Vestibular Rehab For Concussions

12 Oct

We all know, or should know, that balance issues are a primary concern with concussions and post-concussion syndrome.  Along with memory problems, balance disturbance is high on the predictor list for duration of symptoms ergo severity.

As an athletic trainer one of our primary tests, and “go-to” is the Rhomberg Test, or sobriety test as most may know it as.  What is tested there is the gross balance and fine motor movements controlled by the brain and vestibular system of our ears.  During a concussive episode the synapses (or messages being sent) between the neurons in the brain get disrupted, each individual will experience different durations.  Using the knowledge that balance is commonly and most immediately affected by a concussion the Rhomberg provides great feedback.

During the Rhomberg the athlete is challenged with single leg balance, tandem walking, spatial awareness and other concentration efforts that would otherwise be very simple.  These menial tasks become very difficult when you are concussed.  Now imagine those small but difficult tasks and dizziness plaguing you on a daily basis days, weeks or even months after you have sustained a concussion.

Alsalaheen, Mucha, et al. provided a research study in which they looked back in charts of patients that had a concussion and experienced long-term balance/dizziness issues.  This group of patients were sent to a rehabilitation center for vestibular training, usually (mean time) 61 days after initial concussion evaluation.

What they found was that with vestibular rehabilitation (as few as two visits) patients self-reported a decrease in dizziness and increased their scores on the balance tests used at the facility.  What is more, is that the adolescent group (< 16 y/o) improved more significantly and quicker as compared to their “adult” counterparts.

The rehabilitation techniques are not that difficult, and for the majority of them, were done as a home exercise program.  Leading me to believe that identifying the balance issue early and combating it with this type of rehab will allow for quicker return to school and play.

Some of the techniques that were most often used were as simple as;

  • Holding a gaze at a fixed point and moving head, in sitting and standing
  • Standing balance with eyes open/closed
  • Gait challenges like head rotations while walking, or maneuvering around obstacles
  • Getting in and out of a chair while having a fixed gaze

As the authors suggested more research in this area is needed but simple, yet complex tasks like those above could help bring a quicker end to some of the most frustrating symptoms of a concussion.

Reference

B. Alsalaheen, A. Mucha, et al., Vestibular rehabilitation for dizziness and balance disorders after concussion.  Journal of Neurologic Physical Therapy, 2010, June; 34(2):87-93.

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31 Responses to “Vestibular Rehab For Concussions”

  1. Justin October 20, 2010 at 11:23 #

    Hello,

    My name is Justin Pinkerton, and I’m a 2nd year PT student at UMDNJ-Rutgers in New Jersey. I recently started a research project involving the role of vestibular rehab for post-concussion syndrome. Ironically, the above article gives a great idea of how vestibular rehab can play a tremendous role when dealing and treating concussions, and it is the best article we have found to date. I was wondering if you had another other articles, references, etc, that deal with vestibular rehab for concussions. If you do, I would greatly appreciate anything that you have, because my group is having a tough time finding “good” articles.

    Thank you for your time,

    Justin Pinkerton, SPT
    pinkerjt@umdnj.edu

    • Dustin Fink October 20, 2010 at 11:37 #

      Justin,
      That article is the only one I could find on the subject. This reference had been noted in other concussion research, I figured to do a story on it because there was not much on it.

      Here were some other articles;
      Griffiths, MV. The incidence of auditory and vestibular concussion… JLaryngol Otol., 1979
      Kisilevski V, Podoshin L, et al. Results of otovestibular tests… Int Tinnitus J., 2001
      Guskiewicz KM, Ross SE, et al. Postural stability and neuropsych deficits after concussion… J Ath Train, 2001
      Hoffer ME, Fottshall KR, Moore R et al., Characterizing and treating dizziness after mild head trauma. Otol Neurotol., 2004

      • Justin Pinkerton November 5, 2010 at 10:01 #

        Thank you I appreciate your help.

