Melissa Naquin, PT, DPT, CBIS, LSVT, Neuro-IFRAH

Objectives:

1. Improve knowledge of PT treatment of concussion/ PCS2. Improve knowledge of impairments due to concussion that PT’s

can address3. List special tests for cervicogenic HA differential diagnosis4. List special tests for assessment of balance and vestibular

dysfunction5. Describe difference of vestibular vs. oculomotor impairment6. Describe progression for return to play

2

CDC- ~3.8 million sports concussions/ yr.SAFE PLAY Act (S. 436/h>R.829): recognizes PT’s as health care professions qualified to make return to participation decisions for youth sports concussions. APTA: individuals suspected of having a head injury &/or has signs, symptoms, & behaviors of a concussion should be immediately assessed for a concussion by a licensed healthcare provider trained in evaluation & management of concussion

- individual should not return to activity without written clearance from PT or other licensed health care provider

3

❖ 4/6 clinical trajectories for concussion cited in UPMC’s interdisciplinary model for understanding the assessment, treatment, and rehabilitation of the condition- vestibular, oculomotor, cervical, and post traumatic migraine- are squarely within the PT’s scope of practice. Remaining trajectories- cognitive, fatigue, and anxiety/ mood are directly correlated to the other 4.- Jessica Schartz, PT, DPT, Program Director for Concussion Management at Evidence in Motion

4

Symptoms▪ Fatigue▪ Dizziness▪ Headache▪ Impaired balance▪ Impaired coordination▪ Decreased activity

tolerance▪ Weakness

▪ Insomnia

▪ Irritability

▪ Anxiety

▪ Decreased concentration/ memory

▪ Noise/ light sensitivity

5

Why does the patient have headaches?

➢ Cervicogenic headache/ Occipital Neuralgia

➢Oculomotor dysfunction

➢ Psychogenic

6

▪ Most common symptom5, 6

▪ Tension/ migraine HA are commonly reported▪ Tension HA likely due to cervical injury▪ Cervical pain after head injury has not been correlated with

Post-Concussive Syndrome5

Headaches

▪ Secondary HA- referred pain from neck▪ 4 times more prevalent in women10

▪ Diagnosis:-referred pain from neck -imaging or assessment reveals cervical disorder

-responds to nerve block

Cervicogenic Headache

10

Diagnosis Symptoms Assessment Treatment

Cervical Strain/Cervicogenic Headache

• pain at rest & w/ AROM•Dull/achy pain•fluctuating or continuous pain• headache usually begins at back of head•Can be unilateral•Ipsilateral shoulder pain•Environmental

sensitivities

• Dizziness

• Tinnitus

• Nausea

• Imbalance

• Hearing

complaints

• Ear/eye pain

Red flag tests:1. Vertebral A.

test2. Spurling’s Test3. Ligament laxity

assessments

•Typically limited cervical ROM•Tender to palpation at sub occipitals, cervical and thoracic musculature

• PT•Dry needling•Anesthetic blocks•Neurolytic procedure•Botox•Pharmacological •Surgical

▪ TTP: suboccipitals, C2/C3/C4 regions▪ Increased pain with cervical AROM or Spurling’s Test

(may also indicate cervical radiculopathy)▪ Decreased cervical ROM (esp. extension10)▪ Decreased intervertebral ROM▪ Regional Myofascial Pain Syndrome affecting cervical or

masticatory muscles10

▪ Decreased strength of deep cervical flexors

Cervicogenic HA: Assessment

Diagnosis Symptoms Assessment Treatment

Occipital Neuralgia

• Episodes/ attacks few sec. to min.

• Stabbing/ piercing pain

• Pain in back & top of head, behind the ears

• Ipsilateral neck/ shoulder pain

• May have visual disturbances

• May report light or noise sensitivity

• Severe tenderness over nerves

• May have decreased cervical ROM

• Increase in symptoms with palpation to nerve

• PT• TENS• Anti-

inflammatory medication/ Muscle relaxers

• Occipital nerve block

• Occipital nerve stimulator

• Neurolytic procedure

• Preventative-antiepileptic medications & tricyclic antidepressants

• Psychotherapy PRN

12

Special tests

➢ Flexion-Rotation Test (FRT): * (+) 15 deg difference (45 deg norm)= dysfunction at

C1/C2* reliable for HA pts.11

* 90% sensitivity, 88% specificity12

➢ Cranio-cervical Flexion Test: * assesses strength of neck flexors* normal 26-30 mmHg

13

Special Tests

➢ Spurling’s Test: * assesses for cervical radiculopathy* not sensitive, but specific for diagnosis13

➢ Neck Tornado Test (NTT):* assess for cervical radiculopathy* sensitive for dx- superior diagnostic accuracy as compared to Spurling’s14

14

PT for Cervicogenic Headaches

➢ Exercise + manual therapy= 76% success rate for substantial and sustained reductions in headache, 50% decrease in frequency, 35% complete resolution of HA15

➢ PT and ongoing exercise produce best outcomes17

15

Why is the patient dizzy?

