Concussion: The

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Concussion The Unhappy Triad of the Brain
Balance Testing and Treatment

• Brian Werner, MPT
• President Werner Institute
• Of Balance and Dizziness, Inc.

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Who Is Brian Werner, MPT

• Graduate of Northern Arizona University
• Undergraduate degree Exercise Science
• Summa Cum Laude
• Graduate degree
• Masters in Physical Therapy
• Outstanding Scholar of Class 1999
• Certificate of Competency Vestibular Disorder
  Management 2000 at University of Miami
• President Werner Institute of Balance and
  Dizziness, Inc.
• Have treated over 5,000 patients successfully
  with dizziness and balance disorders

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Discussion

• Assessment of Concussion
• The University of Buffalo experiment
• Has been used in physical therapy management of
  dizziness for decades
• Overlap of Cerebral (Cognitive) and Motor Control
  (Balance) Symptoms is common
• Testing Used to Assess the PCS Athlete
• Ex. Common missed diagnosis BPPV
• Sub-threshold concept to treatment

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The Reality of Concussion in the Athlete

• Injuries like concussion are bad news for
  collegiate and professional athletes not just
  because of the physical and mental pain and
  suffering they inflict but also because of the
  pressure to perform that's inherent in collegiate
  and professional sports. No player wants to sit
  on the sidelines any longer than he has to,
  especially when prolonged recovery times can mean
  being sent down to the minors, losing a position,
  or even seeing his career come to a close.

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Common Symptoms Associated with Vestibular
Disorders

• Headaches
• Visual Sensitivity
• Memory Changes
• Depression
• Irritability
• Confusion
• Nausea/Vomiting
• Tinnitus
• Sleep disturbances
• Fatigued
• These are common symptoms associated with
  cerebral concussion as wellmaybe there is more
  to the vestibular system with concussion

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What We Know

• When it comes to managing concussions in sports,
  relying only on an athlete's self report of
  symptoms is inadequate and likely to result in
  under-diagnosing the injury and the athlete
  unsafely returning to play following the
  concussion (Univ. of Pitt, 2005)

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What are We Currently Doing with Post-Concussion

• The 2nd International Conference on Concussion in
  Sport, Prague 2004 recommended the following
  stages of recovery from a concussion
• No activity, complete rest. Once asymptomatic,
  proceed to next levels.
• What if the athlete doesnt get asymptomatic
• How long should we be waiting until asymptomatic
• Lets be real about what the athlete might say
  and how he actually feels
• Light aerobic exercise such as walking or
  stationary cycling, no resistance training
• Sport-specific exercise (eg, skating in hockey,
  running in soccer), progressive addition of
  resistance training at steps 3 or
• Non-contact training drills
• Full contact training after medical clearance.
• Game play.

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Dogma Concussions Cannot Be Rehabilitated

• This was the thought, and still is, with the
  inner ear disorders for decades
• Over 200 peer reviewed articles support treating
  dizziness with therapy works
• Cannot see the concussion thus cannot treat?
  (same thought for inner ear)
• Functional testing is the KEY!!!
• Neurocognitive
• Motor Control/Balance/Dizziness
• Postural Stability Eyes
• Postural Stability Standing and Gait

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Ex. Benign Positional Vertigo Canalithiasis

• Most common disorder of inner ear
• Due to trauma to the head in most cases
• Calcium Stones loosen from the otolith
• Easily fixed with an Epley maneuver
• This symptom can persist for weeks, months, to
  years
• Patient had BPPV post concussion for 5 years
• Why wait to treat?

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Epley Maneuver
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Rest vs. Exercise Post Concussion The Buffalo
Experiment
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Buffalo Treatment Paradigm

• Regulated exercise." The approach consists of
  determining the ideal exercise program for each
  athlete based on a number of individual
  physiological indicators at baseline
• Treatment method in mid-September at the 2006
  Brain Injury Conference of the Americas in Miami,
  where the response was very favorable, according
  to Willer
• As far as we can determine, there is only one
  other group in North America that is using
  regulated exercise as part of the treatment for
  PCS
• Just being able to exercise often reduces the
  depressive symptoms. But it's imperative that the
  patient not go beyond the exercise limits.

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The University of Las Vegas (UNLV)
Concussion Program Could Something Like This Be
Done/Tried Here in Las Vegas at UNLV?
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Problems with a Comprehensive Concussion Program

• COST
• Equipment, staff, software, up-keep, etc.
• Insurance coverage
• TIME
• Testing, re-testing, re-testing
• LOGISTICS
• POLITICS
• COMMITMENT
• OTHER?

