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VESTIBULAR THERAPY AND ASSESSMENT
July 29, 2016
Marc Hinze, PT, MPT, CIMT
Bronson Rehabilitation Services
• Vestibular Assessment
• Vestibular Rehabilitation
• Progression of Vestibular Exercise
Objectives
• Vestibulo-spinal Reflex (VSR)
• Vestibulo-ocular Reflex (VOR)
• Functions
– Postural Stability
– Gaze Stability
– Sensory Integration
Vestibular System
• Impairments
– Dizziness
– Unsteadiness/sense of motion
– Blurred Vision
– Headache
– Nausea
• 90% of children with concussion had 1 or more abnormal balance and vestibular findings (Zhou et al)
• 69% of adolescents with concussion also had a visual diagnosis(Master et al)
– Accommadative Disorder (Focusing)
– Convergence Dysfunction (Viewing near target without double vision)
– Saccadic Dysfunction (eye motion)
Prevalence of Vestibular Symptoms with Concussion
• Dizziness – Motion Provoked: Head movement, Bending,
changing direction
– Visually provoked: Busy patterns, watching motion, busy environments
– Positional Sensitivity: supine<>sit, sit<>stand
– Eye Motion: Visual tracking
• Imbalance
• Difficulty Reading – Blurred vision
– Eye strain
– Headache and fatigue
• Neck Pain: Cervicogenic Dizziness
Vestibular Screening
VOMS Test Not Tested Headache
0-10 Dizziness
0-10 Nausea 0-10
Fogginess 0-10 Comments
Baseline Symptoms
Smooth Pursuits (eyes move, head still) stand 3 ft away, follow PT fingertip in H pattern, 2 reps, 2 seconds/rep-eyes only
Saccades - Horizontal (eyes move, head still) stand 3 ft away, PT 2 fingtips 3ft apart 10 reps as quickly as possible-eyes only L/R
Saccades - Vertical (eyes move, head still) stand 3 ft away, PT 2 fingtips 3ft apart 10 reps as quickly as possible-eyes only up/down
Convergence (Near Point) PT/pt holds 14 point font "x" on tongue depressor move slowly until sees double or eyes turn out measure 3x in cm from end of nose
VOR-Horizontal (eyes on target, head moves) pt holds 14 point font "x" on tongue depressor 10 reps, rotates head 20 deg R/L @ 180 bpm
< 5 cm = normal
VOR-Vertical (eyes on target, head moves) pt holds 14 point font "x" on tongue depressor 10 reps, rotates head 20 deg up/down @ 180 bpm
Visual Motion Sensitivity (VMS) 5 reps, rotate thumb/eyes/head/trunk together 80 deg @ 50 bpm
Vestibular Ocular Motor Screen
• Ability of the eyes to smoothly follow a slow moving target with the head stationary
• Normal eye pursuit is smooth
• Abnormal pursuit is choppy and can increase symptoms
Smooth Pursuits
• Ability of the eyes to move quickly and accurately between targets with the head stationary
• Normal – good ability to track without symptoms
• Abnormal – poor symmetry, nystagmus, increase in symptoms
Saccades
• Ability to view a near target without double vision
• 14 point font target on a tongue depressor
• Abnormal is when one eye turns outward or the patient reports double vision > 5 cm from the end of nose
Convergence
• The ability to stabilize vision as the head moves
• Screen – Head turns 20 deg R/L at 180 beats/min while
maintaining focus on target
• Test is abnormal if eyes slip off target or reports blurred vision and target motion
• Repeat in vertical direction
– Dynamic Visual Acuity Test (DVAT)
• Using Snellen eye chart the patient reads the lowest line within their comfort
• 20 deg of head turns R/L are performed at 120 bpm
• A 3 three line or greater move on the Snellen chart is considered abnormal
Vestibulo-ocular Reflex
• Test visual motion sensitivity
• Head, eyes and trunk all move together while following a visual target
• The patient stands with feet shoulder width apart
Visual Motion Sensitivity
• SOP
• Functional Gait Assessment
• DGI
• BESS
• Positional Sensitivity Assessment
Vestibulo-spinal Assessment Tools
• Feet together EO, EC
• Tandem EO, EC
• Foam EO, EC
• FUKUDA – 20 to 50 marches. Abnormal = spin or drift
Gans Sensory Organizational Performance Test
• VOMS
• DVAT
Vestibular-ocular Assessment
• Decrease Dizziness and Visual Symptoms
• Improve Balance
• Increase Activity Level
• Return to Work, Academics, Reading
• Return to Sport
Goals of Vestibular Therapy
• Individualized Program
• Transient increase in symptoms are expected
• Modify exercise intensity as needed
• Sports specific/work specific
Principles of Vestibular Therapy
• Non-provocative ROM
• Postural education
• Strengthening and stretching for muscular imbalance
• Upper cervical manipulation?
