Concussions in the Workplace & Vestibular Rehabilitation CLM019 Speakers: • Melissa Bloom, PT, DPT, NCS, Physical Therapist, Physio
Concussions in the Workplace &
Vestibular RehabilitationCLM019
Speakers:
• Melissa Bloom, PT, DPT, NCS, Physical Therapist, Physio
Learning Objectives
At the end of this session, you will:
• Explain the reasoning for vestibular deficits post concussion
• Describe symptoms post concussion which can be
addressed with vestibular rehabilitation
• Discuss several assessment tools and treatments used in
vestibular rehabilitation
• Describe the benefits of physical therapy for clients with
dizziness, vertigo, or balance symptoms post concussion
Concussions
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Concussions• Often with misconceptions regarding extent and nature
• Gaps in knowledge on diagnosis, pathology, function, and optimal treatment course
• Synonymous with Mild Traumatic Brain Injury (mTBI)1
• Recent increase in media attention on sequella of repeated and unnoticed concussion
1Http://www.cdc.gov/concussion/headsup/pdf/Facts_for_Physicians_booklet-a.pdf
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Mechanism of injury• Mechanical trauma to the brain
as a result of acceleration/deceleration forces
o Direct blow to the head, face or neck
o Direct blow elsewhere on the body with an impulsive force transmitted to the head
• May or may not involve LOC (4-10%)
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Concussion
• Often under diagnosed secondary to its’ inability to be seen on diagnostic imagingo 95% of patients with concussion have normal CT scans 1
o 70% of patients with concussions have normal MRIs 2
1 Jagoda AS, Cantrill SV, Wears RL, et al. Clinical policy: neuroimaging and decision making inadult mild traumatic brain injury in the acute setting. Ann Emerg Med. 2002;40(2):231-249.
2 Hughes DG, Jackson A, Mason DL, Berry E, Hollis S, Yates DW. Abnormalities on magnetic resonance imaging seen acutely following
mild traumatic brain injury: correlation with neuropsychological tests and delayed recovery. Neuroradiology. 2004;46(7):550-558..
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What causes a concussion?
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• Mechanical Forces to the
moving brain causes sheering
of nerves
• Allows abnormal nerve firing
• This is followed but a period of
abnormal brain functioning
(Toledo et al, 2012) Figure 3
These neuro-metabolic changes lead to…
Swelling in the nerve axon
Decreased ability to of nerves to transmit signals (action potentials)
Decreased transmission of signals and decreased processing of nerve signals
Decreased overall functioning and ability complete daily and work related tasks
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Pathophysiology review
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• Cascade leading to neuronal dysfunction and symptoms
• Secondary to the nature of the changes there are diffuse
areas affected simultaneously
• Produces a constellation of symptoms and signs
involving physical, cognitive, emotional, and somatic
dysfunction
• Leads to increased fatigue and tiredness
• Symptoms are often “invisible” and diffuse
(Giza et al 2001)
Typical symptoms
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Headache
Dizziness
Impaired gait and balance
Motion sensitivity
Impaired memory, concentration, and attention
Fatigue
Sleep dysfunction
Headaches & concussion• Headache is a common symptom post concussion
• Occurrence in 40-86%
• Commonly overlooked symptom
• Presence of PTH
• Known decrease in neuro psychological performance
• Increase severity of symptoms
• May exacerbate neuro-cognitive impairment after injury
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Vestibular Anatomy
Dizziness and imbalance
• Those post concussion often complain of persistent dizziness and imbalance
• Vestibular rehabilitation has been demonstrated to address symptoms and regaining independence
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Dizziness and concussion• Reported in 23-81% of cases in the first days after injury
• Persistent dizziness varies from 1.2- 32.5% from 6 months to 5 years after injury
• Can occur with various levels of severity of concussion
• Griffiths, M. V. (1979). The incidence of auditory and vestibular concussion following minor head injury. The Journal of Laryngology & Otology, 93(03), 253-265.
• Masson, F., Maurette, P., Salmi, L. R., Dartigues, J. F., Vecsey, J., Destaillats, J. M., & Erny, P. (1996). Prevalence of impairments 5 years after a head injury, and their relationship with disabilities and outcome. Brain Injury, 10(7), 487-498.
• Maskell, F., Chiarelli, P., & Isles, R. (2006). Dizziness after traumatic brain injury: overview and measurement in the clinical setting. Brain Injury, 20(3), 293-305.
