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Physical Therapy in the DoD. CDR Henry McMillan, PT, DPT LCDR Alicia Souvignier, MPT, DPT, GCS. Objectives. Identify the common patient presentations seen by PHS PTs working in the DoD Be able to indentify key aspects of the evaluation of a dizzy patient

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Physical therapy in the dod l.jpg

Physical Therapyin the DoD

CDR Henry McMillan, PT, DPT

LCDR Alicia Souvignier, MPT, DPT, GCS


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Objectives

  • Identify the common patient presentations seen by PHS PTs working in the DoD

  • Be able to indentify key aspects of the evaluation of a dizzy patient

  • List 3 treatment techniques used to treat dizziness


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Indentification of mTBI

  • Incident in theatre results in Medivac to CONUS

  • After redeployment, troops inprocess through the Soldier Readiness Center, where history of concussion is identified

  • Soldiers with possible residual symptoms of concussion, are referred to the TBI clinic.


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DoD/Physical Therapy

  • Optimistic expectation for full recovery

  • Therapists incorporate assessment of the Service Members goals and priorities along with MTBI related symptoms


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Areas of concern for a soldier who has a history of concussion/mTBI

  • Vestibular Dysfunction

  • Balance Complaints

  • Post Traumatic Headache

  • Temporomandibular Joint Dysfunction

  • Attention and Dual-Task Deficits

  • Fitness/ Activity intolerance

  • Musculosketetal complaints


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Guidelines for PT Referral concussion/

  • DHI Score > 11 (Yes to any F’s or P’s)

  • Plus yes to one of the following:

  • R/SR (Eyes Closed) less than 30 seconds- (arms across chest)

  • VOR x1 for less than one minute with onset of symptoms

  • Walking with HT increase symptoms, deviated gait, LOB- (Museum Gait)


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Guidelines for PT referral concussion/

  • If the patient reports any of the following

    • Difficulty with balance or dizziness that is affecting their functional performance

    • Unsteady while standing still or walking, in poor lighting, or in crowds

    • Difficulty with balance on uneven surfaces

    • Intense spinning, lightheadedness, or unsteadiness associated with exercise


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Causes of Vertigo concussion/

  • Vestibular Lesions or hypofunction

    • Unilateral- infection/neuritis, lesions, bppv

    • Bilateral- ototoxic medications

  • Central processing

    • Central lesions- brainstem, cerebellum

    • Migranes

    • Anxiety

  • Cervicogenic dizziness

    • Vertebrobasilar insufficiency

    • Altered proprioceptive signals


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Evaluation concussion/

  • Subjective

    • MOI or idiopathic

    • Frequency/Intensity/duration

    • Vision/ Hearing deficits

    • Positional/activity induced

      • Valsalva/ pressure changes

    • Describe symptoms of dizziness

      • Vertigo

      • Imbalance

      • Lightheadedness


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Evaluation concussion/

  • Subjective

    • Activity Level

      • Recreational Sports

    • Exercise Tolerance

      • Unit Physical Training

    • Behavioral Health

    • Quality of Life

      • DHI

      • Family Participation

      • Command/Unit Support


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Vestibular Evaluation concussion/

  • Musculoskeletal Screen

  • Positional Testing

  • Oculomotor

  • Balance


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Oculomotor concussion/

  • Smooth Pursuit

  • Saccadic

  • VOR


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Oculomotor concussion/

  • Vestibular Ocular Reflex

    • Vestibular system sends information regarding speed of movement to the visual system. Allows us to keep focus while performing functional head motions.


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Test for VOR concussion/

  • Head Thrust Test

    • Grasp patients head firmly

    • Tilt patient’s head to 30 deg flex

    • Move head back and forth slowly and instruct patient to keep focus on target

    • Provide a quick movement through a small range and watch for patient’s ability to refocus on target.

    • Refixation saccade indicates decreased VOR


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Test for VOR concussion/

  • Dynamic Visual Acuity

    • Test visual acuity on a Snellen Chart

    • Turn patients head vertical and horizontal plane to the beat of a metronome at 2Hz

    • Retest visual acuity while you are moving the patient’s head.

    • 3 lines loss is significant


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Positional Testing concussion/

  • Dizziness caused by certain positions

    • Spinning

    • Use Frenzal goggles

  • Dix Hallpike

    • BPPV

  • Motion Sensitivity Quotient

    • Motion Sensitivity


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Positional Testing concussion/

  • Dix Hallpike

    • Long sitting, head turned 45 deg, drop down with neck into about 30 deg of extension


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Balance concussion/

  • Functional Gait Assessment

  • Romberg/ Sharpened

  • Neurocom or M-CTSIB


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Treatment Approaches concussion/

  • Adaptation Exercises: adapting residual vestibular function to make up for lost function

    • Example: Maintain visual fixation on object while the head is moving

  • Substitution Exercises

    • Doing exercises with and without visual cues

  • Habituation Exercises

    • Repeated exposure to provocative stimulus, for example motion sensitivity.


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VOR Treatment - Adaptation concussion/

  • Walking head turns

  • Tracking with eyes

  • Tracking with head movements

  • All of the above together

  • Above exercises on varied surfaces


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Motion Sensitivity Treatment concussion/

  • Brandt Daroff (picture)

  • Positions identified from MSQ


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Treatment of BPPV concussion/

  • Canalith Repositioning Technique

  • Liberatory Maneuver


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Postural Stability concussion/

  • Prioprio

  • Neurocom-

  • Balance activities- SOT

    • Foam

    • Unstable surface

    • Uneven terrain


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Treatment Ideas concussion/

  • Foam bowling

  • Bear claws

  • Soccer Toss

  • Wii

  • Dance Revolution

  • Discoball/strobe with balance


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Goals for Physical Therapy concussion/

  • Return to Duty

  • Goals for Civilian Life


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Questions? concussion/


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