders and use of psychotropic medications (3, 12, 23)

§ **Pre-existing neuro-opthamological conditions like strabismus or convergence insufficiency (12)

§ Prior C-Spine injury (12)

§ Non-white ethnic group (3)

§ Other medical considerations § H/o seizures

§ Structural abnormalities

§ Hematological conditions

§ Infectious diseases (12)

§ Time of Injury:§ **On-field dizziness (5, 6, 11)

§ High symptom burden immediately after injury, or delayed onset (5)

§ Early reports of mental fogginess (11)

§ Loss of consciousness or post-traumatic amnesia (12)

§ **Exertional intolerance (12)

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HOW DO WE DIAGNOSE ACUTE

INJURIES?

§ No gold standard test; a clinical diagnosis (1, 8)§ Looking for combination of physical and subjective

symptoms (8)

§ Symptom reports (standardized questionnaires) may be helpful (1)

§ Baseline testing valuable (8)

§ Also need multi-faceted assessment

§ Exam should include: cranial nerves, motor control, reflexes, cerebellar function, gait, balance, VOR, C-spine (4, 12)

§ Imaging is not indicated acutely, unless…§ Findings on a CT (may need an MRI)§ Presence of:

§ Worsening symptoms

§ Focal neurological deficits§ Seizures (12)

§ As PT’s, want to identify individual systems that are not functioning properly§ Treatment focused individually (at each system) and

collectively most beneficial (5)

HOW DO WE DIAGNOSE PCS?

§ No clinical diagnostic rule or guidelines to define PCS (12) § Timeframe: Should be looking at persistent

symptoms (>3-4 weeks) (11, 12)

§ Persistent symptoms may indicate other underlying issues (12)§ Likely these issues are emanating from somewhere

other than the brain (1)

§ Need to think about:

§ C-Spine

§ Oculomotor/Vestibular Function§ Balance

§ Exertional Capacity

§ Emotional Health

§ Cognitive Function§ Testing these domains may show where symptoms

are truly derived from (1)

§ Need physician lead

§ Must follow NYS Law in case of high school athletes§ Clearance from pediatrician

§ Clearance from school physician

§ Following of RTP guidelines

Source: 25

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Rehab

Physicians

Counseling/Support

School Physician

School AT/RN

Patient/Family

TREATMENT APPROACH

CONCUSSION

OCULAR

VESTIBULAR

COGNITIVE/FATIGUE

POST-TRAUMATICMIGRAINE

ANXIETY/MOOD

CERVICAL

VESTIBULAR

Source: 24

Cognitive

Exertion

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Cervicogenic Post Concussion Disorder (C-PCD)

§ Many who experience whiplash, like concussions, recover within the first 3 months (1, 2, 3,14)

§ They share similar negative prognostic factors: § Age at time of injury § Female sex

§ Initial symptom burden (1)

§ Cervical spine tension (5)

§ The symptom profile is quite similar (1, 2, 3, 5, 9, 14)§ Little evidence suggests that symptoms are exclusively due to changes in the brain (2)

§ In rear-end MVC’s, think of the mechanism of injury…(1)§ Head impact <-> Head restraint; acceleration/deceleration injury (2)

§ If head rest is down or head is rotated (not in neutral spine), injury is often worse (1)

WHAT SYMPTOMS MIGHT WE SEE?

§ Headaches

§ Dizziness

§ Blurred Vision

§ Balance Issues/Unsteadiness/Poor Postural Control

§ Poor Memory

§ Concentration Issues

§ Irritability

§ Sleep Disturbances

§ Fatigue (2)

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§ Have to break this assessment down into two components:§ Muscular/structural issue (7)

§ Proprioceptive issue (7, 11)

§ Also have to consider differential diagnosis, and if there is a structural/stability concern§ Remember Sharp-Purser, Alar Ligament

§ Listen for anything that may indicate acute instability or an intracranial hemorrhage (27)

§ Consider clinical prediction rules (NEXUS criteria, etc).

§ Consider helpful apps or links:

§ QxCalculate

§ UpToDate

§ Used to clinically rule out vertebral fracture without imaging

§ Imaging is not indicated if the following criteria apply:

§ No Focal Neurologic Deficit

§ No Midline Spinal Tenderness§ No Altered Level of Consciousness

§ No Intoxication

§ No Distracting Injury Present

§ Post Concussion Symptom Scale: Not sensitive enough to tease out c-spine involvement from other possible symptom causes (2)

§ Neck Disability Index: High degree reliability, internal consistency with patient with WAD (26)

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WHAT MIGHT THE HISTORY

TELL US?

§ Most often if structural, you will hear complaints of headaches first

§ May likely to hear phrases like:

§ ”My head feels heavy”

§ “I get a headache/dizzy out of the blue; I’m usually not doing anything!”

§ “My headache gets worse as the day goes on” (Ocular?)

§ “My headache goes away once I lay down”

§ “Things get worse the longer I read” (Ocular?)

§ With headaches, need to know MORE…

§ Location (be very specific!)

§ Intensity

§ Duration

§ Frequency

§ Triggers (Look for postural cues!)

