Vestibular Therapy in Concussion


Q: Can you provide more detail on the causes of and the appropriate treatment for vision motion sensitivity?


Answer:

Anne Mucha, PT, DPT, MS, NCS: “Typically, at least the general rule of thumb is, when you find BPPV that involves more than one canal, you try to find the thing that’s most symptomatic to the patient and treat that first. And most clinicians do not treat more than one canal on the same day just because the mechanics of moving one canal’s crystals out usually are contradictory to the other canal. So, usually you do one canal one day, treat that, and then once that is resolved, then you go to the next, most symptomatic place. But, I’d be happy to hear what other people do too.”

Shelly Massingale, PT, MPT: “Well, I’ll tell you that I 100 percent agree with all of that. That’s exactly how we would do it too. And that would be my theory on post-traumatic BPPV. The mechanism of injury versus spontaneous BPPV is usually just in one canal. And it is much more challenging and truly because you are trying to treat so many canals and the nystagmus gets more difficult to delineate where it’s coming from. So, Frenzel lenses help a lot with that.”

Faculty:

Anne Mucha, PT, DPT, MS, NCS & Bridgett Wallace, PT, DPT

Q: Is it recommended to start some level of returning to activities at day 2-3 (subthreshold exertion)?


Answer:

Amy Alexander, PT: “Shelly Massingale, PT, MPT mentioned it always depends on what the patient can tolerate, so there’s always the oculomotor exam with symptom provocation. I get through that because that, to me, is a critical piece, and then depending on how motion intolerant they are, I usually do a postural test because they usually cannot get through an entire dynamic visual acuity or gaze stability test. I can’t get to an answer, as I usually tell them. I can’t get to a full result.

For somebody to get through everything that I’m going to look at, they have to come in being nearly asymptomatic. So I don’t plan on getting everything done on that first visit. Gaze stability. For people that really don’t tolerate a lot of head turns, I get them started on the habituation piece, so they’re getting more motion tolerant, and then the next time they come in, then I’ll start to look at gaze stability, and then I bring in that group of exercises.”

Faculty:

Amy Alexander, PT & Bridgett Wallace, PT, DPT

Q: When doing VOR off center, is the head maintained in neutral?


Answer:

Amy Alexander, PT: “So correct. So we call it VOR around the clock in our clinic. That’s the colloquial term we use. So yeah, the target is, so I’m here, the targets there. I tell them to kind of point your nose. The nose is at the center of the target. So it’s left and right of the target. So it is off-center. So they’re not doing the VOR out of the corner of their eye. It’s still off. It’s just turned more like that.”

Bridgett Wallace, PT, DPT: “And we do out of the corner of the eye sometimes when we’re trying to separate, it’s not a true VOR times two, but on the eye chart that we use in the clinic, we’ll put an X on each side, and ask the patient look over to the X but keep their head forward. And that’s to work on the VOR to create a little bit more error message.”

Faculty:

Amy Alexander, PT & Bridgett Wallace, PT, DPT

Q: What if they already have a headache at baseline? Do you still progress fast?


Answer:

Amy Alexander, PT: “You can. So what I usually will tell a patient, kids, I’m like, if you wake up and your headache is a zero and at the end of the day, having done your exercises, school, and whatever your headache is a three, if it resets by the next morning, if you wake up and it’s back to what it was, as long as they’re okay with that amount of challenge, that’s okay with me. But if day over day, their headache is only escalating, then I have to back down the intensity. So I’ll back off from that. So it just depends on how they’re responding, but headache is not necessarily a reason that I won’t work with a person. Like it’s not always a stop.”

Faculty:

Amy Alexander, PT & Bridgett Wallace, PT, DPT

Q: I have an athlete who has progressed brilliantly with exertional return to play loading, but it’s getting a lot of nausea with screen time, returned to work. But her gaze stability rehab is at a high level. Any advice?


Answer:

Amy Alexander, PT: “In a perfect world, you have a neuro optometrist because I would be more suspicious of convergence or divergence or oculomotor issue too.”

Bridgett Wallace, PT, DPT: “And to expand on that, because I had a patient, not post-concussion, but a very similar patient. I reached out to Dr. DeAnn Fitzgerald, OD on that very same thing. And we use the tinted glasses a lot to try to decrease the blue tint, so first we tried glasses. It can also be that they are on the screen because they want to be or they are on the screen because they have to be. Dr. Fitzgerald said it’s always something to consider that if it’s returned to work and there’s maybe some underlying stress that may be a contributing factor. It is also what happens when you have to process a screen. And I think, Amy, I mean, you’re the one that sees all the athletes. Most of the concussions we see are either from our car wreck or older adults from a fall. There’s just a lot of sensitivity to screen time, scrolling in certain directions on the phone, but yet they can still have a high VOR function. I’m sure you’ve seen that.”

