PCS –V 3 –VISUAL/VESTIBULAR · 2020-04-17 · Disorders of the vestibular system • Unspecified peripheral vestibular dysfunction –most common cause of dizziness seen in outpatient

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PCS – VISIT 3A – VISUAL/VESTIBULAREvidence-Based Concussion Care

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Complete Concussion Management Inc. © 2019. All rights reserved

PCS Management Algorithm

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Main Causes of PCS:3. Visual/Vestibular

4. Cervical Spine Dysfunction• Visual and Vestibular issues may coexist or overlap

• May be pre-existing or due to concussion– Pre-existing = subclinical but brain injury brings them to

forefront• Cervical spine dysfunction may be heavily involved in

this as wellTypically Assessed on Visit 3

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3rd Visit• Rule out obvious vestibular impairment (BPPV) • Rule out visual impairments that require

referral

• VOMS• Cervical Spine

• future visits – look for more subtle causes of “dizziness” if complaint is still there

Should’ve been done at 1st visit

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Clinical evaluation of patients with vestibular dysfunction (a review on the vestibular system)Disorders of the vestibular system• Unspecified peripheral vestibular dysfunction – most common cause of dizziness seen in outpatient setting and

could be from prior infection, trauma, or medication. • Presbyvertigo – ie. aging vestibular system, is the most common cause of vertigo in the elderly. • Cervicogenic dizziness – neck movement limited by arthritis, trauma, or neck spasm is likely to cause dizziness. • BPPV – due to dislodged otoconia from the utricle into the endolymph. Results in dizziness related to head position. • Meniere’s disease – increase endolymphatic fluid, which increases pressure causing dysfunction in hearing and

balance. • Superior canal dehiscence – erosion of the bony superior canal causing erratic pressure in the canals and therefore

dizziness. • Perilymphatic fistula – abnormal communication between the inner and middle ear • Vestibular migraine – often a diagnosis of exclusion. Symptoms of vestibular dysfunction• Unilateral peripheral vestibular dysfunction causes vertigo, where as bilateral dysfunction is perceived as lightheaded

or imbalance. • Double vision, vertical nystagmus or limb ataxia suggest more proximal lesions at the level of brainstem or cerebellum. • Hearing loss, tinnitus and ear fullness often occur on the side of the peripheral lesion. • “most patients with vestibular dysfunction end up with a tight neck. This is probably due to maladaptive mechanism

as described, which can lead to chronic headaches.”

Renga 2019

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Clinical evaluation of patients with vestibular dysfunction (a review on the vestibular system)Clinical evaluation of vestibular dysfunction • Eye movements – nystagmus is a telltale sign. Using a cell phone camera with slow motion is useful to review

for nystagmus. People with vestibular dysfunction generally get some dizzy symptoms following a target to the affected side.

• Head impulse test – patient is asked to fixate their eyes on a target while the examiner quickly turns their head (around 20 degrees) to throw the eyes off the fixated target. A displacement off target to the affected side with a catch-up saccade is an indicator of vestibular dysfunction.

• Dix-Hallpike or Roll test • Dynamic visual acuity test – patients are asked to read from a Snellen eye chart to check baseline visual

acuity. Patient rotates head and asked to re-read from Snellen eye chart while rotating. If there is impairment or dizziness it is likely vestibular dysfunction. Follow-up with keeping the head steady and have the patient twist at the trunk/neck (Rotatory chair). Re-read from the chart and if there is impairment on this and not with head turns then it is likely cervicogenic.

• Balance tests, eye closed tandem stance – removing visual system (closing eyes) and disrupting sensory system (tandem stance) can help determine vestibular dysfunction. With eyes closed tandem stance if there is sway/fall mainly to one side this is the affected side and indicates a peripheral unilateral vestibular lesion. If the patients fall equally to either side or shake it indicates bilateral dysfunction.

Management of vestibular dysfunction• The most recognized treatment is Vestibular Rehabilitation Therapy, as the vestibular system has exceptional

neuroplasticity.

Renga 2019

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Peripheral vestibular disorders in children and adolescents with concussion

A proposed algorithm for the identification and management of vestibular disorders following a concussion

Suggested treatment is hydration and gradual reconditioning

Vestibular rehabEply’s or BBQ roll

Brodsky, et al., 2018

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Physical examination of dizziness in athletes after a concussion: a descriptive review • 41 athletes (age 10-23 years old) who sustained a sport-related concussion and

scored at least 3 for dizziness or the PCSS scale were included. • All athletes were examined at 10 days post concussion. • Evaluation findings were grouped as follows:1. Central dysfunction – include oculomotor disorders (smooth pursuit, saccade or

convergence), motion sensitivity, central vestibular dysfunction as demonstrated by positive VOR.