§ Alleviators

• Early detection/treatment of this issue, or concomitant ocular/vestibular issue can reduce symptoms, speed recovery

• Helps to move away from prescription of strict rest (2)

No standard evaluation exists…yet

• Posture• ROM (4) • Manual segmental exam/Tenderness To

Palpation (4) • Strength testing: NOT MMT! (18)

• DCFE• CCFT • NEET

Current literature suggests evaluting:

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§ Contra-indication: Pain with testing

§ Protocol§ 2 Phases

§ 1: Analysis of performance of Cranio-cervical flexion

§ 2: Isometric endurance of Deep Cervical Flexors

§ Using a blood pressure cuff, inflate to 20 mm Hg

§ Hold 3x10 sec each at 22, 24, 26, 28 and 30 mmHg

§ May also use this as a baseline test

Source: 18

§ Builds on the Cranio-cervical Flexion Test (CCFT)

§ Functional test looking at deep cervical flexor recruitment and endurance

§ Procedure:§ Patient in hook-lying, hands

on abdomen§ 2 stages/phases to test

§ 1: Cue patient to perform chin tuck, then lift head ~2.5 cm from bench. Mark skin folds; patient relaxes

§ 2: Cue patient to perform chin tuck and head lift. Track time patient can maintain this position.

Source: 19

Source: 19

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All Subjects All Women All Men All Active All Sedentary

# of subjects 126 63 63 83 43

Age (mean + SD) 48.9 + 17.8 49.2 + 18.5 48.7 + 17.3 46.8 + 19.2 53.2 + 14.1

DCFE – seconds (mean + SD)

34.2 + 17.7 29.3 + 13.7 39.1 + 20 32.2 + 17.2 38 + 18.5

Source: 20

§ Equipment: Plinth, tape measure, Myrin goniometer, 2 velcro straps (1 large, 1 small), stopwatch

§ Procedure:§ Patient lies prone, velcro

strap around T2 for counter support

§ Small velcro strap placed around head, with Myringoniometer place just superior to left ear

§ Tape measure attached to velcro strap between patient’s eyebrows, case hanging just short of the floor

§ Stopwatch started when support removed from head

Source: 21

§ Why start here vs. evaluating proprioceptive input? § Fatigue of cervical/scapular muscles can adversely affect C-Spine joint position sense

and postural control (11)

§ Deep neck flexors are what maintain C-Sp lordosis, stability during ADL’s (11)

§ Strengthening the deep neck flexors can increase joint position sense accuracy (11)

§ Those with chronic neck pain tend to have lower endurance in deep neck flexors (11)

§ C-spine trauma may prolong post-concussion headaches (5)

§ May contribute to cognitive symptoms (2)

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§ Multimodal treatment shown to be effective (4, 5, 6, 7) § Most often patients will respond immediately (6, 7)

§ May help progress to other training (including exertion), more quickly (2)

§ May help with faster return to sport (5)

§ Options: § Soft tissue massage (6,7)

§ Mobilizations/manipulations (6, 7)

§ Therapeutic Exercise: Strengthening, Stretching (6, 7)

§ Modalities (6, 7)

§ Deep Cervical Flexor Retraining (based off test results) (22)

PROPRIOCEPTIVE ISSUES: WHAT

MIGHT THE HISTORY TELL

US?

§ You may hear phrases like:

§ “I’m dizzy all the time!” § Will deny any visual confirmation of room spinning§ Positive sense of motion with eyes closed

§ “I get dizzy when I’m reading/sitting for a prolonged period”

§ “I feel a ‘whooshing’ sensation when I move”

§ Need to also focus on the neurological input from the cervical spine: § Proprioceptive input is result of C-spine afferents, found mainly in upper C-spine (C1-3) (7, 10)

§ Afferents receive information from mainly muscle spindles; C-spine musculature is rich in these structures. Provides information about head on truck orientation (10, 11)

§ These afferents have complex neurophysiologic interaction with sensory and motor nuclei in brainstem; also integrates with visual and vestibular information in the cerebellum (7, 10)

§ Because they converge with vestibular nuclei, can give information about head movement to align with visual/vestibular information (10)

§ Impairments in proprioception and postural control have been observed in whiplash-type injuries, those with chronic head/neck pain of nontraumatic origin (2, 9)

§ C-spine afferents most likely to injured in acceleration/decelerations injuries (7)

§ Proprioceptive deficit may be predisposing factor to pain given lack of motor control (11)

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§ Key to this type of testing: § See if C-Spine afferents are the ones disrupting balance and oculomotor control (7)

§ Looking to isolate C-spine afferents from visual, vestibular influences (7)§ Want to see their unique control over position, motion sense

§ Positive test results that implicate the C-Spine:§ Reproduction of symptoms

§ Loss of motor control-accuracy (7)

§ Testing should ideally include: § Basics from structural assessment (ROM, Palpation, Ligament testing)

§ Structured, standardized assessments:§ JPE/Modified JPE§ SPNTT (12)

§ Primary test to clinically operationalize joint position sense error (JPSE) (10)

§ Investigates cervicocephalic kinesthetic sensibility – the ability to reposition the head to previous reference point (10)

