Vestibular and Balance Dysfunction Following Sport-Related Concussion

Abstract

Purpose Sport-related concussion is a significant public health concern that requires a multidisciplinary team to appropriately manage. Athletes often report dizziness and imbalance following concussion, and these symptoms can predict increased time to recover. Vestibular diagnostic evaluations provide important information regarding the athlete's oculomotor, gaze stability, and balance function in order to identify deficits for rehabilitation. These measures also describe objective function helpful for determining when an athlete is ready to return to play. The purpose of this clinical focus article is to provide background on the current understanding of the effects of concussion on the peripheral and central vestibular system, as well as information on a protocol that can be used for acute concussion assessment. Case studies describing 3 common postconcussion presentations will highlight the usefulness of this protocol. Conclusion Sport-related concussion is a highly visible disorder with many symptoms that may be evaluated in the vestibular clinic. A thoughtful protocol evaluating the typical presentation of these patients may help guide the multidisciplinary team in determining appropriate management and clearance for return to sport.

Vestibulo-ocular dysfunction in mTBI: Utility of the VOMS for evaluation and management – A review

“…Range of prevalence for the most common vestibular and oculomotor impairments post-concussion include smooth pursuit dysfunction (43-60%), saccadic dysfunction (21.6-30%), convergence insufficiency (47-55%), accommodative dysfunction (35-54.2%) (Capó-Aponte et al, 2012;Gallaway et al, 2017;Master et al, 2016;Merezhinskaya et al 2019;Suh et al, 2006b), vestibular-ocular reflex (VOR) impairment (0-71%) (Bogle, 2019), visual motion sensitivity, and balance deficits (40-68%) (Alsalaheen et al, 2010;Mucha et al, 2014). The oculomotor and vestibular systems overlap in symptomatology and pathoanatomy, and it is important to understand each system's independent contributions post-concussion to effectively manage and rehabilitate.…”

“…There is limited research into the prevalence of VOR specific dysfunction post-concussion. Some studies demonstrate a wide range of objective abnormalities in the VOR pathways from 0-71% (Bogle, 2019) and symptomatic reproduction with VOR testing range in up to 61% (Mucha et al, 2014).…”

“…Symptoms of VOR dysfunction include but are not limited to nausea, imbalance, dizziness, movementrelated blurry vision, unsteadiness, vertigo, anxiety in busy environments and visual motion sensitivity (Akin et al, 2017, Mucha et al, 2014. Children/adolescents (8-18 years old) and adults who experience dizziness/vertigo report considerably lower physical and emotional well-being (Deissler et al, 2017;Ten Voorde et al 2012;Weidt et al, 2014).Vestibular symptoms post-concussion may be related to peripheral vestibulopathy (Brodsky 2018b), central vestibulopathy due to injury to the cerebellum, thalamus, hippocampus, and oculomotor pathways (Alhilali et al, 2014), posttraumatic headache or migraine (Heyer et al, 2016, Stolte et al, 2015, autonomic dysfunction, altered multisensory integration (Bogle, 2019) and/or possible psychiatric concerns (Fife & Kalra, 2015).…”

“…Post-concussion, adults demonstrate BPPV in 5-57% of cases, while children and adolescents present less frequently in 5-20% of cases. Children with migraine diagnoses are five times more likely to present with BPPV (Bogle, 2019;Liu 2012).…”

“…Despite a lack of consensus on the optimal exercise program, multiple studies have demonstrated the efficacy of vestibular physical rehabilitation for individuals after mTBI (Alsalaheen et al, 2010;Alsalaheen et al, 2013;Gurley et al, 2013;Kleffelgaard et al, 2016;Murray et al, 2017;Prangley et al, 2017;Schneider et al, 2017). Vestibular rehabilitation is tailored towards the individual's impairments, and typically physical therapists work with the patient to improve balance, gaze stability, vestibulo-oculomotor function, canalith repositioning maneuvers if BPPV is present, and habituation exercises for specific head and body movements associated with that patient's daily activities/sport challenges (Bogle, 2019).…”