OBJECTIVES:The purpose of this chapter is to provide an update on the clinical management of vestibular and balance dysfunction in a concussed athlete with a focus on diagnosis, initial work-up, and initial and continuing management. Although much is still unknown about the etiology of vestibular and balance dysfunction in a concussed athlete, we briefly review current theories about neural pathophysiology to help link proposed treatment methodologies. INTRODUCTION:The treatment and management of vestibular and balance dysfunction in concussed athletes requires a multidisciplinary approach and is based on continuous reassessment of the presenting symptoms. The clinical challenge toward managing persistent symptoms of the post-concussive athlete is discerning whether a set of symptoms match diagnostic testing and whether further neurological work up is necessary. Because there are no discrete time boundaries to make such judgment calls, we offer a guide to help with the difficult clinical decisions necessary to treat the post-concussive athlete. METHODS: Literature search was performed using the following keywords: Vestibular and balance dysfunction, concussion, concussed athlete and treatment, vestibular rehabilitation therapy. Original research studies, literature reviews, and clinical guidelines were reviewed between 1997 and 2012, with the majority of articles dating beyond 2004. Although we acknowledge that post-concussive states lie within a continuum, we decided to divide treatment and management into three stages: time after initial impact, recovery, and prolonged recovery. RESULTS: In post-concussive athletes, impairments in balance may exist as a result of transmitted force to peripheral and central neural substrates that integrate sensory information and coordinate motor function. Corroborative information, clinical examination, neuropsychological testing, and continual reassessment are means to determine severity of dysfunction and track clinical course and resolution of symptoms. Persistence of symptoms beyond initial impact may require medication trials or adjustments that are tailored to the patient's medical history and/or neurocognitive rehabilitative techniques such as vestibular rehabilitation therapy to prevent progression of neurologic sequelae. Prolonged recovery of more than six months may require neurological consultation. CONCLUSION: Concussion management and treatment of vestibular and balance impairments in athletes should be assessed in a stepwise manner, from initial impact to resolution of symptoms. If symptoms are prolonged, impaired neuronal mechanisms or irreversible cerebral damage may underlie persistent symptoms and cognitive deficits seen in neurocognitive testing. Management protocols are currently focused on individualized assessment of neurocognitive assessment and comprehensive symptomatic evaluation (Reddy et al., 2008). It is widely accepted that neurocognitive and resolution of concussion-induced symptoms must be resolved prior to returning to sport or play and therefore...

INTRODUCTION:Dizziness and vertigo encompass a spectrum of balance-related symptoms caused by a variety of etiologies. Balance is affected by many systems: proprioceptive pathways, and visual, cerebellar, vestibulocochlear, and vascular/vasovagal systems. Treatment includes antihistamines, antiemetics, benzodiazepines, anti-inflammatory, anti-Meniere's, anti-migraine, antidepressants, anticonvulsants, and aminopyridines. Many medications may cause these balance-related symptoms. Onset characteristics differ and may be reversible or irreversible. Ototoxic drugs may affect the cochlea, the vestibular system, or both. Medications, whether at "therapeutic" or toxic doses, have a spectrum of side effects, depending on the medication and individual. PURPOSE: The section on drugs that treat dizziness and balance deficiencies was divided to elaborate on medications by classes and etiology specific treatment. Drugs with potential to cause balance-related symptoms were chosen to elaborate on specific medical issues encountered in rehabilitation. Background on advantages of certain drugs and methods to minimize adverse effects are reviewed. SUMMARY: Effective treatment depends on generating an accurate diagnosis, using the appropriate drug, appropriate dosage, and for an appropriate duration. For every medication, there is a spectrum of side effects at "therapeutic" and toxic doses, depending on the medication and individual. CONCLUSION: Practitioners must ensure correct diagnoses and cater their treatments to the patients' clinical scenario and medical units' capacities.

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