sideline concussion tools and vestibular rehabilitation
TRANSCRIPT
© The Children’s Mercy Hospital, 2016
Mary Helfer, MS, LAT, ATC
Shannon Margherio, PT, OCS, CSCS
Tiffany Whitney, PT, SCS
Sideline Concussion Tools and
Vestibular Rehabilitation
▪ Learn basic components of an initial concussion evaluation
▪ Overview of SCAT5 tool and VOMS for a sideline concussion
evaluation
▪ Learn about the various tests and tools used in vestibular
therapy after an athlete sustains a concussion
There are no disclosures or conflicts of interest for this
presentation
Learning Objectives:
Identifying Concussions and Process
▪ Athletic vs General
populations
– Healthcare providers
– Coaches
– Parents/guardians
▪ Process after injury ID:
– Initial evaluation
– Diagnosis
– Proper referrals
– Monitoring
– Progression back to
ADLs/athletics
3
▪ On field assessment
– Red flags? Call 911
– Observable signs
– Maddocks Qs
– Glascow Coma Scale (GCS)
– C-spine eval
▪ Sideline/Office tests
– Sport Concussion Assessment
Tool 5 (SCAT5)
– Vestibular Ocular-Motor
Screening (VOMS)
– King-Devick test
– Balance testing
Initial Evaluation
4
SCAT5
- Background
- Post-Injury Symptom Evaluation
- Orientation*
- Immediate memory*
- Concentration*
- Neurological screening
- Balance Examination (mBESS)
- Delayed recall*
- https://bjsm.bmj.com/content/bjs
ports/early/2017/04/26/bjsports-
2017-097506SCAT5.full.pdf
5
Post Concussion Scale
Rate 0-6 : 0: none, Mild: 1-2, Moderate: 3-4,
Severe 5-6
1. Headache
2. Nausea and Vomiting
3. Balance Problems
4. Dizziness
5. Fatigue
6. Trouble falling asleep
7. Sleeping more than usual
8. Sleeping less than usual
9. Drowsiness
10. Sensitivity to Light
11. Sensitivity to Noise
12. Irritability
13. Sadness
14. Nervousness
15. Feeling more emotional
16. Numbness or Tingling
17. Feeling slowed down
18. Feeling mentally “foggy”
19. Difficulty concentrating
20. Difficulty remembering
21. Difficulty sleeping
22. Vision problems (double vision, blurring, etc)
6
▪ Symptom check: baseline and after each test
▪ Smooth pursuits (H test)
▪ Saccades (horizontal and vertical)
▪ Convergence (near point)
▪ VOR (horizontal and vertical)
▪ VOR cancellation/Visual motion screening
VOMS
7
VOMS Score Chart
8
P.T. Initial Evaluation
9
Concussion
Vestibular
Ocular
Cognitive/
Fatigue
Post-TraumaticHeadache
Anxiety/Mood
Cervical
Gather subjective and
objective data to
help prioritize order of
these deficits. Try to find
the driving subtype.
