1
Concussion
Introduction and Assessment
Domains
Bara Alsalaheen, MS,PT
University Of Pittsburgh
UPMC Sport concussion Team
• Cara Camiolo Reddy, MD
• Michael Collins, Ph.D
• Joseph Furman, Ph.D
• Anthony Kontos, Ph.D
• Mark Lovell, Ph.D, MD
• Anne Mucha, PT, NCS
• Patrick Sparto, Ph.D,PT
• Susan Whitney, PT, DPT, PhD, NCS, ATC, FAPTA
• Bara Alsalaheen, MS,PT
Concussion Incidence
• Most TBI injuries are mild TBI(i.e.
concussion)
• The annual rate of mTBI is 130-546 per
100,000 persons
• Approximately 300,000 sports-related
concussions occur in the United States
every year
Concussion & Public Health
• The estimated annual cost (direct and indirect)
in U.S ranges between $12 -17 billion
• Concussion has a negative effect on
psychological well being and health related
quality of life (HRQOL)
• Concussion is linked to higher family burden and
emotional distress
Concussion Terminology
• Minor head injury
• Mild closed head injury – The American Academy of Pediatrics
• Mild traumatic brain injury - (WHO) and ACRM
• Concussion and Sports- concussion – the American Academy of Neurology and Concussion in sport group, respectively
Concussion definition
• Until the CDC definition, no consensus on
a definition
• Lack of consensus is problematic when
reporting incidence and prevalence of
symptoms
• Lack of consensus becomes problematic
during process of care
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• A complex pathophysiologic process affecting the brain,
induced by traumatic biomechanical forces secondary to
direct or indirect forces to the head.
• Caused by a jolt to the head or body that disrupts the
function of the brain.
• Typically associated with normal structural neuroimaging
findings (ie CT scan, MRI).
• Results in a constellation of physical, cognitive,
emotional or sleep-related symptoms that may or may
not involve a loss of consciousness (LOC).
• Duration of symptoms is highly variable and may last
from several minutes to days, weeks, months, or longer
in some cases.
Concussion: CDC Definition
Centers for Disease Control, 2007
Concussion severity
• At least 17 grading scales
– None of them is evidence- based
– Heavily based on LOC and other markers of
severity
– Assumed universal effects of concussion for
all age and gender groups
Concussion Management STANDARDIZED CONCUSSION
GRADING SCALES
INDIVIDUALIZED CONCUSSION
MANAGEMENT
Neurocognitive
testing and
comprehensive
symptom
evaluation
Slide courtesy of Cara Camiolo Reddy, MD
Concussion Assessment
Domains
• Neuropsychological testing
– Paper & Pencil testing
– Computerized testing
• Self report symptoms
– Instrumented (i.e. checklists)
– Non instrumented (e.g. interview)
• Balance and postural stability
– Clinical testing
– Laboratory testing (e.g. posturography)
Neuropsychological
Assessment
Most significant advancement in the field
of sports concussion
– Allows for reliable and valid approach to
quantify major manifestations
• Processing speed, reaction time, visual/verbal
memory
– Tracks recovery
– Provides dependent variable to research
individual factors in recovery
Slide courtesy of Cara Camiolo Reddy, MD
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Neuropsychological
Assessment
• Now the cornerstone of proper concussion
management
– Baseline testing (preseason/preinjury)
– Repeated post injury evaluations
– Computer-based models currently used:
• ImPACT
• Cog Sport
• Headminders
ImPACT
• Self administered software
• Use a number of tests to generate 4
composite scores for different areas of
cerebral functioning
– Visual memory
– Verbal memory
– Reaction time
– Processing speed
Neuropsychological
Assessment
This is not a stand-alone instrument
– Must be used in conjunction with
• clinical interview
• overall symptom presentation
• medical/concussion history
• results of other diagnostic studies
Slide courtesy of Cara Camiolo Reddy, MD
Recovery
• 80% of athletes recover spontaneously within three weeks of trauma
• Who does worse?
– Preexisting learning disability
– Younger age
– Prior concussive injury
– Amnesia
– Migrainous symptoms
– Over-exerters
Collins et al, 2006; Yang et al, 2007; Collins et al, 1999; Iverson et al, 2004.