16

➢ Peripheral vestibular impairment➢ Central vestibular impairment➢ Cervicogenic dizziness➢ Vestibulo-ocular impairment➢ Oculomotor impairment➢ Migraine associated vertigo➢ Psychogenic dizziness

17

18

Diagnosis Symptoms Assessment Treatment

BPPV (peripheral/ mechanical)

• Dizziness with nystagmus (rotational or geotropic/ apogeotropic)•<1-2 min duration•“room spinning”•Dizziness associated with position change or head movement•Lasting>2 weeks•Nausea

Red flag screening: 1. Vertebral A.

Test2. Cervical ROM

•Hallpike- Dix • Roll test

Treatment as indicated- PT can usually perform in several sessions

19

Diagnosis Symptoms Assessment TreatmentLabyrinthine concussion (peripheral)

• immediate vertigo &/or disequilibrium•Presents similar to uncompensated vestibulopathy

• hearing assessment (>high freq loss)•Balance assessments•mCSTIB•BESS

• PT can address impairments as needed

• Vestibular rehab

Perilymph fistula(peripheral)

•Sudden Hearing loss or tinnitus •Nystagmus that does not fatigue•Positional vertigo•“fullness” in ear•Sx ↑ w/ change in altitude or Valsalva

•CT scan (temporal)•MOI, pt sx•Hearing assessment

• avoid lifting, bending, straining

• Rest (1-2 wks)• Surgery

Temporal bone fx •Hearing loss•Facial paralysis•Vertigo/ imbalance•Bleeding from ear•Battle sign

•CT scan•Hearing assessment•Facial N assessment

• Directly tx PRN• Vestibular PT for

persistent sx

20

Diagnosis Symptoms Assessment Treatment

Central vestibular Impairment

•Dizziness lasting longer than “minutes”•May report unsteadiness/ lightheadedness•May report diplopia, dysphagia, dysarthria, dysmetria

•Balance assessments•mCSTIB•BESS•↓ smooth pursuits & saccades•↓ VOR/VOR cancellation •↓ balance w/ eyes closed (esp. on foam)•↓ balance w/ head movement

• PT can address impairments as needed

• Vestibular rehab

21

Oculomotordysfunction

• diplopia• difficulty reading• LOB•Difficulty with stairs•May describe as “motion sickness”

• convergence/ divergence

• saccades• CN testing• VOR/ VOR

cancellation

• PT •OT

Diagnosis Symptoms Assessment Treatment

22

Diagnosis Symptoms Assessment Treatment

Cervicogenic Dizziness

•General imbalance •Neck pain•↓ cervical ROM•HA•Lasts min-hrs•Concurrent whiplash•Related to change in cervical spine position

•Red flag screening for cervical•r/o other causes of dizziness•Head-neck differentiation test•Joint position sense

PT: • tx of cervical

impairments• Vestibular

rehab

Why test balance?➢ 3rd Annual Consensus on Concussion: postural stability

is a useful tool for objectively measuring motor domain of neurologic function

➢ Balance Error Scoring System (BESS)- Stance, SLS, tandem stance on hard surface and foam

- good retest reliability17, 18

-high specificity19

23

Vestibular PT

▪ 43% report balance problems20

▪ Balance issues have been reported years after concussions.21

▪ Visual deficits can exacerbate cognitive difficulties such as memory, attention, & concentration.

- 1st yr. post TBI is an important period which neural recovery occurs22

▪ Vestibular rehab is a useful treatment for pts w/persistent dizziness and balance problems not resolved w/ rest

- significant improvement in subjective reports (2010)23

24

ANS symptoms

▪ ↑ HR at rest26

▪ ↑ HR with physical stress- ↑ sympathetic NS activity, ↓ parasympathetic NS activity27

▪ ↑ HR with cognitive stress28

25

Return to Activity- Acute

Rest from activity *exercise in acute period ↑ metabolic demand29

*exercise can affect production of BDNF30

* limit screen time* limit aggravating factors* limit/ accommodate work or school as needed