-Clinical interview
-Post Concussion Symptom
Scale
-Vestibular-Ocular tests
-Balance tests
-Cervical screen
-Exertional testing
PT Vestibular Assessment
Evaluation of gaze stabilization, balance, and motion
sensitivity
May include:
– VOR (Vestibular Ocular Reflex) slow—similar to VOMS test
– VOR fast: head impulse or head shake
– DVA (Dynamic Visual Acuity)
– Balance: static and dynamic testing
– Positional testing
10
Motion Sensitivity TestingPosition Change Symptoms
Intensity
(0-5)
Symptom
Duration
(0-3)
Score (I+D) Nystagmus
Baseline Symptoms
1. Sitting to Supine
2. Supine to Left side
3. Supine to Right side
4. Supine to sitting
5. Left Dix-Hallpike
6. Return to Sitting
7. Right Dix-Hallpike
8. Return to Sitting
9. Sitting Nose to left knee
10. Return to Sitting erect
11. Sitting Nose to right
knee
12. Return to Sitting erect
13. Sitting Neck rotation
14. Sitting Nectk flexion &
extension
15. 180 degree turn to the
right
16. 180 degree turn to left
Total
MSQ
11
a. symptom intensity: subjective (patient report) scale
from 0 to 5
(0 = no symptoms, 5 = severe symptoms)
b. symptom duration: scale from 0-3
(5-10 sec = 1 point; 11-30 sec = 2 points; >30 sec =
3 points)
c. total score = intensity + duration for each position
change
d. MSQ (motion sensitivity quotient) = Total Score/ 20.48
Abbott: 0-10% = mild; 11-30% = moderate; 31-100% =
severe
Vestibular Strategies
▪ Targeted vestibular therapy: progress slowly if there is a
headache/migraine component
– VOR/gaze stabilization exercises
– Balance exercises
– Core stabilization to “settle” symptoms
– Progress by layering in multi-sensory stimuli—this holds true for all the
concussion “subtypes”.
Buffalo Concussion Treadmill Test
3.2/3.6 (pending height) MPH at 0% grade – increase grade every minute
Stop once symptoms develop/worsen
Grade HR Rated Perceived Exertion(1-10) Symptoms Worse?
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
If still going, increase MPH by 1 MPH every minute until symptoms develop/worsen.
Symptom Threshold HR_______________________________________________________
At 80% of Symptom Threshold HR_______________________________________________
Guidelines for Exercise
▪ Start with 10 minutes at 80% of symptom Threshold
▪ If well tolerated, increase by 1 minute per day
▪ If symptoms increase, do not increase duration, but do continue to exercise for at least 10 minutes per day
13
-- Begin slower at 60bpm and build up to 180bpm
– Begin in sitting and advance to single leg stance and
then while walking
– Progress from a white background to a busy
background
– Can use the following site for different speeds and
backgrounds
https://www.youtube.com/playlist?list=PL3NyX9dfE
9BIM4z-LXTJ6ZEQgXwlrANch
– Progress to sport specific – some examples include:
VOR while doing ball toss, soccer dribbling or toe
taps looking from ball up to a target, vertical ball
toss, prone head turns for swimmers, passing a puck
on a slide board for hockey
– May et al has good recommendations for sport
specific return to sport
VOR Treatment
14
Smooth pursuit
▪ Abnormalities- nystagmus
▪ Treatment
• Following a moving target while the head stays still. Tracking exercises,
ball toss between hands, Marsden ball activities, marble rolling
• Progress by increasing speed, layering in multiple sensory and cognitive
tasks. Busy backgrounds, balance challenges, multi-tasking.
• Site for additional treatments:
https://eyecanlearn.com/tracking/pursuits/
Ocular
15
Eye Tracking Maze
16
Eyecanlearn.com
Ocular
Saccades
▪ Abnormalities – hypometric (undershooting) or hypermetric
(overshooting)
▪ Treatment
– Vertical and Horizontal saccades
– Disorganized scanning pattern—post-it notes on a wall
– HART chart
– Reading handouts progress from larger letters to smaller letters
– Online activities: https://eyecanlearn.com/tracking/saccades/
17
Examples of Hart Charts and Disorganized
Scanning Patterns
18
Eyecanlearn.com
Ocular
Convergence
▪ Abnormalities –unable to converge eyes within 6cm
from the tip of the nose, report double vision prior to 6
cm; 1 eye may abduct
▪ Treatment
– Pencil push-ups
– Convergence beads—Brock string
– Marsden ball
19
Brock string example
20
Helping the eyes work together as a team to
focus near and far.
Cervical
▪ Signs and Symptoms – Symptoms increase or are triggered with cervical mobility and
trigger points
▪ Treatment
– Cervical ROM and manual therapy
• AROM and PROM
• Manual therapy for restrictions found
– Suboccipital release
– Cervical strengthening
• Upper cervical flexion
• Isometric hold with theraband as walk out forward, retro and lateral
• Theraband resisted cervical lateral flexion, upper cervical flexion
• Not research supported but offers proximal stability to assist.
