Dizziness after traumatic brain injury: Overview and measurement in the clinical setting

Quantitative measurement of post-concussion syndrome Using Electrovestibulography

In this study, a noninvasive quantitative measure was used to identify short and long term post-concussion syndrome (PCS) both from each other and from healthy control populations. We used Electrovestibulography (EVestG) for detecting neurophysiological PCS consequent to a mild traumatic brain injury (mTBI) in both short-term (N = 8) and long-term (N = 30) (beyond the normal recovery period) symptomatic individuals. Peripheral, spontaneously evoked vestibuloacoustic signals incorporating - and modulated by - brainstem responses were recorded using EVestG, while individuals were stationary (no movement stimulus). Tested were 38 individuals with PCS in comparison to those of 33 age-and-gender-matched healthy controls. The extracted features were based on the shape of the averaged extracted field potentials (FPs) and their detected firing pattern. Linear discriminant analysis classification, incorporating a leave-one-out routine, resulted in (A) an unbiased 84% classification accuracy for separating healthy controls from a mix of long and short-term symptomatology PCS sufferers and (B) a 79% classification accuracy for separating between long and short-term symptomatology PCS sufferers. Comparatively, short-term symptomatology PCS was generally detected as more distal from controls. Based on the results, the EVestG recording shows promise as an assistive objective tool for detecting and monitoring individuals with PCS after normal recovery periods.

Dizziness-related disability following mild-moderate traumatic brain injury

OBJECTIVE

To investigate the associations between dizziness-related disability after mild- moderate Traumatic Brain Injury (TBI) and personal factors, injury-related factors and post-injury functioning using the International Classification of Functioning, Disability and Health (ICF) as a framework.

METHODS

Baseline assessments for a Randomised Controlled Trial (RCT) were obtained for 65 patients (mean age 39.2 years; SD 12.9 years; 70.8% women) who had dizziness and reduced balance 2-6 months after injury. The severity of the brain injury, physical and psychological self-reported symptoms and results from the performance based tests were used as independent variables. The main outcome measure (dependent variable) was the Dizziness Handicap Inventory (DHI).

RESULTS

Multivariate analyses showed that, the dizziness-related disability was predicted by pre-injury comorbidities (p ≤ 0.05) and was associated with self-reported vertigo symptoms (p < 0.001), reduced performance-based balance (p ≤ 0.05) and psychological distress (p ≤ 0.05). These factors accounted for 62% of the variance in DHI.

CONCLUSION

Dizziness and balance problems after mild-moderate TBI appear to be complex biopsychosocial phenomena. Assessments linked to the ICF domains of functioning might contribute to a broader understanding of the needs of these patients. Further, prospective clinical studies with non-dizzy control groups are needed to investigate dizziness-related disability after TBI.

Patients with chronic dizziness following traumatic head injury typically have multiple diagnoses involving combined peripheral and central vestibular dysfunction

OBJECTIVE

We hypothesised that chronic vestibular symptoms (CVS) of imbalance and dizziness post-traumatic head injury (THI) may relate to: (i) the occurrence of multiple simultaneous vestibular diagnoses including both peripheral and central vestibular dysfunction in individual patients increasing the chance of missed diagnoses and suboptimal treatment; (ii) an impaired response to vestibular rehabilitation since the central mechanisms that mediate rehabilitation related brain plasticity may themselves be disrupted.

METHODS

We report the results of a retrospective analysis of both the comprehensive clinical and vestibular laboratory testing of 20 consecutive THI patients with prominent and persisting vestibular symptoms still present at least 6months post THI.

RESULTS

Individual THI patients typically had multiple vestibular diagnoses and unique to this group of vestibular patients, often displayed both peripheral and central vestibular dysfunction. Despite expert neuro-otological management, at two years 20% of patients still had persisting vestibular symptoms.

CONCLUSION

In summary, chronic vestibular dysfunction in THI could relate to: (i) the presence of multiple vestibular diagnoses, increasing the risk of 'missed' vestibular diagnoses leading to persisting symptoms; (ii) the impact of brain trauma which may impair brain plasticity mediated repair mechanisms. Apart from alerting physicians to the potential for multiple vestibular diagnoses in THI, future work to identify the specific deficits in brain function mediating poor recovery from post-THI vestibular dysfunction could provide the rationale for developing new therapy for head injury patients whose vestibular symptoms are resistant to treatment.