Slide courtesy of Cara Camiolo Reddy, MD
Predictors of Outcome:
Age
– Research with severe TBI suggest that
children undergo more prolonged and diffuse
cerebral swelling after TBI
• Increased risk for secondary injury
• More sensitive to glutamate
• These factors may lead to a longer recovery period
and could increase the likelihood of permanent or
severe neurologic deficit
Field et al, 2003
Recovery Rates Vary by Age/Dependent Measure Authors Sample
Size Population Tests
Utilized Total Days Cognitive
Resolution
Total Days Symptom Resolution
Lovell et al.
2005
95
Pro (NFL) Paper and
Pencil
1 day 1 day
Echemendia
2001
29
College Paper and
Pencil
2 days 2 days
McCrea et al.
2003
94
College Paper and
Pencil
5-7 days
7 days
Guskiewicz
2003
94 College Balance
BESS
3-5 Days 7 Days
Bleiberg et al.
2005
64
College Computer
ANAM
3-7 days
Did Not
Evaluate
Iverson et al.
2006
30 High School Computer
ImPACT
10 days 7 Days
McClincy
2006
104 High School Computer
ImPACT
14 days 7 Days
Slide courtesy of Micky Collins, PhD
4
Signs and Symptoms of
Sports Concussion
Signs observed by staff
• Appears to be dazed or stunned
• Is confused about assignment
• Forgets plays
• Is unsure of game, score, or
opponent
• Moves clumsily
• Answers questions slowly
• Loses consciousness
• Shows behavior or personality
change
• Forgets events before play
(retrograde)
• Forgets events after hit
(posttraumatic/anterograde)
Sx reported by athlete
• Headache
• Nausea
• Balance problems or dizziness
• Double or blurry vision
• Sensitivity to light or noise
• Feeling sluggish or slowed down
• Feeling “foggy” or groggy
• Concentration or memory
problems
• Change in sleep patterns
Slide courtesy of Cara Camiolo Reddy, MD
Cognitive Symptoms
• “Fogginess”
• Difficulty concentrating
• Memory deficits
• Cognitive Fatigue
Somatic Symptoms
• Headaches
• Dizziness
• Nausea
• Light/Sound Sensitivity
Mood Disruption
• Irritability
• Feeling sad
• Anxiety
Sleep Alterations
• Difficulty falling asleep
• Fragmented sleep
• Too much/too little sleep
Slide courtesy of Cara Camiolo Reddy, MD
Symptom Evaluation
• Can be evaluated by instrumented and non
instrumented methods
• Different checklists have been
implemented
• Used to quantify highly subjective
complaints, and to track recovery
• Commonly used by athletic trainers
Post Concussion Symptom
(PCS) Checklist – Most commonly used checklist
– Used to track recovery in symptom resolution
– Patients are asked to rate their symptoms on
a scale from 0 (no symptoms) to 6 (severe)
– The scale consists of 22 symptoms
– Total score is calculated by adding all the
individual symptom’s scores
– Higher scores are worse
The Rivermead Post-Concussion Symptom
Questionnaire
• 0 = Not experienced at all
• 1 = No more of a problem
• 2 = A mild problem
• 3 = A moderate problem
• 4 = A severe problem
Somatic Symptoms • Headaches
• Dizziness
• Nausea
• Light/Sound Sensitivity
Somatic Symptoms:
Treatment
• Dizziness /Balance Disorders – Vestibular Therapy
• Headaches – Musculoskeletal (manual
therapy)
– Vascular
– Biochemical
– “Cognitive Fatigue”
Slide courtesy of Cara Camiolo Reddy, MD
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Balance and Posture Evaluation
• Balance deficit up to 3 days after
concussion using the Clinical Test for
Sensory Interaction of Balance ( CTSIB) (Guskiewicz,1996)
• Increased sway, and decreased balance
up to 10 days after concussion via the
Sensory Organization Test (SOT)
• Balance Error Scoring System (BESS) and
force plate testing found not to be sensitive
to detect the balance deficit after
concussion (Guskiewicz,2004)
Summary
• Concussion is a major public health
concern
• 3 domains of assessment are used, none
of them is stand alone
• Individualized treatment approach is
recommended rather than using one based
solely on concussion grading scales
• Closer look is needed when interpreting the
evidence
• PT’s Role? Are we doing enough?
