Balancing Act: Post-Concussion PT

SPRING
20053
Volume
10, Issue
Balancing Act: Post-Concussion PT
By Jessica Heath and Neal Goulet
Tommy Roe had a pop hit
in 1969 called “Dizzy.”
“I’m so dizzy, my head is
spinnin’/Like a whirlpool, it
never ends,” went the song.
It dealt with affairs of the
heart, a boy singing about a
girl, but today it also applies to
a more serious matter of the
mind: sports concussions and
their after-effects. Another line
from the song: “I need to call a
doctor for some help.”
Each year, according to the
Obama administration, youths
make nearly 250,000 emergency
room visits with sports or recreation-related brain injuries. More
than 3.8 million concussions
occur each year owing to sports,
according to the Centers for
Disease Control and Prevention.
Though rarely fatal,
concussions are an injury to
the brain — it is shaken inside
the skull — that can cause
significant and even lasting
problems. Some 50 percent of
concussions go unreported.
Among the post-concussion
symptoms for which physical
therapy can provide considerable relief are those involving
dizziness and imbalance.
SOCCER NOW CITED
Concussions are particularly
common in collision and contact
sports such as football, ice
hockey, rugby and basketball.
Concussion risk is highest
in football: male participants
The impact speed of a soccer ball being headed by a player can
reach 50 to 70 mph.
ally has been thought to be
have a 75 percent chance of
safer than other sports; after
suffering one, according to the
all, soccer players don’t even
Sports Concussion Institute.
wear helmets. However, a New
The National Football
York Times article titled, “Brain
League and the National Hockey
trauma extends to the soccer
League have each been sued by
field,” challenged that assumpformer players over concussions.
tion by recounting the story of
For its part, the NFL Foundation
Patrick Grange.
has donated $45 million to USA
At only 3 years of age,
Football, the sport’s national
Grange could “head” a soccer ball
governing body, to teach safer
into a net. It was an act he no
tackling to youth players to
doubt performed thousands of
avoid head injuries.
times as his passion and skill
Drayer Physical Therapy
allowed him to play soccer in colInstitute and the University
of South Carolina are partnering
lege and as a semi-professional.
That repetition and the
on a three-year youth football
damage it may have caused to
safety study in conjunction with
the front of his brain
USA Football to assess
is at the heart of
potential risk factors
Grange’s tragic
and to help create
story, which came
policies to make
to national promiyouth football safer.
nence in 2014.
These efforts include
Grange, who
research studies on
died at age 29 in
head injury and conScan code for con2012, became the first
cussion assessment.
cussion
signs and
soccer player to be
Soccer tradition-
symptoms video.
diagnosed with the degenerative
brain disease known as chronic
traumatic encephalopathy, or CTE.
But concussions account
for 6 to 9 percent of all soccer
injuries, according to an article
on Scientific American’s website.
“One [study] shows some 63
percent of all varsity soccer players have sustained concussions –
yet only 19 percent realized it.”
Traumatic brain injuries such
as a concussion can contribute
to CTE. Researchers believe that
Grange’s brain damage was “the
precipitating factor” in his diagnosis, at age 27, of ALS, also known
as Lou Gehrig’s disease, a degenerative disease of the nervous system.
A soccer player might
head the ball a dozen times in
a game but many more times
in practices. Impact speeds can
reach 50 to 70 mph.
Grange’s case suggests some
of the longer-term implications
of concussions; the Times article
cited one concussion during a
high school game in which he
was knocked unconscious. This
raises the issue of what can be
done to mitigate the complications that result from concussions
– and how concussions can be
prevented in the first place.
SAFETY AND PREVENTION
It might not be possible to
prevent all concussions. Two
athletes playing fairly but aggressively might accidentally butt
heads, causing injury. But there
are ways to reduce the incidence,
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3
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namely by ensuring that athletes
follow the rules of the sport
and the rules for safety.
Good sportsmanship is
important, such as when hockey
players are taught not to check a
vulnerable opponent from behind.
Wearing a helmet can reduce
the risk of a severe brain injury
and skull fracture, but the CDC
notes that there is no such thing
as a “concussion-proof” helmet.
