concussion for conn ota
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Latent Effects of Concussion on Vestibular Functioning
Salvador Bondoc
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.
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…
What do we know about Concussions in Adolescents and Young Adults?
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?
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
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
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
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)
Long term studies show that most lingering effects tend to be Cognitive (decreased attention, concentration, memory)
or Emotional (lability, irritability, depression) in nature
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
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
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)
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)
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
Other Clinical Screens Modified Epley/ Dix-
Hallpike Maneuver Peripheral lesion
Head-shaking Test Peripheral Central (cross
coupling)
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.
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
Balance Master
Eyes closed, Compliant
surface
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
Is this Best Practice?
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
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.
After 3 months
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