Vestibular (Balance/ Dizziness) & Vision Dysfunction

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Persistent vertigo, dizziness, imbalance and visual disturbance are common symptoms of patients with concussion and are often associated with objective impairments of the vestibular system.1,2 
When assessment suggests vestibular dysfunction, vestibular interventions can be considered. While historically, medications have been used to suppress vestibular symptoms, including nausea, current evidence does not support this approach.3  

The most common cause of post-traumatic peripheral vestibular dysfunction is benign paroxysmal positional vertigo (BPPV).4,5 Patients experience episodes of vertigo, nystagmus and nausea with sudden changes in position, often including rolling over in bed or looking up. Other causes of dizziness can also be caused by post-concussion migraines, autonomic dysregulation, medications and other peripheral vestibular disorder. Patients with dizziness frequently experience concurrent psychological disorders such as anxiety.6 A tool such as the Dizziness Handicap Inventory can help to assess the functional impact of dizziness7.
A Cochrane review by Hillier and Hollohan (2007) identifies vestibular rehabilitation as an effective intervention for unilateral peripheral vestibular dysfunction1; this has been supported by Gurley et al.6 Weaker evidence also suggests vestibular rehabilitation may be helpful for central vestibular dysfunction.8 Vestibular rehabilitation is typically provided by a specialized a healthcare professional with specialized training and involves various movement-based regimens to bring on vestibular symptoms and desensitize the vestibular system, coordinate eye and head movements, and improve functional balance and mobility.

Vision Dysfunction

Patients presenting with vision disorders post-concussion may have impairment of visual acuity, accommodation, versional eye movements, vergence eye movements, visual field integrity and may experience photosensitivity. Practitioners should take a detailed history of vision symptoms and screen for potentially unrecognized visual deficits using simple confrontational field testing.9,10 Concussion patients with complex visual symptoms including diplopia and/or impaired vision should be referred to a neuro-ophthalmologist.11-13 Patients with impairments of accommodation, version or vergence movements, and/or photosensitivity may benefit from rehabilitative techniques rendered by qualified optometrists.11-13 Vision rehabilitation can be beneficial for some patients14, and should be considered for the treatment of persistent vision disorders. 

References supporting introduction:

  1. Hillier SL, Hollohan V. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2007(4):CD005397.
  2. Maskell F, Chiarelli P, Isles R. Dizziness after traumatic brain injury: overview and measurement in the clinical setting. Brain Inj. 2006;20(3):293-305.
  3. Bronstein AM, Lempert T. Management of the patient with chronic dizziness. Restor Neurol Neurosci. 2010;28(1):83-90.
  4. Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003;169(7):681-693.
  5. Ahn SK, Jeon SY, Kim JP, et al. Clinical characteristics and treatment of benign paroxysmal positional vertigo after traumatic brain injury. J Trauma. 2011;70(2):442-446.
  6. Staab JP, Ruckenstein MJ. Expanding the differential diagnosis of chronic dizziness. Arch Otolaryngol Head Neck Surg. 2007;133(2):170-176.
  7. Gurley JM, Hujsak BD, Kelly JL. Vestibular rehabilitation following mild traumatic brain injury. NeuroRehabilitation. 2013;32(3):519-528.
  8. Jacobson GP, Newman CW: The development of the Dizziness Handicap Inventory. Arch Otolaryngol Head Neck Surg 1990;116: 424-427
  9. Hansson EE, Månsson NO, Håkansson A. Effects of specific rehabilitation for dizziness among patients in primary health care. A randomized controlled trial. Clin Rehabil. 2004;18(5):558-565.
  10. Fox R. The rehabilitation of vergence and accommodative dysfunctions in traumatic brain injury. Brain Injury Professional. 2005;2(3):12-15.
  11. Cohen A. The role of optometry in the management of vestibular disorders. Brain Injury Professional. 2005;2(3):8-10.
  12. Rutner D, Kapoor N, Ciuffreda KJ, Craig S, Han ME, Suchoff IB. Occurrence of ocular disease in traumatic brain injury in a selected sample: a retrospective analysis. Brain Inj. 2006;20(10):1079-1086.
  13. Hillier C. Vision rehabilitation following acquired brain injury: A case series. Brain Injury Professional. 2005;2(3):30-32.
  14. Kapoor N, Ciuffreda KJ. Vision Disturbances Following Traumatic Brain Injury. Curr Treat Options Neurol. 2002;4(4):271-280.
10.1

