Concurrent vestibular activation and postural training recalibrate somatosensory, vestibular and gaze stabilization processes.

Postural instability is a common symptom of vestibular dysfunction that impacts a person's day-to-day activities. Vestibular rehabilitation is effective in decreasing dizziness, visual symptoms and improving postural control through several mechanisms including sensory reweighting of the vestibular, visual and somatosensory systems. As part of the sensory reweighting mechanisms, vestibular activation exercises with headshaking influence vestibular-ocular reflex (VOR). However, combining challenging vestibular and postural tasks to facilitate more effective rehabilitation outcomes is under-utilized. Understanding how and why this may work is unknown. The aim of the study was to assess sensory reweighting of postural control processing and VOR after concurrent vestibular activation and weight shift training (WST) in healthy young adults. Forty-two participants (18-35years) were randomly assigned into four groups: No training/control (CTL), a novel visual feedback WST coupled with a concurrent, rhythmic active horizontal or vertical headshake activity (HHS and VHS), or the same WST with no headshake (NHS). Training was performed for five days. All groups performed baseline- and post-assessments using the video head impulse test, sensory organization test, force platform rotations and electro-oculography. Significantly decreased horizontal eye movement variability in the HHS group compared to the other groups suggests improved gaze stabilization (p = .024). Significantly decreased horizontal VOR gain (p = .040) and somatosensory downweighting (p = .050) were found in the combined headshake groups (HHS and VHS) compared to the other two groups (NHS and CTL). The training also showed a significantly faster automatic postural response (p = .003) with improved flexibility (p = .010) in the headshake groups. The concurrent training influences oculomotor function and suggests improved gaze stabilization through vestibular recalibration due to adaptation and possibly habituation. The novel protocol could be modified into progressive functional activities that would incorporate gaze stabilization exercises. The findings may have implications for future development of vestibular rehabilitation protocols.

Experienced Clinical Decision-Making in Physical Therapist Management of Concussion: A Qualitative Study.

OBJECTIVE: The recent publication of the Physical Therapy Evaluation and Treatment After Concussion Clinical Practice Guideline is intended to assist clinicians in their decision-making specific to evaluation and intervention. Clinical practice guidelines are supported by best available evidence, though it is unknown what other factors drive clinical decision-making in the realm of concussion management. The purpose of this study was to explore factors related to the process of clinical decision-making of experienced physical therapists who treat individuals with concussion. METHODS: This grounded theory approach used semi-structured interviews of physical therapists who have practiced concussion management ≥3 years and have treated ≥15 individuals for postconcussion symptoms in the last year. Following the inductive approach, deductive qualitative methodology was used to explore alignment with recent guidelines. Member checking was used to ensure trustworthiness. RESULTS: Ten therapists' experience in treating concussion ranged from 5 to 20 years. Four overarching themes were identified that contribute to clinical decision-making: expert practice behaviors through use of reflection in action, clinical reasoning, collaboration, and evidenced informed practice; therapeutic alliance building using individualized education, reassurance, and relationship building; adaptability in prioritizing, assessing, and responding to patients' needs; and listening and observing. Clinician decision-making statements showed alignment with clinical practice guideline recommendations. CONCLUSION: Experienced therapists demonstrate a consistent approach that parallels the current clinical practice guideline while building off clinical experience to tailor individualized care focusing on patient centeredness. These factors may assist more novice clinicians to develop and improve their management strategies for optimal outcomes. IMPACT: Identified themes may broaden frameworks and guidelines for the management of individuals postconcussion specific to the field of physical therapy.

Agreement Between Physical Therapists in Diagnosing Benign Paroxysmal Positional Vertigo.

BACKGROUND AND PURPOSE: Individuals with benign paroxysmal positional vertigo (BPPV) are frequently referred to physical therapy for management, but little is known on how reliable therapists are at diagnosing BPPV. The purpose of the study was to examine the agreement between physical therapists in identifying nystagmus and diagnosing BPPV. METHODS: Thirty-eight individuals with complaints of positional vertigo, 19 from each of 2 clinics (clinics 1 and 2) that specialize in vestibular rehabilitation, had eye movements recorded using video goggles during positioning tests including supine-to-sit, supine roll, and Dix-Hallpike tests. Three therapists from each of the clinics independently observed videos, documented nystagmus characteristics of each testing position, and made a diagnosis for each case. Kappa (κ) statistics were calculated between therapists within each clinic for nystagmus identification and diagnosis. RESULTS: Clinic 1 therapists demonstrated substantial to almost perfect agreement in identifying nystagmus during positional tests (κ = 0.68-1, P < 0.005). Clinic 2 therapists showed moderate to almost perfect agreement for presence of nystagmus (κ = 0.57-1, P < 0.005). Therapists at both sites had almost perfect agreement of diagnosis side, canal, and mechanism (κ = 0.81-1, P < 0.005). DISCUSSION AND CONCLUSION: Therapists utilized observations from multiple positional tests to determine diagnoses. This was evident by occasional disagreement in nystagmus presence and characteristics, but agreement in diagnosis, including ruling out BPPV. The results may not be generalizable to all physical therapists or therapists' ability to diagnose central and atypical nystagmus presentations. Experienced physical therapists demonstrated strong agreement in diagnosing common forms of BPPV.Video Abstract available for more insight from the authors (see the Video Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A340).