The CDC developed Heads
Up: Concussion in Youth Sports,
which provides information to
coaches, parents and athletes
on how to prevent, recognize
and respond to a concussion.
Diagnosing a concussion
can be difficult. Diagnostic tests
such as magnetic resonance
imaging (MRI) and computed
tomography (CT) usually come
back negative for concussion.
Initially developed for the
National Football League,
ImPACT (Immediate PostConcussion Assessment and
Cognitive Testing) is the most
widely used tool for diagnosing
and managing concussions. But
the computerized system has been
criticized for giving inconsistent
results and having high error rates.
VESTIBULAR REHABILITATION
Once a concussion is diagnosed, physical and cognitive
CONCUSSION SIGNS OBSERVED
BY COACHES:
• Athlete appears dazed or
stunned
• Is confused about assignment or
position
• Forgets an instruction
• Is unsure of game, score or
opponent
• Moves clumsily
• Answers questions slowly
• Loses consciousness (even briefly)
• Shows mood, behavior or
personality changes
• Can’t recall events prior to hit or fall
• Can’t recall events after hit or fall
Q&A
exertion – including returning
to sports, school, work –
should be limited until the
symptoms “have improved and
stay improved,” according to
MoveForwardPT.com.
Daily stress and overuse of
the brain actually can take
away the focus on healing and
recovery. The most important
course of treatment is to rest
the brain as much as possible,
both physically (sports/activities) and cognitively (school).
The next step in recovery is to
address any symptoms that have
not recovered with rest. A physical
therapist trained in vestibular
therapy can help if post-concussion symptoms include dizziness
or difficulty with balance or gait.
The primary cause of postconcussion symptoms is impaired
postural control. Many factors
play a role in postural control,
including the proprioceptive and
vestibular systems, joint mobility,
muscle power, muscle tone and
gait pattern. Each component may
need to be addressed in therapy.
The vestibular system
comprises the inner ear and its
connections with the brain. It
is responsible for sensing head
movement, keeping your eyes
focused when you move your
head, and helping you maintain balance.
SYMPTOMS REPORTED
BY ATHLETE:
• Headache or “pressure” in head
• Nausea or vomiting
• Balance problems or dizziness
• Double or blurry vision
• Sensitivity to light
• Sensitivity to noise
• Feeling sluggish, hazy, foggy
or groggy
• Concentration or memory problems
• Confusion
• Does not “feel right” or is
“feeling down”
Source: Centers for Disease Control and Prevention
With approximately 23
percent of post-concussion
patients presenting with
dizziness, it is important to
look at the vestibular system.
Evaluation and treatment will
address sensory integration
exercises (processing environment), oculomotor training (eye
reflexes), eye-head coordination,
balance training, visual motion
sensitivity training, neuromuscular control, strength training,
body mechanics and posture.
Once symptoms are managed, the next step is to challenge
the system by integrating functional strengthening, sportsspecific training and aerobic
exercise.
Treatment may include balancing on one leg, changing the
surface to make activities more
difficult, quick turns and walking
with head turns, cone pick up,
multi-tasking, ball throw with
movement. All exercises should
be submaximal, should gradually
progress, and should not cause
symptoms as this can lead to
exacerbation and slow recovery.
REFERENCES
Alsalaheen, B.A., Mucha, A., Morris, L.O.,
Whitney, S.L., Furman, J.M., CamioloReddy, C.E., Collins, M.W., Lovell, M.R.,
Sparto, P.J. “Vestibular rehabilitation for
dizziness and balance disorders after concussion.” Journal of Neurologic Physical
Therapy. June 2010; 34(2):87-93.
Branch, John. “Brain trauma extends to
the soccer field.” The New York Times, Feb.
26, 2014, accessed online May 2014.
Leddy, J.J., Kozlowski, K., Donnelly, J.P.,
Pendergast, D.R., Epstein, L.H., Willer, B.
“A preliminary study of subsymptom
threshold exercise training for refractory
post-concussion syndrome.” Clinical
Journal of Sport Medicine, January
2010; 20(1):21-27.
