Physical Therapy in the DoD CDR Henry McMillan, PT, DPT LCDR Alicia Souvignier, MPT, DPT, GCS.

Physical TherapyPhysical Therapyin the DoDin the DoD

CDR Henry McMillan, PT, DPT

LCDR Alicia Souvignier, MPT, DPT, GCS

ObjectivesObjectivesIdentify the common patient

presentations seen by PHS PTs working in the DoD

Be able to indentify key aspects of the evaluation of a dizzy patient

List 3 treatment techniques used to treat dizziness

Indentification of mTBI Indentification of mTBI Incident in theatre results in

Medivac to CONUSAfter redeployment, troops

inprocess through the Soldier Readiness Center, where history of concussion is identified

Soldiers with possible residual symptoms of concussion, are referred to the TBI clinic.

DoD/Physical TherapyDoD/Physical Therapy

Optimistic expectation for full recovery

Therapists incorporate assessment of the Service Members goals and priorities along with MTBI related symptoms

Areas of concern for a soldier Areas of concern for a soldier who has a history of who has a history of concussion/mTBIconcussion/mTBIVestibular DysfunctionBalance ComplaintsPost Traumatic HeadacheTemporomandibular Joint

DysfunctionAttention and Dual-Task DeficitsFitness/ Activity intoleranceMusculosketetal complaints

Guidelines for PT ReferralGuidelines for PT ReferralDHI Score > 11 (Yes to any F’s or P’s)Plus yes to one of the following:◦ R/SR (Eyes Closed) less than 30

seconds- (arms across chest)

◦ VOR x1 for less than one minute with onset of symptoms

◦ Walking with HT increase symptoms, deviated gait, LOB- (Museum Gait)

Guidelines for PT referralGuidelines for PT referral◦If the patient reports any of the

following Difficulty with balance or dizziness that is

affecting their functional performance

Unsteady while standing still or walking, in poor lighting, or in crowds

Difficulty with balance on uneven surfaces

Intense spinning, lightheadedness, or unsteadiness associated with exercise

Causes of VertigoCauses of VertigoVestibular Lesions or hypofunction

◦Unilateral- infection/neuritis, lesions, bppv

◦Bilateral- ototoxic medicationsCentral processing

◦Central lesions- brainstem, cerebellum◦Migranes◦Anxiety

Cervicogenic dizziness◦Vertebrobasilar insufficiency◦Altered proprioceptive signals

EvaluationEvaluationSubjective

◦MOI or idiopathic◦Frequency/Intensity/duration◦Vision/ Hearing deficits◦Positional/activity induced

Valsalva/ pressure changes

◦Describe symptoms of dizziness Vertigo Imbalance Lightheadedness

EvaluationEvaluationSubjective

◦Activity Level Recreational Sports

◦Exercise Tolerance Unit Physical Training

◦Behavioral Health◦Quality of Life

DHI Family Participation Command/Unit Support

Vestibular EvaluationVestibular EvaluationMusculoskeletal ScreenPositional TestingOculomotorBalance

Oculomotor Oculomotor Smooth PursuitSaccadicVOR

OculomotorOculomotorVestibular Ocular Reflex

◦Vestibular system sends information regarding speed of movement to the visual system. Allows us to keep focus while performing functional head motions.

Test for VORTest for VORHead Thrust Test

◦Grasp patients head firmly◦Tilt patient’s head to 30 deg flex◦Move head back and forth slowly and

instruct patient to keep focus on target

◦Provide a quick movement through a small range and watch for patient’s ability to refocus on target.

◦Refixation saccade indicates decreased VOR

Test for VORTest for VORDynamic Visual Acuity

◦Test visual acuity on a Snellen Chart◦Turn patients head vertical and

horizontal plane to the beat of a metronome at 2Hz

◦Retest visual acuity while you are moving the patient’s head.

◦3 lines loss is significant

Positional TestingPositional TestingDizziness caused by certain

positions◦Spinning◦Use Frenzal goggles

Dix Hallpike◦BPPV

Motion Sensitivity Quotient ◦Motion Sensitivity

Positional TestingPositional TestingDix Hallpike

◦Long sitting, head turned 45 deg, drop down with neck into about 30 deg of extension

BalanceBalanceFunctional Gait AssessmentRomberg/ Sharpened Neurocom or M-CTSIB

Treatment ApproachesTreatment ApproachesAdaptation Exercises: adapting

residual vestibular function to make up for lost function◦Example: Maintain visual fixation on

object while the head is movingSubstitution Exercises

◦Doing exercises with and without visual cues

Habituation Exercises◦Repeated exposure to provocative

stimulus, for example motion sensitivity.

VOR Treatment - VOR Treatment - AdaptationAdaptationWalking head turnsTracking with eyesTracking with head movementsAll of the above togetherAbove exercises on varied

surfaces

Motion Sensitivity Motion Sensitivity TreatmentTreatmentBrandt Daroff (picture)Positions identified from MSQ

Treatment of BPPVTreatment of BPPVCanalith Repositioning TechniqueLiberatory Maneuver

Postural StabilityPostural StabilityPrioprioNeurocom-Balance activities- SOT

◦Foam◦Unstable surface◦Uneven terrain

Treatment IdeasTreatment IdeasFoam bowlingBear clawsSoccer TossWiiDance RevolutionDiscoball/strobe with balance

Goals for Physical TherapyGoals for Physical TherapyReturn to DutyGoals for Civilian Life

Questions?Questions?