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May report “dizziness or vertigo”, but…
…may complain of an overall fogginess or non specific dizziness
Swimminess
Light headedness
Floating
Rocking
Disoriented
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Dizziness or vertigo
Unilateral weakness
BPPV
Decreased sensory
integration & processing of
sensory information
Vestibular causes
• Loss of vestibular hair cells or neurons
• Abnormal firing on one ear results in asymmetric signals to
the brain
• Asymmetric signals can result in :• Vertigo
• Dizziness
• Disequilibrium
• Postural instability
• Oscillopsia (blurred vision)
Vestibular Weakness
Vestibular weakness nystagmus
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Head Thrust Test
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•Difficulty getting to work
•Dizziness with turning, bending,
and moving head at work
•Dizziness with walking
•Dizziness with computer work
•Bending, reaching, and turning will
likely be imbalanced, inaccurate,
and unsafe
How this impacts work
• Positional vertigo caused by changes in head or body position
• A common form of vertigo, affecting at least 9 out of 100 older adults
• Can be accompanied with balance deficits
• Creates a true vertigo vs. dizziness or blurred vision
BPPV
Hain, TC. http://www.dizziness-and-hearing.com. 1 March 2016<https://encrypted-
tbn1.gstatic.com/images?q=tbn:ANd9GcTiXBSGzm6diw7tOaWiytj367cKDWO4MvFN82QNfGI1bdwtWrEjzw
BPPV Nystagmus
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•Difficulty with getting out of bed to
get to work
•Vertigo with turning, bending, and
looking up
•May have dizziness and imbalance
with walking
•Bending, reaching, and turning may
be imbalanced, inaccurate, and unsafe
•Nausea/vomiting with movement
common
How this impacts work
Sensory Input Central Processing Motor
Output
Visual
(Eyes)
Vestibular
(Ears)
Somatose
nsory
(Joints)
Central Processing
Centers of the
Brain
Motor Neurons
Dizziness
Balance
Central deficits or limitations of sensory integration
•Difficulty with getting to work, due
to dizziness and imbalance
•Dizziness and imbalance with
turning, bending, and moving head
at work
•Dizziness and imbalance with
walking
•Dizziness with computer work
•Upright standing and moving tasks
may be unsafe
How this impacts work
◦ Uneasiness created by situational
stimuli
Moving crowds, supermarkets, busy
patterns, etc
Heightened awareness of normal motion
(Jacob et al, 1993)
Space and motion discomfort
•Dizziness and instability with
walking in halls
•Difficulty with tasks in busy
environments
•Difficulty talking with coworkers
involving head turns
•Difficulty with computer tasks
How this impacts work
•Not uncommon after injury involving hitting head
•High presence of balance deficits after a sports related concussion
•Can be seen with multiple severity of injury
•LOC not necessary to have symptoms
Imbalance Post concussion
• Gait and mobility limitations are common abnormalities after neurologic injury
• Dysfunction can result in falls, disability, psychological problems, and secondary medical problems…and difficulty getting back to work
Gait
•Difficulty with getting to work
•Imbalance and safety concerns
with walking, reaching, bending,
turning
•Increased risk for falls and further
injury
How this impacts work
Vestibular Rehabilitation:
the basics
• Known benefits to multiple populations including concussion
• Used to address dizziness, vertigo, and imbalance
• Management can be challenging post concussion
Vestibular rehabilitation
• While there is a high incidence of dizziness & imbalance, vestibular rehabilitation is often under utilized in this population
• Vestibular rehabilitation has shown to be effective in this population although the time course may be longer than in peripheral vestibular disorders1
1. Shepard, N. T., Telian, S. A., Smith-Wheelock, M., & Raj, A. N. I. L. (1993). Vestibular and balance rehabilitation therapy. The Annals of otology, rhinology, and laryngology, 102(3 Pt 1), 198-205.