§ Equipment is generally low cost and test is quick to administer

§ Laser pointer

§ Hat/helmet to mount laser

§ Goggles (occlude vision)

§ Headphones or ear muffs (block sound)

§ JPE Target available online to print (22, 23)

§ Target set 90 cm from patient§ Patient sits with laser mounted to hat or

helmet, has goggles and ear muffs on§ Patient’s head is positioned to center of

target, and asked to remember the position

§ Testing protocol: § Passively move patient’s head to desired

position, hold for 2 seconds, ask them to return to center

§ Record on target the location of reposition and measures difference between reposition and neutral

§ Complete three trials each for: left rotation, right rotation, flexion, and extension (22)

Source: 23

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§ Protocol for modified test: § Head/neck held stable.

§ Laser placed on mid-sternum.

§ PT holds head stable, patient moves body rotated R or L as far as able, tries to return to center

§ Patients are seated on soft form to minimize proprioceptive cues (3, 24)

§ C-Sp proprioceptive error calculated using: § Mean of absolute errors for 6 L and 6 R trials.

§ Difference between star and returning position of laser beam on target

§ Measured in degrees using formula angle=tan-1 (error distance/90 cm).

§ 12 measured averaged to give overall mean score. (3, 24)

§ With both tests: Keep movements SLOW (<2.1 degrees/second) (10)

SPNTT: SMOOTH PURSUIT NECK TORSION TEST

§ Uses electro-oculography to record velocity of eye movements

§ Subject tested in three positions (head always facing forward):

§ Neutral

§ Trunk ONLY rotated 45 degrees right or left

§ Eye Movement: Total excursion of gaze – saccadic corrections

§ Needs further research to establish as a reliable and valid tool for the cervical spine, with respect to populations who are diagnosed with WAD or Concussion (22)

§ Treatment at C-spine can improve symptoms in individuals with suspected cervicogenic dizziness§ Can improve overall function

§ Can shorten recovery timeline (5)

§ Use results of JPSE to guide treatment

§ Charts/mazes§ Proprioceptive re-training (Find

center, R, L, etc)

Source: 25

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§ Matuszak J, McVige J, McPherson J, et al. A practical concussion physical examination toolbox: evidence-based physical examination for concussion. Sports Health. May/June 2016;8(3):260-269.§ See all appendices!

§ Physiopedia’s Deep Cervical Flexor Endurance Training Protocols§ Link: https://www.physio-pedia.com/Deep_Neck_Flexor_Stabilisation_Protocol

§ Rob Landel’s JPE Target: http://www.skillworks.biz/Resources/Documents/JPE%20Target%20and%20Instructions.pdf

§ APPS: § QxMD, QxCalculate (Free)§ UpToDate ($500-600/year)

§ Targets and head lamp laser: OPTP

Next break: Lunch (Noon)

§ Visual input – approximately 2/3 of all sensory info being processed by the brain (17) § Makes visuospatial, visual-perceptual deficits common (5, 17)

§ Damage can occur to pathways or areas in frontal lobe, anterior temporal pole, supramodal areas, midline brain structures, CN’s may all be damaged be shear forces –impacts vision (17)

§ Visual symptoms are common post-concussion (3, 5, 8)§ 65-90% of athletes have some type of oculomotor dysfunction – monocular or binocular

(5, 6, 14)

§ Near point convergence (NPC) insufficiency is a binocular deficiency that occurrs in 42-49% of athletes; accommodation (monocular deficiency) also very common (8, 17)

§ Likely will see impairments with visual tracking, saccades (7, 17)

§ May also see impact of oculomotor system on neurocognitive testing (23)

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§ “Reading makes my symptoms much worse”

§ “I can’t do homework, or read anything on my phone/laptop”

§ “I can’t look between my notes and the smartboard in the classroom”

§ “I had a lazy eye (strabismus) as a child”

§ “I used to wear prism glasses”

§ “Things look blurry/doubled” (More often up close)

§ “Math class is now more challenging”

OCULAR SIGNS/SYMPTOMS

§ Symptoms:

§ Localized, frontal-based headache

§ fatigue

§ distractibility

§ pressure behind eyes

§ difficulties with saccades, visual tracking, NPC

§ Blurred/double vision, particularly up close

§ Trouble with visually stimulating environments

§ Ocular alignment

§ Pupillary function (12)

§ Visual Acuity (Snellen chart) (12)

§ Visual Fields (12)

§ Cover/Uncover Tests (5)

§ VOMS (5, 8) § Saccades

§ Smooth Pursuits§ **NPC (should be <6 cm to be WNL) (7, 14) –

looking for convergence insufficiency (CI)

§ Accommodation (7) – looking for accommodative insufficiency (AI)

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§ Interdisciplinary Tool – meant to be symptom-dependent (5, 8, 13, 15)§ Concussed athletes will report higher symptom severity scores (5, 15)

§ Established in research – valid, reliable, high internal consistency§ High internal consistency (5, 13, 15)§ High sensitivity (5, 15)

§ Acceptable false-positive rate – (female sex, h/o motion sensitivity increases this) (5, 13, 14, 15)