Symptoms following concussion should be documented using a standardized symptom assessment scale (i.e., Rivermead Post-Concussion Symptoms Questionnaire or the Sport Concussion Assessment Tool (SCAT-5)). If vestibular, vision, balance and coordination symptoms are endorsed, they should be screened for and monitored at follow-up appointments using the VOMS. 

Vestibular and vision symptoms following concussion are common and have been reported in approximately 60% of athletes following sport-related concussion. Acute vestibular and vision dysfunction may be associated with prolonged recovery and delayed return to activity. Primary care providers should identify those patients at risk for prolonged vestibular and vision symptoms, and continually monitor their recovery. A valid and reliable tool to screen and monitor these symptoms is the Vestibular/Ocular-Motor Screening (VOMS) tool. If time is limited, other tools may be considered such as the modified VOMS (mVOMS) consisting of only four items (Smooth Pursuits, Horizontal Saccades, Horizontal VOR, VMS). The use of an objective screening tool can increase confidence in making decisions regarding potential referral for further assessment of patients not improving.

References supporting context:

  1. Ferris LM, Kontos AP, Eagle SR, et al. Optimizing VOMS for identifying acute concussion in collegiate athletes: Findings from the NCAA-DoD CARE consortium. Vision Res. 2022;200:108081.
  2. Mucha, A., Collins, M. W., Elbin, R. J., Furman, J. M., Troutman-Enseki, C., DeWolf, R. M., Marchetti, G., & Kontos, A. P. (2014). A Brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions: preliminary findings. The American Journal of Sports Medicine, 42(10), 2479–2486.
  3. Whitney SL, Eagle SR, Marchetti G, et al. Association of acute vestibular/ocular motor screening scores to prolonged recovery in collegiate athletes following sport-related concussion. Brain Inj. 2020;34(6):840-845.
  4. Yorke AM, Smith L, Babcock M, Alsalaheen B. Validity and Reliability of the Vestibular/Ocular Motor Screening and Associations With Common Concussion Screening Tools. Sports Health. 2017;9(2):174-180.
Level of Evidence B
( Standardized symptom assessment scale )
Level of Evidence A
( VOMS )
Last updated  
10.2

If vestibular, vision, balance and coordination symptoms remain functionally limiting at a time point greater than 1-month post-injury, the patient may require further assessment to identify potential causes of symptoms in order to direct treatment. Referral to a healthcare professional with specialized training in the vision or vestibular system is recommended at this stage.

Prolonged symptoms post-concussion are often non-specific and may be attributed to multiple contributors. For example, clinical context suggests that prolonged vestibular, vision and balance symptoms may be influenced by various mental health issues, neurological causes, uncorrected refractive error, binocular vision issues, etc.

Level of Evidence C
Last updated  
10.3

Benign paroxysmal positional vertigo (BPPV) should be suspected if there are positional symptoms such as brief vertigo with head position change lasting less than one minute. Once the cervical spine has been cleared, then a test such as the Dix-Hallpike Manoeuvre (Appendix 10.2) can be done to confirm BPPV. 

Most commonly, the posterior semi-circular canal is impacted in BPPV and may be tested using the Dix Hallpike manoeuvre, followed by the Epley/canalith repositioning manoeuvre if positive. However, if not responsive, other manoeuvres may be useful to assess other canals, which can be completed by healthcare professionals with specific vestibular assessment and management training. Refer to BPPV clinical practice guidelines for identification of the appropriate canals involved and management.