26

Return to Activity- Sub acute

➢ once symptoms improve- begin light aerobic exercise, progress as tolerated

* aerobic exercise 14-21 days after TBI increases cognitive performance31

* sub-symptom threshold should be used32

➢ Progression: ↑ intensity 10% once 20-30 min tolerated

27

Return to Activity- Chronic

➢ Progress to returning to activity* 71% return to full activity following a graded exercise

program33

➢ Ongoing symptoms may be related to secondary impairment

28

Secondary Benefits of Exercise

➢ Improved sleep, mood, and depression34, 35

➢ ↓ systemic markers of inflammation36

➢ ↑ CV/ activity tolerance➢ ↑ posture/ ↑ strength

29

Questions???30

Works Cited1. APTA. Federal Concussion Management Legislation.

http://www.apta.orf/FederalIssues/Sports/ConcussionManagement/ updated (11/3/17). Accessed 1/5/2019. 2. APTA. Physical Therapist’s Role in Management of Person with Concussion. http://www.apta.org/uploaded

files/APTAorg/About_US/Policies/Practice/ManagementConcussion.pdf (HOD P06-12-10) Accessed 1/5/2019. 3. Ries, E. Physical Therapists and Concussion Management. PT in Motion and Beyond Rest. March 2017.

http://www.apta.org/PTinMotion/2017/3/Feature/BeyoundRest/. Accessed 1/5/2019.4. Fowler Kennedy- Stay Active, St. Joseph’s Healthcare London. Post Concussion Syndrome Management

Guidelines. https://www.fowler-kennedy.com/wp-content/uploads/2017/02/Post-Concussion-Treatment-Guidelines.pdf Accessed 1/5/2019

5. Legome EL, Wu T, Alt R. Post Concussive Syndrome Clinical Presentation. Medscape. Updated 9/16/2015. http://emedicine.medscape.com/article/828904-clinical. Accessed June 28, 2016.

6. Post Traumatic Headache. American Migraine Foundation. Updated 11/4/2013. https://americanmigrainefoundation.org/living-with-migraines/types-of-headachemigraine/post-traumatic-headache/. Accessed July 10, 2016.

7. Rohling ML, Larrabee GJ. A Review of Mild Head Trauma: Part 1. Meta- analytic Review of Neuropsychological Studies. Journal of Clinical Experienced Neuropsychology. 1997; 19(3): 421-431.

8. Faux S, Sheidy J. A prospective Controlled Study in Prevalence of Post Traumatic Headache Following Mild Traumatic Brain Injury. Pain Medicine. 2008; 8:1001-11.

9. Robert T. Cervicogenic Headache. American Migraine Foundation. http://americanmigraine/cervicogenic-headache/ . Updated February 20, 2012. Accessed July 10, 2016.

10. Biondi DM. Cervicogenic Headache: A Review of Diagnostic and Treatment Strategies. The Journal of American Osteopathic Association. 2005; 105: 16S-22S.

31

Works Cited11.Hall, TM, Briffa K, Hopper D, et al. Therapeutic Relationship Between Cervicogenic Headaches and Impairment

Determined by the Flexion-rotation Test. Journal of Manipulative and Physiological Therapeutics. 2010; 33(9): 666-671.

12.Hall TM, Robinson KW, Fujinawa O, et al. Intertester Reliability and Diagnostic Validity of Cervical Flexion-rotation Test. Journal of Manipulative and Physiological Therapeutics. 2008; 31 (4):293-300.

13.Tong HC, Haig AJ, Yamakawa K. The Spurling’s Test and Cervical Radiculopathy. Spine. 2002; 27(2): 156-159.14.Park J, Park WY, Hong S, et al. Diagnostic Accuracy of Neck Tornado Testa as a Screening Test in Cervical

Radiculopathy. International Journal of Medical Sciences. 2017; 14(7): 662-667. http://www.ncbi.nlm.gov/pmc/articles/PMC5562117/ doi: 10.7150/ijms.19110. Accessed 1/23/2019.

15.Jull G, Trott P, Potter H, et al. A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headaches. Spine. 2002; 27: 1835-1843.

16.Robert T. Cervicogenic Headache. American Migraine Foundation. http://americanmigraine/cervicogenic-headache/. Updated February 20, 2012. Accessed July 10, 2016.

17.Reimann BL, Guskiewicz KKM, Shields EW. Relationships Between Clinical and Force plate Measurements of Postural Stability. Journal of Sports Rehabilitation. 1999; 8(2): 71-82.