2. Peripheral disorder – positive head impulse test or BPPV (based on Dix-Hallpike test).– Schneider, 2019 – Peripheral Vestibular Hypofunction – absent or reduced ability of the

peripheral vestibular apparatus to sense motion – a mismatch in afferent input between the two labyrinths (right & left) – pathophysiology unknown• Identified by Head impulse test & dynamic visual acuity (which could also indicate cervicogenic

involvement)3. Cervical dysfunction – cervicogenic dizziness based on provocation of dizziness

through mobilizations of spinal joints or palpation of cervical muscles, 4. Presence of cervicogenic headaches were recorded based on provocation of

symptoms through cervical mobilization of spinal joints or palpation of cervical muscles.

Reneker, et al., 2017

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Physical examination of dizziness in athletes after a concussion: a descriptive review

Results • All 41 (100%) athletes had findings consistent with

central dysfunction, however only 4 (9.8%) athletes had central dysfunction only.

• Within the 41 athletes 19 (46.3%) had peripheral dysfunction and 34 (82.9%) had cervical dysfunction (12 athletes had overlapping dysfunction).

• 27 athletes (65.9%) had cervicogenic headaches. • 0 athletes had orthostatic hypertension.

Reneker, et al., 2017

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Visual Disturbance/Tracking• Common Complaints – may complain of cognitive issues

• trouble focusing when reading• losing their place on page• concentration/memory problems

– headaches with cognitive activity– vertiginous feeling when tracking objects– “visual motion sensitivity” (dizziness when driving, supermarket

syndrome (crowded environments)) – Photosensitivity (thalamus hyperactivity? Excessive activity of

visual cortex? Astafiev et al., 2016)• BPPV and more sinister pathology ruled out and dealt

with at first visit

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Visual/Vestibular Assessment • Once more sinister pathologies have been ruled out…• Often difficult to parse out what is visual, what is vestibular

and what is cervical spine• Visit 3:– VOMS (↑ in symptoms by 2 or more is significant)

• General visual and vestibular issues• Good starting point for rehab

– Cervical spine exam (next video)• Try to recreate symptoms

– Headaches, Dizziness, etc.– If you can’t, doesn’t necessarily rule out cervical spine as a possible cause of symptoms

– Other causes for visual & vestibular symptoms (more specific) – if VOMS ok but still complaining of vestibular/visually-based symptoms

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VOMS• Smooth Pursuits (Horizontal & Vertical)• Saccades (Horizontal & Vertical)• VOR (Horiontal & Vertical)• Visual Motion Sensitivity• Accommodation (Right & Left tested separately)• Convergence

**Initial rehab corresponds to VOMS findings**

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VOMS Testing Video

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Smooth Pursuit Rehab• Target Tracking– a target (own thumb or checkerboard) should be held at arms

length at midline and slowly moved horizontally 5 degrees from midline repeatedly (10x) followed by a break. This should then be repeated with 10 degree excursions, then 20. This should then be repeated in the vertical plane and diagonal – 3-4x per day for 2 weeks

– Dizziness is ok up to about a 5/10 – then rest – Progression - The target distance and object speed should be

altered to challenge the patient working up to 2 mins in each direction with no symptoms

• King-Devick– Photocopies can be given to the patient to practice reading out

loud forwards and backwards at home

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Saccade Rehab• 4 Targets:– Patient places 4 targets on the wall (x’s, playing cards) at 12, 3,

6, and 9 o’clock approximately 20 degrees from midline– Patient shifts their gaze from target to target sequentially (up,

down, right, left)– Sequence is repeated 10x then targets should be adjusted + 10

degrees and repeated• Targets should be adjusted for both near and far vision – with time,

training should be focused on distance of greatest symptomatology

• Number Sheet– Practice different patterns

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Number sheet

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VOR pathology• Symptoms– Dizziness, Shaky vision (camera), Unable to read signs while walking

• Possible causes– Peripheral vestibular lesions – Vestibular neuritis– Central vestibular lesions (brainstem)– Cerebellar deficits– Age (over 75)

• Tests– VOMS– Dynamic Visual Acuity Testing

(https://www.youtube.com/watch?v=7SJYS37iESg)• Management – Gaze stabilization/Vestibulo-ocular rehab– referral to vestibular therapist with experience in this area if your

rehab is ineffective (4-6 weeks)

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Vestibulo-ocular rehab

• Gaze stabilization (progression)–Metronome – 180 bpm (Checkerboard)– Reps/sets – 2-3 sets of 10 reps (2-3 x/day)• Progress at own pace to 15 reps, 20, 30 – goal is 2 mins

– Seatedà2-foot stanceàtandem stanceàwalking forwards & backwards à tandem gait forwards & backwards àstepping over objects à sport specific activities (ladder drills, stickhandling, etc.)

