We recently received a question from one of our followers. Although the email itself only included one question, the statements that proceeded it addressed a number of areas that we receive questions about frequently. So, I thought I would take this opportunity to break down the email...like diagramming a sentence. :-)
I’ll start with the email…making a few deletions for privacy:
We are offering concussion baseline testing. We are doing a SOT test on the XXXXX, oculomotor test using XXXXX goggles, and XXXXX for reaction/cognitive. We need a recommendation for a single leg stance test for single leg stance function. Do you think using the mCTSIB XXXXX force plate with eyes closed firm surface and eyes closed foam surface is good?
Statement #1: We are offering concussion baseline testing.
Response #1: Yay! There are 2 big bonuses in baseline testing: (1) Concussions are heterogeneous and require an individualized clinical approach vs comparing data against a generalized normal population. And, (2) Baseline testing provides the opportunity to identify pre-existing conditions that are considered a risk factor for injury -- particularly orthopedic lower extremity injuries.
Statement #2: We are doing a SOT test...
Response #2: Just as an FYI for those who may not be familiar with SOT... SOT stands for Sensory Organization Test and is done with either a dynamic force plate and visual field moving and is part of a series of test with a unit called Computerized Dynamic Posturography (CDP). Natus (formerly NeuroCom) and Bertec are currently the only companies that provide CDP testing. An SOT consists of 6 sensory conditions:
CDP is very advanced technology and is certainly not readily available, especially for baseline testing. One consideration with this test if you are working with athletes, is that the test is not sensitive enough. Why? Because the head is static and does not put a high enough demand on the vestibular system despite the difficulty of maintaining balance when the force plate is moving. This is also likely one of the most plausible explanations of why the BESS test was not found to be as sensitive with identifying concussion when it was utilized as part of the Vestibular Oculo-Motor Screen (VOMS). As early as 1996, Shepard and Nashner found that adding a head shake test with eyes closed identified vestibular dysfunction on higher level functioning individuals.
For those of you that subscribe to our education and/or have attended one of our live courses, have heard about the COncussion BALance Test (COBALT), which is a balance test that includes head movements with eyes closed as well as a condition placing demands on the vestibular ocular reflex (VOR) cancellation pathway. The VOR Cancellation condition mimics the Motion Sensitivity Test which is part of the VOMS. I think these higher demand testing activities of the COBALT will show a high level of sensitivity to identifying vestibular dysfunction and, ideally, would be integrated into concussion baseline and post-injury testing. The COBALT test utilizing a small force plate is available with Bertec and will soon be released to the public as the modified COBALT (mCOBALT) which does not require a force plate.
Statement #3: (We are offering…) …oculomotor testing…
Response #3: FANTASTIC! For those of you that subscribe to our education know that we strongly encourage oculomotor testing, especially as part of the post-concussion exam. The fact that this is being done as part of baseline is BONUS! And, it allows for a unique opportunity to identify oculomotor impairments that could be affecting the athlete’s performance. Optimizing smooth pursuit, saccades and vergence is becoming more popular for improving athletic performance. And, oculomotor impairments have long been associated with head trauma. The same visual training exercises can be used for enhancement and post-injury but the tolerance to these activities vary significantly and should be used with caution post-concussion.
Statement #4: (We are offering…) … cognitive testing…
Response #4: Another yay! Cognitive testing has long been associated with baseline testing and remains an integral component. What we know now is cognitive testing alone does not define a concussion program. It is necessary to implement a variety of additional components, such as vestibular and visual and it is also important to look at neck strength.
Statement #5: We need a recommendation for a single leg stance test.
Response #5: Considering you are utilizing SOT, it is likely you have the option to perform a single leg stance on the force plate. There should be the option to run single leg stance as well as a weight bear squat. I mention the latter because I was involved in a 3 year study regarding force plate balance testing and we found a higher incidence of ACL injuries in those athletes with asymmetries. Or, you could simply monitor the Center of Gravity (COG) findings with the SOT and make note if there is an asymmetry (e.g., left COG bias or anterior COG bias). Often, you will find a correlation with an asymmetrical COG and a pre-existing lower extremity injury or weakness.
And, now the question…
Question #1: Do you think using the mCTSIB XXXXX force plate with eyes closed firm surface and eyes closed foam surface is good?
Answer #1: I’ll offer a 2-option answer simply because I’m not sure I fully understand the question.
Just a handful of take home notes regarding baseline testing:
I applaud the individual that sent this email for your efforts in utilizing a comprehensive approach to baseline testing, especially considering the amount of time it takes to perform the mentioned series of test. I am also a big proponent of performing a quick deep neck flexor strength test – can be done in less than 60 seconds. Poor neck strength has been correlated with a higher risk for concussion and having a longer recovery post-concussion.
We hope you continue to follow us, especially considering that we will bringing you more educational offerings on these topics, including a soon to be released training on the mCOBALT which is done without a force plate. Here are just a few of the upcoming offerings:
Bridgett Wallace, PT, DPT
360 Neuro Health Institute
Director of Clinical Education
Is vestibular exercise effective at enhancing recovery of function in people with peripheral (unilateral or bilateral) vestibular hypofunction?
Benefit Over Harm
In 2016, The Neurology Section of the American Physical Therapy Association (APTA) released clinical guidelines for clinicians treating vestibular dysfunction. A multi-disciplinary group of experts and researchers identified 125 articles relevant to this research question.
Based on strong evidence and the greater effect of benefit over harm, clinicians should offer vestibular rehabilitation to persons with unilateral and bilateral vestibular hypofunction with impairments and functional limitations related to the vestibular deficit.
Unfortunately, pharmaceutical management is the most common treatment for patients with vestibular dysfunction. Although vestibular suppressants for dizziness and/or nausea may be beneficial in the acute phases (<5 days), it can hinder the natural recovery process and, in most cases, does not improve symptoms.
Dizziness is One of Top 3 Symptoms Reported
Regardless of the clinical setting you practice, the likelihood that you have encountered a patient that reports dizziness is high as is the likelihood that you or someone you know has suffered from dizziness. Dizziness is considered one of the top 3 symptoms reported to physicians and it is estimated that 40% of adults older than 40 years will experience dizziness.
Prevalence of Dizziness
We frequently tell our patients that the first step in their recovery is education. And, this is true for clinicians. Considering the prevalence of dizziness, it is warranted that clinicians should be able to ask simple questions to obtain clues about the possible cause(s) of dizziness and also perform simple but standardized clinical tests to provide more information about the etiology. The majority of these tests can be done in seconds to minutes and a comprehensive neurological exam can be performed in <20 minutes.
Click here to view the article.
Vestibular Dysfunction Across the Life Span Conference
From Pediatrics to Geriatrics
When: March 3 & 4, 2018
Where: Dell Children's Medical Center of Central Texas, Austin, Texas
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The Concussion Health Summit
When: July 27 - 29, 2018
Where: Hilton Dallas Southlake Town Square, Southlake, Texas
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Visual Vestibular Functional Integration Training Certification Course
When: Enrollment is Open
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