Concussion & Vestibular
Rehabilitation
Concussion & Vestibular
Rehabilitation
• Patients usually referred to PT if they did
not recover within the normal window of
recovery
• Patients with dizziness show worse
recovery in neuropsychological
assessment and different self report
symptoms (Chamelian et al, 2004)
Cognitive Symptoms
• “Fogginess”
• Difficulty concentrating
• Memory deficits
• Cognitive Fatigue
Somatic Symptoms
• Headaches
• Dizziness
• Nausea
• Vomiting
• Light/Sound Sensitivity
• Numbness
• Numbness
• Tingling
• Visual problems
• Balance problems
Mood Disruption
• Irritability
• Feeling sad
• Anxiety
Sleep Alterations
• Difficulty falling asleep
• Fragmented sleep
• Too much/too little sleep
Slide courtesy of Cara Camiolo Reddy, MD
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Somatic Symptoms
– Headaches
– Dizziness
– Nausea
– Vomiting
– Light Sensitivity
– Sound Sensitivity
– Numbness
– Numbness
– Tingling
– Visual problems
– Balance problems
Headache
• The most common symptom after concussion
• Prevalence of initial headache between 43% to
86% of patients
• Persistent headache is also reported in a period
up to three months after concussion
Study
(sample size)
Mean age (years) Outcome measure % report initial
headache (mean
severity)
Time of follow up % reporting
headache at follow
up (mean severity)
Blinnman et
al, (116)
14.1
PCS
71.6 (2.7)
2-3 weeks
31.8 (1.8)
Collins et al,
(109)
15.8
PCS
NS
1 week
33.0 (2.7)
Faux et al,
(100)
33.6
RPQ
100
1 month
3 months
30.4 (NR)†
15.4(NR)†
Lannsjo et al
(2523)
31
RPQ
43.2
3months
22 (2.6)
Lovell et al,
(52)
16.8
PCS
88.5
Between 1 &4
weeks
32.7(NR)†
Savola et al,
(37)
33.7
Modified
version of
PRQ
65
4 weeks
38(NR)†
Headache
• Headache at time of admission to the ER is
associated with development of post concussion
symptoms at 1& 6 months after injury
• Individuals with headache have worse
neurocognitive and balance testing, and were
found to report more symptoms than individuals
who do not have headache after concussion
Headache
• Individuals with headache (> 3 hours) have a
prolonged return to play (RTP) compared to
athletes w/o headache (>3 hours) after sport
related concussion.
• Individuals with migraine headache have greater
neurocognitive deficits compared to individuals
with other forms of headache and individuals
with no headache
Dizziness
• Frequent symptom after concussion
• 23 -81% of persons post concussion
report dizziness in the first days
• Of the 61% who reported dizziness in one
study, the severity breakdown is
– 41% mild
– 16% moderate
– 4% severe
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Prevalence of dizziness Study
(n)
Mean
age
(years)
Outcome measure % report initial
dizziness (mean
severity)
Time of follow up % reporting
dizziness at
follow up (mean
severity)
Blinmann et al,
(116)
14.1 PCS 60.3(2.7) 2-3 weeks 27.0 (1.6)
Broglio et al
(32)
19.7 PCS 28.1(.75) NS NA
Lovell et al,
(52)
16.8 PCS 78.8 Between 1
and 4 weeks
17.3(NR)†
Lannsjo at al,
(2523)
31 PRQ 31 3 months 16 (2.6)
Savola et al,
(37)
33.7 Modified
version of RPQ
49 4 weeks 43(NR)†
Dizziness
• More symptomatic, and have worse
psychosocial functioning 6 months after
injury
• Dizziness at ER is associated with severity
of post concussion symptoms at 1 and 6
months after injury
• linked to psychological distress at 6 months
after injury
• Independent factor for failure to return to
work after mild to moderate head injury
Balance Problems Study
(sample size)
Mean age (years) Outcome measure % report initial
symptoms (mean
severity)
Time of follow up % reporting
symptom at follow
up (mean
severity)
Blinmann et al,
14.1
PCS
60.3(2.6)
2-3 weeks
25.4(1.5)
Broglio et al,
(32)
