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Concussion Management – After the Hit
Brian Werner, PT, MPTPresident – Werner Institute for Balance and Dizziness Disorders
Rebecca Cheema, ATC, PTA, EdD
Dr. Cheema’s Perspective
Is Concussion Management Saturated – Do we really know all aspects of a concussion?
What I have learned in a Dizziness Clinic over the year? Vestibular System and its effect on
brain function and recovery
History of Concussion Management Early and Late 1990’s - Computerized
Neurocognitive Testing (Headminder, ImPACT) Late 1999’s – BESS vs. Computerized -
Balance Performance Testing 2004 – NATA Position Statement 2008 - Zurich Statement on RTP Criteria 2008 – SAC and SAC II 2010 – NCAA 2011 …
Zurich Statement – Graduated RTP - 2008Functional Exercise at Each Stage of RehabilitationFunctional Exercise at Each Stage of Rehabilitation
1. No activity Complete physical and cognitive rest OBJECTIVE: RecoveryOBJECTIVE: Recovery
2. Light aerobic exercise Walking, swimming or stationary cycling keeping intensity <70% MPHR. No resistance training.
OBJECTIVE: Increase HROBJECTIVE: Increase HR3. Sport-specific exercise
Skating drills in ice hockey, running drills in soccer. No head impact activities.
OBJECTIVE: Add movementOBJECTIVE: Add movement4. Non-contact training drills Progression to more complex training drills (e.g. passing drills
in football and ice hockey). May start progressive resistance training).
OBJECTIVE: Exercise, coordination, cognitive loadOBJECTIVE: Exercise, coordination, cognitive load5. Full contact practice
Following medical clearance, participate in normal training activities
OBJECTIVE: Restore confidence, assessment of functional skills by OBJECTIVE: Restore confidence, assessment of functional skills by coaching coaching staffstaff
6. Return to play OBJECTIVE: Normal game playOBJECTIVE: Normal game play
History of Concussion Management Early and Late 1990’s - Computerized
Neurocognitive Testing (Headminder, ImPACT) Late 1999’s – BESS vs. Computerized -
Balance Performance Testing 2004 – NATA Position Statement 2008 - Zurich Statement on RTP Criteria 2008 – SAC and SAC II 2010 – NCAA 2011 …
NFL launches new guidelines for assessing concussions
BASELINE TEST Concussion History Self Reported Symptoms SAC Modified BESS
Where are the vestibular tests?Where are the vestibular tests? The league will utilize "standardized" sideline
procedures for assessing whether players have sustained concussions during a game or practice and whether they have crossed the "No Go" threshold for removal.
NFL Sideline
Presentation Objectives Cerebral versus Vestibular Concussion – Is
there a difference? What is the Vestibular System and How
Can It Get Damaged? Why is It So Important to Differentiate
Cerebral versus Vestibular Concussion in the Concussed Athlete?
Training Room Testing for Vestibular Dysfunction in the Athlete – When and How?
Treatment of Vestibular Dysfunction Athlete – How Does It Work?
Cerebral versus Vestibular Cerebral versus Vestibular Concussion – Is there a Concussion – Is there a
Difference?Difference?
The Concussion – What We Know…
Defined as an immediate acceleration and deceleration or stopping event, resulting in temporary or permanent damage to the “structures”“structures” of the head.
Lets not get caught up that every Lets not get caught up that every concussion is cerebral!concussion is cerebral!
This injury is likely associated with low levels of axonal stretch resulting in temporary changes in neurophysiology. (Giza and Hovda, 2004)
The vestibular structures are also affected…they are part of the head.
Difference Between Cerebral and Vestibular Concussion – Symptom Onset and Resolution
Cerebral symptoms come on strong and resolves quickly 7-10 days
Vestibular symptoms may also be at onset but can be delayed and progressively worsens with time Days, weeks, to months
Avoidance Behaviors
The symptoms themselves can be similar in nature
- Lance Jackson, MD Neurotologist (EIT), 2011
What is the Vestibular System, What is the Vestibular System, What Does Do,What Does Do,
and How Can It Get Damaged?and How Can It Get Damaged?
What is the Vestibular System?
Complex set of sensors imbedded in the temporal bone of the skull. Not just your ears…
Cranial Nerve system (CN VIII) Brainstem Vestibular Nuclei Parts of the cerebellum
This is where symptoms can be mixed…cerebral vs. vestibular
Big Question: How Do I know which one is injured – Peripheral, Central or Both …you must know what you are testing.
