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MSK 2 > 1g - HA, concussion, WAD > Flashcards

1g - HA, concussion, WAD Flashcards

1
Q

what is whiplash associated disorder (WAD)

A

variety of clinical manifestations caused by a whiplash injury

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2
Q

acute vs chronic classification of WAD

A

acute <12wks after injury
chronic >12wks

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3
Q

how long does it take for people to typically recover from WAD

A

recover in acute phase (<12wks)
- typically in 2 wks

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4
Q

what are the grades of the Quebec Taskforce Classification of WAD

A

0 - no c/o neck, no physical signs

I - neck c/o pain, stiffness, tenderness only
- no physical sign(s)

II - neck c/o and MSK sign(s)
- MSK signs - dec ROM, point tenderness, etc.

III - neck c/o and neuro sign(s)
- neuro signs - dec/absent tendon reflex, weakness and sensory deficits

IV - neck c/o and fx/dislocation

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5
Q

what education should be provided to pts w acute WAD

A

return to prior level of activity as soon as possible
minimize cervical collar use
will return to normal
- reassure that recovery expected w/i first 2-3mo

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6
Q

what exercises are appropriate for acute WAD

A

postural and mobility exercises to dec pain and inc ROM
- strengthening
- endurance
- flexibility
- postural
- coordination
- aerobic
- functional exercise

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7
Q

what patient education should be provided to pts w chronic WAD

A

advice to focus on reassurance, encouragement, prognosis, and pain management

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8
Q

what interventions should be given to pts w chronic WAD

A

mobilization combined with exercise program to treat deficits
- cervicothoracic endurance
- strengthening
- flexibility
- coordination

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9
Q

how can you assess joint position error

A

w laser on head
3ft from target
close eyes, rotate head and try to return to same spot on target w eyes closed
3 trials

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10
Q

what is a significant result when assessing joint position error and what does this indicate

A

> 4.5deg error

associated w dizziness and cervical joint position error

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11
Q

how can you use the test to train joint position error and what is an important consideration

A

use the laser and change parameters:
- direction
- diagonals
- starting position
- gravity influence
- UE mvmt (internal perturbation)

*always give them target for external cues

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12
Q

allodynia vs hyperalgesia

A

allodynia
- nonpainful stim is painful

hyperalgesia
- normal noxious stim is heightened

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13
Q

how do you dx central sensitization and nociplastic pain

A

not a specific test to assess
use clinical hx and findings

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14
Q

what test can indicate nociplastic pain

A

inc pain w a hot or cold stim earlier than normal

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15
Q

what test can indicate hyperalgesia

A

mechanical stim (ie pin)

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16
Q

what test can indicate allodynia

A

dynamic mechanical stim (ie soft)

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17
Q

describes pain processing in someone w chronic pain and how is this relevant to PT

A

high pain tolerance but low pain threshold
- takes less to inc pain

in PT, we impact pain threshold

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18
Q

what is one approach to treating someone w central sensitization and nociplastic pain

A

pain science approach
- conceptual approach to explain pain to pt accurate words to help them understand their hyper responsive nervous system

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19
Q

what is the tissue tolerance point

A

point where tissue breaks

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20
Q

what is protect by pain (PBP)

A

pain threshold
certain amt of input before tissue tolerance that body perceives pain

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21
Q

how does injury impact the protect by pain line

A

after injury, body has a new PBP line that is wayyyy lower and therefore any little input creates pain

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22
Q

how can a PT exercise program use a pain science approach

A

graded exposure
- building intensity, duration, and resistance over time

-> keeping below flare up line

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23
Q

how can graded exposure be implemented into an exercise program

A

global - walking, bike, elliptical

semi-local - UE and trunk

local - DNF/DNE

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24
Q

global vs local vs semi-local exercise

A

global - total body, inc HR
- if hig sweat barrier, release of endogenous opioids

local - anything done w neck
- specific to area
- might not tolerate right away

semi-local - things close to impaired part (ie UE, trunk)
- not specifically related to neck, but close enough for input to neck

