Accommodations at School

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As September rolls around, it’s a good time to check with all your clients who are students or in similar roles about accommodating the learning environment to boost success.

There are lots of clients who might benefit from accommodations:

✅ After concussion, accommodations can help students return to school earlier and manage symptoms better

✅ Patients with vestibular disorders can feel overwhelmed in busy environments, including schools

✅ Patients with balance challenges might also have trouble in busy school environments. 

Remember ❌NOT ALL ACCOMMODATIONS ARE ACADEMIC❌ For some students, school-based accommodations might relate more to the school environment itself than to their learning. 

Making some small changes to the school environment can make a huge difference in the participation and success of these clients. Examples of accommodations might include:

👊 Leaving class 5 minutes early to avoid the rush between classes. This can be helpful for both balance and sensory issues. 

👊 Recording lectures. There are a few options here. Students can record audio and listen to it later, or there are apps (@notabilityapp is one) that can record a lecture and transcribe it to text, if that works better. 

👊 Wearing a hat and/or sunglasses indoors can help with light sensitivity. Sometimes a note from a health care provider can help teachers understand why this is necessary. 

👊 Extra time for tests or exams is often the first accommodation we think of, and it’s helpful for lots of different patients. 

👊 Providing time, space, and permission to take quiet breaks as needed throughout the day. 

Do you have any go-to accommodations that you’ve found beneficial? Anything that allows people to get back to school earlier or feel better while there is worth trying!



Post-Traumatic Headache: Why does headache type matter?

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Research shows that headache is the most common symptom reported after concussion. 

Clinical experience says it’s often the most debilitating and difficult to deal with. 

Headaches are classified by their type, and that allows us to direct treatment. A concussion headache is usually due to trauma, so it gets classified as a post-traumatic headache - a type of secondary headache. 

As a category, though, “post-traumatic headache” doesn’t give us enough information to direct treatment. Knowing it’s secondary to trauma doesn’t tell us enough about the etiology or pathophysiology of the headache. We need to drill down deeper to find out which of the primary headache categories a particular patient’s post-traumatic headache belongs to. Most post-traumatic headaches fall into the category of

1️⃣ Migraines

Followed by

2️⃣ Tension-type headaches


But other factors can complicate the picture. 

Did you know headaches can also occur due to

✅ Whiplash

✅ Other neck muscle or joint problems

✅ Nerve issues

✅ Overuse of painkiller medications


When a patient reports a headache after a concussion, it’s important to drill deeper during your history. Getting more information and figuring out what type of headache it is will allow you to be more targeted, and probably more successful, with your treatment plan. 

Chronic Dizziness: What is Persistent Postural-Perceptual Dizziness?

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Persistent Postural-Perceptual Dizziness. It’s a great name - it says it all (for short, call it 3PD). It’s not great to have, though - it’s a chronic sense of dizziness, unsteadiness, rocking, or swaying. 

It’s considered a chronic functional vestibular disorder - chronic because it may last for months or years, and functional because it is associated with dysfunction in how the vestibular and balance mechanisms operate. It’s not a psychiatric syndrome or a structural condition, and a patient with 3PD is not malingering or “faking it.” Just like we’re starting to understand that chronic pain is real, so is chronic dizziness. 

Other names that have been used in the past to describe what we now call 3PD include phobic postural vertigo, space-motion discomfort, visual vertigo, and chronic subjective dizziness. These terms are slowly falling out of favour because, for the most part, they describe the symptoms but don’t capture the full scope of the disorder. 

Symptoms and Timing of Symptoms

Patients with 3PD report dizziness, unsteadiness, and/or non-spinning vertigo. These symptoms are present on most days, and in most patients, they occur every day or nearly every day. Patients usually report that symptoms increase as the day goes on. 

If a patient doesn’t have symptoms daily, a diagnosis of 3PD is still made if symptoms are present for more than 15 out of 30 days. 

Symptom Exacerbation

It’s in the name - 3PD occurs with persistent symptoms, meaning that they’re always or nearly always present, and don’t have specific triggers. But in patients with 3PD, symptoms get worse with:

  • Upright posture - standing or walking. In some patients, this may also include sitting unsupported

  • Active or passive movement regardless of the direction or position. Examples include walking, riding in a car, or being jostled in a group of people.

  • Moving visual stimuli or complex visual patterns. These can be things like a passing car, a busy carpet or wallpaper, or large screens. In some cases, a small object held up close, like a computer or phone screen, can have the same effect.

Onset and Clinical Presentation

Most often, 3PD develops as a patient recovers from another condition that disrupts balance or causes vertigo or dizziness. These can include peripheral or central vestibular disorders, vestibular migraine attacks, panic or anxiety attacks that include dizziness, concussion, whiplash, or other medical illnesses. 

Most conditions that precede 3PD are acute or episodic, and 3PD usually develops as the acute symptoms of the initial condition resolve. Patients usually don’t have a symptom-free period between the acute and chronic conditions, but as the acute vertigo symptoms fade, they develop the characteristic chronic symptoms of 3PD. This can vary, and less often some patients develop 3PD very gradually.

3PD may be present alone, or it may co-exist with other diseases or disorders. 


Pathophysiology

Prevalence: About 15-20% of patient presenting for evaluation of vestibular symptoms are estimated to have 3PD. This makes it one the most common vestibular diagnoses in adults. 

The reasons why some people develop 3PD are poorly understood. Hypotheses include changes in strategies used for postural control strategies, changes in multi sensory integration, and inefficiencies in the brain networks responsible for spatial orientation. As we often hear, more research is required. 

Risk Factors

There are certain factors that can be correlated with developing 3PD. As always, correlation is not causation - these things go together, but we can’t say what causes what. However, there is a higher risk of developing 3PD in people with:

  • Anxiety-related personality traits (neuroticism and introversion)

  • Family or personal histories of anxiety disorders

On the other hand, people with traits like resilience and optimism were less likely to develop persistent dizziness after an acute vestibular disorder. 

Management

I say this all the time, but rehab is not a DIY project. This is not a condition that a patient should try to self-manage, for a variety of reasons. 3PD should be managed by an experienced vestibular rehab therapist.


If you’re interested, here are the diagnostic criteria for 3PD (from Staab JP et al., 2017)

A) Primary symptom: Dizziness, unsteadiness, non-spinning vertigo

  • Present on most days for ≥ 3 months

  • Persistent but can wax and wane in severity (spontaneously or provoked)

    • Do not need to be present continuously for entire day

    • Tend to increase as day progresses

B) Exacerbating factors

  1. Upright posture

  2. Active or passive motion

  3. Moving visual stimuli or complex visual patterns

C) Onset: Precipitated by an acute vestibular event or other even that disrupts postural control

  • Vestibular disorders (25-30%)

  • Vestibular migraine (15-20%)

  • Panic/anxiety (15% each)

  • Concussion/whiplash (10-15%)

  • Autonomic disorders (7%) or other events which may produce dizziness (ex. cardiac dysrhythmia, adverse drug reactions)

D) Symptoms cause significant distress or functional impairment

E) Symptoms are not better accounted for by another disease or disorder

  • Although 3PD may co-exist with other diseases or disorders


Reference