1g - HA, concussion, WAD Flashcards
what is whiplash associated disorder (WAD)
variety of clinical manifestations caused by a whiplash injury
acute vs chronic classification of WAD
acute <12wks after injury
chronic >12wks
how long does it take for people to typically recover from WAD
recover in acute phase (<12wks)
- typically in 2 wks
what are the grades of the Quebec Taskforce Classification of WAD
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
what education should be provided to pts w acute WAD
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
what exercises are appropriate for acute WAD
postural and mobility exercises to dec pain and inc ROM
- strengthening
- endurance
- flexibility
- postural
- coordination
- aerobic
- functional exercise
what patient education should be provided to pts w chronic WAD
advice to focus on reassurance, encouragement, prognosis, and pain management
what interventions should be given to pts w chronic WAD
mobilization combined with exercise program to treat deficits
- cervicothoracic endurance
- strengthening
- flexibility
- coordination
how can you assess joint position error
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
what is a significant result when assessing joint position error and what does this indicate
> 4.5deg error
associated w dizziness and cervical joint position error
how can you use the test to train joint position error and what is an important consideration
use the laser and change parameters:
- direction
- diagonals
- starting position
- gravity influence
- UE mvmt (internal perturbation)
*always give them target for external cues
allodynia vs hyperalgesia
allodynia
- nonpainful stim is painful
hyperalgesia
- normal noxious stim is heightened
how do you dx central sensitization and nociplastic pain
not a specific test to assess
use clinical hx and findings
what test can indicate nociplastic pain
inc pain w a hot or cold stim earlier than normal
what test can indicate hyperalgesia
mechanical stim (ie pin)
what test can indicate allodynia
dynamic mechanical stim (ie soft)
describes pain processing in someone w chronic pain and how is this relevant to PT
high pain tolerance but low pain threshold
- takes less to inc pain
in PT, we impact pain threshold
what is one approach to treating someone w central sensitization and nociplastic pain
pain science approach
- conceptual approach to explain pain to pt accurate words to help them understand their hyper responsive nervous system
what is the tissue tolerance point
point where tissue breaks
what is protect by pain (PBP)
pain threshold
certain amt of input before tissue tolerance that body perceives pain
how does injury impact the protect by pain line
after injury, body has a new PBP line that is wayyyy lower and therefore any little input creates pain
how can a PT exercise program use a pain science approach
graded exposure
- building intensity, duration, and resistance over time
-> keeping below flare up line
how can graded exposure be implemented into an exercise program
global - walking, bike, elliptical
semi-local - UE and trunk
local - DNF/DNE
global vs local vs semi-local exercise
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
why are psychological factors important to consider with pain science
all contribute to sensory input, heightened alarm system
what is an important strategy when creating a POC
make a problem list (MAPS)
Movement
Activity
Positions
Situations…. that are most painful
what is the concern with using traction in a chronic or flared up state
be painful d/t too much input w altered sensation input
how could STM be implemented if someone has a high irritability
local input may be too much
- maybe to upper back first (get carryover input to neck)
what are the 3 first interventions to start with for someone w a lot of pain
gentle traction
STM - local vs semi-local
exercise
- maybe more global
other than pain relief, why is gentle traction a good tool for therapists to use when first working w a patient
what are indication to therapist of level of irritability of neck
what are 4 primary headache classification
- migraine (w or w/o aura)
- tension type (pericranial pain)
- trigeminal autonomic cephalalgias (TAC)
- severe unilateral pain in orbital, supraorbital, and temporal sites - other primary headache disorders (cough, exercise, sex, cold)
what are 9 secondary headache classifications
- HA d/t trauma or injury to head and/or neck
- HA d/t cranial or vascular disorder
- HA d/t non-vascular intracranial disorder
- HA d/t substance or its withdrawal
- HA d/t infection
- HA d/t disorders of hemeostasis
- HA/facial pain d/t disorders of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial/cervical structures
- HA d/t psych disorder
- painful lesions of CNs and other facial pain
what classification of HAs are more in our scope of practice
secondary HAs
1. d/t trauma/injury to head/neck (ie WAD, concussion)
- d/t disorders of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial/cervical structures (ie neck hypo- or hypermobility, TMJ)
what are 7 red flags w HAs
- persistent unrelenting HAs
- associated trauma
- supine significantly inc HA
- visual changes, nystagmus, pupil dilation, diplopia, etc.