Osteopathic Manipulative Treatment for Somatic Dysfunction After Acute Severe Traumatic Brain Injury

Somatic dysfunction caused by traumatic brain injury (TBI) may be managed by osteopathic manipulative treatment (OMT). In this case report, the authors describe 2 patients with severe TBI who were each treated with OMT in a level-1 regional trauma center. Both patients received OMT beginning in the acute care phase of injury. Somatic dysfunction improved during the course of treatment, and no adverse effects of OMT were noted. More comprehensive research may clarify the efficacy and adverse effects of OMT as part of multimodal acute care of patients with severe TBI.

Vestibular Rehabilitation After Traumatic Brain Injury: Case Series

BACKGROUND AND PURPOSE

There has been an increasing focus on vestibular rehabilitation (VR) after traumatic brain injury (TBI) in recent years. However, detailed descriptions of the content of and patient responses to VR after TBI are limited. The purposes of this case series are (1) to describe a modified, group-based VR intervention and (2) to examine changes in self-reported and performance-based outcome measures.

CASE DESCRIPTION

Two women and 2 men (aged 24-45 years) with mild TBI, dizziness, and balance problems participated in an 8-week intervention consisting of group sessions with guidance, individually modified VR exercises, a home exercise program, and an exercise diary. Self-reported and performance-based outcome measures were applied to assess the impact of dizziness and balance problems on functions related to activity and participation.

OUTCOMES

The intervention caused no adverse effects. Three of the 4 patients reported reduced self-perceived disability because of dizziness, diminished frequency and severity of dizziness, improved health-related quality of life, reduced psychological distress, and improved performance-based balance. The change scores exceeded the minimal detectable change, indicating a clinically significant change or improvement in the direction of age-related norms. The fourth patient did not change or improve in most outcome measures.

DISCUSSION

A modified, group-based VR intervention was safe and appeared to be viable and beneficial when addressing dizziness and balance problems after TBI. However, concurrent physical and psychological symptoms, other neurological deficits, and musculoskeletal problems might influence the course of central nervous system compensation and recovery. The present case series may be useful for tailoring VR interventions to patients with TBI. Future randomized controlled trials are warranted to evaluate the short- and long-term effects of VR after TBI.

Concussion is confusing us all

It is time to stop using the term concussion as it has no clear definition and no pathological meaning. This confusion is increasingly problematic as the management of ‘concussed’ individuals is a pressing concern. Historically, it has been used to describe patients briefly disabled following a head injury, with the assumption that this was due to a transient disorder of brain function without long-term sequelae. However, the symptoms of concussion are highly variable in duration, and can persist for many years with no reliable early predictors of outcome. Using vague terminology for post-traumatic problems leads to misconceptions and biases in the diagnostic process, producing uninterpretable science, poor clinical guidelines and confused policy. We propose that the term concussion should be avoided. Instead neurologists and other healthcare professionals should classify the severity of traumatic brain injury and then attempt to precisely diagnose the underlying cause of post-traumatic symptoms.

Variability of the modified Balance Error Scoring System at baseline using objective and subjective balance measures

Aim:

To investigate preseason modified Balance Error Scoring System (mBESS) performance in a collegiate football cohort; to compare scores to an objective mobile balance measurement tool.

Materials & methods:

Eighty-two athletes completed simultaneous balance testing using mBESS and the King–Devick Balance Test, an objective balance measurement tool. Errors on mBESS and objective measurements in the double-leg, single-leg (SS) and tandem stances were compared.

Results:

Mean mBESS error score was 7.23 ± 4.65. The SS accounted for 74% of errors and 21% of athletes demonstrated the maximum error score. There was no significant correlation between mBESS score and objective balance score.

Conclusion:

The high variability and large number of errors in the SS raises concerns over the utility of the SS in identifying suspected 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.

Measurement properties of the high-level mobility assessment tool for mild traumatic brain injury

BACKGROUND

The High-Level Mobility Assessment Tool (HiMAT) was developed to quantify balance and mobility problems after traumatic brain injury (TBI). Measurement properties of the HiMAT have not been tested in the mild TBI (MTBI) population.

OBJECTIVE

The aim of this study was to examine the reliability, validity, and responsiveness of the HiMAT in a sample of the MTBI population.

DESIGN

A cohort, pretest-posttest, comparison study was conducted.