§ Measures different aspects than King Devick (KD) or BESS (5)

§ Best if baseline information available§ 11-35% adolescent athletes have symptoms with testing at baseline (8, 15)

§ Changes at baseline likely d/t underlying issues§ Prevalence of vestibular disorders in children/adolescents ranges up to 15% (8)§ 25% of children ages 6-18 require corrective lenses (8)

§ Best subset of predictors for concussion on VOMS: VOR, VMS, NPC (Sensitivity – 89%) (5, 8)

Source 18, 19

Clinical cutoff: >2 pt change on any item; and/or >5 cm on NPC distance (5)

§ Therapy can be helpful/successful – both vision and vestibular therapies! (20) § CI can recovery separately from AI (8)

§ One study: of those who received visual-based exercises, for CI: 85% were successful, 15% improved; with AI: 33% were successful, 67% improved (24)

§ Can easily incorporate exercises into treatment/home exercise programs:§ Pencil Pushups (20)

§ Brock String (20)

§ Exercises to address peripheral vision

§ Link: eyecanlearn.com (21)

§ Four Square Saccades

§ Arrows Game

§ Can build these in with vestibular exercises (on foam, yoga ball, etc)

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Source: 21 Source: 22

SaccadesBrock String

§ Post-traum atic dizziness has variety of causes:

§ Peripheral vestibular issues

§ BPPV, labyrinthine concussion, peri-lym phatic fistula, endolym phatic hydrops, otolith dam age (3, 4, 16)

§ Central vestibular issues (4)

§ Visual dysfunction (3,5)

§ Proprioceptive dysfunction (4)

§ Gaze Stability Issues (VOR) (3, 16)

§ Balance Problem s (VSR) (16)

§ Com m on sym ptom post concussion

§ Up to 90% of children in one study had a vestibular/balance deficit (4)

§ In another study, 81% had changes in gaze and tandem gait (5)

§ In another study, 61% had changes in vestibular function, >90% had dizziness with at least one abnorm al finding on balance/vestibular exam (8)

Source 25

§ ”I’m dizzy!”

§ ”I can’t look at busy settings” (rippling pool water, grocery stores, etc)

§ ”I get nauseous a lot, especially when driving”

§ “I have to move very slowly/deliberately to avoid being dizzy”

§ “I can’t bend over quickly”

§ ”I avoid crowded places”

§ “I find I trip a lot at night/low lit situations”

§ “I feel really unsteady”

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§ Symptoms:

§ Dizziness

§ Fogginess

§ Nausea

§ Feeling of being detached

§ Anxiety

§ Easily overstimulated

§ Impaired gaze stability (VOR), impaired balance

§ Dizziness Handicap Inventory

§ Visual Vertigo Scale

§ Rivermead Post Concussion Symptom Scale

BREAKING DOWN THE

ASSESSMENT

§ At a minimum, should include: § Full neurological exam (Cranial nerves, motor,

sensory, reflex, cerebellar function) (16)

§ Most often, this will be completely normal! (If not, consider referral)

§ Balance, gait (16)

§ Cognitive function (16)

§ Baseline vitals – BP, HR (16)

§ Ocular assessment (VOMS) (19)

§ Vestibular Assessment§ VOMS – VOR, VMS (19)

§ DVA (Dynamic Visual Acuity) (6)

§ Peripheral Testing (as needed if suspect BPPV) (12)

§ Otolith organs appear to be involved <20% of cases (6)

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§ Vestibular rehabilitation is standard of care…can: § **Decrease sense of dizziness (should see evidence on DHI) (1,2, 4, 7)

§ Improve gaze stability (1,2, 7)

§ Improve balance and gait (1, 2, 4, 7, 11)§ Improve motion sensitivity (1, 2, 7)

§ Improve scores on neurocognitive testing (2)

§ Can even be effective in cases with prolonged symptoms/deficits (7)

§ One systematic review demonstrated no adverse effects (4)

§ One RCT demonstrated incorporation of vestibular and cervical based treatment made participants 10.27x more likely to be cleared to return to sport (1, 4)

§ Likely will be part of multimodal treatment approach (manual therapy for C-spine, strength training, occupational tasks, pharmacotherapy) (4) § Optimal timing to initiate VRT not yet determined (4)

§ Lack of standardization across studies/best balance of exercises not determined (4, 11)

§ Gold standard for VRT in general is using a problem-oriented approach (4)

§ Vestibular Rehab: Incorporates habituation, adaptation/gaze stability, compensatory/substitution strategies, balance and aerobic ther ex (4) § May also need to incorporate canalith repositioning (always comes first!) (4)

§ With problem-based approach, should be looking at: § Results of standardized assessments

§ Patient goals

§ Impairments/limitations noted on exam

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§ Since much of VRT after concussion is based on central impairments, using an assessment that looks for increases in motion sensitivity is helpful!

§ MSQ (Motion Sensitivity Quotient) -- my suggestion!

