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Physical Therapy in the DoD CDR Henry McMillan, PT, DPT LCDR Alicia Souvignier, MPT, DPT, GCS.

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Presentation on theme: "Physical Therapy in the DoD CDR Henry McMillan, PT, DPT LCDR Alicia Souvignier, MPT, DPT, GCS."— Presentation transcript:

1 Physical Therapy in the DoD CDR Henry McMillan, PT, DPT LCDR Alicia Souvignier, MPT, DPT, GCS

2 Objectives Identify the common patient presentations seen by PHS PTs working in the DoD Be able to indentify key aspects of the evaluation of a dizzy patient List 3 treatment techniques used to treat dizziness

3 Indentification of mTBI Incident in theatre results in Medivac to CONUS After redeployment, troops inprocess through the Soldier Readiness Center, where history of concussion is identified Soldiers with possible residual symptoms of concussion, are referred to the TBI clinic.

4 DoD/Physical Therapy Optimistic expectation for full recovery Therapists incorporate assessment of the Service Members goals and priorities along with MTBI related symptoms

5 Areas of concern for a soldier who has a history of concussion/mTBI Vestibular Dysfunction Balance Complaints Post Traumatic Headache Temporomandibular Joint Dysfunction Attention and Dual-Task Deficits Fitness/ Activity intolerance Musculosketetal complaints

6 Guidelines for PT Referral DHI Score > 11 (Yes to any F’s or P’s) Plus yes to one of the following: ◦ R/SR (Eyes Closed) less than 30 seconds- (arms across chest) ◦ VOR x1 for less than one minute with onset of symptoms ◦ Walking with HT increase symptoms, deviated gait, LOB- (Museum Gait)

7 Guidelines for PT referral ◦ If the patient reports any of the following  Difficulty with balance or dizziness that is affecting their functional performance  Unsteady while standing still or walking, in poor lighting, or in crowds  Difficulty with balance on uneven surfaces  Intense spinning, lightheadedness, or unsteadiness associated with exercise

8 Causes of Vertigo Vestibular Lesions or hypofunction ◦ Unilateral- infection/neuritis, lesions, bppv ◦ Bilateral- ototoxic medications Central processing ◦ Central lesions- brainstem, cerebellum ◦ Migranes ◦ Anxiety Cervicogenic dizziness ◦ Vertebrobasilar insufficiency ◦ Altered proprioceptive signals

9 Evaluation Subjective ◦ MOI or idiopathic ◦ Frequency/Intensity/duration ◦ Vision/ Hearing deficits ◦ Positional/activity induced  Valsalva/ pressure changes ◦ Describe symptoms of dizziness  Vertigo  Imbalance  Lightheadedness

10 Evaluation Subjective ◦ Activity Level  Recreational Sports ◦ Exercise Tolerance  Unit Physical Training ◦ Behavioral Health ◦ Quality of Life  DHI  Family Participation  Command/Unit Support

11 Vestibular Evaluation Musculoskeletal Screen Positional Testing Oculomotor Balance

12 Oculomotor Smooth Pursuit Saccadic VOR

13 Oculomotor Vestibular Ocular Reflex ◦ Vestibular system sends information regarding speed of movement to the visual system. Allows us to keep focus while performing functional head motions.

14 Test for VOR Head Thrust Test ◦ Grasp patients head firmly ◦ Tilt patient’s head to 30 deg flex ◦ Move head back and forth slowly and instruct patient to keep focus on target ◦ Provide a quick movement through a small range and watch for patient’s ability to refocus on target. ◦ Refixation saccade indicates decreased VOR


16 Test for VOR Dynamic Visual Acuity ◦ Test visual acuity on a Snellen Chart ◦ Turn patients head vertical and horizontal plane to the beat of a metronome at 2Hz ◦ Retest visual acuity while you are moving the patient’s head. ◦ 3 lines loss is significant

17 Positional Testing Dizziness caused by certain positions ◦ Spinning ◦ Use Frenzal goggles Dix Hallpike ◦ BPPV Motion Sensitivity Quotient ◦ Motion Sensitivity

18 Positional Testing Dix Hallpike ◦ Long sitting, head turned 45 deg, drop down with neck into about 30 deg of extension

19 Balance Functional Gait Assessment Romberg/ Sharpened Neurocom or M-CTSIB

20 Treatment Approaches Adaptation Exercises: adapting residual vestibular function to make up for lost function ◦ Example: Maintain visual fixation on object while the head is moving Substitution Exercises ◦ Doing exercises with and without visual cues Habituation Exercises ◦ Repeated exposure to provocative stimulus, for example motion sensitivity.

21 VOR Treatment - Adaptation Walking head turns Tracking with eyes Tracking with head movements All of the above together Above exercises on varied surfaces

22 Motion Sensitivity Treatment Brandt Daroff (picture) Positions identified from MSQ

23 Treatment of BPPV Canalith Repositioning Technique Liberatory Maneuver

24 Postural Stability Prioprio Neurocom- Balance activities- SOT ◦ Foam ◦ Unstable surface ◦ Uneven terrain

25 Treatment Ideas Foam bowling Bear claws Soccer Toss Wii Dance Revolution Discoball/strobe with balance

26 Goals for Physical Therapy Return to Duty Goals for Civilian Life

27 Questions?

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