2. Latent Effects of
Concussion on
Vestibular
Functioning
Salvador Bondoc

3. Case
 Timothy is a high school junior who was referred to an outpatient
rehab facility due to shoulder and neck pain. He reported that his
shoulder problem was associated with a car accident from 4
months ago but his symptoms did not occur until 4 weeks ago.
Timothy happen to work at a shop 4 hours daily as part of his HS.
 Provocative tests indicate impingement syndrome. His condition
was treated conservatively. He progressed very well. However, he
felt he could use more “therapy.” One day, he came to the clinic
upset that he may have to attend summer school. His grades have
suffered since the car accident. He said that he has troubles taking
tests and reading.

4. Case
 His pediatrician has already cleared him from any neurological
signs. He also has undergone a battery of psychological tests at
the request of the mother to determine whether there may be
cognitive effects of concussion. The psychologist cleared him. The
psychologist also determined that there an underlying depression is
less likely.
 Timothy and his mother disclosed that he has been sleeping a lot
but such sleep does not feel restful. “It’s hard to wake him up,”
exclaimed the mother.
 He used to be an active gamer but lately, video games and sitting
in front of the computer would give him headaches. One time, we
tried playing the Wii Tennis. Peculiar behaviors were noted…

5. What do we know about Concussions
in Adolescents and Young Adults?

6. Concussions
 Part of Brain Injury spectrum (NINDS, 2012)
 Accounts for 75 to 90% of BI
 Used interchangeably as mild TBI
 But TBI is assessed based on target measures
 Glasgow Coma Scale
 Lost of consciousness (LOA)
 Post-traumatic amnesia (PTA)
How about concussions?

8. Issues
 Sports-related concussions are most cited in
the literature
 MVAs are most common causes of
concussions in 15-24 years
Return to play is the target outcome
 Teens drop out of school, Adults lose
their jobs & go into long term
depression
 Latent effects have been examined in the
literature but only recently given relevance

9. Issues
 1.4 Million go to the ED due
to head trauma
 1.1 Million receive care
from ED and discharged
 Not all those who receive
concussion seek medical
help

10. Post-Concussion Syndrome
 Cluster of physical, psychosocial and cognitive
impairments or symptoms, foremost of which
include:
 Headaches
 Fatigue
 Irritability
 Dizziness
 Decreased memory
 Decreased attention, distractibility
 Persists in 15-40% in young persons adults for
months to years

14. Underreported PCS Conditions
 Executive dysfunctions (MacLennan & MacLennan, 2007)
 Postural instability or poor vestibular integration
(Bara et al, 2010)
 Visual processing and visual motor (Heitger et al, 2009)

15.  Long term studies show that most lingering effects tend to be
 Cognitive (decreased attention, concentration, memory) or
 Emotional (lability, irritability, depression) in nature

17. Decreased cognitive performance
Decreased visual-motor functioning
 May be readily detected
Impaired vestibular functions
 May come and go
Oculomotor and Vestibular
Dysfunctions are poorly detected by
brain neuroimaging diagnostics

18. Clinical Rationale
 Clients often manifest oculomotor and
vestibular disturbances together
 Blurred or double vision
 Bouncing images
+
 Vertigo
 Tipping over or falling
 Oculomotor Disturbance, Vertigo and
Nystagmus have Brainstem and/or
Cerebellar origins

19. 6 Physiologic Forms of
Oculomotor Function
 Gaze pursuit
 Saccade
 Fixation
 Vergence
 Vestibulo-ocular reflex
 Optokinetic reflex (pursuits + saccades)
 All functions are intended to keep the visual
target stable (on the macula)

20. Red Flags
Parameter Behavioral Signs
Posture Head tilt
Eye Motility Misalignment, nystagmus
Gaze ahead,
up, down, side
Horizontal/vertical rebound nystagmus
[Can the nystagmus be suppressed?]
Pursuit Appears saccadic
Saccades
@ 10o and 40o
Imprecise, lag speed, non-conjugated
VOR 1 Poor fixation with rapid head thrust
VOR 2 No VOR suppression (central)

21. Ruling Things Out
 Peripheral vestibular impairment is a diagnosis
of exclusion – i.e., no oculomotor disturbances
 Unilateral oculomotor presentation is a
peripheral condition
 Bilateral presentation is central in nature
 Isolated gaze impairments have brainstem
origin; may affect some VOR
 Cluster of gaze impairments have cerebellar
origin; often accompanied by balance
impairments

22. Other Clinical Screens
 Modified Epley/ Dix-
Hallpike Maneuver
 Peripheral lesion
 Head-shaking Test
 Peripheral  
 Central (cross
coupling)

23. Back to the Case
 While playing Wii Tennis, Timothy would stumble backwards as the ball
“approached” him. He also had trouble sidestepping and appeared to
get “clumsier” as the game went on.
 During break, Timothy had his head slumped down and one eye was
squinting. Although there was no nystagmus noted he seemed to
struggle with looking straight ahead.
Timothy’s manifestations prompted a more thorough vestibular screening.
No signs of nystagmus was noted with gaze, pursuit and saccades, but his
modified CTSIB results showed significant findings.

24. CTSIB
Modified
EYES OPEN EYES CLOSED
FEET ON FIRM
SURFACE
All Senses
On-Line,
“Balanced”
Vestibular,
Somatosensory
available
FEET ON UNEVEN
SURFACE
Somatosensory
inaccurate;
Vestibular + Visual
available
Vestibular
demands
increased

25. Balance Master
Balance Master SOT Results
Participant 1
Eyes
closed, Compliant
surface

27. More on the Case
 After discussion with pediatrician, Timothy
was “discharged” from hand therapy and
was “picked” again for OT to address neuro
concerns.
 Insurance authorized 4 visits + eval.
 Two main foci of intervention were:
 Self-management (fatigue)
 Vestibular retraining

30. Practice Implications
 Vestibular and oculomotor dysfunctions
 Have latent manifestations
 Are associated with decreased cognitive
performance and participation
 OT practitioners must routinely screen clients for
persons with history of concussion
 Start with Rivermead PCS Quest (RPQ).
 Screen further based on RPQ
 Visual motor
 Vestibular
 Executive function

31. Case Conclusion
 Timothy’s mother decided that he should take
the year off from school.
 He was referred for NeuroOptometrist who
identified problems with anti-saccade latency.
 He qualified for BRS assistance. He began
working at a garden center and took a liking for
growing roses.
 He stopped counseling indicating that the
strategies he learned from OT were more
useful.