21
Anxiety and Mood
▪ Signs and Symptoms: High Concussion Grading Score
but no ocular symptoms
▪ Treatment
– Increase activity
– Education on sleep and hydration
– Referral to counselor/therapist
– Work with physician for medication as needed- anti-
depressants
22
Cognitive and Fatigue
▪ Signs and Symptoms – Difficulty with school work and
not sleeping well but no increase in symptoms with
physical activity
▪ Treatment
– Proper sleep habits – no naps
– Increase activity (Buffalo test can be used as a guideline for
exercise)
– Water intake – 8 8oz
23
Migraine
▪ Signs and Symptoms – primary symptom is headache
and has history of headaches
▪ Treatment
– Education on proper sleep and water intake – 8 8oz
– Increase physical activity
– Working with physician on proper medication
24
▪ Kontos AP, Deitrick JM, Collins MW, Mucha A. Review of Vestibular and Oculomotor Screening and Concussion Rehabilitation. Journal of Athletic Training. 2017;52(3):256-261. doi:10.4085/1062-6050-51.11.05
▪ Reynolds E. Concussion Clinical Trajectories. June 2017. Part of ITAT certification course materials.▪ Galetta KM, Brandes LE, Maki K, Dziemianowicz MS, Laudano E, Allen M, Lawler K, Sennett B, Wiebe D, Devick S, Messner LV, Galetta SL, Balcer LJ. The King-Devick test and sports-related concussion: study of a rapid visual screening tool in a collegiate cohort. J Neurol Sci. 2011 Oct 15;309(1-2):34-9.▪ Sport concussion assessment tool - 5th edition. British Journal of Sports Medicine 2017;51:851-858.▪ Davis GA, Purcell L, Schneider KJ, et al. The child sport concussion assessment tool 5th edition (child SCAT5): background and rationale. British Journal of Sports Medicine 2017;51:859-861.▪ Leddy, Baker, Willer (2016) Active Rehabilitation of Concussion and Post-concussion Syndrome. Physical Medicine and Rehabilitation Clinics of North America, 2016-05-01, Volume 27, Issue 2, Pages 437-454▪ Murray, Meldrum, Lennon (2017) Can vestibular rehabilitation exercises help patients with concussion? A systematic review of efficacy, prescription and progression patterns. British Journal of Sports Medicine, 51(5) March 2017, 442-451▪ Worts PR, Schatz P, Burkhart SO. (2018) Test Performance and Test-Retest Reliability of the Vestibular/Ocular Motor Screening and King-Devick Test in Adolescent Athletes During a Competitive Sport Season. American Journal of Sports Medicine, 46(8) July 2018, 2004-2010. ▪ May K, Marshall D, Burns T, Popoli D, Polikandriotis J. (2014) Pediatric Sports Specific Return to Play Guidelines Following Concussion. International Journal of Sports Physical Therapy, 9(2), April 214, 242-255.
References
25
▪ Broglio SP, Cantu RC, Gioia GA, Guskiewicz KM, Kutcher J, Palm M, Valovich McLeod TC; National Athletic Trainer's Association. National Athletic Trainers' Association position statement: management of sport concussion. J Athl Train. 2014 Mar-Apr;49(2):245-65.
▪ Leddy J, Baker J, Haider M, Hinds A, Willer B. (2017) A Physiological Approach to Prolonged Recovery From Sport-Related Concussion. Journal of Athletic Training, 52(3), March 2017, 299-308.▪ Quatman-Yates CC, Hunter-Giordano A, Shimamura K, et al; (2020) Physical Therapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury. Journal of Orthopaedic & Sports Physical Therapy, 50(4), April 2020, CPG1-CPG73
▪ CDC Pediatric mTBI Guidelines: https://www.cdc.gov/traumaticbraininjury/PediatricmTBIGuideline.html
References Continued
26