Maron, Dina. “Concussions abound in
soccer, too.” Scientific American website,
accessed May 2014.
Sosnoff, et al. “Cumulative head impact
burden in high school football.” Journal
of Neurotrauma. October 2011;
28:2069–2078.
Concussions
By Jeremy Ansbach
WHAT IS A CONCUSSION AND
HOW CAN IT OCCUR?
Common within the
United States, concussions are a
disturbance in brain function
caused by high-impact trauma
to the head or neck in which the
brain often “bounces” within the
skull. Concussions result from
motor vehicle accidents, contact
sports, falls and other activities.
WHAT ROLE DOES THE
VESTIBULAR SYSTEM PLAY?
Concussions often affect the
inner ear, or vestibular system,
which assists with balance. The
vestibulo-ocular reflex (it assists
with the ability to focus on moving objects) and gaze stability of
the eyes, specifically, are disrupted,
making it challenging to focus. If
the cerebellum of the brain (controls coordination) is involved,
balance can be affected. Vertigo
or dizziness can occur when
structures within the inner ear are
damaged as a result of trauma.
HOW CAN PHYSICAL
THERAPISTS PLAY A ROLE
IN REHABILITATION?
The first step in recovery is
rest. If symptoms continue, rehabilitation should be considered.
Because no two concussions are
identical, a physical therapist
will develop an individualized
treatment program based upon
the needs of the patient as identified during an evaluation of the
vestibular system. Treatment
may include eye training and
balance and gait; it may address
secondary complaints of the
musculoskeletal system, including deficits in range of motion,
joint mobility and strength that
may have resulted from trauma.
Graded exposure to aerobic
activity will be designed by a PT
to promote blood and oxygen
flow for healing and will be
closely monitored for symptoms.
WHAT IS SECOND IMPACT
SYNDROME AND HOW CAN
RISKS BE DECREASED?
Second Impact Syndrome
is swelling of the brain caused
by a second concussion when
symptoms from the first concussion have not yet subsided.
Approximately 50 percent
of concussions are undiagnosed.
Once a concussion occurs, it is
important to recognize the signs
in order to protect the brain
against further damage. Common
complaints associated with
concussions include nausea, vomiting, dizziness, concentration and
cognitive difficulties, headaches,
fatigue, sensitivity to light, double
vision and uncoordinated
balance. Rapid changes in
emotions are common.
It is important to
treat the concussion
with rest and other
therapies prior to the
return to activities
such as sports.
2
3
Q&A
CASE STUDY
Concussions
By Jeremy Ansbach
WHAT IS A CONCUSSION AND
HOW CAN IT OCCUR?
Common within the
United States, concussions are a
disturbance in brain function
caused by high-impact trauma
to the head or neck in which the
brain often “bounces” within the
skull. Concussions result from
motor vehicle accidents, contact
sports, falls and other activities.
WHAT ROLE DOES THE
VESTIBULAR SYSTEM PLAY?
Concussions often affect the
inner ear, or vestibular system,
which assists with balance. The
vestibulo-ocular reflex (it assists
with the ability to focus on moving objects) and gaze stability of
the eyes, specifically, are disrupted,
making it challenging to focus. If
the cerebellum of the brain (controls coordination) is involved,
balance can be affected. Vertigo
or dizziness can occur when
structures within the inner ear are
damaged as a result of trauma.
HOW CAN PHYSICAL
THERAPISTS PLAY A ROLE
IN REHABILITATION?
The first step in recovery is
rest. If symptoms continue, rehabilitation should be considered.
Because no two concussions are
identical, a physical therapist
will develop an individualized
treatment program based upon
the needs of the patient as identified during an evaluation of the
vestibular system. Treatment
may include eye training and
balance and gait; it may address
secondary complaints of the
musculoskeletal system, including deficits in range of motion,
joint mobility and strength that
may have resulted from trauma.
Graded exposure to aerobic
activity will be designed by a PT
to promote blood and oxygen
flow for healing and will be
closely monitored for symptoms.
WHAT IS SECOND IMPACT
SYNDROME AND HOW CAN
RISKS BE DECREASED?