• Upper cervical joint mobilization
Cervico-vestibular Rehab
• Perform 2-3 times per day
• Exercise should not increase headache a ½ level on the pain scale
• Exercise may provoke dizziness.
• If dizziness reaches a level of 5-7/10 make modifications to reduce intensity of exercise – Decrease reps
– Decrease speed
– Perform sitting vs standing
General Guidelines for Vestibular Exercise
• Sitting
• Standing
• Decrease base of support (stand shoulder width to feet together, modified tandem to true tandem etc..)
• Altered surface
VOR Progression
• Level surface
• Base of support
• Altered surface
• Single leg stance
• Static to dynamic
Balance Progression
Clinician-Directed Program
• Adaptation
Clinician-Directed Program
• Adaptation and Substitution
Clinician-Directed Program • Substitution
• Carender W, Alsalaheen BA, Vestibular Physical Therapy Post-Concussion: Indications, Assessment and Treatment, Return on Investment: A Sports Medicine Approach, U of M Health System. May 20-21, 2016
• Alsalaheen BA, Whitney SL, Mucha A, Morris LO, Furman JM, Sparto PJ. Exercise prescription patterns treatedwith vestibular rehabilitation after concussion. Physiother. Res. Int 2012
• Alsalaheen BA, Whitney SL, Mucha A, Morris LO, et al. Rehabilitation for dizziness and balance disorders after concussion. JNPT 2010; 34:87-93.
• Barnett BP, Singman EL. Vision concerns after mild traumatic brain injury. Curr Treat Options Neuol 2015;17:5.
• Broglio SP, Tomporowski PD, Ferrara MS. Balance performance with a cognitive task: A dual-task testing paradigm. Medicine & Science in Sports & Exercise. 2005; 689-695.
• Collins MW, Kontos AP, Reynolds E. A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion. Knee Surg Sports Traumatol Arthroscm 2013.
• Ellis MJ, Leddy JJ, Willer B. Physiological, vestibulo-ocular and cervicogenic post-concussion disorders: an evidence-based classification sysyem with directions for treatment. Brain Injury. 2015;29(2):238-48.
• Kontos AP, Elbin RJ. Schatz P, et al. A revised factior structure for the Post-Concussion Symptom Scale: baseline and post-concussion factors. Am J Sports Med. 2012; 40(10):2375-2384.
• Kontos AP, Elbin RJ, Lau B et al. Posttraumatic migraine as a predictor of recovery and cognitive impairment after sport-related concussion. Am J Sports Med. July 2013;41(7):1497-1504.
References
• 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;39(11):2311-2318.
• Lee H, Sullivan SJ, Schneiders AG. The use of dual-task paradigm in detecting gait performance deficits following a sports-related concussion: A systematic review and meta-analysis. Journal of Science and Medicine in Sports. 2012; 705:2-6.
• Master CL, Scheiman M, Gallaway M et al. Vision diagnoses are common after concussion in adolescents. Clinical Pediatrics 2016;55(3):260-267.
• Mucha A, Collins MW, Elbin RJ, Furman JM, Troutman-Enseki C, DeWolf RM, Marachetti G, Kontos AP. A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions. Am J Sports Med. October 2014;42(10):2479-2486.
• Schneider et al Cervicovestibular rehabilitation in sport-related concussion: a randomized controlled trial. Br J Sports. 2014.
• Zhou G, Brodsky JR. Objective vestibular testing of children with dizziness and balance complaints following sports-related concussion. Otolaryngology-Head and Neck Surgery 2015;152(6):1133-1139.
• Gans R, Vestibular Rehabilitation Seminar, The American Institute of Balance. 2005
References
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