Sensors of the Inner Ear
Linear Accelerometers
Otolith Organs
Key – these are accelerometers – abnormal accelerations are the common cause to concussions…
Semicircular Canals
Angular Accelerometers
What Do They Control
YAW PITCH ROLL BOB HEAVE SURGE
EYES, HEAD ON NECK, POSTURE
Primary Functions of the Vestibular System
(VOR) Maintains gaze stability of the eyes
(VCR) Maintains position of head on neck
(VSR) Maintains balance during transitions, standing, and gait
New thoughts…
The Vestibular – Cognition Connection – New Thoughts
Damage to the vestibular system can directly create cognitive deficits
Spatial navigation Object recognition memory
You don’t have to have symptoms of dizziness to have the cognitive symptoms
(Smith et al, 2005, Hanes, 2006 – Journal of Vestibular Research)
Could improvement in vestibular function reduce cognitive dysfunction?
Example: Zach T.
The Vestibular-Blood Flow Connection – New Findings out of Harvard
The purpose of the otolith organ of the inner ear is assist in auto-regulation of blood flow to the head.
Injury to this organ can lead to symptoms that commonly are thought to be cerebral deficits. Serrador,et al, 2008
Dr. Leddy – Univ. of Buffalo Program
The Vestibular-Autonomic Nervous System Connection
Vestibular system lesions produce a number of injurious effects, including:
Disruption in the ability to rapidly adjust blood pressure
Respiratory muscle activity during movement and changes in posture
These perturbations in autonomic regulation are transient, and largely dissipate over time.
Could we be seeing a disruption of the vestibular system as the cause of the symptoms of concussion?
What Structures Are Injured to the Vestibular System After Concussion? Actual sensors
(otolith/cupula of SCC) or entire end organ gets damaged Baro-trauma, blunt
injury, blast/shockwave from hit
Traction/tethering of the CNVIII nerve From the origin of the
sensor In the axons of the
nerve itself From the insertion in
the brainstem
Why is It So Important to Differentiate Why is It So Important to Differentiate Vestibular from Cerebral Concussion?Vestibular from Cerebral Concussion?
Because We Are Missing Athletes
Young kids… Ex. Stuart N. Ex. Zach T.
Older athletes/soldiers Bob J. Chelsea O.
Symptom management lacking specificity
Vestibular Dysfunction Symptoms That Can Mimic Cerebral Concussion Signs (in the clinic)
VOR (Gaze Instability) Visual Sensitivity, Headaches, Difficulty
concentrating, fatigue, cognitive dysfunction
VCR (Cervical Instability) Visual Sensitivity, Headaches, Cervical
Pain/Stiffness
VSR (Postural Instability) Balance problems, fatigue, cognitive
dysfunction
Dizziness? What does that identify?
What is Dizziness? (Kroenke, 2001)
Dysequilibrium/Dysequilibrium/Off-BalanceOff-Balance
Pre-Syncope/Pre-Syncope/WoozinessWooziness
VertigoVertigo(Spinning)(Spinning)
Motion Intolerance/Motion Intolerance/Visual SensitivityVisual Sensitivity
BehavioralBehavioral(Anxiety, Depression,(Anxiety, Depression,
Withdrawal)Withdrawal)
Dizziness is a Non-Specific Term
Example – Pain can be described as: Sharp, shooting, burning,
aching, deep, superficial, tension, pounding, etc.
Where is the injury? Mechanism of Injury? Time frame on healing?
More specific vocabulary assists medial professionals in providing the proper care
Vestibular System Injury Causes Symptoms That Mimic Cerebral Concussion Example: Vestibular Neuritis (Non-Contact)
No injury to the cerebral system yet damage to the inner ear
Classic symptoms and secondary symptoms include:
VERTIGO MOTION SICKMOTION SICK DYSEQUILIBRIUMDYSEQUILIBRIUM
Inability to concentrate
Difficulty sleeping Mental Fogginess
Nausea Feeling “off” Anxiety
Visual sensitivity
Blurry Vision Fatigue
Note: You don’t have to feel the primary symptoms to have secondary.
Training Room Testing for Vestibular Dysfunction in the Athlete – When and How?