18.Broglio SP, Zhu W, Sopiarz K, Park Y. Generalizability Theory Analysis of Balance Error Scoring System Reliability in Healthy Young Adults. Journal of Athletic Training. 2009;44(5):497-502.

19.Giza CC, Kutcher JS, Ashwal S, et al. Evidence –Based Guideline Update: Evaluation and Management of Concussion in Sports. Report of the Functional Guideline Development Subcommittee of the American Academy of Neurology. American Academy of Neurology. Updated 2013

20.Lovell M, Collins M, Bradley J. Return to Play Following Sports- Related Concussion. Clinics in Sports Medicine. 2004; 23(3): 421-441

32

Works Cited21.Kleffelgaard I, Roe C, Soberg H, Bergland A. Association Among Self-Reported Balance Problems, Post

Concussive Symptoms and Performance Based Tests: A longitudinal Follow Up Study. Disability and Rehabilitation. 2012; 23(3): 421-441.

22.Greenwald BD, Kapoor N, Singh AD. Visual Impairments in First Year After TBI. Brain Injury. 2012; 1-22. 23.Alsalaheen BA, Mucha A, Morris LO, et al. Vestibular Rehabilitation for Dizziness and Balance Disorders after

concussion. Journal of Neurologic Physical Therapy. 2010; 4:87-93. 24.Wristley D, MD. Cervicogenic Dizziness. Vestibular Disorders Association. https://vestibular.org/cervicogenic-

dizziness. Accessed 1/30/2019. 25.Reiley AS, Vickory FM, Funderberg SE, et al. How to Diagnose Cervical Dizziness. Archives of Physical Therapy.

2017; 7:12. http://www.ncbi.nlm.gov/pmc/articles/PMC5759906/ doi:10.1186/s40945-017-0040-x. accessed 1/30/2019.

26.King ML, Litchtman SW, Seiger G, et al. Heart Rate Variability in Chronic Traumatic Brain Injury. Brain Injury. 1997; 11(6):445-453.

27.Gall B, Parkhouse W, Goodman D. Heart Rate Variability of Recently Concussed Athletes at Rest and Exercise. Medicine and Science in Sports and Exercise. 2004; 36(8): 1269-1274.

28.Hanna-Pladdy B, Berry ZM, Bennett T, et al. Stress as a Diagnostic Challenge for Post Concussive Symptoms: Sequalae of Mild Traumatic Brain Injury on Psychological Stress Response. Clinical Neuropsychologist. 2001; 15(3): 289-304.

29.Vissing J, Galbo H, Haller R. Exercise Fuel Mobilization in Mitochondrial Myopathy: A Metabolic Dilemma. Annals of Neurology. 1996; 40(4): 655-662.

30.Barde YA. Trophic Factors and Neural Survival. Neuron. 1989; 2: 1525-1534.

33

Works Cited31.Griesbach GS, Hovda DA, Molteni R, Wu A, Gomez-Pirulla F. Voluntary Exercise Following Traumatic Brain Injury:

Brain- Deprived Neuropeptic Factor Upregulation and Recovery of Function. Neuroscience. 2004; 125(1): 129-139.32.Leddy JJ, Kozlowski K, Fung M, et al. Regulatory and Autoregulatory Physiological Dysfunction as a Primary

Characteristic of Post Concussive Syndrome: Implications for Treatment. Neurorehabilitation. 2007; 4(2): 147-154. 33.Baker JG, Freitas MS, Leddy JJ, et al. Return to Full Functioning After Graded Exercise Assessment and

Progressive Exercise Treatment of Post Concussive Syndrome. Rehabilitation Research and Practice. 2-12; 1-7. 34.Scully D, Kremer J, Meade MM, et al. Physical Exercise and Psychological Well Being: A Critical Review. British

Journal of Sports Medicine. 1998; 32(2): 111-120.35.North TC, McCullagh P Tran ZV. Effect of Exercise on Depression. Exercise and Sports Science Reviews. 1990; 18

(1): 379-416. 36.Ford ES. Does Exercise Reduce Inflammation? Physical Activity and C-Reactive Protein Among US Adults.

Epidemiology. 2002; 13(5): 561-568. 37.Hain T, MD. Perilymph Fistula. Dizziness-and-balance.com. Updated December11, 2017. https://www.dizziness-

and-balance.com/disorders/unilat/fistulahtml. Accessed March 4, 2019.38.Most S, MD. Temporal Bone Fractures. Merck Manual. Updated April 2018.

https://www.merckmanuals.com/professional/injuries-poisioning/facial-trauma/temporal-bone-fractures#v1112254. accessed March 4,2019.

34