References supporting context:

  1. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017;156(3_suppl):S1-S47.
Level of Evidence C
Last updated  
10.4

When the Dix-Hallpike manoeuvre is positive, the Epley/canalith repositioning manoeuvre (Appendix 10.3) should be used to treat benign paroxysmal positional vertigo (BPPV).   

  • If the Dix-Hallpike manoeuvre reproduces vertigo, and there is no evidence of nystagmus, a Roll test should be performed, and other differential diagnoses or referral should be considered. The Epley manoeuvre should still be considered for treatment. 

  • If BPPV does not resolve within 1-3 treatments, consider referral to an otolaryngologist or healthcare professional certified in vestibular rehabilitation. 

Level of Evidence A
( Epley/canalith )
Level of Evidence C
( Roll test/differential diagnosis )
Level of Evidence C
( Referral )
Last updated  
10.5

Vestibular rehabilitation therapy is recommended for patients experiencing functionally limiting dizziness.

Vestibular rehabilitation therapy is an exercise-based treatment with the aims of enhancing gaze and postural stability, improving vertigo, and facilitating activities of daily living. Consisting of habituation, adaptation and substitution exercises, vestibular rehabilitation therapy has been shown to be an effective treatment for patients with prolonged vestibular symptoms following concussion. Habituation involves repeated exposure to stimuli which evoke vestibular symptoms with the aim of gradual desensitization. Adaptation exercises allow for the brain to adapt to incorrect signals coming from the impaired vestibular system. Finally, substitution involves using strategies to replace impaired vestibular function, such as using visual or somatosensory cues.

References supporting context:

  1. Galeno, E., Pullano, E., Mourad, F., Galeoto, G., & Frontani, F. (2022). Effectiveness of Vestibular Rehabilitation after Concussion: A Systematic Review of Randomised Controlled Trial. Healthcare, 11(1), 90.
  2. Han, B. I., Song, H. S., & Kim, J. S. (2011). Vestibular rehabilitation therapy: review of indications, mechanisms, and key exercises. Journal of Clinical Neurology, 7(4), 184–196.
  3. Schlemmer E, Nicholson N. Vestibular Rehabilitation Effectiveness for Adults With Mild Traumatic Brain Injury/Concussion: A Mini-Systematic Review. Am J Audiol. 2022;31(1):228-242.
Level of Evidence A
Last updated  
10.6

For patients with noise, light and other sensory sensitivities, a graduated exposure program is recommended. Patients should receive education about sensory tolerance levels and be encouraged to gradually increase exposure to these stimuli. Specifically, they should recognize the point at which mild symptoms have onset and push to the point that does not result in a significant or prolonged exacerbation of symptoms in order to promote desensitization.

Following an initial period of relative rest, the patient is encouraged to gradually engage in activities which cause minimal worsening of symptoms (i.e., no more than a 2-point increase on the 10-point scale ranging from 0-10), so long as the symptoms resolve shortly afterwards. Patients may consider using noise cancelling headphones or reduced screen brightness when gradually returning to functional activities. Lingering symptoms should not prevent activities of daily living or persist in affecting functioning the following day.

References supporting context:

  1. Schweizer TA, Baker AJ, eds. Tackling the Concussion Epidemic. Springer International Publishing; 2022. 
Level of Evidence C
Last updated  
10.7

When the patient identifies a problem with hearing (i.e., intolerance to everyday sounds, hearing loss, tinnitus), the steps below should be followed: 

  1. Take a detailed patient history, including auditory history to rule out common causes of hearing complications. 

  1. Perform otologic examination, including otoscopy. 

  1. Refer to audiology for hearing assessment if no other apparent cause is found. 

It is important to take a detailed patient history to rule out other common causes of hearing complications which may include basilar skull fracture and excessive ear wax.

Level of Evidence B
Last updated  
10.8

There is no evidence to suggest for or against the use of any particular modality for the treatment of tinnitus after concussion.