§ Consider: § Static balance retraining (on/off foam)

§ Incorporate vision therapy exercises (visual tracking – ie ball tossing) § Consider running exercises in series/back to back

§ EC/static balance

§ EO/tossing ball with PT

§ EO/visual tracking while tossing ball from R hand to L hand

§ EC/marching

§ 15 year old male – played JV football as a running back § Tackled by another player in a game, fell to the ground; no LOC, but dizzy

§ Came to PT 2 ½ months later – reported heightened motion sensitivity, especially with activity§ C-Spine: mild deficits noted with SB and Rot

§ Oculomotor exam: 12 cm NPC average; some symptoms with saccades

§ Vestibular exam: increased dizziness with VOR (horizontal and vertical movement)

§ Balance: Mild deficits noted with SLS/EC

§ 1 Month later: C-Spine ROM now WNL and pain free, oculomotor testing WNL (NPC average 4 cm); Balance (static) WNL§ Vestibular issues persisted…

2 0 0 02 0 0 0

2 0 0 0

2 0 0 0

3.5 cm2 0 0 0 4.0 cm

4.5 cm

3 6 3 03 5 1 0

4 8 4 2

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§ Once able, began exertional retraining in static positions§ Abdominal isometrics, supine SLR’s, planks

§ Slowly introduced seated habituation retraining§ Head turning eyes open/closed

§ Sidelying <-> sitting§ Nose-to-knee

§ Progressed to more dynamic exercise, including sport specific items§ Throwing a discus or shotput

§ Half turns while walking up/down clinic

§ Grapevine with turns§ Burpees

§ Mountain climbers

0 0 0 00 0 0 0

0 0 0 0

0 0 0 0

4.0 cm0 0 0 0 4.0 cm

4.0 cm0 0 0 0

0 0 0 00 0 0 0

§ Ocular Exam: See http://www.neurocular.com/node/1

§ Strabismus Simulator: https://www.aao.org/interactive-tool/strabismus-simulator

§ Toolkit for Visuo-vestibular assessment: http://links.lww.com/JNPT/A209

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Next stop: lunch! (At Noon)

§ VSR: Vestibulo-spinal reflex§ Series of reflexes named according to:

§ Timing (Dynamic vs Static or Tonic) § Sensory Input (Canal vs Otolith)

§ VOR: Vestibulo-ocular reflex§ Angular: modulated by semicircular canals

§ Linear: modulated by otoliths

Source 25

§ Coordination of multiple systems§ Visual (retina)

§ Vestibular (otoliths, semicircular canals)

§ Somatosensory (joint mechanoreceptors) (16)

§ Reasoning for dysfunction poorly understood (16) § Likely d/t multiple mechanisms (16)

§ One of most common symptoms post concussion§ 40-90% children with concussion had vestibular or balance deficit (4, 5, 8)

§ Changes may be seen on BESS, SET, or SOT (3, 9)

§ Postural control is physically demanding/necessary in sports (3)

§ Symptoms are most pronounced early on (3) § Typically will resolve by day 5 post-injury (3)

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§ History will likely include: § “I feel unsteady on my feet”

§ “I have to reach out for the walls when I walk around at night”

§ “I had trouble just walking/standing on the beach”

§ Intake forms that may help: § ABC Scale (older adults)

§ DHI/Pediatric DHI (heights, etc)

§ Delayed balance reactions (3, 9) § Vestibular pattern likely to emerge on balance testing (9)

§ Need challenging balance test (BESS, SET, BESTest) rather than mCTSIB (9)

§ Conservative gait pattern (3, 4, 5) § Increased mediolateral sway, decreased sway in sagittal plane (3)

§ Impaired tandem gait (5)

§ Seated balance righting reactions (eyes closed) § Standing balance reactions (eyes open, closed/with and without pertubations) § Static balance

§ Tandem § Sharpened Rhomberg§ SLS

§ Gait – Regular and Tandem, Forward and Backward, eyes open and closed (7) § Formalized Assessments

§ DGI§ FGA§ SET§ BESS (26-30) § COBALT§ BESTEST

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BESS TEST

§ 6 Conditions§ Sharpened Romberg (on and off foam)

§ SLS stance (on and off foam)

§ Tandem Stance (on and off form)

§ Possible Errors§ Moving hands off iliac crests

§ Opening eyes

§ Step, stumble, or fall

§ ABD or Flex of hip >30 degrees

§ Lifting forefoot or heel off testing surface

§ Remaining out of proper testing position >5 seconds

§ Total Score: Up to 60 (10 possible errors/condition)

§ Poor-good reliability to assess static balance (27) § Reliability the same if clinical version of test or instrumented BESS

(28) § Reliability higher in young children (5-14) (29)

§ Validity:§ Fair concurrent validity between clinical and instrumented format of

BESS (27, 28) § Poor - Adequate validity with ImPACT results (32)§ Poor correlation with PCSS (21)

§ Valid to detect balance deficits where large differences exist (concussion) (27) § Fatigue, distractions will negatively impact results

§ Ceiling and floor effects exist; modified BESS may be better (30) § Double leg stance firm/foam – ceiling effect (30) § SLS foam – floor effect (30) § Modified BESS (no parallel stance) shows improved reliability (31)

§ Gait and balance retraining as part of VRT§ Should see changes in DGI, FGA, TUG, SOT, DHI, ABC Scale (11)

