The Role of the Oculovestibular System in Concussions

The Role of the Oculovestibular
System in Concussions
Jon Almquist, ATC, VATL, ITAT
Concussion Specialist
Fairfax Family Practice Comprehensive Concussion Center
www.FFPC3.com
June 2014

Define Concussion

Review Clinical Signs and Symptoms of Concussion


Review Visual, Vestibular and Oculovestibular
Trajectory of the Concussion Evaluation
Understand Options for Enhancing Recovery from
Oculovestibular Deficits

Induced by trauma

Direct or indirect forces to the head

Complex pathophysiologic process affecting the brain

Disturbance of brain function



Not defined by loss of consciousness


Neurometabolic dysfunction, rather
than structural injury
Constellation of physical, cognitive,
emotional, and sleep-related symptoms
May or may not occur
Symptoms may last minutes to days, weeks, months or
even longer and may not appear for hours to days or until
further exertion
Cantu 2010
Physical
–
–
–
–
–
Headache
Nausea
Dizziness
Balance problems
Visual problems
Emotional
–
–
–
–
–
Irritable
Sadness
Anger
More emotional
Nervousness
Any 1 or more of these symptoms
following trauma = concussion
Cognitive
–
–
–
–
Confusion
Feeling “foggy”
Feeling slowed down
Difficulty concentrating
Sleep
–
–
–
–
Drowsiness
Sleeps too much
Sleeping too little
Trouble falling asleep
Physical
–
–
–
–
–
Headache
Nausea
Dizziness
Balance problems
Visual problems
Cognitive
–
–
–
–
Confusion
Feeling “foggy”
Feeling slowed down
Difficulty concentrating
Emotional
–
–
–
–
–
Irritable
Sadness
Anger
More emotional
Nervousness
Sleep
–
–
–
–
Drowsiness
Sleeps too much
Sleeping too little
Trouble falling asleep
Physical
–
–
–
–
–
Headache
Nausea
Dizziness
Balance problems
Visual problems
Emotional
–
–
–
–
–
Irritable
Sadness
Anger
More emotional
Nervousness
Any 1 or more of these symptoms
following trauma = concussion
Cognitive
–
–
–
–
Confusion
Feeling “foggy”
Feeling slowed down
Difficulty concentrating
Sleep
–
–
–
–
Drowsiness
Sleeps too much
Sleeping too little
Trouble falling asleep



Unremarkable findings on
standard neuroimaging
May or may not involve a loss
of consciousness (LOC)
Symptoms (Typical)
Rapid onset
 Delayed (up to 3 days) onset
 Resolves with rest, often return with
exertion


Recovery from some
neuropathologic sequelae may
be protracted


Home
 Difficulty completing tasks at home
 Reduced play / activity
 Irritability with challenges
School or Work
 Concentration
 Remembering directions
 Disorganized
 Completing assignments
 Fatigue
 Fall behind, fail tests, reduced
grades


Greatly abbreviated
neuropsychology battery
SAC and SCAT mostly useful for
diagnosing concussions



Not validated for follow-up
assessments
No widely accepted diagnostic cut-off
SCOAT: attempt to adapt SCAT
to follow concussions in the office
setting

Yet to be validated
Actual occurrences!!






“Return to sports when your headache is gone”
“You don’t have a concussion because you
didn’t lose consciousness”
“You can play on Monday…”
“Rest for one week, then you can play”
“You have a Grade 1 concussion…”
“You can’t get a concussion by getting hit in
the teeth”




Athletes, parents, coaches all must be
able to recognize concussion signs and
symptoms
The athlete must be removed from
play if concussion is suspected
No return to play that day
Failure to protect from exacerbating
activity or further injury worsens
prognosis  protracted or other
sequelae
EARLY INTERVENTION
REDUCES
PROLONGED RECOVERY
The Spectrum of REST
The Dark Room
No sounds
Low light
No cognitive activity
Maximize Rest
Minimize Educational
Timeloss
Provide Appropriate
Accommodations
Vestibular-Ocular
exercises
Push through pain
Full school
activity
Full physical
activity




