Relationship Between Cognitive Assessment and Balance Measures in Adolescents Referred for Vestibular Physical Therapy After Concussion.

OBJECTIVE: To examine the relationship between cognitive and balance performance in adolescents with concussion. DESIGN: Retrospective case series. SETTING: Tertiary. PATIENTS: Sixty patients. INTERVENTIONS: Correlation analyses were performed to describe the relationship between symptoms, cognitive measure, and balance measure at the time of initiation of vestibular physical therapy. MAIN OUTCOME MEASURES: Cognitive performance was assessed using the Immediate Post-concussion Assessment and Cognitive Testing (ImPACT). The dizziness and balance function measures included dizziness severity rating, Activities-specific Balance Confidence scale (ABC), Dizziness Handicap Inventory (DHI), Functional Gait Assessment, gait speed, Timed "UP and GO," Five Times Sit to Stand, and Sensory Organization Test (SOT). To account for multiple comparisons, the False Discovery Rate method was used. RESULTS: Performance measures of balance were significantly correlated with cognitive measures. Greater total symptom scores were related to greater impairment in the ABC and DHI (r = 0.35-0.39, P ≤ 0.008) and worse performance in condition 2 of the SOT (r = -0.48, P = 0.004). Among the ImPACT composite scores, lower memory scores were correlated with impaired balance performance measures (r = 0.37-0.59, P ≤ 0.012). Lower visual memory was also correlated with worse ABC scores. CONCLUSIONS: The significant relationships reported between the cognitive performance scores and balance measures may reflect that similar levels of functioning exist across domains in individuals with protracted recovery who receive vestibular physical therapy. CLINICAL RELEVANCE: The weak-to-moderate relationships warrant the continuous use of multiple domains of assessment. A better understanding to the relationships between the domains of functioning after concussion may improve the overall management approach for adolescents with concussion.

Performance of high school adolescents on functional gait and balance measures.

PURPOSE: To describe the performance of high school adolescents during common functional gait and balance measures used in vestibular physical therapy. METHODS: A cross-sectional study of 91 participants determined their performance on the Activities-specific Balance Confidence (ABC) scale, Dynamic Gait Index, Functional Gait Assessment, Timed "Up and Go" (TUG), Five Times Sit to Stand (FTSTS) test, tests of gait speed (GS), and the Balance Error Scoring System. In a subset of this sample, GS, TUG, and the FTSTS were repeated twice to examine test-retest reliability. RESULTS: The measures of GS, TUG, and FTSTS were normally distributed. The Activities-specific Balance Confidence, Dynamic Gait Index, and Functional Gait Assessment exhibited a ceiling effect. The timed measures exhibited moderate to good reliability. CONCLUSIONS: These performance scores may provide end points for discharge from vestibular physical therapy. However, clinicians should be aware of the ceiling effect exhibited by some measures.

Validation of the Gait Disorientation Test in children with concussion.

Background: Mild traumatic brain injury (mTBI) or concussion is a complex injury that is difficult to diagnose and assess. There are negative impacts on cognition, balance, and mobility after a concussion. The Gait Disorientation Test (GDT) is an objective measure that assesses a person's balance ability by comparing the walking time with eyes open and the walking time with eyes closed in a standardized walking task. The purpose of this study was to assess the validity and the diagnostic properties of the GDT in children with concussions. Methods: Thirty-six children with concussions, and 91 controls aged between 9 and 18 years old participated in the study. Participants completed demographics, the GDT, the Functional Gait Assessment (FGA), the Pediatric Vestibular Symptom Questionnaire (PVSQ), and the Pediatric Visually Induced Dizziness Questionnaire (PVID). Results: Children with concussions showed higher (worse) GDT scores (M = 2.18 ± 1.93 s) than healthy controls (M = 1.13 ± 0.95 s), which was statistically significant (P = 0.014). Conclusion: The GDT was able to distinguish between children with concussions and healthy controls. Given the simplicity of the GDT, it can be used to assist in discriminating between children with and without concussion.

Vestibular rehabilitation for dizziness and balance disorders after concussion.

BACKGROUND AND PURPOSE: Management of dizziness and balance dysfunction is a major challenge after concussion. The purpose of this study was to examine the effect of vestibular rehabilitation in reducing dizziness and to improve gait and balance function in people after concussion. METHODS: A retrospective chart review of 114 patients (67 children aged 18 years and younger [mean, 16 years; range, 8-18 years]; 47 adults older than 18 years [mean, 41 years; range, 19-73 years]) referred for vestibular rehabilitation after concussion was performed. At the time of initial evaluation and discharge, recordings were made of outcome measures of self-report (eg, dizziness severity, Activities-specific Balance Confidence Scale, and Dizziness Handicap Inventory) and gait and balance performance (eg, Dynamic Gait Index, gait speed, and the Sensory Organization Test). A mixed-factor repeated-measures analysis of variance was used to test whether there was an effect of vestibular rehabilitation therapy and age on the outcome measures. RESULTS: The median length of time between concussion and initial evaluation was 61 days. Of the 114 patients who were referred, 84 returned for at least 1 visit. In these patients, improvements were observed in all self-report, gait, and balance performance measures at the time of discharge (P < .05). Children improved by a greater amount in dizziness severity (P = .005) and conditions 1 (eyes open, fixed support) and 2 (eyes closed, fixed support) of the Sensory Organization Test (P < .025). DISCUSSION: Vestibular rehabilitation may reduce dizziness and improve gait and balance function after concussion. For most measures, the improvement did not depend on age, indicating that vestibular rehabilitation may equally benefit both children and adults. CONCLUSIONS: Vestibular rehabilitation should be considered in the management of individuals post concussion who have dizziness and gait and balance dysfunction that do not resolve with rest.