- CNS s/sx (CNs)
- fevers, temps, wt loss/gain
- onset w exertion, cough, sneeze
the red flag of a persistent unrelenting HA may indicate what
a stroke
the red flag of supine significantly inc HA may indicate what
trauma
the red flag of fevers, temps, wt loss/gain may indicate what
cancer
the red flag of HA onset w exertion, cough, sneeze may indicate what
increased ICP
what are the 3 main categories for differential dx of HAs
migraine
tension
cervicogenic
migraines vs tension vs cervicogenic: onset
M: hormonal changes, stimulus, trauma, insidious
T: insidious
C: micro/macro trauma
migraines vs tension vs cervicogenic: duration/frequency
M: consistent / cyclical
T & C: inconsistent
migraines vs tension vs cervicogenic: location of pain
M: arterial patterns
T: band like
C: side locked
migraines vs tension vs cervicogenic: quality of pain
M: throbbing (+)
T: pressure
C: ache (+)
migraines vs tension vs cervicogenic: aggravating factors
M: mvmt/STM
T: stress
C: mvmt/posture
migraines vs tension vs cervicogenic: what medications are effective
M: yes (triptans)
T: yes (NSAIDs)
C: no
migraines vs tension vs cervicogenic: family hx
M: yes (mother)
T: family tendency
C: no
migraines vs tension vs cervicogenic: ROM
M & T: WNL
C: restrictions
migraines vs tension vs cervicogenic: joint assessment
M & T: negative
C: positive
what are common sx of neck pain w cervicogenic HAs
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
what are expected exam findings for neck pain with cervicogenic HAs: special tests, reproduction, ROM, joint play, strength/endurance/coordination deficits
(+) 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
what part of manual exam was most helpful for r/i cervicogenic HA
FRT (+)
ROM deficits
PAIVMS hypo
acute interventions for neck pain w cervicogenic HA (what would you prioritize?)
*active mobility exercise
* exercise C1-2 self-SNAG
ergonomic intervention
DNF/DNE training
sub-acute interventions for neck pain w cervicogenic HA (what would you prioritize?)
*cervical manip/mob
- OA, C1, C2 mob, sub occipital stretch/STM
*exercise C1-2 self SNAG
ergonomic intervention
DNF/DNE training
chronic interventions for neck pain w cervicogenic HA
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)
what treatment is appropriate for all stages of healing for neck pain w cervicogenic HA (6)
functional training (MAPS)
DNF/DNE
postural training w laser
scap stabilizers
aerobic exercise- 45 min 3x/wk
relaxation exercise - 1-2x/day
what is a concussion or mild TBI
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
what are sx of a concussion d/t
functional disturbance at cellular level
- not a structural injury
what sport has highest incidence of concussions in high school boys and high school girls
boys football
girls soccer
what was seen in the concussion incidence in sex-matched sports
girls experience significantly higher rates compared to boys
what is the pathophys of a concussion
- initial injury leads to axonal stretching
- 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
what is second impact syndrome and why can this be devastating
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
what is chronic traumatic encephalopathy and what can it be linked to
progressive neurodegenerative brain process
may be linked to repeated sub-lethal blows to head
what are pre-existing risk factors that make someone less likely to heal from a concussion
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)
at what age does the majority of sports related concussions happen
13-21yo
what are 2 injury specific risk factors for poor healing from a concussion
delayed removal from play
acute dizziness
what are post injury risk factors for poor healing from a concussion (7)
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
what are concussion red flags (11)
- ms weakness, hemiparesis
- visual field deficit (blurriness)
- pupillary abnormality
- horner syndrome
- vomit 2+ times
- persistent neuro changes/deterioration
- fx, skull depression, SCI
- unconscious >1min
- sz
- severe worsening HA
- incontinence
lot of sx but what are the 5 most commonly reported sx in sports related concussions
HA
dizziness
difficulty concentrating
sensitivity to light
sensitivity to noise
what sx is often the worst in concussions
HA
what is the SCAT 5 and when is this used
sports concussion assessment tool
- glasgow scale
- standardized assessment concussion (SAC)
- balance and coordination
use as baseline for athletes
what is the ImPACT and when is this used
immediate post-concussion assessment and cognitive testing
use as baseline
what is the CRT5 and what is it designed for
concussion recognition tool 5
designed for identification of suspected concussion and help remove athletes from play
what should you examine (4) if someone has sx of HA or dizziness after concussion
vestib-oculomotor
OH
autonomic impairments that may contribute to dizziness and/or HA (room spinning vs lightheadedness)
motor function impairments per pt tolerance
what should you examine (4) if someone has neck pain after a concussion
cervical MSK impairments
- special tests / safety tests
- ms
- joint
- neuro exam
what are 3 post concussive disorder classifications
physiologic PCD
vestibulo-ocular PCD
cervicogenic PCD
when is post concussive disorder assessed
