I N - S E R V I C E C R E A T E D & P R E S E N T E D B Y :

S U S A N M I L L E R , S P T

R E G I S U N I V E R S I T Y , A P R I L 2 0 1 5

Management & Treatment for Concussions

Objectives

Overview of Concussion

Screen Tools: VOMS & BESS

Vestibular exercise program

What is a concussion?

According to Centers of Disease Control (CDC):

“A type of traumatic brain injury, or TBI, caused by a bump, blow or jolt to the head that can change the way your brain normally works. Concussions can also occur from a fall or blow to the body that causes the head and brain to move quickly back and forth.”

How can a concussion occur?

Head strikes a stationary item Head hitting ground/object

Head hitting an object during MVA

Object hitting the head I.E. - ball or stick during sports or human collision

Quick acceleration/deceleration of the head

These events cause Quick deceleration of the head

Shifting of brain tissue inside the skull

If Rotational force occurs LOC & nausea will occur

(Miranda, 2013)

What is affected from a concussion?

Reaction time & brain processing

Abnormal vestibular functioning Brain receives abnormal signals about position & movement of

head in space

Relies on visual input resulting in:

Fatigue

Difficulty with ADL’s

Eyestrain

Tension headaches

Dizziness

Sense of irritability

(Miranda, 2013)

Diagnosis of a concussion

Cannot be seen on CT or MRI Help rule out more series brain injuries (IC bleeding,

contusion, and/or lesions)

A Group of Symptoms will occur immediately or weeks to months after incident

Length of time for symptoms: Acute symptoms: 1-2 weeks following

Post Concussion Syndrome: 3-4 weeks to months

10-20%

(Johnston et al, 2004; Harmon et al, 2013; Miranda, 2013)

Signs & Symptoms: 4 domains

Adapted from Center of Disease Control:http://www.cdc.gov/concussion/signs_symptoms.html

Create a Multi-Disciplinary Team Approach

Team Includes: School Professionals

Physical Team: School nurse, certified athletic trainer, coach, & PE teacher, athletic director & other

Academic Tam: teacher, counselor, school psychologist, school social worker, and administrator and others

Medical Professionals

Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), Nurse Practitioner (NP), Physician Assistant (PA), a licensed psychologist (with training in concussion management or a neuropsychologist

Family

Student, parents, guardians, grandparents, siblings, student’s peers

Adjunct team

Physical Therapist, Massage Therapist, Chiropractors & OT *

Graded Symptoms Checklist

• Help speak a common language

• 0-6 symptom scale

• Graded symptom checklist recommend by National Associate of Athletic Trainers

(Harmon, et al., 2013)

Determining Return to Play

Health care provider: Doctor of Medicine

Licensed Nurse Practitioner

Doctor of Osteopathic medicine

Licensed Physician Assistant

Licensed Doctor of Psychology w/ training in neuropsychology or concussion evaluation & management

Physical Therapist? Introduced in Feb. 2015 to House & Senate

SAFE PLAY Act (Supporting Athletes, Families and Educators to Protect Lives of Athletic Youth Act)

Concussion/Examination

History Cervical Evaluation VOMS* Ocular/Visual Assessment Gaze Stability Head Righting Neurologic Screen Cervicogenic Dizziness Balance Gait Assessment Exertion Response Positional Vertigo/Dizziness

Adapted from Kinetic Energy PT

Concussion Screening Tools

University of Pittsburgh Medical Center Vestibular/Ocular Motor Screening (UPMC VOMS)*

Balance Error Scoring System (BESS) test*

Computerized neurocognitive test (ImPACT)

UPMC VOMS

Develop to assess vestibular & ocular motor impairment

5 Domains: Smooth Pursuit

Horizontal & vertical saccades

Convergence

Horizontal & vertical Vestibular Ocular Motor Reflex (VOR)

Visual Motion Sensitivity (VMS)

Patients verbally rate changes: Headache, dizziness, nausea & fogginess Scale: 0 (none) to 10 (severe)

5 mins to administrate

See handout for test (Mucha, A. et al., 2014)

BESS test

Clinical balance test: 6 conditions (EO/EC), 3 stances, 2 surfaces (firm & foam); hands on hips for 20 s Feet together

Single leg

Tandem Stance

Total Errors: Lifting hands off hips

Opening eyes (in eyes closed conditions)

Leaning >30° of flexion/extension or adduction/abduction

Stepping out of position

Protracted time out of position

Acute Interventions

Physical:

Strategic rest periods: 15-20 min through the day

Sunglasses, quiet rooms, frequent breaks

Remove physical activity that provokes systems

Cognitive:

Reduce workload

Emotional:

Secondary depression & anxiety

Sleep/Energy:

Rest breaks; late start, early leave

Adapted from Colorado Department of Education: http://www.cde.state.co.us/healthandwellness/braininjury

Vestibular Treatment for Concussions

Head trauma can cause inner ear damage

Resulting in balance & dizziness

Vestibular treatment can help improve sensory input for vestibular, visual, and proprioceptive systems

Vestibular Therapy:

EXERCISES

Vestibular Adaption exercise (Gaze Stability)

Vestibular stimulation (habituation)

Static & Dynamic Balance Cardiovascular

Manual Therapy- Cervical

Gaze Stability & Vestibular Adaption Exercises

VOR training

Includes movement of eyes that function to stabilize during head movement

Exercises Include:

X1 viewing

X2 viewing

Scanning exercises

Saccade Exercises

Positions:

Seated Standing Walking and/or Unstable Surfaces

Hand out & next slide for example

Let’s Practice: Example of Exercises Vestibular Adaptions:

1x Viewing:

2x Viewing - same & opp.