METHODS

Ninety-two patients (69% men, 31% women) with a mean age of 37.1 years (SD=13.8) and a mean Glasgow Coma Scale score of 14.7 (SD=0.7) were recruited from Oslo University Hospital. All patients were tested with the HiMAT (range of scores=0 [worst] to 54 [best]) at 3 months postinjury. Fifty-one patients were retested at 6 months. A subgroup of 25 patients was selected for the reliability testing. Balance function reported on the Rivermead Post Concussion Symptoms Questionnaire was chosen as a criterion and anchor. Criterion-related validity was studied with correlation analysis. Intraclass correlation coefficients (ICCs) were used for assessing interrater and intrarater reliability. Minimal detectable change (MDC) for the HiMAT was estimated. Responsiveness was assessed with receiver operating characteristic curve analyses.

RESULTS

The mean HiMAT sum score was 46.2 (95% confidence interval=44.4 to 48.1). The HiMAT had a ceiling effect of 22.8%. The correlation between HiMAT scores and self-reported balance problems was large (r=-.63, P<.001). Interrater and intrarater reliability of the HiMAT sum score was high (interrater ICC=.99, intrarater ICC=.95). The MDC was -3 to +4 points. Responsiveness was good, and the HiMAT discriminated well between patients with self-perceived improved balance function versus unchanged balance function (area under the curve=0.86).

LIMITATIONS

The small sample size, a ceiling effect, and lack of a gold standard were limitations of the study.

CONCLUSIONS

The HiMAT demonstrated satisfactory measurement properties for patients with MTBI. The HiMAT can be used as an outcome measure of balance and mobility problems in patients with MTBI.

Associations among self-reported balance problems, post-concussion symptoms and performance-based tests: a longitudinal follow-up study

PURPOSE

The main objectives of this study were to describe long-term self-reported balance problems and to explore their associations with post-concussion symptoms and performance-based tests.

METHOD

Prospective study of patients with mild traumatic brain injury (MTBI). Self-reported balance problems and post-concussion symptoms were measured with the Rivermead Post-concussion Symptoms Questionnaire at 1 and 4 years after injury. Performance-based tests were performed 4 years after injury and included posturography, the Dynamic Gait Index (DGI), walking speed tests, and the six-minute walk test.

RESULTS

Self-reported balance problems were reported in 31% of patients 4 years after injury and correlated significantly with post-concussion symptoms. The correlations with performance-based tests varied from ρ = 0.18 to ρ = 0.70 and were strongest for the maximum walking speed test (ρ = 0.70) and a dual-task test (ρ = 0.43). The DGI had a considerable ceiling effect.

CONCLUSIONS

Balance problems were long-term consequences of MTBI in one third of this study sample. Self-reported balance problems correlated with post-concussion symptoms and some of the performance-based tests. Future research needs to develop and evaluate appropriate rehabilitation strategies that also address the balance problems.

Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players?

BACKGROUND

There has been increasing attention and understanding of sport-related concussions. Recent studies show that neurocognitive testing and symptom clusters may predict protracted recovery in concussed athletes. On-field signs and symptoms have not been examined empirically as possible predictors of protracted recovery.

PURPOSE

This study was undertaken to determine which on-field signs and symptoms were predictive of a protracted (≥21 days) versus rapid (≤7 days) recovery after a sports-related concussion. On-field signs and symptoms included confusion, loss of consciousness, posttraumatic amnesia, retrograde amnesia, imbalance, dizziness, visual problems, personality changes, fatigue, sensitivity to light/noise, numbness, and vomiting.

STUDY DESIGN

Cohort study (prognosis); Level of evidence, 2.

METHODS

The sample included 107 male high school football athletes who completed computerized neurocognitive testing within an average 2.4 days after injury, and who were followed until returned to play as determined by neuropsychologists using international clinical concussion management guidelines. Athletes were then grouped into rapid (≤7 days, n = 62) or protracted (≥21 days, n = 36) recovery time groups. The presence of on-field signs and symptoms was determined at the time of injury by trained sports medicine professionals (i.e., ATC [certified athletic trainer], team physician). A series of odds ratios with χ(2) analyses and subsequent logistic regression were used to determine which on-field signs and symptoms were associated with an increased risk for a protracted recovery.

RESULTS

Dizziness at the time of injury was associated with a 6.34 odds ratio (95% confidence interval = 1.34-29.91, χ(2) = 5.44, P = .02) of a protracted recovery from concussion. Surprisingly, the remaining on-field signs and symptoms were not associated with an increased risk of protracted recovery in the current study.

CONCLUSION

Assessment of on-field dizziness may help identify high school athletes at risk for a protracted recovery. Such information will improve prognostic information and allow clinicians to manage and treat concussion more effectively in these at-risk athletes.