Second Impact Syndrome
is swelling of the brain caused
by a second concussion when
symptoms from the first concussion have not yet subsided.
Approximately 50 percent
of concussions are undiagnosed.
Once a concussion occurs, it is
important to recognize the signs
in order to protect the brain
against further damage. Common
complaints associated with
concussions include nausea, vomiting, dizziness, concentration and
cognitive difficulties, headaches,
fatigue, sensitivity to light, double
vision and uncoordinated
balance. Rapid changes in
emotions are common.
It is important to
treat the concussion
with rest and other
therapies prior to the
return to activities
such as sports.
Post-Concussion Syndrome
By Rob Volstad
PATIENT HISTORY
While driving, a 52-year-old
technology saleswoman was struck
on the driver’s side by another
vehicle. She struck her head
against the window and lost consciousness. She was taken to the
hospital, where all testing, including MRI and X-ray, was normal.
She complained of vertigo
with bed mobility. Vestibular
positional testing found that
she suffered from benign
paroxysmal positional vertigo
(BPPV). Repeated repositioning maneuvers were unsuccessful in correcting this.
She was released from the
hospital with continued vertigo,
dizziness, headaches and neck
pain, but with no further instructions for follow up, being told
she only had a concussion. She
returned to work immediately but
found that concentrating and driving triggered stronger headaches,
dizziness, and word-finding difficulties. She felt constantly exhausted and could no longer perform
her work responsibilities.
Approximately two weeks
after the accident, she noticed
some loss of her visual field.
She was referred to a neuroopthamologist, who diagnosed
her with a left optic nerve stroke.
This physician then referred her
to vestibular physical therapy
for her complaints of vertigo
and symptoms consistent with
post-concussion syndrome.
ASSESSMENT
At initial evaluation, the
patient’s primary complaint was
vertigo with positional changes.
Dix-Hallpike testing was positive
for BPPV on the left posterior
canal. All other oculomotor
testing was within normal limits,
though several of the test movements did provoke dizziness or
nausea. The presentation of busy
visual stimulation and patterned
backgrounds also provoked
strong symptoms, indicating high
space and motion discomfort.
Dizziness Handicap
Inventory score was 50/100.
Functional Gait Assessment
score was 25/30, with imbalance
most noted with quick head
turns and nods. She had poor
head-shoulder dissociation when
turning. Motion Sensitivity
Quotient was moderate at 18.75.
Because of the patient’s
neck pain, dizziness and vertigo, a full cervical spine assessment was completed, finding
significant trigger points activity and upper cervical range of
motion (ROM) restrictions,
mostly on the left and with
movements to the left. Original
verbal pain score was 7/10.
TREATMENT
The patient was seen for
eight weeks, primarily for vestibular PT to address the imbalance,
space and motion discomfort,
abnormal gaze stabilization, and
poor visual preference. The BPPV
identified on the initial visit was
successfully treated at that time.
Initially, vestibular exercises
included basic head and eye coordination movements until they
could be performed against plain
backgrounds and busy backgrounds without any symptoms.
Her balance exercises progressed
as she improved, to include walking with changes in motion,
with eyes closed, and with narrowing of her base of support.
At the onset, manual therapy was initiated to decrease cervical and upper thoracic pain
and strain. Soft-tissue massage
and upper cervical mobilization
were the primary focuses.
During the coming weeks, as
the patient reported improving
symptoms, vestibular exercises
were advanced to include dynamic
visual adaptation. She moved her
head with increasing speed while
maintaining visual contact on near
and distant targets, first while
standing and then when walking.
To address her space sensitivity, she was placed in a dark room
with a disco ball rotating colored
lights across the walls of the room
until triggering her symptoms.
Her tolerance without symptoms
increased from just seconds at the
initial trial to several minutes by
the time of her discharge – including when she moved around.
Cervical and upper thoracic strengthening exercises
were added several weeks into
her therapy to assist with good
posture and cervical stability.
Balance and vestibular exercises continued to advance as the
patient reported improved function with less pain and dizziness.
By week four, she was able to drive
in all traffic without dizziness.