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GOALS of the Evidence-Based Post-Concussion
Program

• Return to Play (RTP) could be expected
• Safer
• Sooner
• Athletes brain function could be expected to
• Work more efficient
• Less long term complications

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Quick Review Balance System

• Sensory Inputs
• Vision
• Somatosensory
• Vestibular
• Integration
• Processing
• Motor Outputs
• Strength
• Reaction Times

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The Vestibular Concussion

• Bony Labyrinth
• Membranous Labyrinth
• Floats in perilymph like the brain in CSF
• Traumatic Blow disrupts sensors
• Otoliths ? Linear
• Canals ? Angular

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Proposed Treatment Model Vestibular Concussion
Objective Graded Increases In Therapeutic stimuli
Focus on Challenging Vestibular/Cognitive
Symptoms Similar to the Musculo-skeletal Model
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What are Werner Institute is Doing for PC
Patients/Athletes?

• Cognitive Testing ? ImPACT
• Subjective Symptoms test (part of ImPACT program)
• Motor Control (Balance)
• Imbalance/Dizziness ?VSR and VOR testing
• (VOR Vestibulo-Ocular Reflex/VSR
  Vestibulo-Spinal Reflex)
• CDP ? (Computerized Dynamic Posturography)
• VOR ?Visual Acuity and Gaze Stability Testing
• IVOG, DVA, GST, VAT
• Performance Balance Tests
• MCTSIB, Sharpened Romberg, SLS Testing
• Tandem Gait (EO/EC)
• Testing is done weekly
• Physician, Neuropsycologist, ATC, PT determine
  RTP
• Orthopedic
• Cervical Dysfunction ?Modalities, Manual Therapy,
  etc.

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The Unhappy Triad of the Concussion

CONCUSSION
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Current Treatment Paradigm

• There is no treatment for the concussion only
  time and rest!
• Glisick et al, 2003
• Neuropsychological assessment post-concussion is
  shown to be of value, the cornerstone, but it
  should not be done until all S/S have resolved,
  and should never be the sole criteria to
  determine return to play decision (Prague 2004)
• How many high school programs are using S/S and
  cognitive tests to determine RTP?
• How many are using the BESS or postural testing?

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Postural Stability Standing

• Computerized Dynamic Posturography (CDP)
• Based off 100 scale ? no sway
• Developed at MIT for the NASA program
• Sensory Organization Test (SOT)
• Measure balance performance without head movement
  in standing
• Measures sway/shear
• Head-Shake SOT (YAW, PITCH, ROLL)
• Performance with head movement
• Designed originally at NAMRL for military fighter
  pilots
• Motor Control Test (MCT)
• Measure reaction times in lower extremities to
  1/1000 of a second

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Ex. of SOT and MCT reports
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Postural Stability - IVOG

• Infrared Video-nystagmograph (VNG)
• Allows us to measure nystagmus
• Eye movements
• Can be measured in degrees/sec.
• Common dysfunction with PSC
• Down-beating nystagmus
• Right/Left beating nystagmus
• Nystagmus reduces with improved function

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Postural Stability Gaze

• Sx Headaches, visual sensitivity, blurred vision
• TESTS
• Dynamic Visual Acuity (DVA)
• Measures visual acuity at fixed speed
• Normal 1.5 line difference
• Gaze Stabilization Test (GST)
• Measures eye/gaze stability at highest speed.
• Normal 120 deg/sec

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DVA and GST Reports
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Postural Stability Gaze

• Vestibular Auto-Rotational Test (VAT)
• Developed at USC for NASA program
• Measure across functional Hz (0.5 to 10)
• Strength of gaze stability ? GAIN
• Norm 1.0
• Timing of gaze system ?PHASE
• Norm 180 deg/sec
• Stability of gaze ? ASYMMETRY
• Nom 4.0 deg R/L

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Ex. Pre- and Post VAT Test Results
Pre-Rx
Post-Rx
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Problems with Computerized Balance Testing

• Cost!!!
• Portability
• SMART EquiTEST weighs 880 lbs
• Four SMART EquiTESTs available in the LV valley
• Static force-plates are available
• Research on efficacy on post-concussion balance
  disorder identification is sparse in the
  literature
• Research on dizziness/balance management in inner
  ear disorders is abundant in ENT and PT
  literature.

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Sub-Threshold Balance Training

• Balance retraining therapy is below the
  threshold
• Put little stress to the body
• Can be started early into the program
• Regulated based on symptoms and objective
  re-testing

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