Vestibular Concussion Rehab

Here is a recent Article written by Kathleen McGuire, PT, DPT on Vestibular Concussion Rehab. APT Vestibular Concussion Rehab

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Vestibular Rehabilitation: The Missing Piece in the Treatment of Concussions Written by Kathleen McGuire, PT, DPT

Concussion is a prevalent health issue facing athletes, especially those involved in impact sports. Arroyo Physical Therapy of Pasadena, CA., believes there is a vital component of concussion rehabilitation that is commonly overlooked. This missing piece in concussion treatment is addressing dizziness and vestibular function.

According to the Center for Disease Control and Prevention, concussion is synonymous with the term “mild TBI (traumatic brain injury).” Concussion is a complex patho-physiologic process induced by traumatic forces secondary to direct or indirect forces to the head that disrupts the function of the brain.1 Head trauma can cause central nervous system trauma (eg, a post-concussion syndrome), peripheral vestibular system trauma (eg, labyrinthine concussion, BPPV, perilymphatic fistula), neck injury (eg, whiplash), or some combination of these injuries.3

As concussions have been shown to potentially damage the central, peripheral and cervicogenic parts of the vestibular system, a full comprehensive evaluation of the aforementioned systems is indicated post-head injury. The neurological location of the insult plays an important role in concussion prognosis. Outcomes of rehabilitation in patients with central vestibular disorders are not as good as outcomes following peripheral vestibular disorders. Patients with only central vestibular disorders, however, have better outcomes than do patients with combined peripheral and central dysfunction.3

Central vestibular function controls eye movements, postural movements and spatial orientation3 as needed for high level sports activities. The central vestibular system is also important for modulating vestibular responses and allowing the vestibular system to adapt to injury, disease and changes in sensorimotor demands as well as affects the person’s ability to recover from a peripheral vestibular ailment. This has implications in recovery from multiple concussions and plays a role if the head injury has resulted in both a central and peripheral vestibular injury.3

The primary symptom indicating vestibular damage is dizziness. Dizziness as a symptom of concussion has been reported to occur in 23% to 81% of cases in the first days after injury. The report of the presence of persistent dizziness highly varies from 1.2% at 6 months to 32.5% at 5 years.1 In a study by Meehan et al. 2010, they found the symptom of dizziness/unsteadiness to be the second most commonly reported symptom with concussion, only second to headache. Dizziness was reported in 74.6 of all concussions they studied.

In a study by Lau et al. 2011, they looked at which on-field symptoms at the time of injury were predictive of a protracted recovery (>20 days). The symptoms they assessed included confusion, loss of consciousness, posttraumatic amnesia, retrograde amnesia, imbalance, dizziness, visual problems, personality changes, fatigue, sensitivity to light/noise, numbness, and vomiting. Dizziness at the time of injury was associated with a 6.34 odds ratio of a protracted recovery. To their surprise no other on-field symptoms were associated with a longer recovery period. Therefore they concluded that the assessment of on-field dizziness might help identify those athletes who are at risk for a protracted recovery.

A longer recovery period post-concussion puts the athlete at risk of developing Post-Concussion Syndrome (PCS). PCS refers to a large number of symptoms and signs resulting from a concussion that do not resolve independently with time. The most common complaints are headaches, dizziness, fatigue, irritability, anxiety, insomnia, loss of consciousness and memory, and noise sensitivity.

Despite the high incidence of dizziness and balance dysfunction status-post concussion, reports of vestibular and balance rehabilitation in the management of concussion are sparse.1 Research is limited, but it has been documented that vestibular rehabilitation in the treatment of concussion related dizziness and balance dysfunction has been promising.1 A chart review of patients treated with vestibular rehab post-concussion conducted by Alsalaheen et el. 2010, showed a significant treatment effect in self-reported outcome measures and performance measures. Vestibular rehabilitation showed to reduce dizziness and improve overall balance for individuals with concussion.

The current standard in baseline testing for at-risk athletes is to perform cognitive screens and balance evaluations to compare to post-concussion results. The pre-post tests currently used in concussion management include a thorough cognitive assessment looking at orientation, memory and concentration, and a balance and coordination evaluation assessing static stability and upper limb tasks controlled by the cerebellum. While these tests have been found to be reliable and valid for cognitive and balance function, they have not been shown to be useful in predicting the need for more comprehensive therapy, including vestibular rehabilitation. We propose that baseline and post-injury vestibular function testing should be performed in addition to the cognitive and balance screens for a more comprehensive and efficient post-concussion evaluation.

Based on their research, Alsalaheen et al. recommend having a profile for the patient with concussion in which all the tests for the different domains (symptoms, neurocognitive, and balance) at all evaluation points (baseline, immediately after concussion, and throughout recovery) are documented in a systematic manner and kept accessible to every member of the treatment team. They propose that a proper concussion rehabilitation team consist of a multidisciplinary group of physicians, neuropsychologists, physical therapists and athletic trainers.

Arroyo Physical Therapy proposes that vestibular rehabilitation is the missing component for comprehensive concussion recovery. Based on our research review and professional experience, athletes who report a symptom of dizziness post head injury are at risk for delayed returned to play and increased risk of repeated injury. We believe that supplementing the athlete’s current rehabilitation program with vestibular exercises will enhance and quicken their concussion recovery.

REFERENCES 1. Alsalaheen BA, Mucha A, Morris LO, et al. Vestibular rehabilitation for dizziness and balance disorders after concussion. JNPT. 2010;34: 87-93. 2. Broglio SP, Ferrara MS, Sopiarz K, Kelly MS. Reliable change of the sensory organization test. Clin J Sport Med. 2008 Mar;18(2): 148-54. 3. Furman JM, Whitney SL. Central causes of dizziness. Phys Ther. 2000;80: 179-187. 4. Lau BC, Kontos AP, Collins MW, Mucha A, Lovell MR. Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players?. Am J Sports Med. 2011 Jun 28. 5. Meehan III WP, d’Hemecourt P, Comstock RD. High school concussion I the 2008-2009 academic year: Mechanism, symptoms and management. Am J Sports Med. 2010 Dec;38(12): 2405-2409. 6. Register-Mihalik JK, Mihalik JP, Guskiewicz KM. Balance deficits after sports-related concussion in individuals reporting posttraumatic headache. Neurosurgery. 2008 Jul; 63(1): 76-80; discussion 80-2.