Physical Therapy in the DoD

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Physical Therapyin the DoD

• CDR Henry McMillan, PT, DPT
• LCDR Alicia Souvignier, MPT, DPT, GCS

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Objectives

• Identify 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

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Indentification of mTBI

• Incident in theatre results in Medivac to CONUS
• After 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.

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DoD/Physical Therapy

• Optimistic expectation for full recovery
• Therapists incorporate assessment of the Service
  Members goals and priorities along with MTBI
  related symptoms

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Areas of concern for a soldier who has a history
of concussion/mTBI

• Vestibular Dysfunction
• Balance Complaints
• Post Traumatic Headache
• Temporomandibular Joint Dysfunction
• Attention and Dual-Task Deficits
• Fitness/ Activity intolerance
• Musculosketetal complaints

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Guidelines for PT Referral

• DHI Score gt 11 (Yes to any Fs or Ps)
• 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)

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Guidelines 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

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Causes of Vertigo

• Vestibular Lesions or hypofunction
• Unilateral- infection/neuritis, lesions, bppv
• Bilateral- ototoxic medications
• Central processing
• Central lesions- brainstem, cerebellum
• Migranes
• Anxiety
• Cervicogenic dizziness
• Vertebrobasilar insufficiency
• Altered proprioceptive signals

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Evaluation

• Subjective
• MOI or idiopathic
• Frequency/Intensity/duration
• Vision/ Hearing deficits
• Positional/activity induced
• Valsalva/ pressure changes
• Describe symptoms of dizziness
• Vertigo
• Imbalance
• Lightheadedness

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Evaluation

• Subjective
• Activity Level
• Recreational Sports
• Exercise Tolerance
• Unit Physical Training
• Behavioral Health
• Quality of Life
• DHI
• Family Participation
• Command/Unit Support

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Vestibular Evaluation

• Musculoskeletal Screen
• Positional Testing
• Oculomotor
• Balance

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Oculomotor

• Smooth Pursuit
• Saccadic
• VOR

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Oculomotor

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

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Test for VOR

• Head Thrust Test
• Grasp patients head firmly
• Tilt patients 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 patients ability to refocus on
  target.
• Refixation saccade indicates decreased VOR

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Test for VOR

• Dynamic 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
  patients head.
• 3 lines loss is significant

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Positional Testing

• Dizziness caused by certain positions
• Spinning
• Use Frenzal goggles
• Dix Hallpike
• BPPV
• Motion Sensitivity Quotient
• Motion Sensitivity

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Positional Testing

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

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Balance

• Functional Gait Assessment
• Romberg/ Sharpened
• Neurocom or M-CTSIB

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Treatment Approaches

• Adaptation Exercises adapting residual
  vestibular function to make up for lost function
• Example Maintain visual fixation on object while
  the head is moving
• Substitution Exercises
• Doing exercises with and without visual cues
• Habituation Exercises
• Repeated exposure to provocative stimulus, for
  example motion sensitivity.

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VOR Treatment - Adaptation

• Walking head turns
• Tracking with eyes
• Tracking with head movements
• All of the above together
• Above exercises on varied surfaces

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Motion Sensitivity Treatment

• Brandt Daroff (picture)
• Positions identified from MSQ

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Treatment of BPPV

• Canalith Repositioning Technique
• Liberatory Maneuver

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Postural Stability

• Prioprio
• Neurocom-
• Balance activities- SOT
• Foam
• Unstable surface
• Uneven terrain

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Treatment Ideas

• Foam bowling
• Bear claws
• Soccer Toss
• Wii
• Dance Revolution
• Discoball/strobe with balance

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Goals for Physical Therapy

• Return to Duty
• Goals for Civilian Life

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Questions?