19.7
PCS
34.4 (.75)
NS
NA
Lovell et al,1
(52)
16.8
PCS
55.8
Between 1 and 4
weeks
11.5(NR)†
Rationale for vestibular
rehabilitation post- concussion
• Post- traumatic dizziness associated with
impairments in the vestibular system
• Post- Concussive balance disorders may be
attributed to dysfunction in sensory integration
system
• Vestibular rehab dizziness & imbalance
Vestibular/ Balance
Rehabilitation For concussion
• Evidence for vestibular rehab post-
concussion
• Vestibular/ balance evaluation
Evidence for Vestibular
Rehabilitation
Gurr et al, 2001 • Graded exposure to head and body movements
• Anxiety management
• Coping strategies and education
Results: reduced complaints of vertigo and dizziness, and improved
balance of individuals standing on an unstable surface
Hoffer et al, 2004 Somatosensory exercises combined with aerobic activity, vestibulo-
ocular reflex, and cervico–ocular reflex activities
Results: reduced the complaints of dizziness and accelerated return to
work
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• Subjects
• 114 patients (67 F/47 M)
• 84 patients received vestibular
Rehabilitation Therapy
• Median number of visits:4 (2-13)
• Median Duration: 7 days(2-181)
Oculomotor abnormalities
• Cover/uncover 8 subjects
• Convergence 7
• Smooth Pursuit 7
• VOR Cancellation 6
• VOR 4
• Saccades 3
• Dynamic visual acuity 3
Results/Self Report Outcome Measure Pre-treatment Post-treatment
Dizziness Severity 21(22) 12 (18)
ABC 64 (27) 84 (17)
DHI 49 (21) 30 (22)
All measures are statistically significant, P <.05
Results/Performance Outcome Measure Pre-treatment Post-treatment
DGI 20 (3) 23 ( 1)
FGA 22 (5) 28 (3)
Gait Speed 1.02 (.28) 1.28 (.23)
TUG (sec) 9.7 (2.5) 7.8 (1.8)
FTSTS( Sec) 13.1 (6) 9.7 (5)
SOT (Composite) 48 (19) 71 (13)
All measures are statistically significant, P <.05
Results (Age effect)
Outcome measures Children Adults
DHI 36 + 6 46 + 20
FGA 25 + 2 23 + 3
5TSTS 9.5 + 2.6 s 13.8 + 5.8 s
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Conclusion
• Significant treatment effect for vestibular
rehabilitation
• Age effect for some balance measures
• Interaction effect for dizziness severity
only
• Meaning vestibular rehab can be used for
both population(i.e. adults and children)
Vestibular Rehab & Whiplash
In a review, it was found that vestibular
rehab reduces handicap and improves
postural control
Goals of VR After Concussion
• Reduce dizziness, imbalance, headache
and other symptoms
• Improve balance performance
• Improve gaze stability and eye-head
coordination
• Offer entry point to exertion program for
athletes
Concussion Evaluation
• Three domains:
Neuropsychological performance
Balance performance
Self report symptoms (Somatic, mood, sleep,
and cognitive)
Concussion Evaluation
• History of concussion
Mechanism of injury
Date of Injury
On field symptoms
• Present symptoms and dysfunctions
Somatic symptoms (Keep in mind other
clusters: mood, sleep, and cognition)
Duration & severity of symptoms
Exacerbating and relieving factors
Post concussion symptom
checklist (PCS)
• 22 symptom severity
• 7- point likert scale
• 0 (no symptom) - 6 (severe)
• Add up the scores
• Used by athletic trainers and
neuropsychologists
• Acute phase
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Vestibular Evaluation for
concussion
• Assessment of symptoms (dizziness,
headache)
• Assessment of Eye-Head coordination
• Balance assessment
Assessment of dizziness/
vertigo
• Spontaneous or provoked
– If provoked, precipitating factor?
– All directions or Dix-Hallpike
• Characteristics
• Onset, duration, effect of repeated head
movement
• Presence/ type of nystagmus
Provoked dizziness
• Are you dizzy when?
