Concussions in the Workplace & Vestibular Rehabilitation CLM019

Speakers:

• Melissa Bloom, PT, DPT, NCS, Physical Therapist, Physio

Learning Objectives At the end of this session, you will: • Explain the reasoning for vestibular deficits post concussion • Describe symptoms post concussion which can be addressed with vestibular rehabilitation • Discuss several assessment tools and treatments used in vestibular rehabilitation • Describe the benefits of physical therapy for clients with dizziness, vertigo, or balance symptoms post concussion

Concussions

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Concussions • Often with misconceptions regarding extent and nature • Gaps in knowledge on diagnosis, pathology, function, and optimal treatment course • Synonymous with Mild Traumatic Brain Injury (mTBI)1 • Recent increase in media attention on sequella of repeated and unnoticed concussion 1Http://www.cdc.gov/concussion/headsup/pdf/Facts_for_Physicians_booklet-a.pdf

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Mechanism of injury • Mechanical trauma to the brain as a result of acceleration/deceleration forces o Direct blow to the head, face or neck o Direct blow elsewhere on the body with an impulsive force transmitted to the head

• May or may not involve LOC (4-10%)

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Concussion • Often under diagnosed secondary to its’ inability to be seen on diagnostic imaging o 95% of patients with concussion have normal CT scans 1 o 70% of patients with concussions have normal MRIs

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1 Jagoda AS, Cantrill SV, Wears RL, et al. Clinical policy: neuroimaging and decision making inadult mild traumatic brain injury in the acute setting. Ann Emerg Med. 2002;40(2):231-249.

2 Hughes DG, Jackson A, Mason DL, Berry E, Hollis S, Yates DW. Abnormalities on magnetic resonance imaging seen acutely following mild traumatic brain injury: correlation with neuropsychological tests and delayed recovery. Neuroradiology. 2004;46(7):550-558..

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What causes a concussion? •

Mechanical Forces to the moving brain causes sheering of nerves

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Allows abnormal nerve firing

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This is followed but a period of abnormal brain functioning

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(Toledo et al, 2012) Figure 3

These neuro-metabolic changes lead to…  Swelling in the nerve axon  Decreased ability to of nerves to transmit signals (action potentials)

 Decreased transmission of signals and decreased processing of nerve signals  Decreased overall functioning and ability complete daily and work related tasks

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Pathophysiology review • Cascade leading to neuronal dysfunction and symptoms

• Secondary to the nature of the changes there are diffuse areas affected simultaneously • Produces a constellation of symptoms and signs involving physical, cognitive, emotional, and somatic dysfunction • Leads to increased fatigue and tiredness

• Symptoms are often “invisible” and diffuse (Giza et al 2001)

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Typical symptoms  Headache  Dizziness  Impaired gait and balance  Motion sensitivity  Impaired memory, concentration, and attention

 Fatigue  Sleep dysfunction 12

Headaches & concussion • Headache is a common symptom post concussion • •

Occurrence in 40-86% Commonly overlooked symptom

• Presence of PTH • • •

Known decrease in neuro psychological performance Increase severity of symptoms May exacerbate neuro-cognitive impairment after injury

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Vestibular Anatomy

Dizziness and imbalance • Those post concussion often complain of persistent dizziness and imbalance

• Vestibular rehabilitation has been demonstrated to address symptoms and regaining independence

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Dizziness and concussion • Reported in 23-81% of cases in the first days after injury • Persistent dizziness varies from 1.2- 32.5% from 6 months to 5 years after injury

• Can occur with various levels of severity of concussion

• Griffiths, M. V. (1979). The incidence of auditory and vestibular concussion following minor head injury. The Journal of Laryngology & Otology, 93(03), 253-265. • Masson, F., Maurette, P., Salmi, L. R., Dartigues, J. F., Vecsey, J., Destaillats, J. M., & Erny, P. (1996). Prevalence of impairments 5 years after a head injury, and their relationship with disabilities and outcome. Brain Injury, 10(7), 487-498. • Maskell, F., Chiarelli, P., & Isles, R. (2006). Dizziness after traumatic brain injury: overview and measurement in the clinical setting. Brain Injury, 20(3), 293-305.

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May report “dizziness or vertigo”, but… …may complain of an overall fogginess or non specific dizziness  Swimminess  Light headedness  Floating  Rocking  Disoriented

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Vestibular causes BPPV Unilateral weakness Dizziness or vertigo

Decreased sensory integration & processing of sensory information

Vestibular Weakness • Loss of vestibular hair cells or neurons • Abnormal firing on one ear results in asymmetric signals to the brain •

Asymmetric signals can result in : • • • • •

Vertigo Dizziness Disequilibrium Postural instability Oscillopsia (blurred vision)

Vestibular weakness nystagmus

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Head Thrust Test

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How this impacts work •Difficulty getting to work •Dizziness with turning, bending, and moving head at work

•Dizziness with walking •Dizziness with computer work

•Bending, reaching, and turning will likely be imbalanced, inaccurate, and unsafe

BPPV • Positional vertigo caused by changes in head or body position • A common form of vertigo, affecting at least 9 out of 100 older adults

• Can be accompanied with balance deficits • Creates a true vertigo vs. dizziness or blurred vision

Hain, TC. http://www.dizziness-and-hearing.com. 1 March 2016