Dizziness & imbalance
Improve gaze stability
Improve postural stability
Improve activities of daily living
Promote mechanisms for central
adaptation and/or compensation
Decrease feelings of dizziness and
unsteadiness
Decrease fall risk
Goals of vestibular rehabilitation
•Improve gaze stability
•Improve postural stability
•Improve activities of daily living
•Promote mechanisms for central
adaptation and/or compensation
•Decrease feelings of dizziness
and unsteadiness
•Decrease fall risk
Dizziness, blurred vision
especially with head movement
Balance and job related
movement
Bathroom, hygiene, preparing for
work
Dizziness and balance for job
related tasks
Increase confidence and self
efficacy with ability to work
Increased safety in the work
place
Goals of vestibular rehabilitation: in relation to return to work
•Immediately after concussion, exertion and activity should be
limited
•Do not over load the system, watch for increasing symptoms
•Patients should be encouraged to increase daily mobility and
activities as long as symptoms do not increase
•Mild increase in symptoms is OK and expected but should
resolve quickly when movement stops
Intervention strategies
•Partial duty work may be OK if
symptoms don’t increase with work
task and balance is safe
•Increase of symptoms is a sign the
task is too demanding
•Modifying work to minimize visual
stimulation, head/body movements,
and dynamic standing tasks
How this impacts work
Gaze stabilization exercises
Adaptation exercises
Habituation and movement exercises
OKN stimulation
Somatosensory training
Dynamic balance and gait training
Canal Repositioning as needed
Vestibular rehabilitation post concussion
•Long term changes to “recalibrate”the way the brain utilizes the inner
ears sensory input
Purpose:•Decrease retinal slip/blurred vision
•Increase balance
•Decrease dizziness
•Central compensation
Gaze Stability/Adaptation exercises
Improved visual acuity with head movement (Herdman
2003)
Improved balance and decreased perception of disequilibrium (Herdman 1995)
Reduced dizziness (Enticott 2005)
Improved perception of unsteadiness, level of disability (DHI), and postural stability in chronic vestibular hypofunction (Giray 2009)
Evidence for adaptation exercises
•Able to move head without
getting dizzy
•Can walk without dizziness
•Increased balance with
movement
•Decreased perception of
impairments and disability!
How this impacts work
•A long-term reduction in the pathologic response to a specific
movement (noxious stimuli),brought about by repeated
exposed to the provocative stimulus
•Decreased and often asymmetrical vestibular function leads to
sensory mismatch, which leads to symptom provocation•High alert
•Repeated exposure to noxious stimuli decreases that
hypersensitivity
•Desensitization
•Exposure therapy
Habituation exercises
•Decrease intensity and duration of
symptoms with movement
•Increase ability to perform functional
activities, such as bathing and dressing,
household chores, work activities
Goals/purpose of habituation
•Patients who are avoiding particular
movements or activities
•Patients who present with anxiety with
movement or motion
Those who typically respond well to Habituation Exercises…
•Able to walk, bend, and move
without dizziness
•Increased balance and stability
•Greater ability to perform
functional movements required at
work
How this impacts work
Canal repositioning for BPPV
Hain, TC. http://www.dizziness-and-hearing.com. 1 March 2016<http://www.dizziness-and-balance.com/disorders/bppv/epley/epley.html
•Able to get out of bed without
vertigo
•Able to reach overhead, pick
objects off the floor, and move head
at work without vertigo
•Safer walking and balance with all
upright movement
•Resolution of nausea/vomiting
How this impacts work
•Goals of treatment:
•Decreased visual dependence for balance (Pavlou 2011)
•Improve tolerance of visual stimulation
•Decrease motion intolerance
•Improve dynamic balance and balance confidence (Rendon 2012)
Visual motion sensitivity training
•Movements in the visual field to induce optokinetic nystagmus and
promote increased sensory stimulation to the visual centers in the brain
Optokinetic Stimulation (OKS)
•Disco Ball
•Train
•You Tube
•Hallways with busy
walls or heavy foot
traffic
Treatment ideas
•More likely to be able to drive to
work
•Able to tolerate walking in halls at
work
•Able to communicate with
coworkers while looking at them
without dizziness
•Able to tolerate computer work
•Increased walking & balance
stability
How this impacts work
•Bringing in other sensory input
(beyond the vestibular system) to help
system integrate and better sensory
information
•Good for increased body awareness
for those with constant “floaty”symptoms (likely due to a sensory
mismatch)
•Utilize other sensory systems to
decrease symptoms and increase
awareness of body position
Somatosensory retraining
•Tolerate standing and balance
tasks including walking
•Better able to participate due to
decreased constant dizziness
•Increased safety with standing
and walking
How this impacts work
•Function focused
•Task specific
•Must be challenging
•If symptoms allow, high
amounts of intense training
Balance & Gait
•Safe and efficient performance of
work related movement
•Safe walking in work environment
•Decreased risk for falls and further
injury
How this impacts work
•Symptom free at rest
•Symptom free following exertion
•Dizziness with walking, bending,
thinking, driving, using computer?
•Balance, safety, and fall risk
Return to work
•Concussions can result in a number of symptoms that can
often be overlooked secondary to the lack of objective
medical measures and “invisible” nature of injury
•Numerous studies show an increase in dizziness and
imbalance after multiple intensities of concussion
•Dizziness and imbalance caused by concussion are both
addressable by Vestibular Rehabilitation
Wrap Up
Thank you!
Melissa S. Bloom, PT, DPT, NCS
Board Certified Specialist in Neurologic Physical Therapy
Tucker/Decatur
Physio
2799 Lawrenceville Hwy, Suite 205
Decatur, GA 30033
Ph: 770-491-0920