Amy Alexander, PT: “Absolutely. That’s usually more of that visual motion sensitivity. So they might need that far VOR that I talked about just in day in, day out. It’s not going to address the scroll issue per se, but if there’s still some lingering visual motion sensitivity in that larger sense, the far VOR having to do the optic flow as they move towards and away from the target can be a helpful way to address that. Otherwise, you guys touched on it earlier this week about treatment strategies around visual motion sensitivity and big screens, free apps or not free apps and YouTube videos for addressing that.”

Faculty:

Amy Alexander, PT & Bridgett Wallace, PT, DPT

Q: Why is it thought that BPPV with concussion is more complex?


Answer:

Anne Mucha, PT, DPT, MS, NCS: “Why is it more complex? Why does it involve more canals? I think it’s purely, we’ve never studied this, but it has to do with the mechanics of the injury. I think the nature of there being trauma to the ear, shaking the crystals loose more indiscriminately, maybe larger chunks. We don’t know, but it has to have something to do with the mechanical nature of concussion and what that does to the labyrinth itself.”

Faculty:

Anne Mucha, PT, DPT, MS, NCS & Bridgett Wallace, PT, DPT

Q: When you have multiple canal BPPV, how do you choose which canal to treat first?


Answer:

Anne Mucha, PT, DPT, MS, NCS: “Typically, at least the general rule of thumb is, when you find BPPV that involves more than one canal, you try to find the thing that’s most symptomatic to the patient and treat that first. And most clinicians do not treat more than one canal on the same day just because the mechanics of moving one canal’s crystals out usually are contradictory to the other canal. So, usually you do one canal one day, treat that, and then once that is resolved, then you go to the next, most symptomatic place. But, I’d be happy to hear what other people do too.”

Shelly Massingale, PT, MPT: “Well, I’ll tell you that I 100 percent agree with all of that. That’s exactly how we would do it too. And that would be my theory on post-traumatic BPPV. The mechanism of injury versus spontaneous BPPV is usually just in one canal. And it is much more challenging and truly because you are trying to treat so many canals and the nystagmus gets more difficult to delineate where it’s coming from. So, Frenzel lenses help a lot with that.”

Faculty:

Anne Mucha, PT, DPT, MS, NCS & Bridgett Wallace, PT, DPT



RESOURCES & LINKS:



FACULTY BIOs:

Amy Alexander, PT

Amy is the primary vestibular physical therapist for Banner Sports Medicine and Concussion Specialists Clinic, a physician led multiple discipline clinic in Phoenix, AZ. Amy has been practicing physical therapy since 1988. She chose to specialize in vestibular physical therapy in 2003, completing the APTA competency course in 2006. She started working at the Banner Health concussion specialty clinic in August 2014, managing vestibular and balance disorders in the post injury population. In vestibular physical therapy, Amy’s interest is in assessing athletes in ways that more closely approximate sport related activity. Through her work with MMA fighters, Amy was part of a multiple discipline team that developed a sport specific return to play protocol for combat sports. She was also a part of the clinical research project assessing normative gaze stability in elite baseball players. Sport specific exertion and gaze stability is a current project that has evolved from working with athletes experiencing post-concussion syndrome.

Anne Mucha, PT, DPT, MS, NCS

An expert in the assessment and rehabilitation of balance, dizziness and visual symptoms following concussion, Anne Mucha coordinates the vestibular rehabilitation for the Concussion Program at UPMC. In addition to her clinical practice, she works in research and also serves as an adjunct faculty member at the University of Pittsburgh. Dr. Mucha, with 20 years of clinical experience, has lectured nationally on the subject of concussion and, in particular, the presence and treatment of balance and vestibular concerns after concussion. Dr. Mucha holds appointments on national concussion panels for the American Physical Therapy Association. Mucha, board certified as a neurologic physical therapist, is a Pittsburgh native.

Bridgett Wallace, PT, DPT

Bridgett Wallace, PT, DPT, has a doctorate of physical therapy and holds competency-based certifications in vestibular rehabilitation and concussion management. Dr. Wallace has been treating patients with dizziness and balance disorders for more than 20 years and is the founder and President of 360 Balance & Dizziness – a specialty clinic for the evaluation and treatment of dizziness and balance disorders that includes both audiology and therapy services. She is also the co-founder and Director of Clinical Education for 360 Neuro Health Institute, which provides online, mobile and live educational offerings for health care providers.