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25
Q

why are psychological factors important to consider with pain science

A

all contribute to sensory input, heightened alarm system

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26
Q

what is an important strategy when creating a POC

A

make a problem list (MAPS)
Movement
Activity
Positions
Situations…. that are most painful

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27
Q

what is the concern with using traction in a chronic or flared up state

A

be painful d/t too much input w altered sensation input

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28
Q

how could STM be implemented if someone has a high irritability

A

local input may be too much
- maybe to upper back first (get carryover input to neck)

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29
Q

what are the 3 first interventions to start with for someone w a lot of pain

A

gentle traction
STM - local vs semi-local
exercise
- maybe more global

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30
Q

other than pain relief, why is gentle traction a good tool for therapists to use when first working w a patient

A

what are indication to therapist of level of irritability of neck

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31
Q

what are 4 primary headache classification

A
  1. migraine (w or w/o aura)
  2. tension type (pericranial pain)
  3. trigeminal autonomic cephalalgias (TAC)
    - severe unilateral pain in orbital, supraorbital, and temporal sites
  4. other primary headache disorders (cough, exercise, sex, cold)
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32
Q

what are 9 secondary headache classifications

A
  1. HA d/t trauma or injury to head and/or neck
  2. HA d/t cranial or vascular disorder
  3. HA d/t non-vascular intracranial disorder
  4. HA d/t substance or its withdrawal
  5. HA d/t infection
  6. HA d/t disorders of hemeostasis
  7. HA/facial pain d/t disorders of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial/cervical structures
  8. HA d/t psych disorder
  9. painful lesions of CNs and other facial pain
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33
Q

what classification of HAs are more in our scope of practice

A

secondary HAs
1. d/t trauma/injury to head/neck (ie WAD, concussion)

  1. d/t disorders of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial/cervical structures (ie neck hypo- or hypermobility, TMJ)
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34
Q

what are 7 red flags w HAs

A
  1. persistent unrelenting HAs
  2. associated trauma
  3. supine significantly inc HA
  4. visual changes, nystagmus, pupil dilation, diplopia, etc.
  5. CNS s/sx (CNs)
  6. fevers, temps, wt loss/gain
  7. onset w exertion, cough, sneeze
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35
Q

the red flag of a persistent unrelenting HA may indicate what

A

a stroke

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36
Q

the red flag of supine significantly inc HA may indicate what

A

trauma

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37
Q

the red flag of fevers, temps, wt loss/gain may indicate what

A

cancer

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38
Q

the red flag of HA onset w exertion, cough, sneeze may indicate what

A

increased ICP

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39
Q

what are the 3 main categories for differential dx of HAs

A

migraine
tension
cervicogenic

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40
Q

migraines vs tension vs cervicogenic: onset

A

M: hormonal changes, stimulus, trauma, insidious

T: insidious

C: micro/macro trauma

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41
Q

migraines vs tension vs cervicogenic: duration/frequency

A

M: consistent / cyclical
T & C: inconsistent

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42
Q

migraines vs tension vs cervicogenic: location of pain

A

M: arterial patterns
T: band like
C: side locked

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43
Q

migraines vs tension vs cervicogenic: quality of pain

A

M: throbbing (+)
T: pressure
C: ache (+)

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44
Q

migraines vs tension vs cervicogenic: aggravating factors

A

M: mvmt/STM
T: stress
C: mvmt/posture

45
Q

migraines vs tension vs cervicogenic: what medications are effective

A

M: yes (triptans)
T: yes (NSAIDs)
C: no

46
Q

migraines vs tension vs cervicogenic: family hx

A

M: yes (mother)
T: family tendency
C: no

47
Q

migraines vs tension vs cervicogenic: ROM

A

M & T: WNL
C: restrictions

48
Q

migraines vs tension vs cervicogenic: joint assessment

A

M & T: negative
C: positive

49
Q

what are common sx of neck pain w cervicogenic HAs

A

non-continuous, unilateral neck pain and associated/referred HA

HA is precipitated or aggravated by neck mvmts or sustained positions/postures

dull ache beginning in neck or occipital region -> “ram’s head” pattern

50
Q

what are expected exam findings for neck pain with cervicogenic HAs: special tests, reproduction, ROM, joint play, strength/endurance/coordination deficits