If tinnitus is present, patients should be referred to a neuro-otolaryngologist. Though there is no evidence for specific treatments for tinnitus (i.e., perception of sound that does not have an external source, so other people cannot hear it), clinical experience suggests that self-management strategies may aid with symptom coping. For example, patients may benefit from adding noise to their environment, such as white noise, to mask the ringing sound. White noise consists of the equal distribution of energy across all sound frequency, resulting in a humming noise like the sound of a fan. Many patients have also found brown noise to be helpful, consisting of higher energy at lower frequencies, such as the sound of a waterfall. Patients may be referred to free apps such as the Sleep Pillow or Soundly Sleeping app.

References supporting context:

  1. Parkwood Institute. Education Package Acquired Brain Injury Outpatient & Outreach Program. St. Joseph’s Hospital. May 20, 2022. https://www.sjhc.london.on.ca/regional-acquired-brain-injury-outpatient-program.
Level of Evidence C
Last updated  
10.9

If changes in vision are reported using a validated screening tool, the steps below should be followed:

  1. Take a detailed patient history, including visual history to rule out common causes of visual symptoms. 

  1. Perform assessments of visual acuity, pupillary function, visual fields, fundoscopy, binocular vergence, and extra-ocular movements that are within scope of practice (see Appendix 10.4).

Adapted from Reed, N., Zemek, R., Dawson, J., Ledoux, AA., et al. Living Guideline for Pediatric Concussion Care. 2021.

Symptoms affecting vision following concussion include but are not limited to blurred vision, photosensitivity, double vision, headache, fatigue and difficulty reading. Symptoms may be exacerbated by bright lights or overwhelming visual environments. An ocular exam should be completed to rule out ocular injuries and/or pre-existing disease that could impact vision such as glaucoma, hemorrhages, retinal detachment, etc.

References supporting context:

  1. Barnett BP, Singman EL. Vision concerns after mild traumatic brain injury. Curr Treat Options Neurol. 2015;17(2):329.
  2. Simpson-Jones ME, Hunt AW. Vision rehabilitation interventions following mild traumatic brain injury: a scoping review. Disabil Rehabil. 2019;41(18):2206-2222.
Level of Evidence C
Last updated  
10.10

Patients with significant functionally limiting visual symptoms should be considered for a referral to a regulated healthcare professional with specific training in vision assessment and providing vision rehabilitation (i.e., ophthalmologist, optometrist, occupational therapists, or physiotherapists).

Level of Evidence B
Last updated  
Appendix 10.1
Dizziness Handicap Inventory
 

EVALUATION

Title of Resource: Dizziness Handicap Inventory Hand

Reference: Jacobson,G. Newman, C. The Development of the Dizziness Handicap Inventory. Arch Otolaryngol Head Neck Surg. 1990;116(4):424–427. doi:10.1001/archotol.1990.01870040046011

Description: The Dizziness Handicap Inventory was developed to assess the effects of vestibular disorder on functional abilities. 

Resource Criteria:

Population

Adults attending vestibulometric testing. 

Reliability/ Validity

Test re-test reliability: r=.97

Proprietary?

Yes (Rightslink) 

Time to Administer

3-7 min

Method to Administer

Self-report

Formal Instructions (Mention if special environment/ equipment is needed)

Patient is to complete scale, ensure that they have completed all items. Subscale scores can be used to track changes. 

Instructional Video Available?
No

Ease of Use (By Patient)
Very Difficult   1     2     3     4     5   Very Easy


Ease of Administration (By Administrator)
Very Difficult   1     2     3     4     5   Very Easy


Other Comments
None

Jacobson,G. Newman, C. The Development of the Dizziness Handicap Inventory. Arch Otolaryngol Head Neck Surg. 1990;116(4):424–427. doi:10.1001/archotol.1990.01870040046011

Appendix 10.2
Dix-Hallpike Manoeuvre and Particle Repositioning Manoeuvre (PRM)
Appendix 10.3
The Epley Manoeuvre
Appendix 10.4
Screening Techniques for Vision Dysfunction
To learn more about strengths and limitations of the evidence informing each recommendation, click here.