OUTCOME
After eight weeks of physical
therapy, education and behavior
modification, the patient had met
each of her goals and returned to
her demanding job. She was able
to drive, tolerate busy visual environments such as a grocery store
or mall, and walk with quick head
and body turns without dizziness or
imbalance. She had full cervical painfree ROM and no longer complained
of vertigo with positional changes.
Her Dizziness Handicap
Inventory score improved to
2/100; Functional Gait Assessment
score improved to 30/30; Motion
Sensitivity Quotient score
improved to 0.4, mild. She
reported 0/10 pain at worst.
4
RESEARCH ABSTRACT
Vestibular Rehab After Concussion
By Branden Fleishman
and younger) demonstrated
significant improvement in
dizziness severity and on the
SOT compared with adults.
INTRODUCTION
A concussion is one of the
most common neurological
conditions among children and
young adults. The growing rate of
concussions in contact and collision sports has made for a major
public health concern worldwide.
A concussion, also referred
to as a mild traumatic brain
injury, disrupts brain function,
resulting in physical, cognitive,
emotional and/or sleep-related
symptoms and may involve a
loss of consciousness. Symptom
duration can vary from minutes
to months or even longer.
Dizziness, causing poor
balance and postural instability,
is a frequent symptom in the
first days after injury, occurring
in 23 to 81 percent of cases.
The purpose of this paper
was to examine the effect of
vestibular rehabilitation on
reducing dizziness and improving gait and balance function
after concussion.
METHODS
The authors conducted a
retrospective study reviewing
charts of 114 patients referred
for vestibular rehabilitation after
concussion. Duration of time
between the concussion and referral for evaluation was a median
61 days. Vestibular rehabilitation
interventions were customized
based on each patient’s impairments and functional limitations
that related to dizziness, oculomotor function, and gait and balance function. Clinical and home
DISCUSSION
Post-concussion dizziness and gait and balance dysfunction
improved after vestibular rehabilitation, according to the study.
exercises included gaze stabilization, standing balance, walking
with balance challenge, and, in a
few cases, canalith repositioning
maneuvers, or techniques used
to assist in the correct placement
of crystals in the ear canals.
Self-reported and performance measures were taken at the
initial evaluation and at discharge.
Self-reported measures included
dizziness severity, the Activitiesspecific Balance Confidence
(ABC) scale, and the Dizziness
Handicap Inventory (DHI). Gait
and balance performance were
measured using the Dynamic
Gait Index (DGI), Functional Gait
Assessment (FGA), gait speed,
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Timed Up and Go, Five Times
Sit To Stand (FTSTS) test, and
Sensory Organization Test (SOT).
A mixed-factor, repeated-measures
analysis of variance was used to
test whether there was an effect of
vestibular rehabilitation therapy
and age on the outcome measures.
RESULTS
Of the 114 patients referred,
84 returned for at least one visit.
Median number of visits was
four and median duration was
33 days. Among these patients,
improvements were observed in
all self-reported gait and balance
performance measures at time
of discharge. Children (ages 18
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The primary finding of this
study is that people who had
persistent dizziness and gait and
balance dysfunction after having
a concussion improved after
vestibular rehabilitation. For most
outcome measures, improvement
in post-concussion symptoms did
not depend on age, indicating
that vestibular rehabilitation
may equally benefit children and
adults. While many symptoms
may resolve within the first few
weeks after the injury, this study
indicates that skilled intervention
may be beneficial in improving
symptoms that persist in the
sub-acute and chronic phases
and do not resolve with rest.
Future research evaluating
patients from time of injury
to return to full activity or
function can assist health care
professionals in providing
appropriate care. Concussion
severity markers such as loss
of consciousness, amnesia and
confusion should be included
for determining prognosis and
appropriate interventions. A
multidisciplinary approach
incorporating a vestibular rehabilitation program should be
implemented after concussion.
REFERENCE
Alsalaheen, B., Mucha, A., Morris, L., et
al. “Vestibular rehabilitation for dizziness
and balance disorders after concussion.”
Journal of Neurologic Physical Therapy.
June 2010; 34:87-93.
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