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Concussion for conn ota

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Concussion for conn ota

  1. 1. Latent Effects of Concussion on Vestibular Functioning Salvador Bondoc
  2. 2. Case  Timothy is a high school junior who was referred to an outpatient rehab facility due to shoulder and neck pain. He reported that his shoulder problem was associated with a car accident from 4 months ago but his symptoms did not occur until 4 weeks ago. Timothy happen to work at a shop 4 hours daily as part of his HS.  Provocative tests indicate impingement syndrome. His condition was treated conservatively. He progressed very well. However, he felt he could use more “therapy.” One day, he came to the clinic upset that he may have to attend summer school. His grades have suffered since the car accident. He said that he has troubles taking tests and reading.
  3. 3. Case  His pediatrician has already cleared him from any neurological signs. He also has undergone a battery of psychological tests at the request of the mother to determine whether there may be cognitive effects of concussion. The psychologist cleared him. The psychologist also determined that there an underlying depression is less likely.  Timothy and his mother disclosed that he has been sleeping a lot but such sleep does not feel restful. “It’s hard to wake him up,” exclaimed the mother.  He used to be an active gamer but lately, video games and sitting in front of the computer would give him headaches. One time, we tried playing the Wii Tennis. Peculiar behaviors were noted…
  4. 4. What do we know about Concussions in Adolescents and Young Adults?
  5. 5. Concussions  Part of Brain Injury spectrum (NINDS, 2012)  Accounts for 75 to 90% of BI  Used interchangeably as mild TBI  But TBI is assessed based on target measures  Glasgow Coma Scale  Lost of consciousness (LOA)  Post-traumatic amnesia (PTA) How about concussions?
  6. 6. Issues  Sports-related concussions are most cited in the literature  MVAs are most common causes of concussions in 15-24 years Return to play is the target outcome  Teens drop out of school, Adults lose their jobs & go into long term depression  Latent effects have been examined in the literature but only recently given relevance
  7. 7. Issues  1.4 Million go to the ED due to head trauma  1.1 Million receive care from ED and discharged  Not all those who receive concussion seek medical help
  8. 8. Post-Concussion Syndrome  Cluster of physical, psychosocial and cognitive impairments or symptoms, foremost of which include:  Headaches  Fatigue  Irritability  Dizziness  Decreased memory  Decreased attention, distractibility  Persists in 15-40% in young persons adults for months to years
  9. 9. Underreported PCS Conditions  Executive dysfunctions (MacLennan & MacLennan, 2007)  Postural instability or poor vestibular integration (Bara et al, 2010)  Visual processing and visual motor (Heitger et al, 2009)
  10. 10.  Long term studies show that most lingering effects tend to be  Cognitive (decreased attention, concentration, memory) or  Emotional (lability, irritability, depression) in nature
  11. 11. Decreased cognitive performance Decreased visual-motor functioning  May be readily detected Impaired vestibular functions  May come and go Oculomotor and Vestibular Dysfunctions are poorly detected by brain neuroimaging diagnostics
  12. 12. Clinical Rationale  Clients often manifest oculomotor and vestibular disturbances together  Blurred or double vision  Bouncing images +  Vertigo  Tipping over or falling  Oculomotor Disturbance, Vertigo and Nystagmus have Brainstem and/or Cerebellar origins
  13. 13. 6 Physiologic Forms of Oculomotor Function  Gaze pursuit  Saccade  Fixation  Vergence  Vestibulo-ocular reflex  Optokinetic reflex (pursuits + saccades)  All functions are intended to keep the visual target stable (on the macula)
  14. 14. Red Flags Parameter Behavioral Signs Posture Head tilt Eye Motility Misalignment, nystagmus Gaze ahead, up, down, side Horizontal/vertical rebound nystagmus [Can the nystagmus be suppressed?] Pursuit Appears saccadic Saccades @ 10o and 40o Imprecise, lag speed, non-conjugated VOR 1 Poor fixation with rapid head thrust VOR 2 No VOR suppression (central)
  15. 15. Ruling Things Out  Peripheral vestibular impairment is a diagnosis of exclusion – i.e., no oculomotor disturbances  Unilateral oculomotor presentation is a peripheral condition  Bilateral presentation is central in nature  Isolated gaze impairments have brainstem origin; may affect some VOR  Cluster of gaze impairments have cerebellar origin; often accompanied by balance impairments
  16. 16. Other Clinical Screens  Modified Epley/ Dix- Hallpike Maneuver  Peripheral lesion  Head-shaking Test  Peripheral    Central (cross coupling)
  17. 17. Back to the Case  While playing Wii Tennis, Timothy would stumble backwards as the ball “approached” him. He also had trouble sidestepping and appeared to get “clumsier” as the game went on.  During break, Timothy had his head slumped down and one eye was squinting. Although there was no nystagmus noted he seemed to struggle with looking straight ahead. Timothy’s manifestations prompted a more thorough vestibular screening. No signs of nystagmus was noted with gaze, pursuit and saccades, but his modified CTSIB results showed significant findings.
  18. 18. CTSIB Modified EYES OPEN EYES CLOSED FEET ON FIRM SURFACE All Senses On-Line, “Balanced” Vestibular, Somatosensory available FEET ON UNEVEN SURFACE Somatosensory inaccurate; Vestibular + Visual available Vestibular demands increased
  19. 19. Balance Master Balance Master SOT Results Participant 1 Eyes closed, Compliant surface
  20. 20. More on the Case  After discussion with pediatrician, Timothy was “discharged” from hand therapy and was “picked” again for OT to address neuro concerns.  Insurance authorized 4 visits + eval.  Two main foci of intervention were:  Self-management (fatigue)  Vestibular retraining
  21. 21. Practice Implications  Vestibular and oculomotor dysfunctions  Have latent manifestations  Are associated with decreased cognitive performance and participation  OT practitioners must routinely screen clients for persons with history of concussion  Start with Rivermead PCS Quest (RPQ).  Screen further based on RPQ  Visual motor  Vestibular  Executive function
  22. 22. Case Conclusion  Timothy’s mother decided that he should take the year off from school.  He was referred for NeuroOptometrist who identified problems with anti-saccade latency.  He qualified for BRS assistance. He began working at a garden center and took a liking for growing roses.  He stopped counseling indicating that the strategies he learned from OT were more useful.

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