Looking up
Walking in supermarket aisle
Reading
Turning over in bed
Bending over
Lying down
Getting out of bed
Cervicogenic Dizziness
• A non-specific sensation of altered orientation in space, and dysequilibrium originating from abnormal afferent activity from the neck (Furman and Cass, 1996)
• Associated with cervical flexion/extension (whiplash) injuries and head trauma
• Symptoms • Ataxia
• Unsteadiness of gait
• Postural instability
• Associated with neck pain, limited neck ROM or headache
• Illusionary sense of motion
Cervicogenic Dizziness
• Diagnostic Criteria – Complaints of ataxia, unsteadiness of gait, postural
imbalance, and illusory sensation of movement
– Close temporal relationship between neck pain or headache and symptoms of dizziness
– Previous neck pain or pathology
– Elimination of other causes of dizziness
– Onset of symptoms may be sudden or gradual and occur days to weeks following the injury
– Symptoms are usually episodic and last minutes to hours
Slide courtesy of Susan L. Whitney PT, DPT, PhD, NCS, ATC, FAPTA
Canalith
repositioning
Maneuver
Chief Complaint
Dizziness or Vertigo
Neck pain associated
with dizziness
yes
Dix-Hallpike
Positive test
Posterior canal
BPPV
yes
Cervicogenic
dizziness likely
no
no
Co-treat
or refer to VR-PT
History of neck pain,
injury or pathology
Cervicogenic
dizziness unlikely
Treat neck appropriately
and refer to MD for
dizziness
BPPV, vestibular disorder,
and/or cervicogenic dizziness
Vestibular disorder, and/or
cervicogenic dizziness
Treat neck appropriately
and refer to MD for
vestibular testing
Co-treat or
refer to VR-PT
Vestibular
disorder
abnormal results normal results
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Cervicogenic Dizziness
• Suggested Treatment in Literature
– Cervical collar Cope and Ryan, 1959
– Cervical traction Mayoux et al, 1951; Jongkees, 1969
– Neck manipulation Stoddard, 1952; Ledru, 1955
– Cold spray and local anesthetic Weeks and
Travell, 1955
– Local anesthetic injection and massage Gray, 1956
• May also benefit from vestibular rehabilitation for residual space and motion discomfort or balance impairments
Assessment of Eye–Head Coordination
• Eye–Head (E-H) coordination plays a role
in gaze stabilization and balance
• Dysfunction in E-H coordination can lead
to dizziness and /or imbalance
• By improving E-H coordination, post
concussion dizziness/ imbalance can be
improved
Perception of Eye-Head
movement
• Signals from labyrinth give info about head
movement in space
• Info is integrated with somatosensory and
visual input
• Whenever asymmetry in vestibular function
occurs, brain interprets it as continuous
movement of head
• May cause spinning even when head is not
moving
Vestibulo-Ocular Reflex (VOR)
• Stabilize visual image on retina during head
movement
• Produces an eye movement of equal
velocity but in opposite direction to the
head movement
• VOR Gain = Eye velocity/ head velocity = 1
Normal VOR
• When head moves to right
• Excites Rt horizontal SCC
• Inhibit Lt horizontal SCC
• Drives eyes to left at same velocity of
head movement
Impaired VOR
• With Rt Unilateral peripheral vestibular
hypofunction
• Head stationary
• No discharge of horizontal SCC
• Normal resting discharge of Lt horizontal
SSC
• Difference indicates head movement (to lt in
this example)
• Nystagmus?