Andrew DaCosta and others, Change in Balance Performance Predicts Neurocognitive Dysfunction and Symptom Endorsement in Concussed College Athletes, Archives of Clinical Neuropsychology. 2020;35(7):1123–1130. 

STROBE: 13/23 

Associated with recommendation 10.1 (standardized symptom assessment scale)

Kontos AP, Eagle SR, Marchetti G, et al. Discriminative Validity of Vestibular Ocular Motor Screening in Identifying Concussion Among Collegiate Athletes: A National Collegiate Athletic Association-Department of Defense Concussion Assessment, Research, and Education Consortium Study. Am J Sports Med. 2021;49(8):2211-2217.   

STROBE: 20/23

Associated with recommendation 10.1 (VOMS)

Parrington L, King LA, Hoppes CW, et al. Exploring Vestibular Ocular Motor Screening in Adults With Persistent Complaints After Mild Traumatic Brain Injury. J Head Trauma Rehabil. 2022;37(5):E346-E354.   

STROBE: 17/23

Associated with recommendation 10.1 (VOMS)

Büttner F, Howell DR, Doherty C, Blake C, Ryan J, Delahunt E. Clinical Detection and Recovery of Vestibular and Oculomotor Impairments Among Amateur Athletes Following Sport-Related Concussion: A Prospective, Matched-Cohort Study. J Head Trauma Rehabil. 2021;36(2):87-95.   

STROBE: 20/23

Associated with recommendation 10.1 (VOMS)

Mani R, Asper L, Khuu SK. Deficits in saccades and smooth-pursuit eye movements in adults with traumatic brain injury: a systematic review and meta-analysis. Brain Inj. 2018;32(11):1315-1336.

AMSTAR 2: 11/20

Associated with recommendation 10.1 (VOMS)

Matuseviciene G, Johansson J, Möller M, Godbolt AK, Pansell T, Deboussard CN. Longitudinal changes in oculomotor function in young adults with mild traumatic brain injury in Sweden: an exploratory prospective observational study. BMJ Open. 2018;8(2):e018734. 

STROBE: 20/23

Associated with recommendation 10.1 (VOMS, standardized symptom assessment scale)

Santo AL, Race ML, Teel EF. Near Point of Convergence Deficits and Treatment Following Concussion: A Systematic Review. J Sport Rehabil. 2020;29(8):1179-1193.

AMSTAR 2: 10/20

Associated with recommendations 10.1 (VOMS) and 10.10

Whitney SL, Eagle SR, Marchetti G, et al. Association of acute vestibular/ocular motor screening scores to prolonged recovery in collegiate athletes following sport-related concussion. Brain Inj. 2020;34(6):840-845.   

STROBE: 16/23

Associated with recommendation 10.1 (VOMS)

Ferris LM, Kontos AP, Eagle SR, et al. Predictive Accuracy of the Sport Concussion Assessment Tool 3 and Vestibular/Ocular-Motor Screening, Individually and In Combination: A National Collegiate Athletic Association-Department of Defense Concussion Assessment, Research and Education Consortium Analysis [published correction appears in Am J Sports Med. 2021 Nov;49(13):NP66-NP67]. Am J Sports Med. 2021;49(4):1040-1048.   

STROBE: 17/23 

Associated with recommendation 10.1 (VOMS, standardized symptom assessment scale)

Glendon K, Blenkinsop G, Belli A, Pain M. Does Vestibular-Ocular-Motor (VOM) Impairment Affect Time to Return to Play, Symptom Severity, Neurocognition and Academic Ability in Student-Athletes following acute Concussion?. Brain Inj. 2021;35(7):788-797.

STROBE: 17/23

Associated with recommendation 10.1 (VOMS)

Oldham JR, Howell DR, Knight CA, Crenshaw JR, Buckley TA. Single-Task and Dual-Task Tandem Gait Performance Across Clinical Concussion Milestones in Collegiate Student-Athletes. Clin J Sport Med. 2021;31(6):e392-e397.   

