Return to Learn Fall 2014 Webinar Series: Students …...2014/12/17 · (TBI or non-TBI) that...

1

www.brainsteps.net www.brainsteps.net

Return to Learn

Fall 2014 Webinar Series:

Students (K-12) with Concussion

Vestibular Issues Impacting Academics November 12, 2014


BrainSTEPS was created by: PA Department of Health in 2007

BrainSTEPS funding:

PA Department of Health PA Department of Education, Bureau of Special Education via the PaTTAN network

BrainSTEPS implementation: Brain Injury Association of Pennsylvania


The webinars in this concussion series were created to

build the capacity of teachers working with students

who return to the classroom following concussion.

This series does not replace the official

PA BrainSTEPS Return to Learn (RTL) Concussion Management Team (CMT) Training.

Attendance during this webinar does not denote CMT formation or BrainSTEPS Team Membership.

This webinar is for educational purposes only.

If your Pennsylvania school district is interested in

forming a Concussion Management Team for

academic & symptom management, please register your CMT at www.brainsteps.net and online training

information will be sent to you.


The BrainSTEPS Program, PA Department of Health &

PA Department of Education invite your PA school to form & train a

Return to Learn Concussion Management Team (CMT)

Join the 700+ Return to Learn

Concussion Management Teams

that have formed in PA school districts

within the last 1.5 years

To register:

www.brainsteps.net


The BrainSTEPS Program, PA Department of Health & PA Department

of Education invite your PA school to form & train a


Your CMT will receive: 1. Concussion Training for Return to Learn

2. Concussion RTL Electronic Toolkit

Academic Monitoring Tool Symptom Monitoring Tool

Parent Concussion Letter

Teacher Weekly Accommodation Letters, etc. 3. Ongoing support & networking from your local

BrainSTEPS Team

4. Ongoing information & Training through the Return to Learn CMT Website

To register: www.brainsteps.net

www.brainsteps.net

Student Concussion

CMT Monitoring @ School level 700+ Concussion

Management Teams for

Return to Learn

BrainSTEPS Support begins 4 weeks post @ Intermediate Unit level 31 Regional Consulting Teams

PA’s Unique Layered Statewide Infrastructure for Supporting Return to Learn Following Concussion

1st

layer

2nd

layer

http://www.brainsteps.net/

2


Students who should be referred to your regional Intermediate Unit BrainSTEPS Team

Type of Student Acquired Brain Injury Brain injury occurring anytime

AFTER birth

When to Refer a Student to BrainSTEPS www.brainsteps.net

Concussion

4 weeks post concussion unless student has a history of any of the following then refer sooner: • Prior concussions • Migraines • Learning, attention or emotional disabilities,

sleep disorders

New Moderate TBI, Severe TBI, Non-TBI

As soon as injury occurs, the sooner you refer the better. Don’t wait for the student to experience educational impacts/bad grades. Refer early to prevent issues.

Acquired Brain Injuries (TBI or non-TBI) that occurred in the past

If the student is experiencing educational impacts from an earlier brain injury, make a referral.


BrainSTEPS 2014 (Webinars will be archived & available at www.pattan.net & www.brainsteps.net)

Return to Learn Concussion Series Wednesday, September 10, 2014

Medical Management of Concussion

3:30—5:00pm

Gerard Gioia, PhD

Wednesday, October 1, 2014

School Impacts, Return to School

Progression, Symptom Based Accommodations

3:30—5:00pm

Brenda Eagan Brown, MEd, CBIS

Wednesday, October 22, 2014:

Legal Dimensions for Schools

3:30—5:00pm

Perry Zirkel, PhD, JD, LLM

.

Wednesday, November 5, 2014 Vision Issues Impacting Academics 3:30—4:30pm Nathan Steinhafel, M.S., O.D., F.A.A.O

Wednesday, November 12, 2014 Vestibular Issues Impacting Academics

3:30—4:30pm Lenore Herget, PT, DPT, MEd

December 18, 2014 Supporting Emotional & Mental Health of Students with Protracted Recovery 3:30—5:00pm

David Brent, MD

Webinar Live Registration: www.pattan.net


Email all questions from today’s webinar to:

Brenda Eagan Brown, M.Ed., CBIS BrainSTEPS Program Coordinator

[email protected]


Lenore Herget, PT, DPT, MEd

Massachusetts General Hospital

Concussion: Vestibular Issues Impacting Academics

Lenore Herget, DPT, MEd. Massachusetts General Hospital

Sports Medicine: Physical Therapy


Disclosures

I have no financial relationship with any

commercial entity producing health-care related products and/or services.

http://www.pattan.net/

http://www.brainsteps.net/

3


Post-Concussive Symptom Scale subgroups and medication mgmt • Neuropsychiatric/Mood Symptoms (Rx with SSRIs, Therapy)