      • Dr. Mike Gruttadauria January 1, 2012 at 17:48 #

        If you google eye movements and concussion, you will get 251,000 hits. Eye movements and vestibular conditions are interrelated. We use vestibular rehab and other functional neuro interventions to rehab our concussion patients. – Would love to talk to you about what we are doing and how we might collaborate to help more people dealing with concussion/mTBI. – Dr. Mike.

  2. Amanda February 22, 2011 at 18:16 #

    Have you received any additional information on this subject? I am suffering from PCS and was recently told to take part in vestibula rehab, focusing on balance and even incorporating yoga. Any additional information would be appreciated. Thanks!

    • Dustin Fink February 22, 2011 at 18:19 #

      Amanda,

      This is budding area so information is new, however anecdotal evidence suggests that balance rehabilitation along with congnitive exercises will help with some symptoms of PCS. I would urge your MD or therapist to look into both… Good Luck, glad we could help.

    • Greg February 25, 2011 at 22:24 #

      I have a 14-year-old son who suffered a concussion in a basketball game six weeks ago. Two weeks ago he began PT, doing eye exercises at home a couple of times a day (moving his head back and forth, then up and down while staring at a fixed point, in 30-second increments, and moving a pen back and forth, up and down, and diagonally while following it with his eyes, 30-repetitions each). He had been having symptoms including persistent fogginess, occasional headaches, and recurrent light-headedness when getting up from sitting. After a week of doing the exercises, his headaches and other symptoms decreased considerably. Hard to say whether it was just a coincidence or not, but the decrease in symptoms did correspond remarkably to starting the PT: very little improvement for 4 weeks, then significant improvement in a matter of days.
      Today we had our second visit with the PT, and he significantly stepped up the eye exercises, doing extra sets and for a longer time. Unfortunately, my son got his first headache in days and felt generally lousy most of the day after the PT appointment. I’m hoping it’s just a one-day setback and he’ll feel better tomorrow.
      But overall, the PT seems to have helped. I guess the caution would be to go more slowly in adding difficulty to the exercises.

      • Dustin Fink February 26, 2011 at 09:27 #

        Greg,
        That is both great news and entirely correct. Working on the spacial and visual awareness seems to be one of the base functions concussions get hung up on. This is why when we have an individual get a concussion at our school we ADAMANTLY tell them NO video games, texting, and computers for 72 hours. You know what that might be the most difficult part of the recovery process.

        Discuss with the PT the effects of last visit. I am sure they will be able to help with that.

        If you don’t mind me asking what is the school status of your son?

  3. Greg February 26, 2011 at 22:25 #

    Dustin,

    He’s in eighth grade. The school is being good about things, but overall it’s been a difficult situation. He has pretty much stopped doing school work for the past five weeks, just going to school one or two hours a day, listening in class but taking no notes, doing no homework, taking no tests. Also virtually no TV for the past six weeks, no videogames, and only in the past two weeks has he been using the computer, in 10-minute timed intervals four or five times a day.

    Unfortunately, for the first week after the concussion diagnosis, he did a full school schedule (but no physical activity) with a fairly heavy load of studying, a couple of tests, etc. It’s a competitive school, and my son was very unhappy with the prospect of falling behind. The doctor had diagnosed his concussion as minor and said it was fine to continue with school as long as the work didn’t worsen my son’s symptoms. They didn’t worsen, but he was very tired and the symptoms weren’t improving, either. He still had the constant fogginess and persistent light-headedness and headaches.

    When he wasn’t getting better after a week, I read up on concussions on the Internet and learned about the need for total brain rest. The next week we kept him home from school, and after that he has been going to school at most three hours a day, and some days not at all. But I wish I had known enough to give him complete mental rest that first week!

    When we were able to get in to see a concussion specialist, after about three weeks, she did an impact test and found some deficiency in short-term memory and somewhat low scores overall, consistent with what she’d expect in a concussion. She recommended PT. The doctor sent a letter to the school laying out restrictions, such as no make-up work, no note-taking, permission to attend school part-time and leave class at any time to go to the nurse if needed. The school was fine with that and assured us that my son could take as much time off as needed and that his graduation from eighth grade wouldn’t be at risk.