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Visual Motion Sensitivity• 3 rehab techniques for this:– Tinted spectacles/contacts

• to reduce light intensity of disturbing visual stimulus entering the eye

• Be careful of this because this will promote chronic light sensitivity (Truong et al., 2014)

– Desensitization or habituation manoeuvers• VOMS assessment as rehab – Thumb twists

– 3 sets of 10 (then 15, 20, 30) 2-3x/day• Hanging out in crowded places – shopping malls,

grocery stores– Symptoms increase – leave; symptoms reduce - return

• Pushing down the hall in a rolling chair, sitting as a passenger in a moving vehicle

• I’ve used video games as rehab for this (Guitar Hero, racing)

– Binasal Occlusion (also good for improved reading in patients with visual crowding problems)

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Visual Motion Sensitivity• Binasal Occlusion– Dollar store glasses, pop out lenses, put medical tape on

the medial (nasal) side of the glasses and see if this reduces reading difficulties

– Tape can be vertical or angled 15O superiorly-templeward– Anecdotal reports of better focus and retention of

information read (Parkwood in London)– Study (Yadav et al., 2014) – Chronic mTBI• Visual Evoked Potential é, improved subjective visual

sensorimotor performance, more stable walking (subjective) – Only use as needed and then gradually wean off

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Binasal Occlusion

Yadav et al., 2014

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Convergence• Normal is between < 5 cm• >5cm = Convergence insufficiency– Pencil Pushups

• Focus on small letters on side of pencil as you move it closer to the bridge of your nose – stop motion just before the point you have double vision

• Hold this position for 10 seconds (5 to start), then bring it back out and repeat – 10 reps, 3-4x/day 5-6 days per week (start gradually and work up to this frequency)

• Not as effective as in-house rehab with a vision therapist!– Prisms

• Referral to performance vision optometrist is not getting progress within 4 to 6 weeks

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Accommodation• Normal is less than 10 cm–Many concussed patients have Accommodative disorders

(51% of adolescents/teenagers)• 36% of these also have convergence insufficiency

– Use Ramp and Step Exercises (next slide)– Combine convergence rehab (pencil pushups &

eventually Brock string)

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Accommodation Rehab• Accommodative Dysfunction – training should start

monocularly and progressed to binocular– Ramp Exercises – a target is brought from arms length slowly

toward the patient until blur occurs. The object is then brought back out to arms length, and the exercise is repeated (similar to pencil pushups)

– Step accommodation – patient should look at a target 10 feet away for 3 seconds and then rapidly shift attention to a target 16 inches away for 3 seconds. Over time the near target is progressively moved closer to the patient – can use brock string at later stages

– Referral to vision therapy optometrist for more advanced rehab using different lenses

– Thiagarajan et al., 2015 – 6 weeks of rehab for vergence & accommodation produced significant improvements in these areas – on 3 & 6 month follow-up, results persisted

Barnett et al, 2015

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VOMS Rehab Summary ChartDeficiency Assessment RehabSmooth Pursuit Finger tracking (VOMS) Finger tracking, Checkerboard (all

directions)

Saccades VOMS assessment – Horizontal & Vertical – 1 to 2 eye motions, King-Devick 4 targets, number sheet, King-Devick

VOR VOMS – Checkerboard – fixate vision on dot and turn head side to side at 180 bpmDynamic Visual Acuity – Snellen eye chart – decrease by 3 or more lines while moving as compared to no movement (metronome = 120 bpm or 2 hz)

Gaze stabilizations

Visual motion sensitivity

Standing thumb twists with vision fixated on thumbs (metronome at 50 bpm). Self-report, difficulty in crowds, riding in cars, feeling better with binasalocclusion (AKA visual vertigo, supermarket syndrome)

Thumb twists, Habituation/Adaptation (exposure to provoking stimulation), tinted glasses, binasal occlusion

Convergence Object to nose – see double? (<5 cm is normal) Insufficiency – pencil pushups, referral to vision therapyExcess – thumb spreading

Accommodation Object to nose – blurry? (<10cm is normal for under 30 yrs) Ramp & Step exercises, brock string

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Other Visual Rehab• Dynavision D2

– Improves peripheral vision & reaction time• Light sensitivity & screen intolerance

– Iris Technologies – Screen attachment• Mansur et al., 2018 – Significant improvement in screen time, reading comprehension with

reduced symptom burden • Several Apps available to help

– Focus Builder, eyescanlearn.com (tons of exercises)• Fixation Deficit

– Assessment:• Patient should be able to maintain steady fixation on fixed targets 20 degrees from midline

in horizontal and vertical planes for 20 secs – if they can’t then…– Rehab:

• Patient should fixate on target at midline for 3 sec (arms length away), then close eyes for 3 sec as you move the target 5 degrees laterally, then they open and fixate for 3 sec and close again – all the way out to 20 degrees

• Repeat in other direction and then vertically• As they improve over time, increase fixation time in each position gradually up to 20

seconds

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Documents

PCS –V 3 –VISUAL/VESTIBULAR · 2020-04-17 · Disorders of the vestibular system • Unspecified peripheral vestibular dysfunction –most common cause of dizziness seen in outpatient