A

(+) FRT - >10deg
HA reproduced w mobilization of upper cervical segments (OA, C1, C2)
limited cervical ROM
restricted upper c segments
dec DNF/DNE performance
weakness of postural ms
c ms length deficits
- UT, levator scap, scalenes

51
Q

what part of manual exam was most helpful for r/i cervicogenic HA

A

FRT (+)
ROM deficits
PAIVMS hypo

52
Q

acute interventions for neck pain w cervicogenic HA (what would you prioritize?)

A

*active mobility exercise
* exercise C1-2 self-SNAG

ergonomic intervention
DNF/DNE training

53
Q

sub-acute interventions for neck pain w cervicogenic HA (what would you prioritize?)

A

*cervical manip/mob
- OA, C1, C2 mob, sub occipital stretch/STM
*exercise C1-2 self SNAG

ergonomic intervention
DNF/DNE training

54
Q

chronic interventions for neck pain w cervicogenic HA

A

short term relief:
- cervical manip
- cervical &thoracic manip

exercise for cerv & scap-thor region:
- strengthening & endurance exercise w NM training
- include MC and biofeedback elements

combo manual therapy (mob or manip) + exercise (stretching, strengthening, and endurance training)

55
Q

what treatment is appropriate for all stages of healing for neck pain w cervicogenic HA (6)

A

functional training (MAPS)
DNF/DNE
postural training w laser
scap stabilizers
aerobic exercise- 45 min 3x/wk
relaxation exercise - 1-2x/day

56
Q

what is a concussion or mild TBI

A

TBI induced by biomechanical forces transmitted to head by direct blow or forces exerted on body
- doesn’t result in extended period of LOC, amnesia, or other significant neuro signs which may indicate a more severe brain injury

57
Q

what are sx of a concussion d/t

A

functional disturbance at cellular level
- not a structural injury

58
Q

what sport has highest incidence of concussions in high school boys and high school girls

A

boys football
girls soccer

59
Q

what was seen in the concussion incidence in sex-matched sports

A

girls experience significantly higher rates compared to boys

60
Q

what is the pathophys of a concussion

A
  1. initial injury leads to axonal stretching
  2. axonal stretching results in:
    - release of EAAs & K+ triggering brief period of hyperglycolysis
    - persistent Ca2+ influx causing vasoconstriction and dec blood supply
    - Na/K pump works to restore neuronal membrane potential which inc demand for ATP
    - inc ATP demand triggers inc in glucose metabolism
    - inc demand for glucose in setting of reduced blood supply creates a supply & demand disparity
61
Q

what is second impact syndrome and why can this be devastating

A

occurs when individual suffers concussion, before recovering, suffers a second impact resulting in catastrophic neurologic activity

brain loses ability to auto-regulate intracranial and cerebral perfusion pressures
- can cause cerebral edema w brainstem herniation

62
Q

what is chronic traumatic encephalopathy and what can it be linked to

A

progressive neurodegenerative brain process

may be linked to repeated sub-lethal blows to head

63
Q

what are pre-existing risk factors that make someone less likely to heal from a concussion

A

age
- younger takes longer to recover (older than 13, better healing <13)
- healing worst in ages 13-17
- older adults prolong impairment

sex - worse outcomes in females

psych hx - depression, anxiety

hx of migraine (or family hx)

64
Q

at what age does the majority of sports related concussions happen

A

13-21yo

65
Q

what are 2 injury specific risk factors for poor healing from a concussion

A

delayed removal from play
acute dizziness

66
Q

what are post injury risk factors for poor healing from a concussion (7)

A

larger sx magnitude
acute neuropsych deficits
posttraumatic migraine HA
mood psych sx
vestib s/sx
ocular s/sx
- abnormal convergence/sx provocation
activity
- unrestricted activity & sedentary

67
Q

what are concussion red flags (11)