Physical AND Cognitive REST
Immediate removal from physical
activity
Don’t push homework, reading,
computer work, travel, noisy
environments, bright lights, etc.
Continuing to play or not resting
appropriately may PROLONG
overall symptoms and recovery
time

REST – both physical and cognitive





Limit texting, video games, computer use, etc.
Allow a good night sleep, family members
check heart rate and respirations
Monitor for changes in signs, symptoms &
behavior
School attendance based on student’s
disposition
Close follow-up, watch for recovery
Only after COMPLETE resolution of
ALL signs & symptoms should one
BEGIN the process
 ANY signs or symptoms return =>
REST
Close Monitoring
 Close contacts: LOOK FOR signs &
symptoms DAILY
 Continue to monitor teacher
observations and parent
observations
Rehabilitation Stage
Functional Exercise
Objective
1. No activity
Complete physical and
cognitive rest
Recovery
2. Light aerobic activity
Walking, swimming,
stationary cycling. Mild
intensity
Increase HR
3. Sport-specific activity
Vestibular Ocular Exercises
Running or skating drills.
No head impact activities
Add movement
4. Non-contact training
drills
Progression to more
complex training drills
Exercise, coordination,
cognitive load
5. Full contact practice
Following medical
clearance. Normal training
activities
Restore confidence,
assessment of functional
skills by coaching staff
6. Return to play
Normal game play


Best managed by providers with experience
and training
Multidimensional and interdisciplinary






Neurocognitive
Vestibular
Oculomotor
Pharmacologic
Exertional
Rehabilitative

What ImPACT is:



A useful, valid, and reliable tool
Provides information to help manage
concussion (e.g. return to exertion, return
to academics, return to play)
What ImPACT is not:



NOT a substitute for medical evaluation /
treatment
NOT “clearance maker:” cannot by itself
be used to safely clear an athlete for
activity
NOT the only game in town

Reported as six composite scores, along with RCI
(Reliability Change Index) and percentile rank:

Verbal Memory Composite

Visual Memory Composite

Processing (Visual-Motor)
Speed Composite

Reaction Time Composite

Impulse Control Composite

Total Symptom Score

ADHD / ADD
BASELINE Impulse Control Composite of > 19.52
 68% predictive (PPV) for ADHD / ADD


Migraine / Post-traumatic Migraine


Vestibular Dysfunction


Persistently poor performance in both verbal and visual memory
composites
Persistently poor performance in in visual-motor speed composite
Ocular (Oculomotor) Dysfunction

Persistently poor performance in visual memory & reaction time
composites

Oculomotor System


Multiple components
Vestibular System

Multiple components



NOT just balance
Complex system that
integrates afferent input
from other systems
Coordinate information
about our environment and
position in space

Peripheral vestibular system






Sx: rapid spinning
Semicircular canals
Otolith
Vestibular ganglia
Vestibular nerve
Central vestibular system






Sx: slow, boggy wave; anxiety, thrill, apprehension
Vestibular nuclei
Cerebellum
Autonomic nervous system
Thalamus
Cerebral cortex

Vestibulo-Spinal Reflex (VSR)
Provides postural stability
 Balance strategies
 Usually improves earliest in concussions


Vestibulo-Ocular Reflex (VOR)
Gaze stability on a target during rapid head
movements
 Common in concussions


Vestibulo-collic Reflex (VCR)
Activates muscles in the neck to stabilize the head
during motion
 Aligns the head in relationship to gravitational
vertical


Smooth Pursuits (H-Test)
Look for nystagmus (isolated upbeat
nystagmus concerning)
 Look for symptom provocation


Saccades (1-to-1)
Both horizontal and vertical
 Look for undershooting (hypometria) or
overshooting (hypermetria)
 Look for acquired nystagmus
 Look for symptom provocation


Gaze stability:
Vestibular Ocular Reflex (VOR)
Both horizontal and vertical
 Look for saccades, nystagmus
 Look for symptom provocation


