Evidence of Balance Impairments
Following a Concussion
Andrea Cripps, PhD, ATC, ATL
Mikaela Boham, EdD, ATC, ATL
Objectives
• At the conclusion of the program participants should be
able to:
• Identify signs and symptoms of a concussion including
balance deficits.
• Understand the current research in support of conducting
balance assessments at pre-season and post-injury.
• Begin to understand visuo-motor processing impairments
and their impact on the balance assessments.
• Assess balance deficits using a variety of methods.
• Identify evidence-based practices in determining therapeutic
rehabilitation for the balance impaired athlete.
• Identify the best practices for returning a concussed athlete
who has suffered from balance impairments to participation.
What is a Concussion???

A complex pathophysiological process
affecting the brain, induced by biomechanical
forces (Aubry, 2002; International Concussion in Sport Group, 2013; McCrory, 2008)
Common Features of Concussion
• Concussions:
• may be caused by a direct blow to the head, face,
neck, or elsewhere on the body with an ‘impulsive’
force transmitted to the head;
• typically result in rapid onset of short-lived
impairment of neurological function that resolve
spontaneously;
• may result in neuropathological changes but the
acute clinical symptoms largely reflect a functional
disturbance rather than a structural injury;
Common Features of Concussion
• result in a graded set of clinical symptoms that
may or may not involve LOC
• resolution of clinical and cognitive symptoms
typically follow a sequential course
Background on Concussion
• $76.5 billion direct
and indirect
medical costs
associated with
traumatic brain
injury (Finkelstein, 2006)
• CDC reports that
~75% of all TBI’s
are classified as
mild (CDC, 2003)
Background
• 1.6-3.8 million
reported concussion
annually (Langlois, 2006)
• 250,000 sport related
concussions in a high
school football season
alone (Grindel, 2003)
►
68% between 10-19
years old (Gilcrest, 2011)
Background
• 22% of all high
school injuries are
classified as
concussion (Comstock,
2012)
• 56% of all
concussion go
unreported (Guskiewicz,
2000)
Legislative Consequences
SIGNS & SYMPTOMS OF
CONCUSSION
Somatic
•
•
•
•
Headache
Nausea
Vomiting
Balance
difficulty/dizziness
• Numbness/tingling
• Sensitivity to
light/noise
Piland, JAT, 2003
Neurobehavioral
• Fatigue
• Trouble falling
asleep
• Sleeping more than
usual
• Drowsiness
• Sadness
• Nervousness
Piland, JAT, 2003
Cognitive
• Feeling “slowed
down”
• Feeling “in a fog”
• Difficulty
concentrating
• Difficulty
remembering
Piland, JAT, 2003
Clinical Signs & Symptoms
•
•
•
•
LOC
Amnesia
Disorientation
Changes in attitude/emotional
state/energy
PRE-SEASON/POST-INJURY
TESTING
Baseline Testing
• Conducted prior to
sport participation
• Conducted annually
(especially in
middle/high-school)
• Conducted in all
athletes at high risk of
concussion
• Research = fair on
baseline testing &
which athletes to test
Baseline Testing
• Method of baseline testing be the same for
post-concussion testing
• Conducted in an environment similar to
practice/game
• Research = poor on consistent method &
environment
• Athlete should be free of injury/illness
during testing
• Medication intake should be well documented
• Research = fair
Post-Concussion Testing
• Timing & Frequency
• Asymptomatic vs. Immediately following
injury?
• Research = poor for either approach
• Recommendations are to wait until athlete
is asymptomatic
RETURN-TO-PLAY
FOLLOWING A CONCUSSION
Returning An Athlete To
Participation
• Check state laws for:
• Who can make RTP decisions
• If there is a minimum time to begin protocol
• May be dependent on the age of the
athlete?
• Evidence = fair
RTP Protocol
• RTP protocol should begin once athlete
is asymptomatic for at least 24 hours
(dependent on your state law), this RTP
Protocol includes:
• At least 24 hours between each step
• Any provocation or return of symptoms
means return to previous step
• Evidence = poor, however highly
recommended
Returning An Athlete To
Participation
• All objective measures should be
returned or better than baseline before
athlete is returned to participation
• Research = poor, most suggest that
balance has not recovered by RTP
Returning An Athlete To
Participation
• RTP decisions should not be solely
based on one measure
• Research = poor, however highly
recommended
BALANCE
Balance Testing
• Objective measure that does not require
a neuropsychologist to interpret results
• Two classifications of testing types
• High technology (e.g. forceplate)
• Low technology (e.g. BESS)
Evidence for Balance Impairments
Following Concussion
• Balance impairments are commonly
noted following concussion
• Worst impairments between 24-48
hours after injury
• Spontaneous recovery of balance
typically occurs within 3- 10 days of the
injury
• Research = fair
Where does balance come from?
Visual
Somatosensory
Vestibular
• Thought to be
caused by a
failure of the
sensory systems
to properly
integrate
SENSORY SYSTEM
IMPAIRMENTS
Visual Impairments
• Emerging research suggests that visual
system is impaired following a
concussion
• Underlying cause for balance
impairments?
Vestibular Impairments
• Often overlooked in assessment,
management, and rehab of concussed
athletes
• Linked to balance impairments
Vestibular Ocular
Testing/Training
•
•
•
•
•
•
Smooth Pursuits • Dix-Hallpike
Maneuver
Convergence
• Epley Maneuver
Divergent
• Dynamic Visual
Saccades
Acuity
Test*
Head Thrust Test
Gaze Stabilization *requires
equipment
BALANCE TRAINING?
Dynamic Balance Training/Testing
• Little is understood regarding
appropriate intervention and
rehabilitation following concussion
• Use of dual task training may help to
reduce persistent symptoms
Conclusions &
Recommendations
• Balance is an important diagnostic
indicator of neurological impairment
following concussion and should be
assessed in an objective manner.
• Balance should be objectively assessed
at the sideline and serially in the clinic to
track recovery as part of a multifaceted
approach to concussion management.
QUESTIONS?