A
  1. ms weakness, hemiparesis
  2. visual field deficit (blurriness)
  3. pupillary abnormality
  4. horner syndrome
  5. vomit 2+ times
  6. persistent neuro changes/deterioration
  7. fx, skull depression, SCI
  8. unconscious >1min
  9. sz
  10. severe worsening HA
  11. incontinence
68
Q

lot of sx but what are the 5 most commonly reported sx in sports related concussions

A

HA
dizziness
difficulty concentrating
sensitivity to light
sensitivity to noise

69
Q

what sx is often the worst in concussions

A

HA

70
Q

what is the SCAT 5 and when is this used

A

sports concussion assessment tool
- glasgow scale
- standardized assessment concussion (SAC)
- balance and coordination

use as baseline for athletes

71
Q

what is the ImPACT and when is this used

A

immediate post-concussion assessment and cognitive testing

use as baseline

72
Q

what is the CRT5 and what is it designed for

A

concussion recognition tool 5

designed for identification of suspected concussion and help remove athletes from play

73
Q

what should you examine (4) if someone has sx of HA or dizziness after concussion

A

vestib-oculomotor

OH

autonomic impairments that may contribute to dizziness and/or HA (room spinning vs lightheadedness)

motor function impairments per pt tolerance

74
Q

what should you examine (4) if someone has neck pain after a concussion

A

cervical MSK impairments
- special tests / safety tests
- ms
- joint
- neuro exam

75
Q

what are 3 post concussive disorder classifications

A

physiologic PCD
vestibulo-ocular PCD
cervicogenic PCD

76
Q

when is post concussive disorder assessed

A

3 wks post concussion

77
Q

what are tests to assess what classification the post concussive disorder most applies to

A

buffalo concussion treadmill test
BESS
VOMS
cervical joitn position error

78
Q

what are 8 physiologic PCD s/sx and what is the most common one

A
  1. HA exacerbated by physical and/or cog activity
  2. nausea or intermittent vomiting
  3. photophobia
  4. dizziness
    *5. fatigue (physical/mental)**
  5. difficulty concentrating
  6. slowed speech
  7. treadmill test stopped early d/t sx
79
Q

what is the buffalo concussion treadmill test

A

HR, RPE, NPRS, sx measured at rest
every minute inc by 1 grade and re-record those numbers/vitals

80
Q

what are the stop criteria for the buffalo concussion treadmill test

A

pt wants to stop
sx inc >/= 3
examiner notes rapid progression of complaints
90% of age predicted max HR w low RPE score

81
Q

what are 12 vestibulo-ocular PCD s/sx and what is the most common one

A

1. dizziness/vertigo
2. nausea
3. lightheadedness
4. gait/postural instability
5. blurred/double vision
6. difficulty tracking objects
7. motion sensitivity (sx if people walk past them)
8. photophobia
9. eye strain / brow ache
10. HA w activities that worsen vestibulo-ocular sx (like reading)
11. impairments on standard balance or gait testing (BESS)
12. impaired VOR, fixation, convergence, horizontal/vertical saccades (VOMS)

82
Q

what are the 3 main components of VOMS testing

A

ocular
VOR
VOR cancellation

83
Q

VOR vs visual motion

A

VOR - rotating head while fixating on still object

visual motion - rotating trunk w object in hand so that fixating on object moving same rate as body

84
Q

what are 4 examples of ocular components of the VOMS and if there are deficits how will sx present

A

smooth pursuit
saccades (horizontal)
saccades (vertical)
convergence

difficulty w oculomotor tracking
c/o eye strain/fatigue, HA, sensitivity to bright lights & busy environments

85
Q

what are 2 examples of VOR components of the VOMS, what is this testing and if there are deficits how will sx present

A

VOR - horizontal
VOR - vertical

assessing means by which person’s gaze can stay fixed on target even if head is moving

inc in sx w coordinating eye movements w cervical movements

86
Q

what is an example of the VOR cancellation component of the VOMS - what is this testing

A

visual motion sensitivity test

cancelling out VOR to track moving object while head is moving
- ex: like watching tennis match

87
Q

what do cervical PCD s/sx often correspond to

A

whiplash mechanism

88
Q

what are 6 cervical PCD s/sx

A
  1. neck pain, stiffness, and dec. ROM
  2. occipital HA exacerbated by head mvmts and not physical or cog activity
  3. lightheadedness and postural imbalance (based on head position)
  4. cervical lordosis dec (guarding w superficial ms - will be tender to palpation)
  5. TTP in paraspinals and suboccipitals
  6. JPE impairment (mismatch of brain to cerv proprioceptors)
89
Q

what are 6 general classifications of PCD and why have such broad classifications?

