I have to admit it has been quite a while since my last blog post! The last couple of months have been spent learning, developing and refining my skills as a therapist to provide a more integrated, multi-dimensional approach to the treatment of athletes and individuals with concussion injuries.
For this Edublog, I was inspired by a course I took recently with Bernard Tonks, which focused on vestibular assessment and rehabilitation. The reason I chose to learn more about treating the vestibular system is that more and more research has been published to show that the vestibular system can also be affected by the functional disturbance of a concussion injury. It is widely known that this system plays an integral role in balance, postural control, proprioception and oculomotor function. According to a review by Broglio et al., approximately 60% of athletes experience vestibular and oculmotor impairments following a concussion and if not addressed appropriately during rehabilitation, may lead to prolonged recovery. Therefore, it is a vital component of concussion rehabilitation for those who experience symptoms of dizziness and/or vertigo to improve outcomes.
A quick anatomy lesson,
The vestibular apparatus lies deep within the inner ear and is separated from the auditory canal by the tympanic membrane (eardrum). It consists of a bony labyrinth and a membranous labyrinth, which is suspended inside of the bony portion. The bony labyrinth consists of the cochlea, the vestibule and three semicircular canals (anterior, posterior and horizontal) that detect angular vertical and horizontal motion of the head and body. Within the membranous labyrinth there are the membranous portions of the semicircular canals and the two otolith organs; the saccule detects linear motion in the vertical plane and the utricle detects horizontal linear motion in the A-P plane. The vestibular nerve (cranial nerve VIII) transmits information about orientation and movement of the head in space to the brain from the labyrinth. It is then sent to two primary areas; the vestibular nuclei and the cerebellum for processing. These areas also interact with the somatosensory and visual areas of the brain. The afferent sensory information is transmitted into motor output to the ocular and spinal muscles, and control the vestibulo-ocular (VOR), vestibulospinal (VSR) and vestibulocollic reflexes. These reflexes act to control gaze stability during head movements (VOR), and muscles of the spine (VSR) and neck (VCR) to maintain upright postural control.
What happens after a concussion?
Vestibular and balance impairments are highly prevalent for individuals with a concussion. Sign and symptoms of these impairments can include reported dizziness, vertigo, unstable vision and poor gaze control (VOR), and/or disequilibrium. The presence of dizziness at the time of injury has been associated with prolonged recovery time.
So what is the evidence for treatment interventions?
Firstly, a study by Gottshall (2011), found that vestibular physical therapy led to more positive outcomes for patients with mTBI. Results showed improved balance, dynamic visual acuity and gait for those who experienced either exertional, migraine-associated or spatial disorientation dizziness. Furthermore, Alsalaheen et al. (2011), found similar positive group treatment effects for those who received an individualized treatment programs following a concussion. Treatment programs included exercises for gaze stability (VORx1, VORx2), balance control, habituation exercises and occasionally a canalith repositioning maneuver was used for the few subjects diagnosed with BPPV. The key point in both of these studies is that vestibular rehabilitation is very subjective and a program must be tailored to the individual and their reported signs and symptoms. Both studies indicated that the efficacy of treatment still needs to be further investigated.
A more recent randomized control trial (RCT) conducted by Schneider et al. (2014), investigated the effects of a combination vestibular and cervical spine rehabilitation on the duration of time for athletes recovering from a concussion to obtain medical clearance for return to play. The treatment group was provided with an individualized treatment plan by a physiotherapist for both the cervical spine (including manual therapy, neuromotor and proprioceptive retraining exercises) and vestibular rehabilitation (including habituation, gaze stability, adaptation, standing and dynamic balance exercises) for 8 weeks or until the time of medical clearance. Both the control and treatment groups received a basic treatment plan consisting of range of motion exercises, stretching and postural education. The results of the study showed a significant reduction in time to medical clearance for the treatment group as 11 of 15 subjects and only 1 of 14 subjects in the control group obtained clearance within 8 weeks. Results of this study indicate that cervicovestibular rehabilitation is an effective means of improving outcomes during recovery from a concussion. Once again, this study emphasized the importance of an individualized treatment plan based on predominant signs and symptoms. Recommendations for future research were to include a more thorough initial vestibular assessment and determining the optimal timing to initiate a rehabilitation program.
Therefore, the evidence does show a positive treatment effect for vestibular rehabilitation for individuals and athletes recovering from a concussion injury. It is an important piece of that multi-dimensional approach to rehabilition which may also include initial physical rest leading to a progression of graded exercise, manual therapy for the cervical spine, vision therapy, and academic accommodations.
With my own future research, I hope to investigate whether vestibular deficits, such as dynamic balance control and gaze stability, exist beyond the symptomatic phases of concussion. If so, we can utilize vestibular assessment strategies to better determine when an athlete should safely return to play. The takeaway message from this is to always approach concussion rehabilitation with a very strong subjective history! This is key to determine the predominant signs and symptoms within the many dimensions of an injury to ensure that you conduct a thorough assessment and effective rehabilitation program!
- Introduction to Vestibular Rehabilitation, presentation by Bernard Tonks (2016)
- Broglio, S. P., Collins, M. W., Williams, R. M., Mucha, A., & Kontos, A. (2015). Current and emerging rehabilitation for concussion: A review of the evidence.Clinics in Sports Medicine, 34(2), 213–231. http://doi.org/10.1016/j.csm.2014.12.005
- Hain, T. C. and Helminski, J. O. Anatomy and physiology of the normal vestibular system. https://www.health.utah.edu/physical-therapy/docs/faculty/materials/courses/Vestib_APreading_sm.pdf
- Gottshall, K. (2011). Vestibular rehabilitation after mild traumatic brain injury with vestibular pathology. NeuroRehabilitation 29(2); 167-171.
- Alsalaheen, B., Mucha, A., Morris, L. O., Whitney, S. L., Furman, J. M., Camiolo-Reddy, C. E., Collins, M. W., Lovell, M. R. and Sparto, P. J. (2010) Vestibular rehabilitation for dizziness and balance disorders after concussion. Journal of Neurologic Physical Therapy. 34(2); 87-93
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