Eye – Head Coordination

Imaginary Targetshttp://www.dizziness-and-balance.com/treatment/rehab/gaze%20stab.html

3

VORx2 Imaginary Target Imaginary Target

Imaginary Target

Imaginary Target

Imaginary Target

Imaginary Target

Standing Static (Feet In Place)

• Upright

• Weight Shift

• Single Leg Stance

• Sit To Stand

• Rocker board

• 1 foot on step

3

VORx2 Imaginary Target Imaginary Target

Imaginary Target

Imaginary Target

Imaginary Target

Imaginary Target

Standing Static (Feet In Place)

• Upright

• Weight Shift

• Single Leg Stance

• Sit To Stand

• Rocker board

• 1 foot on step

3

VORx2 Imaginary Target Imaginary Target

Imaginary Target

Imaginary Target

Imaginary Target

Imaginary Target

Standing Static (Feet In Place)

• Upright

• Weight Shift

• Single Leg Stance

• Sit To Stand

• Rocker board

• 1 foot on step

3

VORx2 Imaginary Target Imaginary Target

Imaginary Target

Imaginary Target

Imaginary Target

Imaginary Target

Standing Static (Feet In Place)

• Upright

• Weight Shift

• Single Leg Stance

• Sit To Stand

• Rocker board

• 1 foot on step

http://www.aaompt.org/education/conference11/precon/Garrigues_Treatment_handouts.pdf

3

VORx2 Imaginary Target Imaginary Target

Imaginary Target

Imaginary Target

Imaginary Target

Imaginary Target

Standing Static (Feet In Place)

• Upright

• Weight Shift

• Single Leg Stance

• Sit To Stand

• Rocker board

• 1 foot on step

Vestibular Stimulation Exercises

Exercises to improve cervical ROM Flexion, extension, Rotation

Rotational exercises Picking items up from the ground

Exercises to improve static balance in the absence of vision

Motion Sensitivity exercise (Habituation) Based from Motion Sensitivity Score

Pick 4 positions that causes moderate level of symptoms

Pt. to repeat 2-3x’s

Hand out for test

Static & Dynamic Balance Exercises

Maintain Balance for 30s Static:

Eyes Open Closed

Firm surface Soft Surface

Different Stances: comfortable, narrow, tandem, single stance

Dynamic:

Walking w/ head movements: rotation, flexion, extension maintain direction & velocity of gait

Toss a ball to the patient while walking

Ambulation on unstable surface

Narrow BOS

(Kristjansson et al. 2009; Lee et al, 2013)

Manual Therapy - Cervical Cardiovascular

Soft Tissue Massage

Sub-occipital release

ROM exercise

Strengthening & improvement of posture (exercise & education)

Stationary Bike

Treadmill walking or jogging

Agility drills

Manual Therapy & Cardiovascular

(Schneider et al., 2014; Wells et al, 2015)

Exercise Program Progression

Type: Combo of cervical & vestibular training

Repetitions: 3-5 progressing towards 10

Duration: min. 6 -12 weeks

Until dizziness symptoms goes away altogether

Frequency: PT 1-2x/week; HEP 1-2x/day

Intensity: Should produce temporary increase in dizziness

Normal response & should try to work through these symptoms

(Schneider et al., 2014 Kristjansson et al. 2009)

References

Concussion Management Guidelines. Colorado Department of Education. http://www.cde.state.co.us/healthandwellness/concussionguidelines11-6-14 . Accessed on March 2015.

Harmon KG, Drezner JA, Gammons M, Guskiewicz KM, Halstead M, Herring SA, Kutcher JS, Pana A, Putukian M, Roberts WO. American Medical Society for Sports Medicine position statement: Concussion in sport. British Journal of Sports Medicine. 2013;47(1):15–26.

Heads Up Basic on Concussions. Center for Disease Control. http://www.cdc.gov/headsup/basics/concussion_whatis.html. March 2015.

Injury Prevention & Control: Traumatic Brain Injury. Center of Disease Control. http://www.cdc.gov/concussion/signs_symptoms.html. Accessed March 2015.

Johnston KM, Bloom GA, Ramsay J, Kissick J, Montgomery D, Foley D, Chen JK, Ptito A. Current concepts in concussion rehabilitation. Current Sports Medicine Reports. 2004;3(6):316–323.

Kristjannsson E, Treleaven J. Sensorimotor function and dizziness in neck pain: implications for assessment and management. J Orthop Sports Phys Ther. 2009; 39(5): 364-377.

Lee H, Sullivan, J, Schneiders A. The use of the dual-task paradigm in detecting gait performance deficits following a sports related concussion: A systematic and meta-analysis. J Sci and Med in Sp. 2013: (48) 2-7.

Miranda, N. Concussion: When Recovery Is Complicated By Vestibular Involvement and How Vestibular Rehabilitation Can Help. Vestibular Disorder Association. 2013.

Mucha, A. et al. Brief Vestibular and Ocular Motor Screening (VOMS) Assessment: Preliminary Finding in Patient following Sport-related Concussion. Am J Sports Med. Aug 2014

Schneider K, Meeuwissee W, Nettel-Aguirre A, Barlow K, Boyd L, Kang J, Emery C. Cervicovestibularrehabilitation in sport-related concussion: a randomized controlled trail. Br J Sports Med. 2014: (48) 1294-1298.

Vestibular Rehabilitation: Rehabilitation Options for Patients with Dizziness and Imbalance. American Speech-Language-Hearing Association. http://www.asha.org/aud/articles/vestibularrehab. Accessed March 2015.

Wells E, Goodkin H, Griesbach G. Challeneges in Determining the Role of Rest and Exercise in Management of Mild Traumatic Brain Injury. J Child Neuro. 2015: 1-7.