Concussion Management – After the Hit Brian Werner, PT, MPT President – Werner Institute for Balance and Dizziness Disorders Rebecca Cheema, ATC, PTA,

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.