§ May help with earlier return to sport (11)

§ Can help all ages, including children and adolescents (7)

§ VRT alone may help improve balance and gait (2)

§ Similar to VRT, balance training ideally utilizes a problem-based approach (11) § Incorporates focus on reliance of other balance systems (1, 4)

§ Consider static balance exercises prior to dynamic/ambulation (4)

§ Consider simple exercises prior to more complex (4)

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§ Balance§ Static (eyes open or closed)

§ Stable vs unstable surfaces

§ Vestibular Exercises§ Seated

§ Static balance - standing/stable surface

§ Static balance – standing/unstable surface

§ Dynamic Exercises§ Infinity walk

§ Obstacle course

§ Rehab Measures: https://www.sralab.org/rehabilitation-measures§ Information available on BESS, TUG, DGI, FGA, etc

Physiologic Post Concussion Disorder (P-PCD)

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§ Controversial topic (14) § Caused by persistent alterations in cellular metabolism (14)

§ Acute/subacute period – there’s transient cardiovascular autonomic dysfunction (increased sympathetic nervous system input) (4)

§ Will appear as exertional intolerance with symptom exacerbation (13)

§ Evidence is emerging to support this: § Retrospective study (n = 20) were evaluated for dizziness that happened during quiet standing

and with exercise§ Results: linked dizziness with ANS dysfunction (5)

§ Challenge: clear timeline to decide when to initiate exercise is lacking§ Current appears that physiological recovery may exceed clinical recovery (9) § Why we have prescription of graded physical activity prior to return to sport to reduce

potential risk for further injury (9)

§ Goal: Effectively decide between acute concussive symptoms and secondary sequelae (9)

§Consider both extremes:

§Physical/cognitive rest§OR

§No rest, full return to sport

…How do we decide?

Complete Physical/Cognitive Rest

§ Rest is most commonly prescribed component in acute phase (1) § May be advantageous early on, but

evidence is limited/inconclusive, sparse (1, 2)

§ Prolonged rest can end up being detrimental, leading to: § Physical deconditioning – important

especially in athletic population (12)§ Depression

§ Feels of social isolation (2)

§ Ultimately, may lengthen recovery timeline (2, 3)

No Rest/Early Return to Activity

§ Uncontrolled early activity likely detrimental§ More likely to experience longer

recovery timeline (3)

§ May also have worse clinical findings (3)

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§ Need a balanced approach! But how do we do that???

§ Remember the goal: have to decide if the symptoms we are dealing with are acute concussive in nature or secondary sequelae

§ Supported by most recent consensus statement (15)

§ Utilizes beneficial components of early physical/cognitive rest, but doesn’t advocate for prolonging this form of care (11)

§ Encourages: § Brief period of physical/cognitive rest (24-48) hours for most patients, though exact

window of time not well defined (11, 15)

§ Then advocates for slow reintegration of normal activity (11, 15)

§ Supports our role as therapists to:§ Initiate activity safely/feasibly into clinical treatment (2)

§ Clinically test/define safe limits for activity (3)

§ Clinical testing! § Not only will it give us a “safe” window for activity, but may also help diagnose

other secondary sequelae/clinical sub-types of concussion (4) § Physiologic PCD§ Cervicogenic PCD

§ Oculo-vestibular PCD

§ If there is a physiological issue, will present as: § Exercise intolerance with symptom exacerbation (with submax effort) (13)

§ Dizziness or vestibular dysfunction (13)

§ Orthostatic hypotension (13) § Altered HR and BP in response to exercise (13) § POTS (13)

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§ Need baseline vital signs (BP, HR) and must make sure patient is cleared for activity by referring MD (14)

§ Buffalo Concussion Treadmill Test § Graded exertional testing utilizing modified Balke Protocol (12, 13) § Take vitals at beginning, end, 5-30 minutes after; explain Borg/RPE scale

§ Patients walk at speed of 3.0-3.3 mph; increase incline by 1%/minute

§ If they max out on incline, increase speed by 0.2-0.4 mph/minute

§ Every minute, patients will give:§ Symptom profile

§ RPE § HR (continuously monitor) (12, 13)

§ Test stopped once symptom-limited threshold reached, or voluntary exhaustion (RPE 18-20) (12, 13)

Time Intensity RPE HR BP Symptoms

0 -

1 3.0/0%

2 3.0/1%

3 3.0/2%

4 3.0/3%

5 3.0/4%

6 3.0/5%

7 3.0/6%

8 3.0/7%

STOP -

Rest (5 Min) -

Time Intensity RPE HR BP Symptoms

0 - 6 75 120/80 -

1 3.0/0% 8 86 -

2 3.0/1% 9 94 -

3 3.0/2% 10 105 -

4 3.0/3% 12 115 -

5 3.0/4% 14 123 -

6 3.0/5% 15 130 -

7 3.0/6% 17 137 -

8 3.0/7% 18 150 -

STOP - 6 100 128/78 -

Rest (5 Min) 6 78 120/79 -

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Time Intensity RPE HR BP Symptoms

