Vestibular concussion therapy: A multidisciplinary approach

Shelly Massingale, PT, MPT, is the expert when it comes to concussion.

Having seen concussion patients solely the past seven years, she has deep knowledge of oculomotor dysfunction among this patient population and functional assessment of vestibular deficits.

We had a chat with Shelly to dig into her vast insights on vestibular therapy.

What patients do you see?

Since 2013, I have only seen patients who have suffered a concussion.

Our center is an acute concussion center, which primarily evaluates patients who have been diagnosed with a concussion within 0-3 months of injury.

We are a multidisciplinary center that is run by sports medicine physicians.

All patients that visit our center are seen by one of our physicians at initial evaluation and if indicated, will refer to vestibular therapy for further treatment if dizziness and balance problems are present.

What do you use VisualEyes™ for?

I have been using VisualEyes™ for oculomotor assessment and positional assessment when evaluating for benign paroxysmal positional vertigo (BPPV).

The VisualEyes™ system has changed my practice when evaluating and treating concussed patients because they almost always have some form of oculomotor dysfunction.

I have been able to detect significantly more abnormalities when using this system than when I was only doing a clinical exam without goggles.

How is VisualEyes™ beneficial for your practice?

Personally, I love that I can compare my injured patients to the normative values for the oculomotor assessment battery.

I can get objective measurements that can be assessed over time to determine the extent of rehabilitation, which was something I was unable to do prior to having the equipment.

Our physicians love that they can report on objective measurements of eye movement when making decisions on keeping an athlete out of a sport or returning them back to play.

It has changed our practice as a multidisciplinary team.

Could you elaborate on Saccadometry in patients with concussion?

I have been working closely with Interacoustics on Saccadometry and have found that error rates in anti‑saccades are significantly higher in patients with concussion versus healthy patients.

We also found that patients with concussion fatigued much faster than their healthy counterparts.

My colleagues and I presented this research at the American Balance Society meeting in 2020 as a poster presentation and are beginning a more formal study on Saccadometry in the concussed patient population.

How do you evaluate vestibular deficits in patients with concussion?

Our clinic relies heavily on objective measurements of function when evaluating vestibular deficits in the concussed patient population.

We have developed a trademarked protocol for functional balance assessment called the Concussion Balance Test (COBALT), which uses a force plate to objectively measure sway when asking the athlete to perform tasks that actively stimulate both the visual and vestibular systems.

This assessment has become one of the most valuable tools for us to use to assess postural control in the athletic population.

We also rely on objective measurements of eye movement and the use of video goggles for assessment of BPPV as well as objective testing of the vestibulo-ocular reflex [VOR].

Are any other tests important for concussion treatment?

We are fortunate to have Computerized Dynamic Posturography to perform more in‑depth balance‑function assessments of our patients and are using Gaze Stabilization exercises as well as Dynamic Visual Acuity testing.

We have published a recent article on normative data for Gaze Stabilization function in elite athletes to help clinicians with normative objective measurements of VOR function for an elite athlete versus a community ambulator.

The use of objective measurements of vestibular function is the cornerstone for our physicians to return an athlete back to play.

We would not have the ability to objectively assess these patients without these tests, which I believe have become the gold standard of use for evaluation and treatment of concussion-related vestibular disorders.

Shelly Massingale, PT, MPT, is a Physical Therapist in Phoenix, Arizona, who works at the Banner Sports Medicine and Concussion Center. She has specialized in vestibular and balance therapy for the past 24 years and has focused her practice solely on concussion since 2013. Shelly went to school at Pepperdine University for her undergraduate degree in Sports Medicine and to the University of Southern California for her master’s degree in Physical Therapy.