© The Children’s Mercy Hospital, 2016

Mary Helfer, MS, LAT, ATC

Shannon Margherio, PT, OCS, CSCS

Tiffany Whitney, PT, SCS

Sideline Concussion Tools and

Vestibular Rehabilitation

▪ Learn basic components of an initial concussion evaluation

▪ Overview of SCAT5 tool and VOMS for a sideline concussion

evaluation

▪ Learn about the various tests and tools used in vestibular

therapy after an athlete sustains a concussion

There are no disclosures or conflicts of interest for this

presentation

Learning Objectives:

Identifying Concussions and Process

▪ Athletic vs General

populations

– Healthcare providers

– Coaches

– Parents/guardians

▪ Process after injury ID:

– Initial evaluation

– Diagnosis

– Proper referrals

– Monitoring

– Progression back to

ADLs/athletics

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▪ On field assessment

– Red flags? Call 911

– Observable signs

– Maddocks Qs

– Glascow Coma Scale (GCS)

– C-spine eval

▪ Sideline/Office tests

– Sport Concussion Assessment

Tool 5 (SCAT5)

– Vestibular Ocular-Motor

Screening (VOMS)

– King-Devick test

– Balance testing

Initial Evaluation

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SCAT5

- Background

- Post-Injury Symptom Evaluation

- Orientation*

- Immediate memory*

- Concentration*

- Neurological screening

- Balance Examination (mBESS)

- Delayed recall*

- https://bjsm.bmj.com/content/bjs

ports/early/2017/04/26/bjsports-

2017-097506SCAT5.full.pdf

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Post Concussion Scale

Rate 0-6 : 0: none, Mild: 1-2, Moderate: 3-4,

Severe 5-6

1. Headache

2. Nausea and Vomiting

3. Balance Problems

4. Dizziness

5. Fatigue

6. Trouble falling asleep

7. Sleeping more than usual

8. Sleeping less than usual

9. Drowsiness

10. Sensitivity to Light

11. Sensitivity to Noise

12. Irritability

13. Sadness

14. Nervousness

15. Feeling more emotional

16. Numbness or Tingling

17. Feeling slowed down

18. Feeling mentally “foggy”

19. Difficulty concentrating

20. Difficulty remembering

21. Difficulty sleeping

22. Vision problems (double vision, blurring, etc)

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▪ Symptom check: baseline and after each test

▪ Smooth pursuits (H test)

▪ Saccades (horizontal and vertical)

▪ Convergence (near point)

▪ VOR (horizontal and vertical)

▪ VOR cancellation/Visual motion screening

VOMS

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VOMS Score Chart

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P.T. Initial Evaluation

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Concussion

Vestibular

Ocular

Cognitive/

Fatigue

Post-TraumaticHeadache

Anxiety/Mood

Cervical

Gather subjective and

objective data to

help prioritize order of

these deficits. Try to find

the driving subtype.

-Clinical interview

-Post Concussion Symptom

Scale

-Vestibular-Ocular tests

-Balance tests

-Cervical screen

-Exertional testing

PT Vestibular Assessment

Evaluation of gaze stabilization, balance, and motion

sensitivity

May include:

– VOR (Vestibular Ocular Reflex) slow—similar to VOMS test

– VOR fast: head impulse or head shake

– DVA (Dynamic Visual Acuity)

– Balance: static and dynamic testing

– Positional testing

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Motion Sensitivity TestingPosition Change Symptoms

Intensity

(0-5)

Symptom

Duration

(0-3)