0 - 6 75 120/80 -

1 3.0/0% 8 86 HA - 1

2 3.0/1% 9 105 HA - 2

3 3.0/2% 10 126 HA - 2

4 3.0/3% 12 140 HA - 4

5 STOP 6 125 130/86 HA – 4

6 5 Min Rest 6 90 124/84 HA - 3

7 10 Min Rest 6 75 120/80 HA – 0

Source: 12

Time Intensity RPE HR BP Symptoms

0 - 6 75 120/80 -

1 3.0/0% 8 86 -

2 3.0/1% 9 94 -

3 3.0/2% 10 105 -

4 3.0/3% 12 115 -

5 3.0/4% 14 123 -

6 3.0/5% 16 136 -

STOP - 6 100 128/80 HA – 3

5 Min Rest - 6 82 122/80 HA – 3

10 Min Rest - 6 78 118/80 HA – 2

15 Min Rest - 6 78 118/80 HA - 1

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§ Graded exertion part of multi-modal therapy approach (4)§ May be feasible/safe even within first few weeks (2)

§ Research suggests safe to initiate, regardless of timing (2)

§ One study showed benefit for children/adolescents, regardless if seen <2 or >2 weeks post-injury (2)

§ May speed recovery timeline (10, 12) § One RCT showed reduced days for clearance for return to play. (10)

§ Treatment group: average 15.5 days until cleared§ Control group: average 26 days until cleared (10)

§ May decrease likelihood of developing secondary issues (10, 12)§ Same RCT showed reduction in diagnosis of PCS:

§ Treatment group: 14% did not recover (diagnosed with PCS); 18% were not cleared

§ Control group: 37% did not recovery (diagnosed with PCS); 42% were not cleared (10)

§ Looking to engage a therapeutic window (12)

§ Guidelines: tailored, submaximal exercise (12)§ 80-90% of HR achieved during graded testing

§ 20 min/day of exercise

§ 5-6 daysweek

§ Repeat testing every 1-3 weeks to modify program until asymptomatic (12)

§ Combine with other therapies (10, 12)

§ Vast majority will recover (12)§ If new/worsening migraine, or underlying post-injury psychological diagnosis- may have

incomplete response.

§ Consider referral to neuro or psychiatry (12)

§ Postural Orthostatic Tachycardia Syndrome

§ Form of dysautonomia, characterized by sustained tachycardia, and variable, complex symptoms upon standing (4)

§ Prevalence: 1-4 million Americans

§ Onset: typically adolescent girls – women of childbearing age§ Women affected more than men - ratio 4.5:1

§ Symptoms: Dizziness, headaches, nausea, visceral pain, heaviness of extremities, reduced mental clarity, generalized fatigue, § May also have poor sleep, poor temperature regulation, GI symptoms, skin discoloration,

bladder dysfunction (4)

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§ Hypovolemic§ Have reduced plasma, red cell, and total blood volume

§ Neuropathic§ About 50% of cases

§ Reduced vasoconstriction response/venous return with upright posture

§ Causes blood pooling in lower extremities and abdominal cavity, lowering stroke volume and creating compensatory tachycardia

§ Hyperadrenergic§ Excessive plasma, profound sympathetic activity upon standing

§ Have symptoms of anxiety, palpitations, tachycardia, tremulousness, postural hypertension

Source: 4

§ COMPASS 31 Symptom Questionnaire§ ID’s non-specific autonomic dysfunctions

§ Higher scores = greater symptom severity

§ Not yet validated for POTS d/t concussion (4)

§ Orthostatic Testing – Take BP and HR:§ 10 Min after supine rest

§ Immediately upon standing

§ 3, 5, 7, 10 Min standing

§ NOT validated as a diagnostic test – but if abnormal results seen, should be referred on for further medical evaluation

Source: 4

§ Increase daily fluid intake and sodium consumption

§ Compression stockings

§ Pharmacological agents§ Fludrocortisone

§ Beta-blockers

§ Midodrine

§ Pyrdiostigmine

§ Progressive exercise training

Source: 4

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§ Exercise training can help gradually increase blood volume, exercise capacity, stroke volume, and left ventricular diastolic function

§ Exercise should be monitored and individualized; include aerobic along with strength and resistance training§ Perform strength/resistance training in semi-recumbent positions

Source: 4

§ Core strengthening

§ Neuromuscular and vestibular rehabilitation

§ Exertional retraining (recumbent to start)

§ Heart rate training zones and RPE monitoring

§ Joint stabilization

§ Resistance training

§ Multi-task activities/cognitive engagement

Source: 4

§ POTS – Exercise guidelines: http://www.dysautonomiainternational.org/pdf/ExercisesForDysautonomiaPatients.pdf

§ Miranda (et al) supplementary materials (4)§ http://links.lww.com/JNPT/A212

§ http://links.lww.com/JNPT/A213

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Tying it all together

Health literacy is “the degree to which individuals can obtain, process, and understand the basic health information and services they need to make appropriate health

decisions.” (1)

§ Consider the NAAL Survey (both in 1992 and 2003)§ About 50% of Americans cannot read complex texts

§ NAAL Survey Scores: § Level 1: Below basic: no more than the most simple and concrete skills