Optokinetic Stimulation
Response (OSR): VOR Cancellation
(VORC)
Look for saccades, nystagmus
 Look for symptom provocation


Near-Point Convergence (NPC)
Near point at which image  diplopic
 Abnormal if > 6 cm (convergence insufficiency)
 Look for convergence spasms (exo-, meso-, -phoria, tropia)
 Look for symptom provocation


Accomodation (B, L, and R)





Near point at which image is blurry
Abnormal if > 10 cm in youth athletes
Look for convergence spasms (exo-, meso-, -phoria, tropia)
Look for asymmetry
Look for symptom provocation


Initial mixture of the clinical domains
Protracted: these domains separate out, some resolve,
others persist, worsen, and interact







1) Cogntitive concussion
2) Vestibular concussion
(Labrinthine vs. Brainstem concussions)
3) Ocular (Ocuolo-motor) concussion
4) Post-traumatic migraine
5) Cervical (Cervicogenic) concussion
6) Anxiety-Affective concussion
7) Mixed (Combined)

Concussion Headache







Vestibular Headache


Dull, pressure sensation; stays in the same area(s)
Due to vasocontriction
Better in the morning (after resting all night)
Worse in the PM or at night
Prolonged: often responds to migraine regimens
If worse and with fatigue with cognitive load: consider Amantadine
Made worse by movement or being in a busy place
Ocular (Visual) Headache
Retro-orbital, bitemporal headache
 Made worse by math class: visual (ocular)


Post-traumatic Migraine
Common part of the CognitiveMigraine-Fatigue complex
 Headache, nausea, and sensitivity to
light or noise


Anxiety
Made worse by nothing, and better
by exercise
 Often present in the AM
 Watch for vestibular issues


Cervicogenic Headache
Occipital headache
 Worse in AM, and better with
activity or movement


Regulate sleep schedule in protracted concussions!
Too little is bad, but too much sleep is detrimental too
 Must be militant and rigid on the sleep restrictions
 7-9 hrs, NO naps, set alarms
 May take 3-4 days to regulate


Migraine threshold concept:





Sleep: regular / regulated sleep schedule
Diet: regular, consistent diet; at least 3 meals a day
Hydration: well hydrated
Exercise: regular aerobic exercise
Stress: kept to a minimum

Counseling, Education, and Reassurance:
“Cognitive Restructuring”



May shorten recovery in protracted recovery
May prevent progression to protracted state
Vocational Reintegration: Zone Concept
Social reintegration; Occupational reintegration
 Progressive "Return-to-Learn" approach; school re-entry

 Stimulation or Activity : Recovery Ratio (minutes) of 30:30 to 45:15
Sub-threshold receptive and cognitive activity
 Instructional or workplace modifications / accommodations


Vestibular Therapy

Vestibular Therapy
 Concussion specific
 Common trajectory rehab needed in protracted cases
 Once vestibular system recovers --> exertion therapy

Exertion Therapy



Sub-threshold aerobic exercise may help recovery
Start within first week post–injury (as opposed to continuing rest)
Consider formal / monitored exertion therapy

Optometry and Vision Therapy
Behavioral Neuro-Optomertry
 Vision Therapy


Cognitive Therapy
Usually considered after 3-6 months
 Neurocognitive Rehabilitation: attention,
memory, executive fcn
 Cognitive Behavioral Therapy (CBT)
 Activation Database Guided EEG Biofeedback


Physical Therapy
Cervicogenic headaches
 Benign paroxysmal positional vertigo (BPPV)

Family Home
-
Enforce appropriate rest and prescribed
therapeutic measures
Limit excessive stimulation
Re-engage in physical activity when appropriate
Medical Home
-
Evaluate & Assess
Direct therapeutic measures
Coordinate & Communicate
Advocate recovery
Academic Home
-
Safeguard from further injury
Enforce prescribed therapeutic measures
Coordinate cognitive exertion and stimuli with
adjustments
Physical Activity Home
-
Safeguard from further injury
Enforce prescribed therapeutic measures
Coordinate cognitive exertion and stimuli with
adjustments