Cervical Injury Assessments for Concussion Evaluation: A Review.

BACKGROUND: A concussion is a complex pathophysiologic process that is induced by biomechanical forces and affects the brain. Cervical injuries and concussion can share similar mechanisms and nearly identical symptoms or causes. Therefore, symptoms or causes alone may be insufficient to differentiate between patients with a concussion and patients with cervical injuries. OBJECTIVE: To demonstrate the homogeneous causes and symptoms observed in patients with a concussion and patients with cervical injury and to provide information on clinical tests that can differentiate cervical injury from pathologic conditions of vestibular or central origin. SUMMARY: Given that concussion and cervical injury share similar causes and symptoms, this information alone may be insufficient to diagnose a concussion. Clinical assessments, such as the cervical joint-reposition error test, smooth-pursuit neck-torsion test, head-neck differentiation test, cervical flexion-rotation test, and physical examination of the cervical spine, can be performed after a head and neck pathomechanical event to identify the presence of cervical injury. Differentiating between a concussion and cervical injury is clinically vital for timely and appropriate evidence-based treatment. CONCLUSIONS: Specific clinical tests should be used after a head and neck pathomechanical event to differentiate between symptoms due to a concussion and cervical injury. Continued research on the clinical utility of the 5 identified cervicogenic tests is also recommended.

Using Mean Absolute Relative Phase, Deviation Phase and Point-Estimation Relative Phase to Measure Postural Coordination in a Serial Reaching Task.

The objectives of this communication are to present the methods used to calculate mean absolute relative phase (MARP), deviation phase (DP) and point estimate relative phase (PRP) and compare their utility in measuring postural coordination during the performance of a serial reaching task. MARP and DP are derived from continuous relative phase time series representing the relationship between two body segments or joints during movements. MARP is a single measure used to quantify the coordination pattern and DP measures the stability of the coordination pattern. PRP also quantifies coordination patterns by measuring the relationship between the timing of maximal or minimal angular displacements of two segments within cycles of movement. Seven young adults practiced a bilateral serial reaching task 300 times over 3 days. Relative phase measures were used to evaluate inter-joint relationships for shoulder-hip (proximal) and hip-ankle (distal) postural coordination at early and late learning. MARP, PRP and DP distinguished between proximal and distal postural coordination. There was no effect of practice on any of the relative phase measures for the group, but individual differences were seen over practice. Combined, MARP and DP estimated stability of in-phase and anti-phase postural coordination patterns, however additional qualitative movement analyses may be needed to interpret findings in a serial task. We discuss the strengths and limitations of using MARP and DP and compare MARP and DP to PRP measures in assessing coordination patterns in the context of various types of skillful tasks. Key pointsMARP, DP and PRP measures coordination between segments or joint anglesAdvantages and disadvantages of each measure should be considered in relationship to the performance taskMARP and DP may capture coordination patterns and stability of the patterns during discrete tasks or phases of movements within a taskPRP and SD or PRP may capture coordination patterns and stability during continuous oscillating movement tasks.

Changes in standing postural control during acquisition of a sequential reaching task.

Postural control acquired during learning functional reaching movements has not been well examined. Fourteen healthy adults practiced a serial reaching task 300 times. Task acquisition was examined considering two types of action-goals [1]: hand accuracy and consistency as the focal action-goals and control of equilibrium as the postural action-goal [2,3]. Hand accuracy and consistency were measured as absolute constant error and variable error. Postural control was measured by time to boundary (TtB). Improvements were expected in the focal goals and postural goal; however the timing of improvements might reflect explicit and implicit learning processes. Practice effects resulted in improvements for hand task accuracy, consistency and an increase in TtB values. Changes in postural control may reflect improved efficiency or improved perception-action coupling by the postural system within task performance.