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Impaired VOR (con’t)
• When “false” Lt head movement is
indicated
• Eye will move slowly to Rt (slow phase)
• When eyes get to end range, they will
move back quickly to Lt (fast phase)
• Left beating nystagmus
VORx1 Evaluation
• Negative findings:
– Gross abnormalities
– Symptom provocation
VOR x 1
Slide courtesy of Susan L. Whitney PT, DPT, PhD, NCS, ATC, FAPTA Slide courtesy of Susan L. Whitney PT, DPT, PhD, NCS, ATC, FAPTA
Slide courtesy of Susan L. Whitney PT, DPT, PhD, NCS, ATC, FAPTA
VOR x 1
Slide courtesy of Susan L. Whitney PT, DPT, PhD, NCS, ATC, FAPTA
13
Slide courtesy of Susan L. Whitney PT, DPT, PhD, NCS, ATC, FAPTA
VOR X 2
Slide courtesy of Susan L. Whitney PT, DPT, PhD, NCS, ATC, FAPTA
Slide courtesy of Susan L. Whitney PT, DPT, PhD, NCS, ATC, FAPTA Slide courtesy of Susan L. Whitney PT, DPT, PhD, NCS, ATC, FAPTA
VOR cancellation
• If we want to move eye in same direction
with head, VOR must be suppressed.
• Eyes moves in the same direction as the
moving object
Convergence testing
• Convergence spasm
• Convergence insufficiency
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Smooth Pursuit & Saccade
• Smooth pursuit:
Visually pursue a slow moving object without
moving head
Maintain gaze on moving target
• Saccade: Rapid eye movement to allow refoveation of
stationary targets (e.g. reading)
• Impairments Indicate brain problem
BPPV
• Dix-Hallpike test?
– Positive findings
– -Negative findings
• Head Thrust test?
Balance Assessment
• Gait assessment
• Balance Error Scoring System
• Objective findings vs. symptoms
provocation?
Clinical outcome measures
• Self Report measures: Activities –Specific Balance Confidence Scale(ABC).
Dizziness Handicap Inventory(DHI)
Dizziness Rating (0-100)
Self report symptoms checklist
Performance measures: Dynamic Gait Index (DGI)
Functional Gait Assessment (FGA)
Five Times Sit to Stand (FTSTS)
Timed “UP &GO” (TUG)
Gait Speed
Sensory Organization Test (Posturography)
Activities –Specific Balance
Confidence Scale (ABC)
16 questions
0 -100 scale
0 No confidence
100 Full confidence
e.g.
Walk around the house?
Walk across the parking lot to a mall?
Walk in a crowed mall where people rapidly
walk past you?
Dizziness Handicap Inventory (DHI)
• Individual’s handicap due to their dizziness
• 25 items
• 3 components: physical, emotional, and
functional domains
• Maximum score 100
• Higher score = Worse performance
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Dizziness Rating & Descriptions
• Verbal scale (0-100)
Higher score = more severe
Dizziness descriptions:
Spinning
Lightheadedness
Off balance
Nausea
Sensation of motion
Others.
Performance Measures
Dynamic Gait Index (DGI)
Functional Gait Assessment (FGA)
Five Times sit to Stand (FTSTS)
Timed “UP &GO” (TUG)
Gait Speed
Sensory Organization Test
(Posturography)
Dynamic Gait Index (DGI)
• DGI:
8 items
Questions are rated on 0-3 scale 0 = severe impairments
3 = Normal
Maximum score 24 ( higher score is better)
Functional Gait Assessment (FGA)
• 10 items test
• 7 items from DGI in addition to: Gait With Narrow Base Of Support
Gait With Eyes Closed
Ambulating Backwards
• Maximum score 30 ( higher score is better)
TUG & FTSTS
• TUG (Sec)
Subject stands from a chair, walks three
meters at their normal walking speed, and
returns to the chair
• FTSTS (Sec)
Subject stands-up and sits down from a
standard height chair five times as quickly
as possible.
Dynamic Computerized Posturography
(SOT)
• Tests sensory integration between the
visual, somatosensory, and vestibular
systems
• 1) eyes open, fixed support
• 2)eyes closed, fixed support
• 3)sway-referenced vision, fixed support
• 4) eyes open, sway-referenced support
• 5) eyes closed, sway-referenced support
• 6) sway-referenced vision and support surface
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SOT SOT
Evaluation Guidelines
• Perform the least number of tests
possible ( testing intolerance)
• Evaluation may take more than one visit
• Rule out/ Treat BPPV first Pure BPPV V.S not pure?
• Re-eval oculomotor testing every few visits
Selection of appropriate
measures
• Self report vs. performance
• Expected ceiling effect in young adults
• Validity and test retest reliability in young
adults
• Normative reference values, and Minimal
clinical important difference(MCID)
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