9/6/2017 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 What is the Vestibular System? • Vestibular • Vestibular system – give sensory input – Dizziness about motion, equilibrium, & spacial – Imbalance orientation • Orthopedic – Neck pain (primary) – Other injuries incurred during the traumatic event How are concussion symptoms linked Functions of the Vestibular System to the vestibular system? • Vestibular Ocular Reflex (VOR) • VOR - Gaze instability/Oculomotor deficits – Allows gaze stabilization with head/body movement – Blurred vision, headaches, dizziness, motion • Vestibulocollic Reflex (VCR) sensitivity, visual motion sensitivity – Initiates righting reactions for head on • VCR – Cervical instability neck – Headache, neck pain, dizziness with head • Vestibulospinal Reflex (VSR) movement • VSR – Postural instability – Provides balance/stability with movement of the trunk – Imbalance, “clumsy”, falls 1
9/6/2017 Vestibular Assessment Head Thrust Test / Head Impulse Test • 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) Picture: http://vertigodifferentiation.weebly.com/head-thrust.html Vestibular Treatments PT Treatment Based on Symptoms • VOR Retraining • Vestibular – Dizziness and nausea is normal and expected • dizziness, balance, headaches – Eyes move equal and opposite head • Ocular – Symptoms should improve in minutes (not hours) • headaches, decreased tolerance for close work/school work, eye strain • Referral to Vision – OD or OT – Metronome used to help maintain speed • Manual • headaches, neck pain and any impaired strength • VOR x 1 – Gaze fixed on a stable target while • Progressive Aerobic Activity head or body move • deconditioning or exercise intolerance – Perform horizontal (“no”) and vertical (“yes”) • Dual task Training – Static position with head moving eyes on target • incorporating attention, cognition, concentration with balance and exertion activities – Bouncing on ball or trampoline eyes on target VOR Retraining Continued Vestibular Treatments Continued • VOR x 2 - Gaze fixed on moving target • Balance • while head or body move Static • Feet together -> Tandem -> Single leg – More difficult than 2 objects moving – used • Eyes Open -> Eyes Closed frequently in sports • Firm -> Foam – Tracking a ball or player while moving in the other • Dynamic - Any static position plus additional activity • Head turning and nodding direction • Ball Toss • VOR cancellation - Gaze fixed on a target • D2 pattern pick up objects from floor to waist/overhead moving together with head – Holding an object and spinning or moving 2
9/6/2017 Visual Stimulation Vestibular Treatments Continued • Visual • Habituation – Add saccades • – Add pursuits Walking with head turns • Walking with ball toss hand to hand (horizontal and vertical) – Add noise • Walking while putting down and picking up objects • Vestibular • Turning (half turns and full turns) – Balance • Walking forward ½ turn, walking backward ½ turn • Any normal activity that is symptomatic • Without Fixation • With Fixation • Counting moving dots – Turns / Movement Exertion Cervical Spine Pain and Dizziness • May be performed while symptoms are still • Cervical stabilization exercises present • Cervical stretching • Find activity that with min to no increase in • Scapular stability daily symptoms (<3/10 increase) – Start with light cardio • Postural correction and strengthening – Progress to strength • Manual therapy – Wait to add/try jogging/running, agility and plyometrics until VOR improves Occupational Therapy in TBI OT Evaluation • • ADL Scale Evaluate current level of brain function • King-Devick • Identify limiting factors that impede daily independence • MOCA • Re-train brain skills with graded interventions as appropriate • CISS to further progress independence and reduce symptoms • Self-Perception • What are your patient’s goal(s)? • Cohen Stress Scale – Self-reported goals and factors that limit independence – Client-centered intervention that engages them to help remediate deficits • Mayo-Portland Adaptability Inventory-4 – Home exercise programs that are consistently modified to patient progress each • COPM week 3
9/6/2017 Cognitive Remediation Cognitive Remediation Continued • Requires patience and time • Attention • Complete success cannot be made overnight • Executive Functioning • Using mental manipulation and functional • Memory activities to improve overall brain function • Altering the chemical makeup and electrical • Visuospatial Relations activity in your brain • Visual Skills • Conducting new pathways to complete tasks Compensatory Techniques Functional Vision Deficits • Fixation (and/or visual attention*) • • Internal Techniques External Techniques • - Visualization and Pursuits – Voice recorders pre-planning tasks • Saccades – Calendars/Journals - Chunking (words, • Accommodation – Timers phrases, numbers) • Vergence Movements – Assistive Technology - Association • Photophobia Applications - Mnemonics • Lateral field cut or homonymous hemianopsia – Lists - Pairing • Visual-perceptual abilities - Chaining (Functional Vision Deficits continued) Vision Intervention • Strabismus • Identify deficits • Amblyopia • Improve eye teaming and binocular • Ptosis vision • Cranial Nerve Palsy • Reduce symptoms with activities and – 3 rd – cannot move inward or up Daily HEP – 4 th – vertical misalignment • Return to independence – 6 th – difficulty with lateral movements 4
9/6/2017 Busy Backgrounds Metronome • Pursuits and Saccades (All Planes) – Goal 110-120 beats per minute • Near and far – 80-90 bpm B • Speed and accuracy to reduce symptoms Home Exercise Program Psychological effects from mTBI • Follow the “B” • Depression and Anxiety are common • Eye Jumps due to: • Hart Chart • Column Jumps – Prolonged recovery • Attention Process Training – Significant life status change • Goal: 3-5 times a day and at least 2 times a day – Difficulty processing information • Use Metronome for grading* • Sensory Re-Integration* Sensory Processing Neuro-Optometry, OT, and PT Team Work • “Similar Focus - Same Vision” • What is sensory defensiveness? • Overstimulation of Central Nervous • Collaboration of Optometric Efficiency with System Cognition and Perceptual-Motor Skills • What makes the patient defensive? • Collaborative use of prisms to help with • Intervention balance retraining 5
9/6/2017 Contact Us • Joe Kardine, OTR/L – John.KardineJr@Jefferson.edu • Jenny Rexon, PT, DPT Questions? – Jennifer.Rexon@Jefferson.edu • Jefferson Comprehensive Concussion Center – Main Phone: 267-463-2300 – Rehab Phone: 267-463-2298 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):442-6. • Differential Diagnosis for Vertigo. Available at: http://vertigodifferentiation.weebly.com/head-thrust.html. 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
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