– More emotional, sadness – Nervousness, irritability

• Cognitive Sx (Rx with Neurostimulants: amantidine) – Attention problems, *cognitive slowing

– Memory dysfunction – *Fogginess, fatigue

• Sleep Disturbance Sx (Rx with melatonin, trazadone, zoloft) – Difficulty falling asleep

– Sleeping less than usual

• Migraine/HA Sx (Rx with amitryptiline, topamax, vestibular PT) – HA

– *Dizziness, nausea – Noise/light sensitivity; visual problems

*best predictors of protracted recovery


Why does moving my head and eyes hurt?

www.brainsteps.net

Vestibular disturbance after concussion


Vestibular Pathology

Concussion related impairments • Peripheral Vestibular Disorders

– Benign Paroxysmal Positional Vertigo

– Co-existing Labyrinthine Concussion – Temporal bone fracture (more likely in moderatesevere TBI)

– Perilymphatic fistula

• Central Vestibular Disorders – Brainstem or Cerebellar – Post traumatic Migraine-Related

• Orthostatic Hypotension • Oculomotor Abnormalities • Cervicogenic/Whiplash


Nuts and Bolts of Vestibular System

• Centrally – 4 nuclei located on each side of Brainstem

– Afferent (messages into the brain)-processes information from peripheral vestibular

system, along with proprioceptive (joint receptors in body), visual (eyes) and

auditory (ears)

– Efferent (motor output to the body)-through vestibular system (VOR) and vestibulo-

spinal reflexes (VSR) via oculo-motor nuclei and brainstem

– Cerebellum – monitors vestibular performance and re-adjusts



• Peripherally – Vestibular apparatus - 5 sensory organs

• 3 semicircular canals (ampulla at opening of each)

• 2 otolith organs: utricle and saccule

– SCC filled with endolymph; pressure on sensory hair cells w/ head movement; sends

message to brain about movement direction

4



• Semi-circular canals and eye movements – Each SCC has corresponding EOMs

– When turn head to the R

• SCC on R increases vestibular nerve firing rate

• SCC on L decreases firing rate

• If firing rate on R and L is not equal, you will feel like you're

spinning.



• Vestibular System Function– putting it all together

– Peripherally, inner ear communicates (afferent signal) about head motion with vestibular nuclei

– Vestibulo-ocular tracts ascend (efferent signal) for gaze stability (stabilize vision while head moves)

– Vestibulo-spinal tracts descend (efferent signal) for spatial awareness and balance

• In sum – Stabilize vision while head moves

– Provide spatial information to help maintain balance


Why is balance impaired? Vestibular System Effect on Equilibrium

– VOR (Vestibular Ocular Reflex) – VSR (Vestibulospinal Reflex)

– VCR (Vestibulocollic Reflex)

Interplay of 3 Sensory Systems

• Vision (eyes)

• Somatosensory/Proprioception (muscles, tendons, joints)

• Vestibular (2 - inner ear organs)

• The Brainstem sorts out information and integrates it with learned

information from Cerebellum and communicates with eyes/body to

maintain balance and clear vision

• With concussion, ability to coordinate systems efficiently may be dysfunctional


(Iverson, Lovell, Collins,

JINS 2004)

About what might kids with vestibular impairments complain?

• Headache (71%) • Feeling slowed down (58%)

• Difficulty concentrating (57%)

• Dizziness (55%)

• Fogginess (53%) • Fatigue (50%)

• Visual blurring/double vision (49%) • Light sensitivity (47%)

• Memory dysfunction (43%)

• Balance problems (43%)


(Iverson, Lovell, Collins,

JINS 2004)

How these complaints might affect participation in the classroom

• Dizziness from head movement

• Difficulty focusing

• Difficulty maintaining balance in busy hallways

• Lightheaded (fainting vs dizzy)

• Fogginess (feels like theyre in a cloud)

• Visual Disturbance

– Double vision

– Blurred vision

– Oscillopsia, jumping images from text


How does it manifest in the

classroom?

• Space and Motion Discomfort (aka

‘visual vertigo’ due to optic flow

– Discomfort with moving stimuli

– Co-exists with mood disorders

– Longer recovery

http://trialx.com/curetalk/wp-content/blogs.dir/7/files/2011/05/diseases/Dizziness-2.jpg

5


How does it manifest in the

classroom?

• VOR dysfunction

– Difficulty stabilizing eyes with head

movement

– Input to brain from inner ears/vestibular and

eyes are not congruous


How does it manifest in the classroom?

