VESTIBULAR THERAPY AND ASSESSMENT

July 29, 2016

Marc Hinze, PT, MPT, CIMT

Bronson Rehabilitation Services

• Vestibular Assessment

• Vestibular Rehabilitation

• Progression of Vestibular Exercise

Objectives

• Vestibulo-spinal Reflex (VSR)

• Vestibulo-ocular Reflex (VOR)

• Functions

– Postural Stability

– Gaze Stability

– Sensory Integration

Vestibular System

• Impairments

– Dizziness

– Unsteadiness/sense of motion

– Blurred Vision

– Headache

– Nausea

• 90% of children with concussion had 1 or more abnormal balance and vestibular findings (Zhou et al)

• 69% of adolescents with concussion also had a visual diagnosis(Master et al)

– Accommadative Disorder (Focusing)

– Convergence Dysfunction (Viewing near target without double vision)

– Saccadic Dysfunction (eye motion)

Prevalence of Vestibular Symptoms with Concussion

• Dizziness – Motion Provoked: Head movement, Bending,

changing direction

– Visually provoked: Busy patterns, watching motion, busy environments

– Positional Sensitivity: supine<>sit, sit<>stand

– Eye Motion: Visual tracking

• Imbalance

• Difficulty Reading – Blurred vision

– Eye strain

– Headache and fatigue

• Neck Pain: Cervicogenic Dizziness

Vestibular Screening

VOMS Test Not Tested Headache

0-10 Dizziness

0-10 Nausea 0-10

Fogginess 0-10 Comments

Baseline Symptoms

Smooth Pursuits (eyes move, head still) stand 3 ft away, follow PT fingertip in H pattern, 2 reps, 2 seconds/rep-eyes only

Saccades - Horizontal (eyes move, head still) stand 3 ft away, PT 2 fingtips 3ft apart 10 reps as quickly as possible-eyes only L/R

Saccades - Vertical (eyes move, head still) stand 3 ft away, PT 2 fingtips 3ft apart 10 reps as quickly as possible-eyes only up/down

Convergence (Near Point) PT/pt holds 14 point font "x" on tongue depressor move slowly until sees double or eyes turn out measure 3x in cm from end of nose

VOR-Horizontal (eyes on target, head moves) pt holds 14 point font "x" on tongue depressor 10 reps, rotates head 20 deg R/L @ 180 bpm

< 5 cm = normal

VOR-Vertical (eyes on target, head moves) pt holds 14 point font "x" on tongue depressor 10 reps, rotates head 20 deg up/down @ 180 bpm

Visual Motion Sensitivity (VMS) 5 reps, rotate thumb/eyes/head/trunk together 80 deg @ 50 bpm

Vestibular Ocular Motor Screen

• Ability of the eyes to smoothly follow a slow moving target with the head stationary

• Normal eye pursuit is smooth

• Abnormal pursuit is choppy and can increase symptoms

Smooth Pursuits

• Ability of the eyes to move quickly and accurately between targets with the head stationary

• Normal – good ability to track without symptoms

• Abnormal – poor symmetry, nystagmus, increase in symptoms

Saccades

• Ability to view a near target without double vision

• 14 point font target on a tongue depressor

• Abnormal is when one eye turns outward or the patient reports double vision > 5 cm from the end of nose

Convergence

• The ability to stabilize vision as the head moves

• Screen – Head turns 20 deg R/L at 180 beats/min while

maintaining focus on target

• Test is abnormal if eyes slip off target or reports blurred vision and target motion

• Repeat in vertical direction

– Dynamic Visual Acuity Test (DVAT)

• Using Snellen eye chart the patient reads the lowest line within their comfort

• 20 deg of head turns R/L are performed at 120 bpm

• A 3 three line or greater move on the Snellen chart is considered abnormal

Vestibulo-ocular Reflex

• Test visual motion sensitivity

• Head, eyes and trunk all move together while following a visual target

• The patient stands with feet shoulder width apart

Visual Motion Sensitivity

• SOP

• Functional Gait Assessment

• DGI

• BESS

• Positional Sensitivity Assessment

Vestibulo-spinal Assessment Tools

• Feet together EO, EC

• Tandem EO, EC

• Foam EO, EC

• FUKUDA – 20 to 50 marches. Abnormal = spin or drift

Gans Sensory Organizational Performance Test

• VOMS

• DVAT

Vestibular-ocular Assessment

• Decrease Dizziness and Visual Symptoms

• Improve Balance

• Increase Activity Level

• Return to Work, Academics, Reading

• Return to Sport

Goals of Vestibular Therapy

• Individualized Program

• Transient increase in symptoms are expected

• Modify exercise intensity as needed

• Sports specific/work specific

Principles of Vestibular Therapy

• Non-provocative ROM

• Postural education

• Strengthening and stretching for muscular imbalance

• Upper cervical manipulation?

