OCS - Motor Learning and Concussion

Peripheral (Labyrinth) Vestibular Pathologies

BPPV, vestibular neuritis, labyrinthitis, acoustic neuroma

Central Vestibular Patholgies (Brain related)

CVA, cerebellar disorders, MS

How long does Canalithiasis BPPV last?

< 1 min

How long does Cupulolithiasis BPPV last?

> 1 min

How to Assess and Treat Posterior/Anterior Canal BPPV Canalithiasis (Posterior is way more common?

Dix hallpike; Epley

How to Assess and Treat Posterior/Anterior Canal BPPV Cupulolithiasis?

Dix Hallpike; Semont/Liberatory maneuver

What direction is the torsional Nystagmus in Posterior canal?

Up beating

What direction is the torsional Nystagmus in Anterior canal?

Down Beating

How to Assess and Treat Horizontal Canal BPPV Cupulolithiasis?

Supine Roll Test; Gufoni

How to Assess and Treat Horizontal Canal BPPV Canalithisis?

Supine Roll Test; BBQ Roll;

What direction is the Nystagmus in Horizontal canalithisis?

Geotrophic

What direction is the Nystagmus in Horizontal cupuloliathsis?

Ageotrophic

What are the Oculomotor Examination findings that indicate Central Vestibular Patholgy?

Abnormal smooth pursuits and saccades

Special Test for VOR:

Head Impulse Test

Will someone who has BPPV have a (+) Head impulse test?

No. VOR is intact in BPPV. (VOR is a central problem.)

Special Tests for Vestibular Hypofunction

DVA Testing (more than 2 lines lost), Head Impulse Test

Vestibular Hypofunction Interventions:

Gaze Stability exercises - VOR x1,x2, habituation exercises, balance and gait training, walking for endurance

What exercises should you NOT offer with vestibular hypofunction?

Saccadic or smooth-pursuit exercises in isolation

How long should patients with acute unilateral vestibular hypofunction work on gaze stabilization exercises?

at least 12 minutes daily

How long should patients with chronic unilateral vestibular hypofunction work on gaze stabilization exercises?

at least 20 minutes daily

How long should patients with bilateral vestibular hypofunction work on gaze stabilization exercises?

20-40 minutes

Are Smooth Pursuits and Saccades going to be normal or abnormal in Concussions?

Abnormal

Value to worry about for Moderate or greater brain injury on Glascow Coma Scale?

<13

Recommendaitions for Examination of Concussion Impairment Profiles:

Autonomic Dysfunction/Exertional Tolerance Impairments

Evaluate heart rate and blood pressure in supine, sitting, and standing

Recommendaitions for Examination of Concussion Impairment Profiles:

Motor Function Impairment

Static and dynamic balance, multitasking gait activities, motor coordination

Interventions for Concussion Impairment Profiles:

Progreessive Aerobic exercise, provide education, hold exertional testing and aerobic exercise until the patient’s symptoms stabilize

Autonomic Dysfunction

Interventions for Concussion Impairment Profiles:

Static Balance, Dynamic Balance, Motor coordination and control,

Motor function impairments

What impairment profile should generally be examined first in Concussion patients?

Cervical Spine

What graded exertion test is best for concussion patients?

Bike

How should you respond to symptom reactivity during exercise/treatment for Concussions?

If they are mild it is okay to proceed.

Types of Feedback

Inherent – Proprioceptive, visual, vestibular, and cutaneous signals

Intrinsic

Types of Feedback

Augmented - visual, auditory, biofeedback and tactile cues are forms of ______ feedback

Extrinsic

What type of feedback helps with retention?

Variable

Biggest type of feedback between new learners and more advanced?

New learners use visual feedback and advanced use proprioceptive

Types of Practice:

- High skill and motivation

- When endurance, attention and motivation is

high

E.g. later stages

Massed Practice

Types of Practice:

- Low motivation, attention, endurance

- Improve performance without fatigue or safety

- Motor planning deficit

Distributed Practice

Types of Practice Sequence:

all components of a task done together WITHOUT

INTERRUPTION

• Superior initial performance

• E.g., Early stages of TBI, advanced PD

Blocked Practice

Types of Practice Sequence:

PRACTICE: Tasks are done randomly

• Long term retention

• E.g., NPTE FF daily readings, variability transfer on different surfaces

Random practice

What type of practice would someone with MS benefit from?

Distributed

motor task is imagined or visualized without overt

physical practice

mental practice

Component parts of a task are practiced before practice of the whole task

Part/Whole Practice

Stages of Motor Learning:

• “What to do?”-

• Understanding of personal ability and demand of task

• Visual feedback

• More attention required

• Improvement in performance is ready observed

Cognitive Stage

Stages of Motor Learning:

• Feedback: Balance extrinsic and intrinsic feedback

• After every - improves performance initially

• Variable- improves retention; may decrease performance initially

• Tactile, visual, verbal cues

• Knowledge of performance (KP): focus on errors as they become consistent; do not cue on large number of random errors.

• Knowledge of results (KR): focus on success of movement outcome.

Cognitive Stage

Stages of Motor Learning:

Practice:

• Blocked- improves performance

• Variable- retention

• Mental- improve learning and reduce anxiety

• Break down complex activities

• Start with distributed practice instead of massed

• Environment: Avoid distraction, stressors>>> prefer closed environment

Cognitive Stage

Stages of Motor Learning:

• “How to do?”

• Practices and refine - Errors decrease

• Performance becomes consistent and cognitive activity decreases

• Feedback: Visual feedback decreases and proprioceptive feedback increases (“Feel

the movement”)

• KP: intervene when errors become consistent

• KR: stress relevance of functional outcomes

• Manual guidance not required – Avoid excessive augmented feedback

• Focus on use of variable feedback (summed, fading, bandwidth)

• Practice:

• Variable practice order (serial or random)

• Environment: Closed to open environment (home, community)

Associated Stage

Stages of Motor Learning:

“How to succeed?”

• Performance is high level

• Error free

• Automatic movement

• Feedback: Occasional- if errors evident

• Practice: Massed

• Environment: Vary environment- consistency of performance in variable environments

• Competitive aspect

Autonomous Stage