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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

Physical Therapyin the DoD

CDR Henry McMillan, PT, DPT

LCDR Alicia Souvignier, MPT, DPT, GCS

objectives
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
indentification of mtbi
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.
dod physical therapy
DoD/Physical Therapy
  • Optimistic expectation for full recovery
  • Therapists incorporate assessment of the Service Members goals and priorities along with MTBI related symptoms
areas of concern for a soldier who has a history of concussion mtbi
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
guidelines for pt referral
Guidelines for PT Referral
  • 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)
guidelines for pt referral7
Guidelines for PT referral
  • 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
causes of vertigo
Causes of Vertigo
  • 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
evaluation
Evaluation
  • Subjective
    • MOI or idiopathic
    • Frequency/Intensity/duration
    • Vision/ Hearing deficits
    • Positional/activity induced
      • Valsalva/ pressure changes
    • Describe symptoms of dizziness
      • Vertigo
      • Imbalance
      • Lightheadedness
evaluation10
Evaluation
  • Subjective
    • Activity Level
      • Recreational Sports
    • Exercise Tolerance
      • Unit Physical Training
    • Behavioral Health
    • Quality of Life
      • DHI
      • Family Participation
      • Command/Unit Support
vestibular evaluation
Vestibular Evaluation
  • Musculoskeletal Screen
  • Positional Testing
  • Oculomotor
  • Balance
oculomotor
Oculomotor
  • Smooth Pursuit
  • Saccadic
  • VOR
oculomotor13
Oculomotor
  • 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.
test for vor
Test for VOR
  • 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
test for vor16
Test for VOR
  • 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
positional testing
Positional Testing
  • Dizziness caused by certain positions
    • Spinning
    • Use Frenzal goggles
  • Dix Hallpike
    • BPPV
  • Motion Sensitivity Quotient
    • Motion Sensitivity
positional testing18
Positional Testing
  • Dix Hallpike
    • Long sitting, head turned 45 deg, drop down with neck into about 30 deg of extension
balance
Balance
  • Functional Gait Assessment
  • Romberg/ Sharpened
  • Neurocom or M-CTSIB
treatment approaches
Treatment Approaches
  • 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.
vor treatment adaptation
VOR Treatment - Adaptation
  • Walking head turns
  • Tracking with eyes
  • Tracking with head movements
  • All of the above together
  • Above exercises on varied surfaces
motion sensitivity treatment
Motion Sensitivity Treatment
  • Brandt Daroff (picture)
  • Positions identified from MSQ
treatment of bppv
Treatment of BPPV
  • Canalith Repositioning Technique
  • Liberatory Maneuver
postural stability
Postural Stability
  • Prioprio
  • Neurocom-
  • Balance activities- SOT
    • Foam
    • Unstable surface
    • Uneven terrain
treatment ideas
Treatment Ideas
  • Foam bowling
  • Bear claws
  • Soccer Toss
  • Wii
  • Dance Revolution
  • Discoball/strobe with balance
goals for physical therapy
Goals for Physical Therapy
  • Return to Duty
  • Goals for Civilian Life
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