3 wks post concussion
what are tests to assess what classification the post concussive disorder most applies to
buffalo concussion treadmill test
BESS
VOMS
cervical joitn position error
what are 8 physiologic PCD s/sx and what is the most common one
- HA exacerbated by physical and/or cog activity
- nausea or intermittent vomiting
- photophobia
- dizziness
*5. fatigue (physical/mental)** - difficulty concentrating
- slowed speech
- treadmill test stopped early d/t sx
what is the buffalo concussion treadmill test
HR, RPE, NPRS, sx measured at rest
every minute inc by 1 grade and re-record those numbers/vitals
what are the stop criteria for the buffalo concussion treadmill test
pt wants to stop
sx inc >/= 3
examiner notes rapid progression of complaints
90% of age predicted max HR w low RPE score
what are 12 vestibulo-ocular PCD s/sx and what is the most common one
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)
what are the 3 main components of VOMS testing
ocular
VOR
VOR cancellation
VOR vs visual motion
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
what are 4 examples of ocular components of the VOMS and if there are deficits how will sx present
smooth pursuit
saccades (horizontal)
saccades (vertical)
convergence
difficulty w oculomotor tracking
c/o eye strain/fatigue, HA, sensitivity to bright lights & busy environments
what are 2 examples of VOR components of the VOMS, what is this testing and if there are deficits how will sx present
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
what is an example of the VOR cancellation component of the VOMS - what is this testing
visual motion sensitivity test
cancelling out VOR to track moving object while head is moving
- ex: like watching tennis match
what do cervical PCD s/sx often correspond to
whiplash mechanism
what are 6 cervical PCD s/sx
- neck pain, stiffness, and dec. ROM
- occipital HA exacerbated by head mvmts and not physical or cog activity
- lightheadedness and postural imbalance (based on head position)
- cervical lordosis dec (guarding w superficial ms - will be tender to palpation)
- TTP in paraspinals and suboccipitals
- JPE impairment (mismatch of brain to cerv proprioceptors)
what are 6 general classifications of PCD and why have such broad classifications?
cognitive
cervical
vestibular
migraine
ocular
mood
ensures multi-disciplinary interaction as referral to outside source may be necessary
what 3 broad classifications fit into physiologic PCD
cognitive
migraine
mood
what are 2 treatment interventions we can introduce to someone w physiologic PCD
- subsymptom threshold mod aerobic exercise program
- relaxation techniques
what should be avoided when treating someone w physiologic PCD
avoid passive treatments and modalities
- want pt have active role and actively participate in both goal setting and interventions
what is an important education piece for treating someone with physiologic PCD
physical and cognitive rest (not strict rest)
- encourage normal daily routines and sleep schedule
what are 3 types of treatments (and examples) to introduce to someone w vestibulo-ocular PCD
- vestib rehab based program
- gaze stabilization, VOR x1, x2
- eyes/head separate mvmt
- visual motion sensitivity training (VOR cancellation) - visual rehab
- visual tracking
- pencil pushups
- convergence training - balance training
- EO, EC
- BOS
- surface
what is important education to provide to someone w vestibulo-ocular PCD
educate on provocative sx, habituate to environment
minimize screen time (blue light filters)
VOR x1 training
rotate head horiz or flex/ext while keeping eyes on target in hand in front
VOR x2 training
post it in hand moving opposite to head motion
eye head movement training
what is an impairment that can be picked up on doing this exercise
post-it in each hand, move eyes to other hand and then move head, and then back
might see dysmetria
VOR cancellation training
on spinning stool and rotate trunk while keeping eyes on post-it held w both hands in front
what are 4 treatments to introduce to someone w cervicogenic PCD
- manual therapy
- upper and lower cspine
- upper thoracic spine
- ms stretching - DNF/DNE
- JPE training
- periscap motor control/strength
what PCD does a pt have if there is sx onset from a graded treadmill test
physiologic PCD
what PCD does a pt have if there are sx / deficits identified after a VOMS and BESS
vestibular PCD
what PCD does a pt have if there are cervical dysfunction/sx identified
cervicogenic PCD
what is the sequence of tests/assessments performed to determine what PCD a pt has
- graded treadmill test
- VOMS and BESS
- cervical dysfunction/sx assessed
what is the OT’s role in a multimodal approach to treating a concussion
cognitive retraining / memory
what is the AT’s role in a multimodal approach to treating a concussion
functional training
exertional tolerance
return to sport
sideline and equipment
what is the physicians’s role in a multimodal approach to treating a concussion
med management
mental health
what is the PT’s role in a multimodal approach to treating a concussion (4)
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
what is the PT’s role in a multimodal approach to treating a concussion (4)
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
