1. Physical Therapy in the DoD
CDR Henry McMillan, PT, DPT
LCDR Alicia Souvignier, MPT, DPT, GCS

2. Objectives
Identify the common patient presentations seen by PHS PTs working in the DoD
Be able to indentify key aspects of the evaluation of a dizzy patient
List 3 treatment techniques used to treat dizziness

3. Indentification of mTBI
Incident in theatre results in Medivac to CONUS
After redeployment, troops inprocess through the Soldier Readiness Center, where history of concussion is identified
Soldiers with possible residual symptoms of concussion, are referred to the TBI clinic.
Mace, Warcat, multidisciplinary team

4. DoD/Physical Therapy Optimistic expectation for full recovery
Therapists incorporate assessment of the Service Members goals and priorities along with MTBI related symptoms

5. Areas of concern for a soldier who has a history of concussion/mTBI
Vestibular Dysfunction
Balance Complaints
Post Traumatic Headache
Temporomandibular Joint Dysfunction
Attention and Dual-Task Deficits
Fitness/ Activity intolerance
Musculosketetal complaints

6. Guidelines for PT Referral
DHI Score > 11 (Yes to any F’s or P’s)
Plus yes to one of the following:
R/SR (Eyes Closed) less than 30 seconds- (arms across chest)
VOR x1 for less than one minute with onset of symptoms
Walking with HT increase symptoms, deviated gait, LOB- (Museum Gait)
DHI Handout.

7. Guidelines for PT referral
If the patient reports any of the following
Difficulty with balance or dizziness that is affecting their functional performance
Unsteady while standing still or walking, in poor lighting, or in crowds
Difficulty with balance on uneven surfaces
Intense spinning, lightheadedness, or unsteadiness associated with exercise

8. Causes of Vertigo Vestibular Lesions or hypofunction
Unilateral- infection/neuritis, lesions, bppv
Bilateral- ototoxic medications
Central processing
Central lesions- brainstem, cerebellum
Migranes
Anxiety
Cervicogenic dizziness
Vertebrobasilar insufficiency
Altered proprioceptive signals

9. Evaluation Subjective MOI or idiopathic Frequency/Intensity/duration
Vision/ Hearing deficits
Positional/activity induced
Valsalva/ pressure changes
Describe symptoms of dizziness
Vertigo
Imbalance
Lightheadedness

10. Evaluation Subjective Activity Level Exercise Tolerance
Recreational Sports
Exercise Tolerance
Unit Physical Training
Behavioral Health
Quality of Life
DHI
Family Participation
Command/Unit Support

11. Vestibular Evaluation
Musculoskeletal Screen
Positional Testing
Oculomotor
Balance

12. Oculomotor
Smooth Pursuit
Saccadic
VOR

13. Oculomotor Vestibular Ocular Reflex
Vestibular system sends information regarding speed of movement to the visual system. Allows us to keep focus while performing functional head motions.

14. Test for VOR Head Thrust Test Grasp patients head firmly
Tilt patient’s head to 30 deg flex
Move head back and forth slowly and instruct patient to keep focus on target
Provide a quick movement through a small range and watch for patient’s ability to refocus on target.
Refixation saccade indicates decreased VOR

16. Test for VOR Dynamic Visual Acuity
Test visual acuity on a Snellen Chart
Turn patients head vertical and horizontal plane to the beat of a metronome at 2Hz
Retest visual acuity while you are moving the patient’s head.
3 lines loss is significant

17. Positional Testing Dizziness caused by certain positions Dix Hallpike
Spinning
Use Frenzal goggles
Dix Hallpike
BPPV
Motion Sensitivity Quotient
Motion Sensitivity

18. Positional Testing Dix Hallpike
Long sitting, head turned 45 deg, drop down with neck into about 30 deg of extension

19. Balance Functional Gait Assessment Romberg/ Sharpened
Neurocom or M-CTSIB

20. Treatment Approaches
Adaptation Exercises: adapting residual vestibular function to make up for lost function
Example: Maintain visual fixation on object while the head is moving
Substitution Exercises
Doing exercises with and without visual cues
Habituation Exercises
Repeated exposure to provocative stimulus, for example motion sensitivity.

21. VOR Treatment - Adaptation
Walking head turns
Tracking with eyes
Tracking with head movements
All of the above together
Above exercises on varied surfaces

22. Motion Sensitivity Treatment
Brandt Daroff (picture)
Positions identified from MSQ
Add picture

23. Treatment of BPPV
Canalith Repositioning Technique
Liberatory Maneuver

24. Postural Stability Prioprio Neurocom- Balance activities- SOT Foam
Unstable surface
Uneven terrain
Slide for balance, one slide for proprio, one for neurocom

25. Treatment Ideas Foam bowling Bear claws Soccer Toss Wii
Dance Revolution
Discoball/strobe with balance

26. Goals for Physical Therapy
Return to Duty
Goals for Civilian Life

27. Questions?