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. 

Introduction-only references:

  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.
Vestibular (Balance/Dizziness) Dysfunction
10.1

Evaluation by an experienced healthcare professional(s) with specialized training in the vestibular system, should include a thorough neurologic examination that emphasizes vision, vestibular, balance and coordination, and hearing. The evaluation should be conducted prior to 3 months post-injury. See Appendix 3.4 for specific exam details.

Adapted from the VA/DoD Management of Concussion/Mild Traumatic Brain Injury Clinical Practice Guideline (VA/DoD, 2016).

Level of Evidence Not Applicable
Last updated  

10.2

If symptoms of benign positional vertigo are present, the Dix-Hallpike Manoeuvre (Appendix 10.2) should be used for assessment once the cervical spine has been cleared.

Level of Evidence Not Applicable
Last updated  

10.3

A canalith repositioning maneuver should be used to treat benign positional vertigo (BPPV) if the Dix-Hallpike manoeuvre is positive. The Epley manoeuvre (Appendix 10.3) should be used on patients with positive Dix-Hallpike manoeuvre for both subjective and objective BPPV. Others should be referred to an otolarynthologist or a healthcare professional certified in vestibular therapy.

Level of Evidence Not Applicable
Last updated  

10.4

People with functional balance impairment who screen positive on a balance measure should undergo further balance assessment and treatment by a qualified physician or healthcare professional certified in vestibular therapy pending clinical course.

Level of Evidence Not Applicable
Last updated  

10.5

Vestibular rehabilitation therapy is recommended for unilateral peripheral vestibular dysfunction.

Level of Evidence Not Applicable
Last updated  

10.7

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

Taken from the VA/DoD Management of Concussion/Mild Traumatic Brain Injury Clinical Practice Guideline (VA/DoD, 2016).

Level of Evidence Not Applicable
Last updated  

Vision Dysfunction
10.9

Vision changes can occur post-concussion and should be screened for (see Appendix 10.4). If vision symptoms are reported, take an appropriate case history and complete a visual examination.

Level of Evidence Not Applicable
Last updated  

10.10

When assessed in a medically-supervised interdisciplinary concussion clinic, patients with significant functionally-limiting visual symptoms could be considered for a referral to a regulated healthcare professional with training in vision assessment and therapy (i.e. ophthalmologist, optometrist) for assessment.

Adapted from the VA/DoD Management of Concussion/Mild Traumatic Brain Injury Clinical Practice Guideline (VA/DoD, 2016).

Level of Evidence Not Applicable
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.

Balaban C, Hoffer ME, Szczupak M, et al. Oculomotor, Vestibular, and Reaction Time Tests in Mild Traumatic Brain Injury. PLoS One. 2016;11(9):e0162168.
Country: USA
Design: Case-Control
Quality Rating: DOWNS & BLACK: 16/32 *5 of the sections were not applicable


Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014(12):CD003162.
Country: United Kingdom
Design: Cochrane Review
Quality Rating: N/A *No checklists were appropriate to score this article design


Kleffelgaard I, Soberg HL, Bruusgaard KA, Tamber AL, Langhammer B. Vestibular Rehabilitation After Traumatic Brain Injury: Case Series. Phys Ther. 2016;96(6):839-849.
Country: Norway
Design: Case Series
Quality Rating: DOWNS & BLACK: 11/32 *4 of the sections were not applicable


Yadav NK, Ciuffreda KJ. Objective assessment of visual attention in mild traumatic brain injury (mTBI) using visual-evoked potentials (VEP). Brain Inj. 2015;29(3):352-365.
Country: USA
Design: Case-Control
Quality Rating: DOWNS & BLACK: 16/32 *5 of the sections were not applicable


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.
Country: USA
Design: Delphi Study
Quality Rating: DOWNS & BLACK: 10/32 *16 of the sections were not applicable due to the study design