Physical Therapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury.

Over the last decade, numerous concussion evidence-based clinical practice guidelines (CPGs), consensus statements, and clinical guidance documents have been published. These documents have typically focused on the diagnosis of concussion and medical management of individuals post concussion, but provide little specific guidance for physical therapy management of concussion and its associated impairments. Further, many of these guidance documents have targeted specific populations in specific care contexts. The primary purpose of this CPG is to provide a set of evidence-based recommendations for physical therapist management of the wide spectrum of patients who have experienced a concussive event. J Orthop Sports Phys Ther 2020;50(4):CPG1-CPG73. doi:10.2519/jospt.2020.0301.

Concussion Attitudes and Beliefs, Knowledge, and Clinical Practice: Survey of Physical Therapists.

BACKGROUND: A concussion is considered a mild traumatic brain injury that may cause physical, cognitive, affective, and sleep dysfunction. Physical therapists have been identified as health care providers involved in the multidisciplinary care of a patient with concussion. OBJECTIVE: The purpose of this study was to describe the current attitudes and beliefs, knowledge, and practice of physical therapists in the treatment of patients with concussion. METHODS: A 55-question electronic survey divided into 6 sections-(1) demographics, (2) current practice in concussion, (3) youth concussion legislation, (4) attitudes and beliefs toward concussion management, (5) concussion knowledge, and (6) clinical decision making-was developed and distributed online through selected American Physical Therapy Association sections. RESULTS: A total of 1,272 physical therapists completed the survey. Seventy percent of the respondents (n=894) reported having concussion training. Although supportive of the role of the physical therapist in the treatment of a person with concussion, the respondents demonstrated less confidence when making return-to-play decisions. Respondents correctly answered, on average, 13 (out of 15) concussion knowledge questions, with gaps exhibited in understanding the clinical utilization of concussion severity scales, the conservative treatment of youth who sustain a concussion, and anticipated normal computed tomography and magnetic resonance imaging after a concussion. When provided with clinical scenarios, respondents were able to recognize when a referral to a physician was indicated; however, they demonstrated variability in identifying a need for vestibular or manual physical therapy. LIMITATIONS: Convenience sampling was utilized, limiting generalizability of the results of the study to the physical therapy profession as a whole. CONCLUSION: Physical therapists demonstrated a solid foundation of concussion knowledge, but gaps still existed. Future professional development opportunities should be developed to target identified gaps in knowledge and current practice patterns.

Reliability and concurrent validity of instrumented balance error scoring system using a portable force plate system.

OBJECTIVES: The Balance Error Scoring System (BESS) is a commonly used test in adolescents and young adults. Affordability and portability of newer force plates has led to instrumentation of many clinical balance tests including the BESS. Despite the higher precision of force plate measures compared with clinical scoring, it is unclear if the instrumented BESS demonstrate concurrent validity and reliability when compared with the original BESS. The purpose of this study was to examine the reliability and concurrent validity of instrumented BESS testing using a commercially available force plate system. METHODS: Thirty-six participants participated in the initial testing day (17 male/19 female, M = 15.9 years, SD = 1.5 years). The test-retest sample consisted of 26 participants who completed the same testing procedure after 1 week. For all testing sessions, participants performed the BESS while standing on a portable force plate system. Number of errors and sway velocity were obtained. Concurrent validity was established through correlation analysis examining the relationship between the original and the instrumented BESS scores. Reliability was established using Intraclass Correlation Coefficient (ICC3,1) computed for the instrumented and the original BESS. RESULTS: A significant moderate relationship exists between the total scores of the original and the instrumented BESS (rs = 0.54, p = 0.001). Despite a range of reliability scores for the different conditions in the instrumented BESS (ICC3,1 = 0.19-0.61) and the clinically scored BESS (ICC3,1 = 0.13-0.71), the reliability score for the total test score was the same for the instrumented and the clinical test (ICC3,1 = 0.74). CONCLUSION: Although the instrumented BESS may appear to demonstrate concurrent validity against the original BESS, instrumentation did not improve its reliability. Future research should examine if the instrumented BESS demonstrates validity against laboratory level force plates and if it is able to overcome the ceiling effect reported for the clinical BESS test.

Exercise prescription patterns in patients treated with vestibular rehabilitation after concussion.

BACKGROUND AND PURPOSE: Individuals with concussion often complain of persistent dizziness and imbalance, and these problems have been treated with vestibular rehabilitation exercises. The purpose of this study is to describe the vestibular rehabilitation exercise prescriptions provided to individuals after concussion. METHODS: A retrospective chart review of vestibular rehabilitation home exercise programmes prescribed by physical therapists for 104 participants who were diagnosed with concussion was conducted. Each of the exercises was classified by exercise type, duration and frequency. Frequency counts of the most common exercise types were recorded. Exercise progression patterns were examined by determining how exercise types were modified from visit to visit. RESULTS: Eye-head coordination exercises were the most commonly prescribed exercise type (in 95% of participants), followed by standing static balance exercises (in 88% of participants), and ambulation exercises (in 76% of participants). CONCLUSIONS: Understanding the prescription patterns of expert clinicians may elucidate the vestibular-related impairments of individuals after concussion and may provide a resource for therapists who may be starting vestibular rehabilitation programmes for management of individuals with concussion. To improve quality of care, future research should be directed to relate outcomes to the exercise prescription patterns.