    Still, the upshot is that he is far behind in all his classes and will certainly not catch up. But our main goal now is to get him completely healthy before high school (and hopefully well before then). If doing any work now is going to delay his recovery, it isn’t worth it. With the exception of algebra, which he can complete in the summer, his eighth-grade classes really don’t matter much for him to get off to a good start in high school.

    As you say, the restrictions on computer use, TV, texting, etc. are the hardest part. It’s tough to do without that stuff when the recovery stretches to weeks. He has only recently started reading again for short periods without it seeming to bother him. And it’s often tough to pin down what sets off his symptoms. Sometimes they come for no apparent reason. My wife and I read to him, we play simple games like Chinese checkers. But of course everybody gets sick of that, and he misses his friends and activities. Anyway, he does seem to be improving lately.

    Sorry I rambled on so long. Thanks for the great blog. It’s very helpful.

    • Dustin Fink February 27, 2011 at 17:25 #

      Greg,

      Thank you so very much for sharing, and if you don’t mind, I would like to take the information in the comments and create a post, for more visibility, if that would be OK?
      It sounds like you are on the right track, what I hope is that others like your son and you will have all the information from the get go so there are no setbacks…
      Again thank you!

      • Greg March 1, 2011 at 23:11 #

        Sure, no problem if you want to create a post.

        My son is doing better — no headaches in four days. He did a little algebra tonight for the first time in weeks and it didn’t set off his symptoms.

        Now, in addition to the eye exercises, he’s supposed to do a daily treadmill session, walking only, trying to get his heart rate into the 140 range for 15-20 minutes without headaches. So far, so good with that after a couple of days.

  4. Dr Kirk Alan Lee February 28, 2011 at 17:15 #

    great information! I lecture nation wide on Chiropractic care and its role in sports injuries. A big part of my program is TBI/concussion’s. Your site will be one I will definitely recommend. Thank you

  5. Kaitlin June 6, 2011 at 15:05 #

    Hey Greg,
    At what point in a RTP Protocol would you recommend instituting the vestibular rehab? I am in the process of revamping my concussion policy, and I would love to run this idea past my team physician.
    Thanks!
    Kait

  6. Bridgett Wallace, PT, DPT July 15, 2011 at 21:10 #

    Dustin,

    I am glad to see your mention of vestibular testing as an integral component to concussion assessment, especially considering the simplicity of the tests yet the clinical significance it can provide. However, this particular article references Romberg as including single leg stance, tandem walking, etc. By clinical definition, the Romberg is feet together (double leg stance) with eyes closed and can be performed on firm and foam surface with the latter placing more demand on the vestibular system — specifically the vestibular spinal reflex. It is also recommended to include assessment of the vestibular ocular reflex to compare the difference between static and dynamic vision, which is particular important for testing the dynamic portion of the inner ear.

    • Brian Werner, PT, MPT April 14, 2012 at 16:37 #

      Totally agree, Bridget. We are seeing more patient/athletes that are missed with the misconception that imbalance is the only vestibular dysfunction and the gross misunderstanding of dizziness as a symptom. We need to look at the entire function of the vestibular system including VOR and gaze instability as this is often the cause of headaches, cognitive dysfunction, etc.

  7. Tom September 25, 2011 at 09:46 #

    Dustin,
    I have been very interested in all the posts concerning this subject. I am a 38 year old man who suffered a serious concussion 2 years ago. It was the oddest of circumstances, but basically I was using a sawzall power tool and it got stuck in in thick branch. When I pulled the trigger, it shook my whole body, especially my brain. I was foggy and dizzy for several weeks; luckily I had no headaches. I could not function at work and missed several weeks. After I felt better, I went running 5 months after the injury and suffered dizziness(foggy feeling) for several more weeks. When I told my Dr., he said he had never heard of anyone getting a concussion from running. I know it sounds crazy, but it reaggravated my symptoms.
    Then last week I was in my car and accelerated quickly to make a turn. I was jolted back and I have suffered the same symptoms as before for the past week. It’s been 2 years since my initial injury and I thought I my brain had recovered. Now I am scared to death to make the wrong movements. I haven’t even attempted running again. Frustrated is an understatement. The anxiety I have developed as a result is terrible. I am very encouraged to hear that there may be a way to improve. I plan to contact a vestibular therapist soon. Any thoughts or advice is greatly appreciated. Thank you.

    Tom

  8. Kathy Wooley September 26, 2011 at 08:35 #

    This has all been very enlightening. in December of 2010, my son, then 14 years old, suffered a ‘major’ concussion when he fell hard to the basketball court. Some of the visible symptoms lasted for 2 months. In May of this year, he was diagnosed with another concussion after falling in the yard when attempting to kick a football. His symptoms were short lived, but three days later he experienced paralysis of only part of his left arm. They diagnosed him as having a conversion disorder – no physical explanation for his paralysis, but the brain was taking his anxiety and converting it to a physical ailment. Twenty-four hours later his arm instantly returned to normal, again with no explanation. He was later tested by a neurophsychiatrist who concluded he suffered from depression and a learning disability. Last week while playing basketball, he tripped and fell to the ground. He bounced up and seemed fine for a few seconds, then the symptoms set in again and he very calmly lay himself down in the middle of the court. All of his symptoms had returned and we made yet another trip to the ER. We have been so confused by the lasting affects this has had, not having heard of the term ‘vestibular’ concussion, but his symptoms all fit that diagnosis. He has been uncoordinated (which we assumed was due to his rapid growth in the past 18 months), has dizziness, headaches, and trouble with mathematics. He has sudden mood swings and emotional outbursts. He is, of course, very frustrated with sitting out of team sports, restricted physical activity, and continued setbacks. Since he needs to avoid too much video stimulation, the things we can do for entertainment are limited and get old in a hurry.
    Finding this blog is an answer to prayer. I will be taking this information with me to our next doctor visit and using it to look into rehabilitation exercises for him.

  9. bedford1956 December 29, 2011 at 20:23 #

    This is such an important post ! My 16 yr old daughter had an (ice hockey) concussion that lasted 12 months, at which point it was 90-95% resolved. Then I asked for VRT, mostly to establish a new “balance baseline.” But in fact, over six weeks, it helped immensely. now she is more like 98% back (and took up golf.) I recommend VRT now especially for PCS, but it looks like it’s becoming useful earlier. Comment to Tom: you don’t have to hit your head to get a concussion – it’s called a whiplash concussion, and it got both Jason Bay of the Mets (2010) and Taylor Twellman of the Boston Revolution MLS (2009). Twellman benefited from Craniosacral therapy (a offshoot of cranial osteopathy) if you can find one where you live. Kathy – you might want to look into CST for your son’s extended symptoms. Another hint for schoolwork: books on tape (or on the iPod) really help. Find free downloads at your public library, or for classic titles try iTunesU, in the books section (find the “free” button). It really helped during the recovery because she could listen and follow along in the hardcopy, but she knew how long it would take to to “read” a chapter from the track times on the recording, and her retention was better, too.

    • Kathy December 29, 2011 at 23:18 #

      Thank you, bedford, for your thoughts. I am happy to report that my son is improving thanks to a personal trainer that works with our physical therapist. After discussing VRT with our pediatrician, he encouraged us to give it a try. The personal trainer, along with the physical therapist, researched the appropriate exercises needed. It’s been three months since we began VRT and in the past week, my son has played several hours of basketball with no recurring symptoms!! We have paid the expenses of the therapy out of our pockets and it has been worth every penny.

    • Mary January 6, 2012 at 16:16 #

      Thanks for mentioning Craniosacral Therapy. As a craniosacral practitioner, I’ve worked with a several people who are recovering from concussions.

      One of my clients played college football 30 years ago and he was still having symptoms. After six sessions, he felt “back to normal” and hasn’t had any more problems.

      This light-touch therapy has helped with the dizziness, fogginess and allowed them to feel more clear and focused. Also helps to reduce or eliminate headaches and improves balance issues.

      It’s very gentle work that feels deeply relaxing to the person receiving it. It’s something to consider with all the other conditioning you’re doing.

  10. Dorothy Bedford December 30, 2011 at 16:12 #

    Kathy – Congratulations on following through on the VRT, and thank you for responding. Every family’s experience is important to report, to sketch in a more complete picture of this approach. Thank you to Dustin for the original blog post !

    • Dr. Steven Geanopulos January 4, 2012 at 12:15 #

      When doing VRT or any form of rehabilitation for concussion please pay attention to fatigue-ability. When an highly conditioned athlete is doing simple eye and vestibular exercises we never consider fatigue, after all these are kids who can run a mile in under 5 minutes or clean 2X their body weight.

      One has to remember that the tissue being rehabilitated is brain tissue not muscle tissue. Just like if you were to have a fractured arm in a cast for 6 weeks, after the bone has healed, the muscles are atrophied and need to be rehabilitated before going back to pre-injury workouts, otherwise you would exceed the metabolic rate of the muscle tissue and cause damage. The same hold true for the neurological pathways involved in the exercise. The symptoms of fatigue is not likely to be due to the eye or postural muscles fatiguing, but rather the neurological pathway. Neurons not muscle cells.

      • Dustin Fink January 4, 2012 at 12:47 #

        So true Dr. Geanopulos… We have been doing the Air Force Academy Vision Enhancement program for years out here. Nothing is as “fun” to watch as seeing burly athletes that can do just about anything struggle with simple tracking or focusing exercises (all healthy of course for this program).

        There is enough people that walk out with a headache after doing some vision enhancement that doing too much for a injured brain could be very troubling…

      • Julie Moore September 14, 2012 at 15:08 #

        I am working in vestibular rehab and trying to find more specific information on guidelines is difficult. I completely agree with the fatigue factor and concern about neurological pathways being healed, how much is too much. Recently we have gotten referrals for patients s/p concussion 2 weeks out. I am concerned this is too soon to begin. What would you recommend?

      • Dustin Fink September 17, 2012 at 00:20 #

        Julie,

        I think rehab, be it vestibular or physical, does not need to be included unless there is no progress with the “rest and recover” method. I too believe that one could be introduced to too much “stimuli” with early rehab entrance. However I guess that would completely depend on the resolution or lack there of…

  11. Kathy January 4, 2012 at 15:02 #

    The personal trainer has been very much on top of watching his fatigue level. A neurologist that we had visited prior to working with the PT gave us some paperwork referring to the ‘Stepwise” recovery process. We have been blessed with a trainer and therapist that have a reputation for being conservative in their workouts.

