10.1

Perform a repeat medical assessment on all patients presenting with dizziness, blurred or double vision, vertigo, difficulty reading, postural imbalance, or headaches elicited by prolonged visual or vestibular stimulation 1-2 weeks following acute injury.

Level of Evidence:   

Depending on the nature of the symptoms, the medical assessment should include a focused history, focused physical examination, and consideration for the need for diagnostic brain or cervical spine MRI imaging for those with focal or worrisome symptoms.

Tool 10.1: Post-Concussion Vision, Vestibular, and Oculomotor Disturbances Algorithm.

Tool 2.1: Physical examination.

Recommendation 2.1c: When to consider diagnostic brain or cervical spine imaging.

10.2

Screen for oculomotor or vision deficits.

Level of Evidence:  

Perform an assessment of visual acuity, pupillary function, visual fields, fundoscopy, and extra-ocular movements.

• With appropriate experience, consider an objective assessment of convergence, accommodation, saccades and smooth pursuits.
• Consider additional tests such as automated visual field testing, formal vestibular testing or diagnostic imaging.

Consider referral to an interdisciplinary concussion team or neuro-ophthalmologist, neuro-optometrist, developmental optometrist, occupational therapist, or physiotherapist with competency-based training in vestibular rehabilitation to assess for impairments in convergence, accommodation, saccades and other visual oculomotor disorders.

Online instructional video to consider:

• Link: Visio-Vestibular Examination (The Children’s Hospital of Philadelphia).

10.3

Screen for benign paroxysmal positional vertigo (BPPV) if the patient reports vertigo or dizziness that occurs for seconds following position changes and consider targeted particle re-positioning manoeuvres.

Level of Evidence:  

After completing a neurological screen and clearing the cervical spine to move into the test position, perform the Dix-Hallpike Test. If positive for BPPV (i.e., reproduction of vertigo, typically for seconds, in addition to a characteristic pattern of nystagmus for the canal that is being assessed), a Particle Repositioning Manoeuvre may be appropriate.

Consider the Epley Manoeuvre which can be used to treat the anterior and posterior canals in the case of a canalithiasis. There are many subtypes of BPPV that may require further assessment or alternate canalith repositioning manoeuvres and referral to a healthcare professional (often a physiotherapist with competency-based training in vestibular rehabilitation) for treatment.  If symptoms are provoked by pressure (i.e., val salva) or accompanied by a change in hearing, referral to an otolaryngologist or neuro-otologist is warranted.    

In patients who continue to experience prolonged vertigo or dizziness despite 3 particle repositioning maneouvers, consider referral to an interdisciplinary concussion team or neuro-otologist or physiotherapist with competency-based training in vestibular rehabilitation. These experienced healthcare professionals should rule out alternative peripheral and central vestibular disorders (e.g., superior semi-circular canal dehiscence (SSCD), vestibular hypofunction) and initiate active management with rehabilitation or referral as appropriate.  

Online instructional videos to consider:

• Link: Dix-Hallpike Test  (University of Calgary)
• Link: Epley Manoeuvre (University of Calgary)

10.4

Screen for vestibulo-ocular deficits.

Level of Evidence:   

With appropriate experience, perform an assessment of the vestibulo-ocular reflex (VOR) such as the head thrust test and dynamic visual acuity.

Consider referral to a physiotherapist with competency-based training in vestibular rehabilitation.

Online instructional videos to consider:

• Link: Head Thrust Test and Dynamic Visual Acuity (University of Calgary)
• Link: Visio-Vestibular Examination (The Children’s Hospital of Philadelphia)
• Link: Dynamic Visual Acuity (University of Calgary)

10.5

Screen for balance deficits.

Level of Evidence:  

Assess for prolonged balance deficits and determine which systems (visual reflexes, inner ear, musculoskeletal, nervous system or brain) might be contributing to dizziness, headaches, and balance problems. Vestibular rehabilitation may improve balance and dizziness. If prolonged impairment is identified, refer to a specialist immediately.

Perform assessment of postural stability and balance.

• Standing balance test (eyes open/closed, tandem stance, single leg stance), Balance Error Scoring System.
• Dynamic balance: Consider the Functional Gait Assessment and BOT (Bruininks-Oseretsky Test of Motor Proficiency) tests.

Consider referral to an interdisciplinary concussion team or physiotherapist with competency-based training in vestibular rehabilitation.

Online instructional videos to consider:

• Link: Visio-Vestibular Examination (The Children’s Hospital of Philadelphia)
• Link: Balance Error Scoring System (The University of North Carolina at Chapel Hill)
• Link: Functional Gait Assessment (University of Calgary)
•  

10.6

Screen for and consider underlying psychosocial contributors to vestibular, vision, and oculomotor dysfunction.

Level of Evidence:  

Domain 8: Mental Health and Psychosocial Factors.

10.7

Provide general post-concussion education that outlines symptoms of concussion, provides suggestions regarding activity modification and includes academic accommodations to manage visual, vestibular and oculomotor symptoms. 

Level of Evidence:  

Guidance about how to make a gradual return-to-school, cognitive activities, and physical activities:

• Recommendation 2.3: Recommend graduated return to cognitive and physical activity.
• Recommendation 2.4c: Advise on the use of computers, phones, and other screen devices.
• Domain 12: Return-to-School and Work.

10.8

Encourage patients with post-concussion vestibular, visual, or oculomotor symptoms to engage in cognitive activity and low-risk physical activity as soon as tolerated while staying below their symptom-exacerbation thresholds. Activities that pose no/low risk of sustaining a concussion (no risk of contact, collision, or falling) should be resumed even if mild residual symptoms are present or whenever acute symptoms improve sufficiently to permit activity.

Level of Evidence:   Gradual return to physical activity. Gradual return to cognitive activity.

See Recommendation 2.3.

• Refer select patients (e.g., highly-active or competitive athletes, those who are not tolerating a graduated return to physical activity, or those who are slow to recover) following acute injury to a medically supervised interdisciplinary team with the ability to individually assess sub-symptom threshold aerobic exercise tolerance and to prescribe aerobic exercise treatment. This exercise tolerance assessment can be as early as 48 hours following acute injury. Level of Evidence:
• Patients who are active may benefit from referral to a medically supervised interdisciplinary team with the ability to individually assess sub-symptom threshold aerobic exercise tolerance and to prescribe aerobic exercise treatment. This exercise tolerance assessment can be as early as 48 hours following acute injury. Level of Evidence:

See Tool 2.6: Post-Concussion Information Sheet for examples of low-risk activities.

10.9

Refer patients with prolonged post-concussion vestibular functioning, balance or visual dysfunction (more than 4 weeks following the acute injury) to an interdisciplinary concussion team with appropriate experience. Consider early referral (before 4 weeks) to an interdisciplinary concussion team in the presence of modifiers that may delay recovery.

Level of Evidence:   Medical follow-up. Early referral in the presence of modifiers that may delay recovery.

Tool 10.1: Post-Concussion Vision, Vestibular, and Oculomotor Disturbances Algorithm

Assessment by an interdisciplinary concussion team can assist in identifying the type of management that is required, along with the medical and health professions on the interdisciplinary concussion team or external to this team who can provide the required management. Not all children/adolescents will require care from all members of the interdisciplinary concussion team and care should be targeted based on identified symptoms and patient needs.

See Recommendation 2.1b: Note any modifiers that may delay recovery and use a clinical risk score to predict risk of prolonged symptoms.

10.10

Recommend a medical follow-up to reassess clinical status if vestibular functioning, balance or visual dysfunction symptoms persist. Recommend an immediate medical follow-up in the presence of any deterioration.  

Level of Evidence: