9/6/2017 Physical Therapist Role in Management of Concussions The - - PDF document

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Physical Therapist Role in Management of Concussions

The APTA recognizes that physical therapists are part

• f 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

• Vestibular

– Dizziness – Imbalance

• Orthopedic

– Neck pain (primary) – Other injuries incurred during the traumatic event

What is the Vestibular System?

• Vestibular system – give sensory input

about motion, equilibrium, & spacial

• rientation

Functions of the Vestibular System

• Vestibular Ocular Reflex (VOR)

– Allows gaze stabilization with head/body movement

• Vestibulocollic Reflex (VCR)

– Initiates righting reactions for head on neck

• Vestibulospinal Reflex (VSR)

– Provides balance/stability with movement of the trunk

How are concussion symptoms linked to the vestibular system?

• VOR - Gaze instability/Oculomotor deficits

– Blurred vision, headaches, dizziness, motion sensitivity, visual motion sensitivity

• VCR – Cervical instability

– Headache, neck pain, dizziness with head movement

• VSR – Postural instability

– Imbalance, “clumsy”, falls

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Vestibular Assessment

• 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)

Head Thrust Test / Head Impulse Test

Picture: http://vertigodifferentiation.weebly.com/head-thrust.html

PT Treatment Based on Symptoms

• Vestibular
• dizziness, balance, headaches
• Ocular
• headaches, decreased tolerance for close work/school work, eye strain
• Referral to Vision – OD or OT
• Manual
• headaches, neck pain and any impaired strength
• Progressive Aerobic Activity
• deconditioning or exercise intolerance
• Dual task Training
• incorporating attention, cognition, concentration with balance and

exertion activities

Vestibular Treatments

• VOR Retraining

– Dizziness and nausea is normal and expected – Eyes move equal and opposite head – Symptoms should improve in minutes (not hours) – Metronome used to help maintain speed

• VOR x 1 – Gaze fixed on a stable target while

head or body move

– Perform horizontal (“no”) and vertical (“yes”) – Static position with head moving eyes on target – Bouncing on ball or trampoline eyes on target

VOR Retraining Continued

• VOR x 2 - Gaze fixed on moving target

while head or body move

– More difficult than 2 objects moving – used frequently in sports – Tracking a ball or player while moving in the other direction

• VOR cancellation - Gaze fixed on a target

moving together with head

– Holding an object and spinning or moving

Vestibular Treatments Continued

• Balance
• Static
• Feet together -> Tandem -> Single leg
• Eyes Open -> Eyes Closed
• Firm -> Foam
• Dynamic - Any static position plus additional activity
• Head turning and nodding
• Ball Toss
• D2 pattern pick up objects from floor to waist/overhead

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Vestibular Treatments Continued

• Habituation
• Walking with head turns
• Walking with ball toss hand to hand (horizontal and vertical)
• Walking while putting down and picking up objects
• Turning (half turns and full turns)
• Walking forward ½ turn, walking backward ½ turn
• Any normal activity that is symptomatic

Visual Stimulation

• Visual

– Add saccades – Add pursuits – Add noise

• Vestibular

– Balance

• Without Fixation
• With Fixation
• Counting moving dots

– Turns / Movement

Cervical Spine Pain and Dizziness

• Cervical stabilization exercises
• Cervical stretching
• Scapular stability
• Postural correction and strengthening
• Manual therapy

Exertion

• May be performed while symptoms are still

present

• Find activity that with min to no increase in

daily symptoms (<3/10 increase)

– Start with light cardio – Progress to strength – Wait to add/try jogging/running, agility and plyometrics until VOR improves

Occupational Therapy in TBI

• Evaluate current level of brain function
• Identify limiting factors that impede daily independence
• Re-train brain skills with graded interventions as appropriate

to further progress independence and reduce symptoms

• What are your patient’s goal(s)?

– Self-reported goals and factors that limit independence – Client-centered intervention that engages them to help remediate deficits – Home exercise programs that are consistently modified to patient progress each week

OT Evaluation

• ADL Scale
• King-Devick
• MOCA
• CISS
• Self-Perception
• Cohen Stress Scale
• Mayo-Portland Adaptability Inventory-4
• COPM

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Cognitive Remediation

• Requires patience and time
• Complete success cannot be made overnight
• Using mental manipulation and functional

activities to improve overall brain function

• Altering the chemical makeup and electrical

activity in your brain

• Conducting new pathways to complete tasks

Cognitive Remediation Continued

• Attention
• Executive Functioning
• Memory
• Visuospatial Relations
• Visual Skills

Compensatory Techniques

• External Techniques

– Voice recorders – Calendars/Journals – Timers – Assistive Technology Applications – Lists

• Internal Techniques
• Visualization and

pre-planning tasks

• Chunking (words,

phrases, numbers)

• Association
• Mnemonics
• Pairing
• Chaining

Functional Vision Deficits

• Fixation (and/or visual attention*)
• Pursuits
• Saccades
• Accommodation
• Vergence Movements
• Photophobia
• Lateral field cut or homonymous hemianopsia
• Visual-perceptual abilities

(Functional Vision Deficits continued)

• Strabismus
• Amblyopia
• Ptosis
• Cranial Nerve Palsy

– 3rd – cannot move inward or up – 4th – vertical misalignment – 6th – difficulty with lateral movements

Vision Intervention

• Identify deficits
• Improve eye teaming and binocular

vision

• Reduce symptoms with activities and

Daily HEP

• Return to independence

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Busy Backgrounds

B

Metronome

• Pursuits and Saccades (All Planes)

– Goal 110-120 beats per minute

• Near and far

– 80-90 bpm

• Speed and accuracy to reduce

symptoms

Home Exercise Program

• Follow the “B”
• Eye Jumps
• Hart Chart
• Column Jumps
• Attention Process Training
• Goal: 3-5 times a day and at least 2

times a day

• Use Metronome for grading*
• Sensory Re-Integration*

Psychological effects from mTBI

• Depression and Anxiety are common

due to:

– Prolonged recovery – Significant life status change – Difficulty processing information

Sensory Processing

• What is sensory defensiveness?
• Overstimulation of Central Nervous

System

• What makes the patient defensive?
• Intervention

Neuro-Optometry, OT, and PT Team Work

• “Similar Focus - Same Vision”
• Collaboration of Optometric Efficiency with

Cognition and Perceptual-Motor Skills

• Collaborative use of prisms to help with

balance retraining

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Questions?

Contact Us

• Joe Kardine, OTR/L

– John.KardineJr@Jefferson.edu

• Jenny Rexon, PT, DPT

– 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.