Dizzy after a car accident? The Role of Vestibular Rehab in recovery

Overview of Presentation Epidemiology of Traumatic Brain injury Vestibular Rehabilitation Who wants to experience a temporary vestibular deficit? Review of the evidence

Magnitude and Costs of TBI 175-200/100 000 (US) endure head injuries/year (Krause, 96) 62/100 000 (US) living with impairments in community (Moscato, 94) $48.3 billion/year (US) for traumatic brain injury (Lewin, 91) $152 000 (US) per moderate-severe TBI survivor (Lewin, 91) 75% TBI survivors not working, 66% need help with ADL (Dawson, 95)

Atlanta National Center for Injury Prevention and Control Langlois et al. The Epidemiology and Impact of Traumatic Brain Injury: A Brief Overview. Journal of Head Trauma Rehabilitation. 2006 Oct., 21(5) 375-378. Atlanta National Center for Injury Prevention and Control 1.4 million traumatic brain injuries/year in US 280 000 are motor vehicle induced 2nd most common cause Guesses for number 1?

Sigurdardottir et al. Post concussion symptoms after traumatic brain injury at 3 and 12 months: A prospective study. Brain Injury. 2009 June, 23(6): 489-497. Emphasize age, traffic accident, explain differences in classes.

Sigurdardottir et al. Post concussion symptoms after traumatic brain injury at 3 and 12 months: A prospective study. Brain Injury. 2009 June, 23(6): 489-497. dizziness

Vestibular rehab + physiotherapy Most Common Sequelae after TBI MILD Headaches Visual deficits Pain Dizziness Postural Instability Moderate-Severe Heterotrophic Ossification Hypertonicity Seizures Postural Instability ↓ motor control Visual deficits Insomnia? Fatigue? (McNamee, 2009)

Vestibular Rehabilitation? Let’s begin with a review of how the vestibular system works ….

Vestibular Apparatus

Semicircular Canals vs Otoliths

Peripheral and Central Vestibular (Dizziness) (Visual disturbances) (Imbalance)

Benign Paroxysmal Positional Vertigo Most common cause of vertigo. Imbalance, nausea, dizziness. Etiology Idiopathic 39% Trauma 21% emedicine Treatment 80% remission in 24hrs using CRT Von Brevern, 2006.

BPPV Testing

Efficacy of Treatment for BPPV Canalith repositioning procedure is established as an effective and safe therapy that should be offered to patients of all ages with posterior semicircular canal BPPV. (Level A) American Academy of Neurology, 2008. Von Brevern M et al. Short Term Efficacy of Epley Manoeuvre: a double-blind randomized controlled trial. J Neurol Neurosurg Psychiatry. 2006 Aug, 77(8)980-2. Epley's manoeuvre is shown to resolve PC-BPPV both effectively and rapidly.

Motin et al. Benign Paroxysmal Positional Vertigo as the cause of dizziness in patients after severe traumatic brain injury: Diagnosis and treatment. Brain Injury. 2005 Aug., 19(9) 693-697. Design: 18 month prospective study; n=150. Main outcomes and results: 20 out of 150 patients reported positional vertigo. Of these 10 were diagnosed with BPPV. 100% of patients with BPPV had resolution of their symptoms following CRM manoevers. Conclusion: About half of patients with severe TBI complaining of positional vertigo had BPPV. These patients can be effeciently treated with physical manoevers improving rehabilitation outcomes.

Unilateral Vestibular Lesion Labrynthine Concussion from trauma Imbalance in vestibular sensory information Symptoms: Vertigo (initially) → Dizziness (72hrs onwards) Blurring of vision with head movements ↓ Postural Control Treatment: Specific exercises to promote brain compensation.

Anybody want to experience what these patients go through? Give a temporary imbalance in the vestibular system by spinning: Tests: Observe nystagmus in Infra-red goggles standing with feet together and eyes closed (posture) Visual acuity with head movement (vision) ? Feel vertiginous initially then dizzy? Nauseous?

Efficacy for UVH therapy Hillier SL, Holohan V. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database of Systematic Reviews 2007, Issue 4. Moderate to strong evidence that vestibular rehabilitation is safe, effective for treating unilateral peripheral vestibular dysfunction

What about Post Concussion Syndrome rehabilitation?

Alsahaleen et al. Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion. Journal of Neurological Physical Therapy. June 2010; 34: 87-93. Design: retrospective chart review of 114 patients referred for vestibular rehabilitation after concussion. Intervention: customized program to address dizziness, ocular motor dysfunction, gait and balance disturbances. Median of 4 visits/patient for 33 days. Outcomes: Self report measures of balance/dizziness; gait and balance performance measures. Results: improvement in all measures by discharge; children improved by greater amount. Conclusion: Vestibular rehabilitation should be considered in the management of individuals with PCS who have dizziness and gait/balance dysfunction that do not resolve with rest.

Gurr et al. Psychological consequences of vertigo and the effectiveness of vestibular rehabilitation for brain injury patients. Brain Injury. 2001 May, 15(5) 387-400. Design: n= 18; comparing change while on waitlist vs after therapy. Interventions: vestibular habituation exercises for movements that caused vertigo/dizziness. Outcomes: scores on self rating questionaires pertaining to vertigo, balance, emotional distress, handicap and coping. Results: Significant improvements in all domains post therapy vs no change while on waitlist. Conclusion: Vestibular habituation is effective in treating the psychological consequences of vertigo in brain injury patients.

Leddy et al. A preliminary study of symptom threshold training for refractory post concussion syndrome. Clinical Journal of Sports Medicine. 2010 Jan., 20(1): 21-27. Design: n=12; prospective case series. Interventions: 12 patients with refractory post concussion syndrome trained sub-maximally 5-6 x/week on treadmill for 3 weeks. Self report of symptoms, heart rate, intensity + duration of exercise used as outcome measures. Results: participants reported fewer PCS symptoms, exercised longer and more intensely after training compared with the waitlist period Conclusion: sub-max aerobic training appears beneficial and safe for PCS patients. Randomized controlled trial is warranted.

In Conclusion: MVA major cause of brain injury. Vestibular rehabilitation is proven effective for some of the sequelae of traumatic brain injuries. I have expertise in vestibular rehabilitation for brain injured patients and would be grateful for the opportunity to assist your clients.