2. The Role of Vestibular Rehabilitation in Concussion Management
R. Amadeus Mason MD
Emory Sports Medicine
SEACSM Annual Conference
February 16, 2018

3. Objectives
Briefly discuss concussion, symptoms and Post concussion syndrome
Discuss what the Vestibular system is and why it’s important to sport
Discuss how concussion affects the vestibular system
Describe the interventions that are used.

4. Concussion

5. Concussion According to the CDC:
A type of traumatic brain injury (TBI) caused by a bump,blow, or jolt to the head that can change the way your brain normally works.
Concussions can also occurfrom a fall or a blow to the body that causes the head and/or brain to move quickly back and forth.

6. Concussions
There are 300,000 sport related concussions per year in the U.S. -age 15–24(Gessel,2007)
Football had the highest rate of concussion
when comparing rates and patterns across 20 different sports
Majority of concussions happened in football–47%(n of study=1,936) (Marar,2012)

7. Concussion signs & symptoms
(Pardini, Lovell, Collins et al. 2004)

8. Post concussion symptoms
80% of concussions should get better in 10–14 days
(Consensus Statement Berlin,2017)

9. Post concussion syndrome
Having symptoms > 2-4 weeks
Symptoms include
Chronic persistent headaches (71%)
Fatigue/Sleep disturbances
Fogginess (53%)
Dizziness (55%)
Sensitivity to light and/or sound (47%)
Balance problems (43%)
Lovell, Collins et al. 2004

10. What does the vestibular system actually do?
Senses linear and angular speed
Senses rotational movements of head
Senses linear movements of the head
Senses head position in space

11. Vestibular system function
Emory Course Material 2014

12. Vestibular system function
Vestibular Ocular Reflex (VOR)
Stabilized vision while head is moving
Vestibular Spinal Reflex (VSR)
Balance Control

13. Why is the vestibular system important when playing sports
Eye - hand coordination
Depth perception
Balance
Overall coordination
“Field/Game presence”

14. Concussion : Vestibular system connection
“A combination of cervical and vestibular physiotherapy decreased time to medical clearance to return to sport in youth and young adults with persistent symptoms of dizziness, neck pain and/or headaches following a sport-related concussion. ” Schneider, 2014
“Vestibular and ocular motor impairments and symptoms have been documented in patients with sport related concussions.” “Sixty-one percent of patients reported symptom provocation after at least 1 VOMS item. ” Mucha, 2014

15. Post concussion syndrome
Symptoms include
Chronic persistent headaches (71%)
Fatigue/Sleep disturbances
Fogginess (53%)
Dizziness (55%)
Sensitivity to light and/or sound (47%)
Balance problems (43%)
Lovell, Collins et al. 2004

16. Common post concussion Vestibular impairments
VOR impairment
Difficulty with eye movements,
unclear vision while head is in motion
VSR impairment
Difficulty with compensatory body movement
to maintain head and postural stability,
preventing falls (balance control)
Visual Motion Sensitivity
 Heightened awareness of normal visual motion
BPPV
Low incidence in younger athletes

17. Role of vestibular rehab in return to play
To insure player has appropriate gaze stabilization mecjhanism.
To insure proper integration of visual, vestibular and somatosensory systems.

18. Vestibular Rehab Exam Cervical Range of Motion
Cervical Ligamentous Integrity
General Extremity strength screening
Fine Motor/Coordination Assessment(finger to nose, finger to object etc)
Cranial N. Exam
Ocular Motor Range of Motion
Smooth Pursuit
Saccades
Vestibular Ocular Reflex (horizontal and vertical at different speeds)

19. Vestibular Rehab Exam Head Thrust Test VOR Cancellation Convergence
Spontaneous Nystagmus Fixed Gaze Nystagmus
Head Shaking Nystagmus
Dix Hallpike and Roll Test
(rule out BPPV)
Vertebral Artery Test
Dynamic Visual Acuity (eye chart)
Romberg, Sharpened Romberg, Standing Foam (modified CTSIB)
Dynamic Gait Index or Functional Gait Assessment
Tandem walking
Single Leg Stance
BESS Test if applicable / HiMAT

20. VOR Symptom provocation created by moving or busy environments
school hallway, soccer game
Treatment:
Ball toss, Lunges with medicine ball tracking
Head eye coordination exercise using various targets

21. VoR - Saccades
Function: ability to look at one target, and then quickly at another
Abnormal findings
over / undershooting
More than 3 saccades to get to target
Slow speed
Treatment:2-targetexercise,clockexercise

22. Function: Ability to smoothly follow target with eyes
Vor - Smooth Pursuit
Function: Ability to smoothly follow target with eyes
Abnormal findings
asymmetric eye movement
saccadic movement/ not smooth movement while tracking (age sometimes a factor)
Treatment: 9 point pattern, online computer exercise

23. VOR - Convergence
Function: ability to turn eyes inward to focus on a target
Near-point convergence break cutoff(6cm)
Recovery cutoff(10cm)
Test patient 3 times!!–to see if fatigue is a factor
Abnormal findings
Break point is greater than 6 cm
Recovery point is greater than 10 cm
Treatment: Brock string, Pencil Push-Ups

24. Visual Motor Sensitivity
Abnormal sensitivity with visual/vestibular interaction
“Optokinetic hypersensitivity”
Treatment
Gradual exposure to provocative stimuli
Use of fixation point initially
Then change Posture, Surface and Duration

25. bppv Duration of symptoms less than 1 minute (typically) Treatment:
Occurs when head is in certain positions
Sense of vertigo vs. dizziness
Vertigo = room is spinning–rotational component to symptom
Dizziness caused by getting out of bed, rolling in bed, looking up, or lying down
 Treatment:
CanalithRepositioningManeuver

26. Vestibular rehab focus
Fine Motor Deficits/Reaction time
Vison
Eye head coordination
Headaches
Fatigue
Balance/coordination
Dual task performance
Body Mechanics and Posture

27. Take home points
Vestibular-related history/symptoms predict protracted recoveries
Eg (dizziness/fogginess) and migraine.
Vestibular/Ocular Component is missing Link - look for it on exam.
Vestibular Rehabilitation is more than just balance training
Refer early to appropriate provider

28. Thank you