§ Level 2: Basic: skills necessary to perform simple and everyday literacy activities§ Level 3: Intermediate: skills necessary to perform moderately challenging literacy

activities§ Level 4: Proficient: skills necessary to perform more complex and challenging literacy

activities

§ NAAL Results:§ Prose Literacy: 14% below basic, 29% basic, 44% intermediate, 13% proficient

§ Document Literacy: 12% below basic, 22% basic, 53% intermediate, 13% proficient

§ Numeracy: 22% below basic, 33% basic, 33% intermediate, 13% proficient

Source (2)

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§ 21-23% demonstrated the lowest level of proficiency (level 1)§ This means they could:

§ Total an entry on a deposit slip§ Locate time/place of a meeting on a form§ Identify a piece of information in a news article

§ 25-28% demonstrated skills in the next higher level (level 2) § This means they could:

§ Make low-level of inferences on printed materials

§ Perform quantitative tasks that involve single operation (ie calculate total cost of a purchase)§ Locate a particular intersection on a street map§ Enter background information on a simple form

§ Challenge: Those in Levels 1 and 2 don’t necessarily perceive themselves as being “at risk” and feel they can read English “well” or “very well”

Source (2)

§ Literature suggests a causal relationship between health literacy and health outcomes (1) § Those with low health literacy understand health information less, seek less preventative

care, and utilize more expensive health services more frequently (1)

§ Those with lower educational levels (no high school diploma) tend to be in the lowest two literacy levels (2)

§ With these literacy levels in mind, most will read comfortably at about 4 levels below their highest educational level (3) § For most, this means adults generally read at an 8th grade level (3)

§ If stressed, scared, anxious, these levels may be even lower (3)

§ What does this mean for us?

§ Reading Levels§ Dizziness Handicap Inventory: 7.1

§ Instructions on Rivermead: 7.9

§ Instructions on Neck Disability Index: 10.8

§ ”About Brain Injury” header information on BIANYS website: 10.1

§ “Concussion/Mild TBI” introduction on BIANYS website: 11

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§ Consider adapting informational sheets for patients with language that is at an accessible reading level § If uncertain of the reading level of your target population, aim for a 5th grade reading level

(3, 4)

§ Avoid using “medicalese” – use layman’s terms instead

§ Keep information simple, to the point (for layout and content) (3, 4)§ Need to know vs nice to know

§ Organize information into logical chunks

§ Position key information at TOP and BOTTOM of page

§ Utilize multiple forms of media to ensure understanding and reach learners§ Videos, podcasts, websites, etc

Next break: Class End at 4:30 PM

§ Cover/Uncover Test§ Should be done at near (33 cm) and far distances (> 3 ft)

§ Attention is on eye that has been occluded as occluder is pulled away

§ If covered eye shows refixation movement as occluder is pulled away – positive result for a phoria

§ Direction eye moves determines direction of phoria

§ IE if eye is outward, moves inward as occluder is removed – esophoria (outward deviation)

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§ All VOMS assessments: 3 feet from patient

§ Smooth Pursuits: Tests ability to follow slow moving target

§ Examiner sits 3 feet from patient§ Patient should maintain focus on target

§ Examine moves 1.5 ft R and 1.5 ft L of midline

§ 2 Repetitions should be performed; target should move at rate of approximately 2 seconds to travel full distance

§ Repeat going up/down

§ Record symptom changes on chart

§ Saccades: Tests ability to change fixation quickly between targets

§ Examiner sits 3 feet frm patient§ Examiner holds out two single points (fingertips) horiziontally; targets are 3 ft apart

§ Patient ultimately must gaze 30 degrees left/ 30 degrees right

§ Patient must move eyes as quickly as possible from point to point

§ Patient completes 10 reps

§ Record symptoms

§ Repeat with vertical saccades

§ Near Point Convergence (NPC): Measures the ability to view a near target with no double vision

§ Examiner sits in front of patient to observe quality of eye movement during test. § Patient focuses on small target (Size 14 font) an brings to tip of nose

§ Patient told to stop moving target if they see two distinct images

§ Examiner may end test if they observe outward deviation of an eye

§ Ignore blurriness!!

§ Measure distance in cm between target and nose; repeat three times

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§ VOR Test: Measures gaze stability on fixed target as head moves.

§ Mut use items of approximately size 14 font

§ Examiner sits in front of patient with object held about 3 feet away

§ Set metronome at 180 bpm

§ Instruct patient:§ Sit in upright posture; tilt chin down slightly

§ Move head at amplitude of 20 degrees to each size

§ Complete 10 repetitions to each side

§ Record symptom change

§ Repeat for vertical VOR test

§ Visual Motion Sensitivity: Examines ability to inhibit vestibular-induced eye movements using vision

§ Patient stands with feet shoulder width apart, facing busy/colorful area of clinic

§ Guard the patient!

§ Set metronome at 50 bpm

§ Patient should hold their arm extended in front of them§ Patient will move as a unit, staring at thumb at amplitude of 80 degrees laterally from

midline to each side§ Repeat 5 times to each side

§ Record symptoms