Before the Hit…Before the Hit…
Prior to Concussion Baseline
test/CombinesNCAA 2010
requires it. Identify at-risk
athletes to prevent future injury
Identify old injury not known
After the Hit…
Zurich Stage 1. No activity - Complete physical and cognitive rest OBJECTIVE: RecoveryVESTIBULAR TESTING VESTIBULAR TESTING SHOULD BE DONE WITH SHOULD BE DONE WITH
NEUROCOGNITIVE!NEUROCOGNITIVE! Zurich Stage 2. Light
aerobic exercise Walking, swimming or
stationary cycling keeping intensity <70% MPHR.
No resistance training.
Training Room Vestibular Tests
Gaze Stability Oculomotor Screen (Saccade, Smooth Pursuits) Slow VOR Head Impulse Test (Head Thrust) Illegible-E/Dynamic Visual Acuity Tests Dix-Hallpike Test
Postural Stability Singleton FUKUDA Tandem Gait – Eyes Closed
BESS Station
Your Identification is the Key to Proper Management Identify vestibular
component and refer them out if non-resolution after day four…(Zurich, 2008) Physical Therapy and
Audiology that specializes in vestibular disorders
Medical Doctor with Audiology – Neurotologist - ENT
Tests That Measure Vestibular Function
Videonystagmography Computerized Dynamic
Posturography Rotational Testing
Passive Chair Testing Active Rotation Testing
Vestibular Evoked Myogenic Potentials
InVision DVA and GST Testing
Treatment of Athlete with Vestibular Treatment of Athlete with Vestibular Dysfunction - Dysfunction -
How Does It Work?How Does It Work?
Vestibular Rehabilitation
Started in the mid to late 1940’s
Cawthorne and Cooksey
Treatment of concussed soldiers
Set of eye, head, and body activities to induce movement to facilitate central compensation
Vestibular Rehabilitation 1980’s – Susan Herdman, PT, PhD
started to develop custom treatment approaches to the Cawthorne exercises CC Exercises too general and not specific
Telian and Shepard, 1985 – Custom Vestibular Rehabilitation 85% resolution or significant reduction in
symptoms compared to CC Exercises where on 55% resolution
Cochrane Collaboration (2007) Vestibular rehabilitation is effective.
Treatment of Vestibular Dysfunction Using BRPT
Principle I Dizziness is an error message – avoidance
of the symptom actually prolongs disorder. Principle II
Use the same treatment techniques you would use to treat an ankle sprain/strain
Repetitions and Sets Small movements to dynamic movements Symptoms as your guide
Treatment of Vestibular Dysfunction Using BRPT
Principle III – Taxonomy of Task Progression for Static/Dynamic Balance Open/Closed Environment No Intertrial/Intertrial
Variability Without/With manipulation Body Stable/Body Transport
Gaze Stability Exercises
Fixed/Moving targets Variable distances
from targets Simple to complex
visual backgrounds Simple to complex
surfaces during: Sitting Standing Gait
References
Kroenke, K., Lucas, C.A., Rosenberg, M.L., et al. (1992). Causes of persistent dizziness: A prospective study of 100 patients in ambulatory care. Annals of Internal Medicine, 117, 898–904.
Cawthorne, T. (1944). The physiological basis for head exercises. J Chart Soc Physiother 106-7. El-Kashlan, HK., et al. (1998). Disability from vestibular symptoms after acoustic neuroma. American Journal of Otology
19:101-114. Hain, T. (2006). http://www.dizziness-and-balance.com/treatment/rehab.html Horak, FB., et al. (1992). Effects of Vestibular rehabilitation on dizziness and imbalance. Otolaryngology – Head and Neck
Surgery 106: 175-9. Kreb, DE., et al. (2003). Vestibular Rehabilitation: useful but not universally so. Otolaryngology – Head and Neck Surgery. 128:
240-50. Norre, M. (1988). Vestibular habituation training. Archives of Otolaryngology – Head and Neck Surgery 114: 883-86. Solomon, D & Shepard, N. (2002). Chronic Dizziness. Current Treatment Options in Neurology: Ophthalmology and Otology.
281-288. Whitney, et al. (2000). Efficacy of vestibular rehabilitation. Otolaryngologic Clinics of North America. 33,3; 659-673. Whitney, et al (2003). The effect of age on vestibular rehabilitation outcomes. Laryngoscope. 112,10: 1785-90.