70% of athletes following sports-related concussion will be symptom-free within 7-10 days (Axis unpublished data). For the other 30%, it is important that we recognise the type of concussion so that we can target specific treatment, early. Clinicians working with concussion know it is a complex injury, with a large range of signs and symptoms. Recommendations from the 5th International Consensus on Concussion in Berlin (2017) have identified eight domains, and athletes often present with a bias towards one or more domains.
In this article, we will discuss recognition and management of vestibular and oculomotor dysfunction post-concussion. In a paper published last year by Kathryn Schneider and her colleagues, a combination of cervical and vestibular physiotherapy was found to reduce overall time to return to play.
The vestibular system lies within the inner ear and has an important role in balance. It transmits information to the brain about head movement and position in space. It is also responsible for our ability to keep our gaze stable on a target while the head is moving.
The oculomotor system is within the brain itself and is an umbrella term for the gaze systems that redirect the eyes to new targets. There are three basic types of ‘targeting movements’: (1) saccades, rapid movements the direct the eyes to each new target; (2) smooth pursuit, slower movements that the allow the eyes to follow moving targets; and (3) vergence movements, which adjust for target distance by changing the angle between the eyes.
Clinicians working with athletes will be familiar with the SCAT5 (Sideline Concussion Assessment Tool). It should not be used simply as a number or a score – but an aid to gain a deeper understanding of what is going on for that individual. The symptom reporting section can be useful in identifying clusters of symptoms that may indicate a particular domain is driving their issues. If an athlete is describing symptoms such as feeling off balance, dizzy, floaty, off colour, blurry, “fuzzy in the head”, and/or nauseous – or you observe signs like eye rubbing, balance difficulties, or eyes not focussing correctly, the vestibular / oculomotor systems should be considered.
For further investigation of these systems, the VOMS (Vestibular Ocular Motor Screening) developed at UPMC in Pittsburgh is a useful tool. It is a simple series of tests that an athlete performs and scores their symptoms. It was designed to be used by clinicians without specific vestibular training and a positive score can indicate a need for referral. There is normative data available, but it can also be very useful as part of preseason baseline testing. At an elite level players have baseline data to refer to, and this can be the challenge working with community-level athletes where we often don’t have this information. It would be good practice for any clinician working regularly with a team to take the time at the start of the season to SCAT5 and VOMS baseline their players. Not only can it help aid your concussion return to play planning, but it provides a valuable opportunity to get to know your players.
If a need for further vestibular and/or oculomotor assessment is identified after a concussion, athletes can be referred for vestibular physiotherapy at Axis Sports Medicine. Here, we take a problem-based approach to treatment planning – identifying the deficits and prescribing appropriate exercises and strategies to target these. Common dysfunctions seen post-concussion include issues with the vestibulocular reflex (VOR), loss of near point convergence (NPC) and accuracy issues when moving the eyes quickly between targets (saccades). Balance and gait are assessed, and often we see patterns of increased postural sway, visual reliance, and motion sensitivity.
Appropriate prescription of vestibular rehabilitation (VR) exercises is very important. With exertional management, athletes are given specific heart rate parameters that are below the symptom threshold. With VR, it is necessary to slightly induce their symptoms in a controlled manner, to encourage these systems to re-organise and come back into balance. As an athlete regains normal vestibular and oculomotor function, they can progress through the graduated return to play protocols. During their rehabilitation phase, a little creativity can help to tailor their treatment aims to their specific sport, and position within that sport. At Axis, we find working collaboratively with an athlete’s regular physiotherapist can be a great way to get the best outcomes.
Have you, or do you know someone who has, suffered a concussion recently? It’s better to play it safe and have your injury assessed by an experienced professional before you return to play, than risk further injury. We run Auckland’s most comprehensive sports concussion service.
Learn more here or call 09 521 9811 to make an appointment