By Karen Rich Little, DPT

My name is Karen Rich Little, and I am a Doctor of Physical Therapy, certified in vestibular rehabilitation with a focus in sport related concussion.  I have been treating concussions since 2010 and I am entering my 7th season working with the Carolina Hurricanes Sports Medicine Staff, Dr. Josh Bloom, Dr. Jim Blount, Doug Bennett (ATC), Matt Aiello (ATC) and Nick Mahaffey (PT). 

A typical assessment of a concussed athlete within our team will consist of the initial time of injury SCAT assessment and a follow-up assessment the next morning. This inherently includes a brief assessment of coordination with gross observation of oculomotor tracking and observation for extraocular movements and completion of the mBESS.  However, this is just scraping the surface of vestibular function. 

As a vestibular concussion PT, I will see athletes within 48 hours after injury for a more in-depth assessment. This will consist of a visio-vestibular exam, with symptom tracking, using a visual ocular motor screen (VOMS). Every test will start and end with a subjective rating of headache, dizziness, nausea, fogginess, and eye fatigue/pain/pressure. Testing consists of: Smooth pursuit, horizontal and vertical saccades, horizontal and vertical VOR gaze stability, near point convergence, visual motion sensitivity, and monocular accommodation.

On clinical examination, I am looking for variations from the evidence based normative values, as well as for any of the most common following findings:

Interventions are based on exam findings.  Specifically, I note which directions the corrective saccades and delays occur and at what part of the visual field.  For example, an athlete with right to left, and superior to inferior corrective saccade will likely be given inferior left quadrant exercises.

Interventions are also based on the athlete’s position, as the reactions to the visual/vestibular stimulus, including speed and directions of head/eye movements, and use of peripheral vision, will be different for a goalie versus a center.  

For hockey players specifically, consider your speed and conditions of testing.  A normal tracking speed may be symptom free, but when the speed increases to that of a slapshot symptoms may be elicited.  Cardiovascular and vestibular fatigue can affect this population where their resting state may show no signs of compensations, but once fatigued, deficits are elicited. Before making return to play decisions, I suggest testing athletes at “normal testing speeds” and faster rates, as well as at a rested and fatigued state. It is important to note with speed of testing, that the guidelines are set based on anatomical capabilities, so we are looking at this from a purely symptom standpoint versus an observable deficit.

For treatment, I am utilizing the principles of adaptation, habituation and substitution and will begin with straight plane motions and very quickly progress into functional movement.  I will incorporate direction changes and multiplane movement, to replicate the players position movement demands, with single point and then multi point gaze stabilization. For example, a version of the ProAgility Drill with the typical pattern, and then progressed by adding circling a cone at one end or with the addition of a ball(s) tossed during both straight areas of the pattern and during direction transitions.  Intentional ball tossing into different zones of the visual field based on symptoms during the exercise or during testing will provide additional challenges.  With all exercises during recovery, we are trying to elicit symptoms, but at a level of 1 on our 6 point scale.

Other considerations with testing and recovery include: testing environment, life beyond the rink, and medical history.

Environment: Includes lighting and the stimulation level of the room.  Initial assessment and treatments will be performed in a natural light and low stimulation environment, then progressed to more stimulation and return to practice/play on the competition surface.  Use of the competition surface before complete return to play is an important step as the lights, screens and ad banners in the game arenas are often not replicated otherwise.

Life beyond the rink: Daily self and family care including children, and driving/travel.

Medical History:

• Previous history of concussions including the subtype(s) of concussion,
• History of headache/migraine,
• History of motion sensitivity (car sickness),
• Pre-existing and new anxieties,
• ADD/ADHD (formally diagnosed or not).

We do have research to support that recovery trajectories and timeline can be protracted with any of these history components and all of them can impact vestibular function.

For example, when performing a VOR exercise, the athlete has trouble maintaining focus on an object. We must ask ourselves the cause. Is it a vestibular deficit in tracking or gaze stabilization, a visual deficit in accommodation potentially from an unresolved previous visual subtype concussion, or an attention deficit from an underlying ADD.

Lastly, but perhaps most importantly, is to utilize a multi-disciplinary team approach to care.  It is common to see multiple subtypes of concussions within one athlete including: ocular, post traumatic migraine, cognitive fatigue, anxiety/mood and cervical. Subtypes often overlap, so although they may have vestibular deficits on testing, we should take note if deficits are with specific movements of the neck, or with complaints of blurry/double vision which may indicate a need for other specialties. Working with a team and knowing when to reach out for more specific care is key to recovery.

Concussions in professional athletes is a challenging and multi-factorial diagnosis, but given the right targeted interventions, we can improve the recovery and return to play timeline.

All photos courtesy of Doug Bennett