A

cognitive
cervical
vestibular
migraine
ocular
mood

ensures multi-disciplinary interaction as referral to outside source may be necessary

90
Q

what 3 broad classifications fit into physiologic PCD

A

cognitive
migraine
mood

91
Q

what are 2 treatment interventions we can introduce to someone w physiologic PCD

A
  1. subsymptom threshold mod aerobic exercise program
  2. relaxation techniques
92
Q

what should be avoided when treating someone w physiologic PCD

A

avoid passive treatments and modalities
- want pt have active role and actively participate in both goal setting and interventions

93
Q

what is an important education piece for treating someone with physiologic PCD

A

physical and cognitive rest (not strict rest)
- encourage normal daily routines and sleep schedule

94
Q

what are 3 types of treatments (and examples) to introduce to someone w vestibulo-ocular PCD

A
  1. vestib rehab based program
    - gaze stabilization, VOR x1, x2
    - eyes/head separate mvmt
    - visual motion sensitivity training (VOR cancellation)
  2. visual rehab
    - visual tracking
    - pencil pushups
    - convergence training
  3. balance training
    - EO, EC
    - BOS
    - surface
95
Q

what is important education to provide to someone w vestibulo-ocular PCD

A

educate on provocative sx, habituate to environment

minimize screen time (blue light filters)

96
Q

VOR x1 training

A

rotate head horiz or flex/ext while keeping eyes on target in hand in front

97
Q

VOR x2 training

A

post it in hand moving opposite to head motion

98
Q

eye head movement training
what is an impairment that can be picked up on doing this exercise

A

post-it in each hand, move eyes to other hand and then move head, and then back

might see dysmetria

99
Q

VOR cancellation training

A

on spinning stool and rotate trunk while keeping eyes on post-it held w both hands in front

100
Q

what are 4 treatments to introduce to someone w cervicogenic PCD

A
  1. manual therapy
    - upper and lower cspine
    - upper thoracic spine
    - ms stretching
  2. DNF/DNE
  3. JPE training
  4. periscap motor control/strength
101
Q

what PCD does a pt have if there is sx onset from a graded treadmill test

A

physiologic PCD

102
Q

what PCD does a pt have if there are sx / deficits identified after a VOMS and BESS

A

vestibular PCD

103
Q

what PCD does a pt have if there are cervical dysfunction/sx identified

A

cervicogenic PCD

104
Q

what is the sequence of tests/assessments performed to determine what PCD a pt has

A
  1. graded treadmill test
  2. VOMS and BESS
  3. cervical dysfunction/sx assessed
105
Q

what is the OT’s role in a multimodal approach to treating a concussion

A

cognitive retraining / memory

106
Q

what is the AT’s role in a multimodal approach to treating a concussion

A

functional training
exertional tolerance
return to sport
sideline and equipment

107
Q

what is the physicians’s role in a multimodal approach to treating a concussion

A

med management
mental health

108
Q

what is the PT’s role in a multimodal approach to treating a concussion (4)

A

c spine:
- manual therapy
- sensorimotor
- DNF/DNE training
- proprioception

vestib component
- gaze stabilization
- convergence

balance/gait exercises

autonomic dysfunction
- exertional tolerance
- aerobic exercise
- graded treadmill test

109
Q

what is the PT’s role in a multimodal approach to treating a concussion (4)

A

c spine:
- manual therapy
- sensorimotor
- DNF/DNE training
- proprioception

vestib component
- gaze stabilization
- convergence

balance/gait exercises

autonomic dysfunction
- exertional tolerance
- aerobic exercise
- graded treadmill test

MSK 2 (20 decks)

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