• Visual disturbance

– Ocular issues after concussion are common (poor eye tracking)

– Nerves that innervate these muscles originate in brainstem;

concussion can damage them and affected muscle so eye may not move as quickly or completely diplopia

– Pre-existing compensated ocular misalignment may be exposed after concussion and is associated with protracted

recovery

• Symptoms: headache, eye strain/fatigue, blurriness, double vision,

head tilt


Visual issues related to vestibular pathology

• Visual Acuity

• Accommodative/Convergence dysfunction –

– Allows us to see a single image using 2 eyes (2 images) and

informs us about depth (gives us depth perception)

– Eyes should symmetrically come together while viewing far to

near target-if one eye deviates, it may mean that they're only viewing the image using one eye

• Saccadic eye movements (quick eye movements between two

targets)

• Tracking, Pursuit difficulties

– Highly symptomatic

– Unable to read, watch TV, use computer without headache


Visual issues related to vestibular pathology

• Visual Behavioral Exercises

• Exercises to strengthen and ↑ endurance of eye muscles and improve speed and accuracy of accommodative response

• 2-10 visits with excellent prognosis

• Smart phone apps, HTS online (www.visiontherapysolutions.net)

good resources for home program

• Referral to neuro-optometrist or neuro-opthamologist if needed


Vestibular Disturbance after concussion Self report measures

• DHI (Dizziness Handicap Inventory) – Assess athletes disability d/t dizziness

– 25 item scale relating to physical, emotional and functional domains

– Possible score 100 indicating greater disability

– If >10, refer to PT for balance

• PCSS – 22 item symptom score

• Aid in RTP decision making


Strategies to assist student for best

performance and safe recovery

• Don’t push through ANY symptoms (unlike some

orthopaedic or traditional vestibular rehabilitation)

• Cant allow headache, nausea or dizziness as

these symptoms mean the student’s metabolic energy demands are exceeding their energy output…this prolongs recovery and increases

symptom severity

http://www.visiontherapysolutions.net/

6


Strategies to assist student for best performance and safe recovery • Treat like a migraine-diet

– Adequate sleep – Proper hydration

– Low to moderate exercise

• School accommodations – Note taking-recorder

– Audit classes

• Avoid vestibular symptoms-restrict busy environments – Early dismissal from classroom to avoid hallways

– Limit areas with excess visual/auditory stimulation

• Maintain social connections, avoid developing anxiety/depression and loneliness


Therapies available -training from physical therapist who either specializes in concussion

management or vestibulopathy

• Adaptation – Adaptation can make changes to the way our ears/eyes work

together and compensate for injury

– Gaze stabilization/VOR – Computerized DVA (physical therapist only)

• Habituation – Desensitization, gradual exposure to provocative stimuli

– Down-regulate visual input – decrease visual dependency

– Good for those with space and motion discomfort

• Canalith repositioning (physical therapist only) – BPPV

– Epley, Liberatory Maneuver, etc


Is it definitely a vestibular problem?

Cervicogenic Dizziness and Headache:

• Disturbance of tonic postural control

• Upper c-spine: complex proprioceptive system with

connections to visual and vestibular systems

• Could also be mechanoreceptor dysfunction or

posttraumatic vertebro-basilar circulatory insufficiency

• Diagnosis of exclusion (difficult to treat)

– Head/neck injury with dizziness when all other causes of

dizziness are ruled out

– Use Swivel chair test and info gained from cervical spine

and vestibular exams

www.brainsteps.net www.brainsteps.net (Evans RW, 2009)

Is it definitely a vestibular problem?

• Migrainous sx can look a lot like a concussion (and anxiety

disorder!)

– Vision change 26%

– Lightheadedness 72%

– Vertigo/spinning 33%

– Confusion 4%

• Migraines can occur because of concussion; genetic predisposition may contribute to a protracted recovery

• Migraines: HA with nausea and light/noise sensitivity

• If vestibular-ocular exam normal, these folks can be pushed,

as exertion can be beneficial to migrainers


Does Vestibular Rehabilitation Benefit the Athlete? Literature Review

• Zurich 2012 updated guidelines include visuo-vestibular

• Military: Blast induced head trauma: – DVA, Target Acquisition/Following, Perception Time

– Improves to normative values after 4 weeks PT

• Elderly: with vestibular pathology – Great evidence showing effective for improving vestibular pathology

– Decreasing fall risk

• Athletic Concussions: – ↓ sx/dizziness provoked by head movement, busy environ

– ↑ balance function

• Limitations in studies: retrospective nature of data collection, no control group, chronicity of concussion sx, absence of standardized vestibular function test battery (BUT WAIT!)

• Lacking Level 1 evidence, however…


Thank you

7

Email questions you may have regarding today’s

webinar to:

Brenda Eagan Brown

[email protected]

for Dr. Herget to answer

The BrainSTEPS Program, PA Department of Health &

PA Department of Education invite your PA school to form & train a


Join the 700+ Return to Learn

Concussion Management Teams

that have formed in PA school districts

within the last 1.5 years

To register:

www.brainsteps.net

Return to Learn Fall 2014 Webinar Series: Students …...2014/12/17 · (TBI or non-TBI) that...

Documents

Transcript of Return to Learn Fall 2014 Webinar Series: Students …...2014/12/17 · (TBI or non-TBI) that...