Concussion Management Physiotherapy: What is Vestibular Rehabilitation?
Did you have a concussion recently or in the past? Are you currently experiencing dizziness and/or vertigo as a result, and want to know how to fix it?
Well, you’ve come to the right place! I’m here to talk to you about the role of vestibular rehabilitation in concussion management if you are experiencing dizziness.
As a quick summary, I will be discussing the following below, so sit tight:
- What concussion and post-concussion syndrome is and its associated symptoms
- The role of the vestibular system and how it can be affected following a concussion
- What vestibular rehabilitation is and why it can help post-concussion symptoms
What is a concussion?
Anyone can sustain a concussion, but it most commonly occurs in contact sports, workplace environments, and the elderly population (>65 years old).
A concussion is a mild traumatic brain injury (mTBI). You can sustain a concussion either by a direct blow to the head or via a sudden acceleration-deceleration force to the brain. These forces are either linear and/or rotational (usually combined). As a result of this trauma, microstructural damage to the brain occurs in the form of shearing and stretching forces that are not observable on MRI or CT scan. Hence, imaging following a head injury is purely to determine whether or not there is a brain bleed. If the imaging is clear, you likely had a concussion! NOTE: you do NOT need to lose consciousness to be diagnosed with a concussion.
What are the initial symptoms of a concussion?
The initial symptoms following a concussion include feeling dazed, confused, and increased clumsiness. The concussed individual may also develop temporary amnesia, and experience other initial symptoms such as nausea, light sensitivity, headache, and of course, dizziness. Most people only experience the above symptoms for <14 days, and do well with appropriate levels of relative rest, nutritional and supplemental support, and graded exposure to exercise and activity. However, there are some people who experience on-going symptoms, and these individuals are thought to have post-concussion syndrome.
What is post-concussion syndrome? (PCS)
Post- Concussion Syndrome (PCS)
Sometimes following a concussion, individuals can have ongoing symptoms that may be due to a few reasons. Most post- concussion symptoms can be a result of neck dysfunction – remember, if you have a concussion, you likely had a whiplash too as the force needed to sustain a concussion (70G) far exceeds the force needed to sustain a whiplash (4.5G). Other reasons that can contribute to PCS include but are not limited to anxiety/mood, autonomic nervous system dysregulation, and oculomotor/vestibular causes. As this blog is primarily focused on vestibular rehabilitation, let’s dive into what the oculomotor/vestibular system is.
What is the vestibular system?
The Vestibular System
The vestibular system is an apparatus in the inner ear that contributes mainly to balance, spatial orientation, gaze stability, and postural stability. Newer studies suggest that it may also play a role in spatial memory, but we can discuss that at a later time. Moreover, the vestibular system consists of the 3 semicircular canals and the otolithic system. Together, these systems detect angular and linear head movements, respectively, to provide information to the brain about where you are in space. If this is disrupted in any way, it can lead to symptoms such as:
- Disequilibrium: feeling you’re floating or the ground is tilting
- Oscillopsia: surrounding environment is in motion when you’re still
- Vertigo: the room or you are spinning
- Imbalance
How does injury to the vestibular system occur? It can occur due to many reasons, but most commonly via a viral infection to the inner ear, head trauma (i.e concussions) and/or age-related changes, such as ciliary degeneration.
As concussions can cause axonal shearing and stretching, this can also affect pathways to and from the vestibular system (either peripherally or centrally). The vestibular system also has reflexes with the eyes (oculomotor system) and the cerebellum (fine-tuning of movements). Hence, if the vestibular system is dysfunctional, it can impact your ability to see a clear image when moving your head (gaze stability), and impact your ability to read or track moving objects clearly.
Unfortunately, unless the vestibular system is properly addressed and managed, symptoms are unlikely to go into full resolution.
What is vestibular rehabilitation, and how can it help post-concussion symptoms?
Now, vestibular rehabilitation isn’t always necessary if you are experiencing vestibular symptoms following a concussion. You may be experiencing benign paroxysmal positional vertigo (BPPV), which are crystals dislodged in part of the inner ear (semicircular canals) that should be in a different area (utricle). In essence, these dislodged crystals can lead to vertigo. The good news is that certain maneuvers can be done by vestibular therapists to bring the crystals back from the semicircular canals into their original location. Once this is complete, oftentimes the vertigo disappears with it. Sometimes, however, there is residual dizziness that is not vertigo, that needs to be followed by vestibular rehabilitation. Moreover, there are other reasons for vestibular dysfunction following a concussion that can’t be treated by simple maneuvers because there are processing errors that are occurring, rather than dislodged crystals in the inner ear. Hence, these reasons of vestibular dysfunction should also be followed by vestibular rehabilitation.
Vestibular rehabilitation, in essence, is rehabilitation that focuses on the concepts of adaptation, substitution, and habituation of the vestibular system to restore normal gaze stability and postural control. Adaptation, habituation, and substitution are forms of vestibular compensation and if attained, can lead to full or near-full symptom resolution. However, depending on the dysfunction, there may be a maximal recovery point and this all depends on certain factors that unfortunately will take too long to discuss. Maybe another time!
Moreover, vertigo and dizziness can also come from the neck, or dysfunction in the oculomotor system (the eyes). As these different systems are often treated differently, a well-informed and thorough assessment should be done to detect which system is mostly at play. Oftentimes, it’s a combination of systems that are at play!
So that’s it! Hopefully, that’s helpful if you are experiencing vestibular symptoms following a concussion.
Foundation Physiotherapy can help!
Most of our concussion physiotherapists are also vestibular physiotherapists – hence, the process of referral is minimal (if needed) and there will be less of a change in clinicians in the plan of care.
If you are in the Toronto area, and you are experiencing some concussion and/or vestibular symptoms, check out our Post-Concussion Program for more information on how we can help you navigate these difficult times and get you back towards full recovery!