Concussion Management

1
Concussion Management After the Hit

• Brian Werner, PT, MPT
• President Werner Institute for Balance and
  Dizziness Disorders
• Rebecca Cheema, ATC, PTA, EdD

2
Dr. Cheemas 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

3
History of Concussion Management

• Early and Late 1990s - Computerized
  Neurocognitive Testing (Headminder, ImPACT)
• Late 1999s BESS vs. Computerized - Balance
  Performance Testing
• 2004 NATA Position Statement
• 2008 - Zurich Statement on RTP Criteria
• 2008 SAC and SAC II
• 2010 NCAA
• 2011

4
Zurich Statement Graduated RTP - 2008

• Functional Exercise at Each Stage of
  Rehabilitation
• 1. No activity Complete physical and cognitive
  rest
• OBJECTIVE Recovery
• 2. Light aerobic exercise
• Walking, swimming or stationary cycling keeping
  intensity lt70 MPHR.
• No resistance training.
• OBJECTIVE Increase HR
• 3. Sport-specific exercise
• Skating drills in ice hockey, running drills in
  soccer. No head impact activities.
• OBJECTIVE Add movement
• 4. 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
  load
• 5. Full contact practice
• Following medical clearance, participate in
  normal training activities
• OBJECTIVE Restore confidence, assessment of
  functional skills by coaching staff
• 6. Return to play
• OBJECTIVE Normal game play

5
History of Concussion Management

• Early and Late 1990s - Computerized
  Neurocognitive Testing (Headminder, ImPACT)
• Late 1999s BESS vs. Computerized - Balance
  Performance Testing
• 2004 NATA Position Statement
• 2008 - Zurich Statement on RTP Criteria
• 2008 SAC and SAC II
• 2010 NCAA
• 2011

6
NFL launches new guidelines for assessing
concussions

• BASELINE TEST
• Concussion History
• Self Reported Symptoms
• SAC
• Modified BESS
• 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.

7
NFL Sideline
8
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?

9
Cerebral versus Vestibular Concussion Is there
a Difference?
10
The Concussion What We Know

• Defined as an immediate acceleration and
  deceleration or stopping event, resulting in
  temporary or permanent damage to the structures
  of the head.
• Lets not get caught up that every 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 affectedthey
  are part of the head.

11
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

12
What is the Vestibular System, What Does Do,
and How Can It Get Damaged?
13
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 mixedcerebral vs.
  vestibular
• Big Question How Do I know which one is injured
  Peripheral, Central or Both you must know what
  you are testing.

14
Sensors of the Inner Ear
Semicircular Canals
Otolith Organs
Linear Accelerometers
Angular Accelerometers
Key these are accelerometers abnormal
accelerations are the common cause to concussions
15
What Do They Control

• YAW
• PITCH
• ROLL
• BOB
• HEAVE
• SURGE
• EYES, HEAD ON NECK, POSTURE

16
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

17
The Vestibular Cognition Connection New
Thoughts

• Damage to the vestibular system can directly
  create cognitive deficits
• Spatial navigation
• Object recognition memory
• You dont 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.

18
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

19
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?

20
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

21
Why is It So Important to Differentiate
Vestibular from Cerebral Concussion?
22
Because We Are Missing Athletes

• Young kids
• Ex. Stuart N.
• Ex. Zach T.
• Older athletes/soldiers
• Bob J.
• Chelsea O.
• Symptom management lacking specificity

23
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?

24
What is Dizziness? (Kroenke, 2001)
25
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

26
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 SICK DYSEQUILIBRIUM
Inability to concentrate Difficulty sleeping Mental Fogginess
Nausea Feeling off Anxiety
Visual sensitivity Blurry Vision Fatigue
Note You dont have to feel the primary symptoms
to have secondary.
27

• Training Room Testing for Vestibular Dysfunction
  in the Athlete When and How?

28
Before the Hit

• Prior to Concussion
• Baseline test/Combines
• NCAA 2010 requires it.
• Identify at-risk athletes to prevent future
  injury
• Identify old injury not known

29
After the Hit

• Zurich Stage 1. No activity - Complete physical
  and cognitive rest
• OBJECTIVE Recovery
• VESTIBULAR TESTING SHOULD BE DONE WITH
  NEUROCOGNITIVE!
• Zurich Stage 2. Light aerobic exercise
• Walking, swimming or stationary cycling keeping
  intensity lt70 MPHR.
• No resistance training.

30
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

31
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

32
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

33
Treatment of Athlete with Vestibular Dysfunction
- How Does It Work?
34
Vestibular Rehabilitation

• Started in the mid to late 1940s
• Cawthorne and Cooksey
• Treatment of concussed soldiers
• Set of eye, head, and body activities to induce
  movement to facilitate central compensation

35
Vestibular Rehabilitation

• 1980s 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.

36
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

37
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

38
Gaze Stability Exercises

• Fixed/Moving targets
• Variable distances from targets
• Simple to complex visual backgrounds
• Simple to complex surfaces during
• Sitting
• Standing
• Gait

39
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, 898904.
• 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 19101-114.
• 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.