Post on 14-Dec-2015
Physical TherapyPhysical Therapyin the DoDin the DoD
CDR Henry McMillan, PT, DPT
LCDR Alicia Souvignier, MPT, DPT, GCS
ObjectivesObjectivesIdentify the common patient
presentations seen by PHS PTs working in the DoD
Be able to indentify key aspects of the evaluation of a dizzy patient
List 3 treatment techniques used to treat dizziness
Indentification of mTBI Indentification of mTBI Incident in theatre results in
Medivac to CONUSAfter redeployment, troops
inprocess through the Soldier Readiness Center, where history of concussion is identified
Soldiers with possible residual symptoms of concussion, are referred to the TBI clinic.
DoD/Physical TherapyDoD/Physical Therapy
Optimistic expectation for full recovery
Therapists incorporate assessment of the Service Members goals and priorities along with MTBI related symptoms
Areas of concern for a soldier Areas of concern for a soldier who has a history of who has a history of concussion/mTBIconcussion/mTBIVestibular DysfunctionBalance ComplaintsPost Traumatic HeadacheTemporomandibular Joint
DysfunctionAttention and Dual-Task DeficitsFitness/ Activity intoleranceMusculosketetal complaints
Guidelines for PT ReferralGuidelines for PT ReferralDHI Score > 11 (Yes to any F’s or P’s)Plus yes to one of the following:◦ R/SR (Eyes Closed) less than 30
seconds- (arms across chest)
◦ VOR x1 for less than one minute with onset of symptoms
◦ Walking with HT increase symptoms, deviated gait, LOB- (Museum Gait)
Guidelines for PT referralGuidelines for PT referral◦If the patient reports any of the
following Difficulty with balance or dizziness that is
affecting their functional performance
Unsteady while standing still or walking, in poor lighting, or in crowds
Difficulty with balance on uneven surfaces
Intense spinning, lightheadedness, or unsteadiness associated with exercise
Causes of VertigoCauses of VertigoVestibular Lesions or hypofunction
◦Unilateral- infection/neuritis, lesions, bppv
◦Bilateral- ototoxic medicationsCentral processing
◦Central lesions- brainstem, cerebellum◦Migranes◦Anxiety
Cervicogenic dizziness◦Vertebrobasilar insufficiency◦Altered proprioceptive signals
EvaluationEvaluationSubjective
◦MOI or idiopathic◦Frequency/Intensity/duration◦Vision/ Hearing deficits◦Positional/activity induced
Valsalva/ pressure changes
◦Describe symptoms of dizziness Vertigo Imbalance Lightheadedness
EvaluationEvaluationSubjective
◦Activity Level Recreational Sports
◦Exercise Tolerance Unit Physical Training
◦Behavioral Health◦Quality of Life
DHI Family Participation Command/Unit Support
Oculomotor Oculomotor Smooth PursuitSaccadicVOR
OculomotorOculomotorVestibular Ocular Reflex
◦Vestibular system sends information regarding speed of movement to the visual system. Allows us to keep focus while performing functional head motions.
Test for VORTest for VORHead Thrust Test
◦Grasp patients head firmly◦Tilt patient’s head to 30 deg flex◦Move head back and forth slowly and
instruct patient to keep focus on target
◦Provide a quick movement through a small range and watch for patient’s ability to refocus on target.
◦Refixation saccade indicates decreased VOR
Test for VORTest for VORDynamic Visual Acuity
◦Test visual acuity on a Snellen Chart◦Turn patients head vertical and
horizontal plane to the beat of a metronome at 2Hz
◦Retest visual acuity while you are moving the patient’s head.
◦3 lines loss is significant
Positional TestingPositional TestingDizziness caused by certain
positions◦Spinning◦Use Frenzal goggles
Dix Hallpike◦BPPV
Motion Sensitivity Quotient ◦Motion Sensitivity
Positional TestingPositional TestingDix Hallpike
◦Long sitting, head turned 45 deg, drop down with neck into about 30 deg of extension
Treatment ApproachesTreatment ApproachesAdaptation Exercises: adapting
residual vestibular function to make up for lost function◦Example: Maintain visual fixation on
object while the head is movingSubstitution Exercises
◦Doing exercises with and without visual cues
Habituation Exercises◦Repeated exposure to provocative
stimulus, for example motion sensitivity.
VOR Treatment - VOR Treatment - AdaptationAdaptationWalking head turnsTracking with eyesTracking with head movementsAll of the above togetherAbove exercises on varied
surfaces
Motion Sensitivity Motion Sensitivity TreatmentTreatmentBrandt Daroff (picture)Positions identified from MSQ
Postural StabilityPostural StabilityPrioprioNeurocom-Balance activities- SOT
◦Foam◦Unstable surface◦Uneven terrain
Treatment IdeasTreatment IdeasFoam bowlingBear clawsSoccer TossWiiDance RevolutionDiscoball/strobe with balance