• Upper cervical joint mobilization

Cervico-vestibular Rehab

• Perform 2-3 times per day

• Exercise should not increase headache a ½ level on the pain scale

• Exercise may provoke dizziness.

• If dizziness reaches a level of 5-7/10 make modifications to reduce intensity of exercise – Decrease reps

– Decrease speed

– Perform sitting vs standing

General Guidelines for Vestibular Exercise

• Sitting

• Standing

• Decrease base of support (stand shoulder width to feet together, modified tandem to true tandem etc..)

• Altered surface

VOR Progression

• Level surface

• Base of support

• Altered surface

• Single leg stance

• Static to dynamic

Balance Progression

Clinician-Directed Program

• Adaptation

Clinician-Directed Program

• Adaptation and Substitution

Clinician-Directed Program • Substitution

• Carender W, Alsalaheen BA, Vestibular Physical Therapy Post-Concussion: Indications, Assessment and Treatment, Return on Investment: A Sports Medicine Approach, U of M Health System. May 20-21, 2016

• Alsalaheen BA, Whitney SL, Mucha A, Morris LO, Furman JM, Sparto PJ. Exercise prescription patterns treatedwith vestibular rehabilitation after concussion. Physiother. Res. Int 2012

• Alsalaheen BA, Whitney SL, Mucha A, Morris LO, et al. Rehabilitation for dizziness and balance disorders after concussion. JNPT 2010; 34:87-93.

• Barnett BP, Singman EL. Vision concerns after mild traumatic brain injury. Curr Treat Options Neuol 2015;17:5.

• Broglio SP, Tomporowski PD, Ferrara MS. Balance performance with a cognitive task: A dual-task testing paradigm. Medicine & Science in Sports & Exercise. 2005; 689-695.

• Collins MW, Kontos AP, Reynolds E. A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion. Knee Surg Sports Traumatol Arthroscm 2013.

• Ellis MJ, Leddy JJ, Willer B. Physiological, vestibulo-ocular and cervicogenic post-concussion disorders: an evidence-based classification sysyem with directions for treatment. Brain Injury. 2015;29(2):238-48.

• Kontos AP, Elbin RJ. Schatz P, et al. A revised factior structure for the Post-Concussion Symptom Scale: baseline and post-concussion factors. Am J Sports Med. 2012; 40(10):2375-2384.

• Kontos AP, Elbin RJ, Lau B et al. Posttraumatic migraine as a predictor of recovery and cognitive impairment after sport-related concussion. Am J Sports Med. July 2013;41(7):1497-1504.

References

• Lau BC, Kontos AP, Collins MW, Mucha A, Lovell MR. Which on –field signs/symptoms predict protracted recovery from sport-related concussion among high school football players? Am J Sports Med. 2011;39(11):2311-2318.

• Lee H, Sullivan SJ, Schneiders AG. The use of dual-task paradigm in detecting gait performance deficits following a sports-related concussion: A systematic review and meta-analysis. Journal of Science and Medicine in Sports. 2012; 705:2-6.

• Master CL, Scheiman M, Gallaway M et al. Vision diagnoses are common after concussion in adolescents. Clinical Pediatrics 2016;55(3):260-267.

• Mucha A, Collins MW, Elbin RJ, Furman JM, Troutman-Enseki C, DeWolf RM, Marachetti G, Kontos AP. A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions. Am J Sports Med. October 2014;42(10):2479-2486.

• Schneider et al Cervicovestibular rehabilitation in sport-related concussion: a randomized controlled trial. Br J Sports. 2014.

• Zhou G, Brodsky JR. Objective vestibular testing of children with dizziness and balance complaints following sports-related concussion. Otolaryngology-Head and Neck Surgery 2015;152(6):1133-1139.

• Gans R, Vestibular Rehabilitation Seminar, The American Institute of Balance. 2005

References

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