Guidelines Quick Access
Balance, Dizziness and Sensory Disturbances
Following an initial period of relative rest, people experiencing sensory sensitivity can be encouraged to gradually engage in activities that cause minimal worsening of symptoms (i.e. no more than 20% increase in symptoms), so long as the symptoms resolve shortly afterwards.366 People with mTBI/concussion may consider short-term usage of noise cancelling headphones or reduced screen brightness when gradually returning to functional activities. Lingering symptoms should not prevent activities of daily living.366
CBR 366
For people with noise, light and other sensory sensitivities, a graduated exposure program is recommended. People should receive education about sensory tolerance levels and be encouraged to gradually increase exposure to these stimuli. Specifically, they should recognise the point at which mild symptoms have onset and push to the point that does not result in a significant or prolonged exacerbation of symptoms to promote desensitisation. (children and adults)
Balance, dizziness and vision dysfunction following mTBI/concussion are common. This is highlighted by the fact that approximately 60% of athletes report such symptoms following sport-related mTBI/concussion.367 Acute vestibular and vision dysfunction may be associated with delayed recovery and return to activity. Examination may identify problems such as benign paroxysmal positional vertigo (BPPV), hearing deficits or vestibular migraine, which may require specific treatment.367-370 A careful history may identify psychosocial factors that may impede recovery. The use of an objective screening tool can assist in decision-making regarding referral for further assessment for people not showing improvement.
Symptoms affecting vision following mTBI/concussion include but are not limited to blurred vision, photosensitivity, double vision, headache, fatigue and difficulty reading. Symptoms may be exacerbated by bright lights or overwhelming visual environments.371, 372
EBR (Conditional) 367-370
If vestibular, vision, balance and coordination symptoms are endorsed, they should be screened for and monitored at follow-up appointments. A validated screening tool can be useful. (children and adults)
EBR (Conditional) 371,372
If changes in vision are reported using a validated screening tool, a detailed history, including visual history, should be taken and assessments performed of visual acuity, pupillary function, visual fields, fundoscopy, binocular vergence, and extra-ocular movements. (children and adults)
Practice Points for Children and Adults 371
An eye examination should be undertaken to rule out ocular injuries and/or pre-existing disease that may impact vision. (children and adults)
Visual reflexes, inner ear, musculoskeletal, nervous system or brain may contribute to dizziness, headaches, and balance problems. Vestibular rehabilitation and where appropriate, additional cervical spine therapy may improve balance and dizziness.371, 372
EBR (Conditional) 371,372
Perform oculomotor and vestibulo-ocular examination including (children and adults):
- Assessment of convergence, accommodation, saccades and smooth pursuits
- Assessment of the vestibulo-ocular reflex such as the head impulse test and/or dynamic visual acuity (may require involvement of a vestibular rehabilitation physiotherapist)
- Age-appropriate assessment of postural stability and balance (e.g. standing balance test or Balance Error Scoring System.
In people who continue to experience prolonged vertigo or dizziness despite 3 particle repositioning manoeuvres, referral to an interdisciplinary concussion team or neuro-otologist or physiotherapist with competency-based training in vestibular rehabilitation may be a consideration.
CBR
Screen for benign paroxysmal positional vertigo (BPPV) if the person reports vertigo or dizziness that occurs for seconds following position changes and consider canalith repositioning manoeuvres. (Children and adults)
Practice Points for Children and Adults
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 (e.g. the Epley manoeuvre).
CBR
If the Dix-Hallpike manoeuvre reproduces vertigo, and there is no evidence of nystagmus, a Roll test should be performed, and other differential diagnoses or referral should be considered. The Epley manoeuvre should still be considered for treatment. (children and adults)
| CBR | 30. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.] | Adapted30 |
CBR
Screen for and consider underlying psychosocial factors that may exacerbate symptoms of vestibular, vision, and oculomotor dysfunction. (Children and adults)
Hearing problems as a predominant post-concussion symptom are uncommon following mTBI/concussion, and should alert the health care professional to consider a possible alternative diagnosis. A detailed history can assist in ruling out common causes of hearing complications, which may include basilar skull fracture and excessive ear wax.
Unilateral tinnitus is unusual in setting of mTBI/concussion and could indicate alternate diagnosis and requires an assessment by an ear nose throat (ENT) specialist.
EBR (Conditional) 381,382
When a person with mTBI/concussion identifies a problem with hearing (i.e. intolerance to everyday sounds, hearing loss, tinnitus), a detailed history (including auditory history) should be taken, otologic examination (including otoscopy) performed, and referral for audiological assessment and/or ear nose throat (ENT) opinion if no apparent cause is found. (children and adults)
For people experiencing visual, vestibular and oculomotor symptoms, temporary modifications and accommodations may be helpful as they return to education. Reassure people that these symptoms are usually temporary and will resolve over time. Specific modifications depend on the severity and pervasiveness of symptoms and could include refraining from driving if visual disturbance is severe, breaking chores/assignments into smaller tasks, decreasing reading duration for shorter intervals or using text to speech applications, taking frequent breaks, using caution where dizziness and balance is problematic when operating machinery or performing activities at height.
CBR
Provide general post-concussion education that outlines symptoms of mTBI/concussion, and provide suggestions regarding activity modification and includes academic accommodations to manage visual, vestibular and oculomotor symptoms. (Children and adults)
Benign Paroxysmal Positional Vertigo
The Epley Manoeuvre 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 health professional for treatment (usually a physiotherapist with competency-based training in vestibular rehabilitation). If severe 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.
EBR (Conditional) 223,374-377
When the Dix-Hallpike manoeuvre is positive, the Epley/canalith repositioning manoeuvre should be used to treat benign paroxysmal positional vertigo. (children and adults)
CBR 223,375
If BPPV does not resolve within 1-3 treatments, consider referral to an otolaryngologist or qualified health care professional certified in vestibular rehabilitation. (Children and adults)
EBR (Conditional) 371,372
Consider referral to an interdisciplinary concussion team or physiotherapist with competency-based training. (children and adults)
Further Guidance
Demonstrations of the Dix-Hallpike test and Epley manoeuvre are provided by the RACGP. (See ‘Toolbox’ for resource)
Balance Disturbance
EBR (Strong) 378-380
Vestibular rehabilitation therapy is recommended for people experiencing functionally limiting dizziness. (Children and adults)
Hearing Disturbance
Though there is no evidence for specific treatments for tinnitus (i.e. perception of sound that does not have an external source, so other people cannot hear it), clinical experience suggests that self-management strategies may aid with symptom coping. These can include earwax removal, white noise generators and hearing aids. Tinnitus is associated with psychological distress, depression and anxiety, management strategies that include psychological treatment including cognitive behavioural therapy can be beneficial.
CBR 381
Consider referral to an ENT specialist for people with either unilateral tinnitus or persistent tinnitus that has not responded to self-management strategies. (Children and adults)
Prolonged symptoms post-concussion are often non-specific and may be attributed to multiple contributors. For example, clinical context suggests that prolonged vestibular, vision and balance symptoms may be influenced by factors such as mental health issues, neurological causes, uncorrected refractive error, binocular vision issues.
CBR 383,384
If vestibular, vision, balance and coordination symptoms remain functionally limiting, further assessment to identify potential causes of symptoms to direct treatment is required. Referral to a qualified health care professional with specialised training in the vision or vestibular system is recommended, where available. (Children and adults)