Score (I+D) Nystagmus

Baseline Symptoms

1. Sitting to Supine

2. Supine to Left side

3. Supine to Right side

4. Supine to sitting

5. Left Dix-Hallpike

6. Return to Sitting

7. Right Dix-Hallpike

8. Return to Sitting

9. Sitting Nose to left knee

10. Return to Sitting erect

11. Sitting Nose to right

knee

12. Return to Sitting erect

13. Sitting Neck rotation

14. Sitting Nectk flexion &

extension

15. 180 degree turn to the

right

16. 180 degree turn to left

Total

MSQ

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a. symptom intensity: subjective (patient report) scale

from 0 to 5

(0 = no symptoms, 5 = severe symptoms)

b. symptom duration: scale from 0-3

(5-10 sec = 1 point; 11-30 sec = 2 points; >30 sec =

3 points)

c. total score = intensity + duration for each position

change

d. MSQ (motion sensitivity quotient) = Total Score/ 20.48

Abbott: 0-10% = mild; 11-30% = moderate; 31-100% =

severe

Vestibular Strategies

▪ Targeted vestibular therapy: progress slowly if there is a

headache/migraine component

– VOR/gaze stabilization exercises

– Balance exercises

– Core stabilization to “settle” symptoms

– Progress by layering in multi-sensory stimuli—this holds true for all the

concussion “subtypes”.

Buffalo Concussion Treadmill Test

3.2/3.6 (pending height) MPH at 0% grade – increase grade every minute

Stop once symptoms develop/worsen

Grade HR Rated Perceived Exertion(1-10) Symptoms Worse?

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

If still going, increase MPH by 1 MPH every minute until symptoms develop/worsen.

Symptom Threshold HR_______________________________________________________

At 80% of Symptom Threshold HR_______________________________________________

Guidelines for Exercise

▪ Start with 10 minutes at 80% of symptom Threshold

▪ If well tolerated, increase by 1 minute per day

▪ If symptoms increase, do not increase duration, but do continue to exercise for at least 10 minutes per day

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-- Begin slower at 60bpm and build up to 180bpm

– Begin in sitting and advance to single leg stance and

then while walking

– Progress from a white background to a busy

background

– Can use the following site for different speeds and

backgrounds

https://www.youtube.com/playlist?list=PL3NyX9dfE

9BIM4z-LXTJ6ZEQgXwlrANch

– Progress to sport specific – some examples include:

VOR while doing ball toss, soccer dribbling or toe

taps looking from ball up to a target, vertical ball

toss, prone head turns for swimmers, passing a puck

on a slide board for hockey

– May et al has good recommendations for sport

specific return to sport

VOR Treatment

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Smooth pursuit

▪ Abnormalities- nystagmus

▪ Treatment

• Following a moving target while the head stays still. Tracking exercises,

ball toss between hands, Marsden ball activities, marble rolling

• Progress by increasing speed, layering in multiple sensory and cognitive

tasks. Busy backgrounds, balance challenges, multi-tasking.

• Site for additional treatments:

https://eyecanlearn.com/tracking/pursuits/

Ocular

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Eye Tracking Maze

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Eyecanlearn.com

Ocular

Saccades

▪ Abnormalities – hypometric (undershooting) or hypermetric

(overshooting)

▪ Treatment

– Vertical and Horizontal saccades

– Disorganized scanning pattern—post-it notes on a wall

– HART chart

– Reading handouts progress from larger letters to smaller letters

– Online activities: https://eyecanlearn.com/tracking/saccades/

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Examples of Hart Charts and Disorganized

Scanning Patterns

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Eyecanlearn.com

Ocular

Convergence

▪ Abnormalities –unable to converge eyes within 6cm

from the tip of the nose, report double vision prior to 6

cm; 1 eye may abduct

▪ Treatment

– Pencil push-ups

– Convergence beads—Brock string

– Marsden ball

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Brock string example

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Helping the eyes work together as a team to

focus near and far.

Cervical

▪ Signs and Symptoms – Symptoms increase or are triggered with cervical mobility and

trigger points

▪ Treatment

– Cervical ROM and manual therapy

• AROM and PROM

• Manual therapy for restrictions found

– Suboccipital release

– Cervical strengthening

• Upper cervical flexion

• Isometric hold with theraband as walk out forward, retro and lateral

• Theraband resisted cervical lateral flexion, upper cervical flexion

• Not research supported but offers proximal stability to assist.

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Anxiety and Mood

▪ Signs and Symptoms: High Concussion Grading Score

but no ocular symptoms

▪ Treatment

– Increase activity

– Education on sleep and hydration

– Referral to counselor/therapist

– Work with physician for medication as needed- anti-

depressants

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Cognitive and Fatigue

▪ Signs and Symptoms – Difficulty with school work and

not sleeping well but no increase in symptoms with

physical activity

▪ Treatment

– Proper sleep habits – no naps

– Increase activity (Buffalo test can be used as a guideline for

exercise)

– Water intake – 8 8oz

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Migraine

▪ Signs and Symptoms – primary symptom is headache

and has history of headaches

▪ Treatment

– Education on proper sleep and water intake – 8 8oz

– Increase physical activity

– Working with physician on proper medication

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▪ Kontos AP, Deitrick JM, Collins MW, Mucha A. Review of Vestibular and Oculomotor Screening and Concussion Rehabilitation. Journal of Athletic Training. 2017;52(3):256-261. doi:10.4085/1062-6050-51.11.05

▪ Reynolds E. Concussion Clinical Trajectories. June 2017. Part of ITAT certification course materials.▪ Galetta KM, Brandes LE, Maki K, Dziemianowicz MS, Laudano E, Allen M, Lawler K, Sennett B, Wiebe D, Devick S, Messner LV, Galetta SL, Balcer LJ. The King-Devick test and sports-related concussion: study of a rapid visual screening tool in a collegiate cohort. J Neurol Sci. 2011 Oct 15;309(1-2):34-9.▪ Sport concussion assessment tool - 5th edition. British Journal of Sports Medicine 2017;51:851-858.▪ Davis GA, Purcell L, Schneider KJ, et al. The child sport concussion assessment tool 5th edition (child SCAT5): background and rationale. British Journal of Sports Medicine 2017;51:859-861.▪ Leddy, Baker, Willer (2016) Active Rehabilitation of Concussion and Post-concussion Syndrome. Physical Medicine and Rehabilitation Clinics of North America, 2016-05-01, Volume 27, Issue 2, Pages 437-454▪ Murray, Meldrum, Lennon (2017) Can vestibular rehabilitation exercises help patients with concussion? A systematic review of efficacy, prescription and progression patterns. British Journal of Sports Medicine, 51(5) March 2017, 442-451▪ Worts PR, Schatz P, Burkhart SO. (2018) Test Performance and Test-Retest Reliability of the Vestibular/Ocular Motor Screening and King-Devick Test in Adolescent Athletes During a Competitive Sport Season. American Journal of Sports Medicine, 46(8) July 2018, 2004-2010. ▪ May K, Marshall D, Burns T, Popoli D, Polikandriotis J. (2014) Pediatric Sports Specific Return to Play Guidelines Following Concussion. International Journal of Sports Physical Therapy, 9(2), April 214, 242-255.

References

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▪ Broglio SP, Cantu RC, Gioia GA, Guskiewicz KM, Kutcher J, Palm M, Valovich McLeod TC; National Athletic Trainer's Association. National Athletic Trainers' Association position statement: management of sport concussion. J Athl Train. 2014 Mar-Apr;49(2):245-65.

▪ Leddy J, Baker J, Haider M, Hinds A, Willer B. (2017) A Physiological Approach to Prolonged Recovery From Sport-Related Concussion. Journal of Athletic Training, 52(3), March 2017, 299-308.▪ Quatman-Yates CC, Hunter-Giordano A, Shimamura K, et al; (2020) Physical Therapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury. Journal of Orthopaedic & Sports Physical Therapy, 50(4), April 2020, CPG1-CPG73

▪ CDC Pediatric mTBI Guidelines: https://www.cdc.gov/traumaticbraininjury/PediatricmTBIGuideline.html

References Continued

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