Rehabilitation in the patient with mild traumatic brain injury

Traumatic brain injury (TBI) has garnered increased public attention in the past several years because of high-profile athletes with possible long-term effects of their injuries as well as large numbers of returning combat veterans injured by blast explosions. Most of these injuries are mild in nature and require no specific surgical treatment but may benefit from brief rehabilitation interventions. To appropriately rehabilitate patients with mild traumatic brain injury (mTBI), one must fully understand its clinical course and the factors that accelerate or delay recovery. Education is the centerpiece of mTBI treatment and should be included in the rehabilitation plan. When devising the rehabilitation plan, the neurologist should take into account the goals of the patient and establish a reasonable time frame for treatment paralleling the expected recovery course. Cognitive and vestibular functions are commonly affected after mTBI and are particularly responsive to rehabilitation interventions. Vocational rehabilitation and community reentry planning are aspects of the global rehabilitation plan that should not be neglected. Combat-injured veterans with mTBI present unique challenges to the rehabilitation team, and assessment of these patients often needs to include assessment of psychological function.

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.

Dizziness after traumatic brain injury: Results from an interview study

BACKGROUND

Dizziness is a commonly reported sequel to traumatic brain injury (TBI).

OBJECTIVE

To better define the nature of the symptomatology and the impact that dizziness has on the TBI survivor.

SETTING

A community brain injury rehabilitation programme and a community access programme for TBI survivors.

METHOD

Focus groups with TBI survivors and individual interviews with TBI survivors and some of their carers.

RESULTS

The data confirmed that dizziness is difficult for TBI survivors to define and describe and it consists of multiple symptoms. Dizziness also appears to be associated with significant functional difficulties. Additionally, many of the participants of this study reported falling. Carers reported a number of observable signs of dizziness and indicated that they believed they were able to tell when the person they cared for was dizzy.

CONCLUSION

The results provide information which will help in the development of more appropriate outcome measurement tools for dizziness after a TBI.

Motor impairment rehabilitation post acquired brain injury

OBJECTIVE

We sought to investigate the efficacy of treatment strategies used to manage motor impairments following acquired brain injury (ABI) in order to provide guidance for clinical practice based on the best available evidence.

METHODS AND MAIN OUTCOMES

A systematic review of the literature from 1980-2005 was conducted focusing on pharmacological, non-pharmacological, and exercise interventions available for motor impairments post ABI. The efficacy of a given intervention was classified as strong (supported by two or more randomized controlled trials (RCTs)), moderate (supported by a single RCT), or limited (supported by other types of studies in the absence of RCTs).

RESULTS

Thirty-six studies examining a variety of treatment approaches for motor impairments and activity limitations following ABI were evaluated. The majority of interventions are only supported by limited evidence. However, there is strong evidence that serial casting does reduce ankle plantar contractures due to spasticity of cerebral origin, and strong evidence also suggests that partial body weight supported gait training does not provide any added benefit over conventional gait training. There is also moderate evidence to support the use of functional fine motor control retraining to improve motor coordination, tizanidine for upper and lower extremity spasticity, and specific sit-to-stand training to improve functional ability. There is also moderate evidence that casting alone is as effective as casting and Botulinum toxin injections for plantar contractures.

CONCLUSIONS

Although there are a variety of treatment strategies to manage motor impairments and activity limitations following ABI, most are only supported by limited evidence pointing to the need for studies of improved methodological quality in this area.

Laboratory-free measurement of gait rhythmicity in the assessment of the degree of impairment and the effectiveness of rehabilitation in patients with vertigo resulting from vestibular hypofunction

A portable system for measurement of stride time rhythmicity was developed using the technique of Hausdorff et al (2001a Arch. Phys. Med. Rehabil. 82 1050-6). Measurement was performed for an extended period of walking of 256 steps for each foot outside of the laboratory on 18 normal individuals and 20 patients referred with symptomatic vestibular impairment. Ten of the patients were reassessed following vestibular therapy. Gait rhythmicity measured by standard deviation (SD) stride time was found to be significantly higher in patients with vestibular impairment than in normal volunteers (mean +/- SD 60.3 +/- 39.8 ms versus 21.9 +/- 4.9 ms respectively, P < 0.001, t-test). The ten patients who returned following a course of vestibular rehabilitation displayed significant improvement in SD stride time following therapy (mean +/- SD 57.3 +/- 44.6 ms prior to and 40.9 +/- 23 ms following therapy, P = 0.01, Wilcoxon signed rank test). Gait rhythmicity measurement, specifically measurement of stride time variability, appears to be a powerful assessment tool for objective measurement of extent of impairment and response to therapy in patients with vestibular hypofunction.