  12. Janice January 15, 2012 at 07:10 #

    My son suffered a concussion in football practice back in October of 2011. I picked him up from football practice and he looked pale and discribed symptoms of a concussion. I took him to urgent care and the dr. told us since he did not pass out and vomit he did not have a concussion. He even laughed when I questioned him and told me he was a neurologist. My sons heartrate was up when we went to urgent care and he had every sign of a concussion. I did not feel that the dr was right so I called our family physician (this was around 8 PM) and they wanted to see him the next day. My husband took him the next day they did a catscan and it verified that he had a stage 2 concussion. The dr. put him on 5 days of rest and wanted to see him back weekly. My son continued to have severe headaches, but went back to school, he continued to go to the dr for about 3 more weeks. Finally my son had asked the trainer at school when he could practice?! The trainer asked if he had symptoms still and after talking with my son referred us to a concussion specialist. After seeing the specialist , he was put on bedrest for 7 days and did half days of school, put on medication for the headaches and started physical therapy. He had been doing better, but still suffering dizziness and his heartrate was still high, so they did a brain scan, stress test, and ordered blood work. It all came back and the dr determined he had a vestibular concussion. We are now alittle over 3 months into dealing with this concussion, he sufferes from dizziness very little now and his heartrate is doing better. We just had a vision assesment done on him and he is going to start vision therapy this week, we are hoping we see the end of this soon. It has been very hard to see our son suffer through this, his grades have declined, he is very impatient and grumpy and he is suffering depression off and on. He is involved in baseball and has been told he can’t tryout because he has not been cleared, he will be turning 16 in February, but cannot get his license due to his vision issues. Needless to say it has been very hard on him. We are struggling to let him play football again or not, just so scared he will have to go through all of this again. He is suffereing depression because he wants to participate with the football players. We have been talking with him about not playing football and he will hear nothing of it. I know he could aggrivate the concussion with alot of different things, but we know he will get hit in the head right away with playing football, so we have tried to steer him towards baseball. I am open to hearing suggestions about what everyone thinks and how they dealt with their child going back into sports?

    • Dustin Fink January 15, 2012 at 09:41 #

      Life is a risk after a concussion… Sports increase that risk… When I consult with players and parents I use a “risk assessment” approach… If your son wants to be competitive, then perhaps track, golf, tennis, etc. may appeal to him… If he still wants to be around the collision sports but it is just not safe enough, perhaps as a manager or student athletic trainer?

      Just some thoughts, good luck!!!

    • Joana Valek November 9, 2012 at 00:23 #

      Dear Janice,
      I have suffered a concussion 18 years ago… did not pass out , yet spent the entire night getting up and vomitting… your arrogant urgent care specialist would have admitted I had a concussion as I remained hazed yet conscious…. 2 weeks later I got a speeding ticket… as I was instinctively trying to get away from a car behind me who was so painfully blinding me by its lights I thought I would die from that pain in my eyes…till the 2nd concussion 3 years later when I realized how life-long the results of concussion can be.
      Your son is young, and has a long life ahead of him, the question is- what is more important – a healthy brain or playing football ? We now know from stories of many professional football (and hockey and boxing) athletes that the brain injury results are real.

    • Joana Valek November 9, 2012 at 00:33 #

      This is a very good resource for someone who may wonder why they should be concerned after a consussion while playing impact sports.
      Item 8 discusses cumulative effect of concussions:

      http://www.stopdizziness.com/downloads/The%2015%20Critical%20Questions%20Concussion.pdf

  13. Kathy November 9, 2012 at 10:22 #

    Janice,
    Two years ago my son suffered a level three concussion during basketball practice. He never passed out nor did he vomit, but he did lose cognitive and motor functions: some returned in a few days, others lasted weeks, and still others took months. Six months later he suffered from a second concussion when he slipped and fell, hitting his head on the ground. Four months following that one, he suffered a whiplash concussion during basketball practice. I say ‘whiplash’ because his head did not make contact with anything but it did whip back and forth, bouncing his brain around inside. Each injury required a visit to the ER because he lost cognitive function and motor skills. The second and third injuries, however, he recovered from within a few hours. The doctors were adamant that he had suffered traumatic brain injuries and should not return to sports for several months. He missed several months of school forcing us to hold him back a year. He too suffered from depression due to inactivity, headaches, missing his teammates and frustration. The docs eventually put him on meds temporarily to help the healing process. With all of this we decided he could not return to contact sports until he had been free of any and all symptoms for one year. His physical therapist researched vestibular concussions and worked with him. This was a tremendous help in his recovery. Although he was not happy about it, he submitted to our decision to hold him out. It helped that our doctor supported our decision and told him as much. He is now 16, completely symptom free, and has returned to playing basketball. It is early in the season and I am as nervous as a cat every time he gets on the court. The doctors have informed us that if he has another brain injury, he will be restricted from contact sports indefinitely. I would encourage you not to give in to the ‘wisdom’ of a teenager who can’t see life beyond the next few days. You have his entire future in mind.

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