STROBE: 15/23

Associated with recommendation 10.1 (standardized symptom assessment scale)

Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014(12):CD003162.  

Quality Rating: N/A

Associated with recommendation 10.4 (Epley/canalith)

Rytter HM, Graff HJ, Henriksen HK, et al. Nonpharmacological Treatment of Persistent Postconcussion Symptoms in Adults: A Systematic Review and Meta-analysis and Guideline Recommendation. JAMA Netw Open. 2021;4(11):e2132221. 

AMSTAR 2: 14/20

Associated with recommendations 10.4 (Epley/canalith) and 10.5

Søberg HL, Andelic N, Langhammer B, Tamber AL, Bruusgaard KA, Kleffelgaard I. Effect of vestibular rehabilitation on change in health-related quality of life in patients with dizziness and balance problems after traumatic brain injury: A randomized controlled trial. J Rehabil Med. 2021;53(4):jrm00181. 

Downs & Black: 23/28

Associated with recommendations 10.4 (Epley/canalith) and 10.5

Wong CK, Ziaks L, Vargas S, DeMattos T, Brown C. Sequencing and Integration of Cervical Manual Therapy and Vestibulo-oculomotor Therapy for Concussion Symptoms: Retrospective Analysis. Int J Sports Phys Ther. 2021;16(1):12-20. 

STROBE: 17/23

Associated with recommendations 10.4 (Epley/canalith), 10.5, and 10.10

Langevin P, Frémont P, Fait P, Dubé MO, Bertrand-Charette M, Roy JS. Cervicovestibular Rehabilitation in Adults with Mild Traumatic Brain Injury: A Randomized Clinical Trial. J Neurotrauma. 2022;39(7-8):487-496.

Downs & Black: 22/28

Associated with recommendations 10.4 (Epley/canalith) and 10.5

Kinne BL, Bott JL, Cron NM, Iaquaniello RL. Effectiveness of vestibular rehabilitation on concussion-induced vertigo: a systematic review. Phys Ther Rev. 2018;23(6):338-347.   

AMSTAR 2: 10/20

Associated with recommendation 10.5

Kleffelgaard I, Soberg HL, Tamber AL, et al. The effects of vestibular rehabilitation on dizziness and balance problems in patients after traumatic brain injury: a randomized controlled trial. Clin Rehabil. 2019;33(1):74-84.   

Downs & Black: 23/28

Associated with recommendation 10.5

Schlemmer E, Nicholson N. Vestibular Rehabilitation Effectiveness for Adults With Mild Traumatic Brain Injury/Concussion: A Mini-Systematic Review. Am J Audiol. 2022;31(1):228-242.   

AMSTAR 2: 12/20

Associated with recommendation 10.5

Knoll RM, Herman SD, Lubner RJ, et al. Patient-reported auditory handicap measures following mild traumatic brain injury. Laryngoscope. 2020;130(3):761-767.

STROBE: 15/23

Associated with recommendation 10.7

Santhanam P, Meehan A, Orrison WW, Wilson SH, Oakes TR, Weaver LK. Central auditory processing disorders after mild traumatic brain injury. Undersea Hyperb Med. 2019;46(3):261-269.

STROBE: 16/23

Associated with recommendation 10.7

Goodrich GL, Martinsen GL, Flyg HM, et al. Development of a mild traumatic brain injury-specific vision screening protocol: a Delphi study. J Rehabil Res Dev. 2013;50(6):757-768.  

Downs & Black: 10/32

Associated with recommendation 10.9

Johansson J, Nygren de Boussard C, Öqvist Seimyr G, Pansell T. The effect of spectacle treatment in patients with mild traumatic brain injury: a pilot study. Clin Exp Optom. 2017;100(3):234-242.   

Downs & Black: 12/28

Associated with recommendation 10.10

Smaakjær P, Wachner LG, Rasmussen RS. Vision therapy improves binocular visual dysfunction in patients with mild traumatic brain injury. Neurol Res. 2022;44(5):439-445.   

Downs & Black: 18/28

Associated with recommendation 10.10