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Neuro 2 > Concussion > Flashcards

Concussion Flashcards

1
Q

CPG definition of concussion

A

Traumatic injury that affects the brain, induced by biomechanical forces transmitted to the head by a direct blow to, or forces exerted on, the body, but that does not result in an extended period of unconsciousness, amnesia, or other significant neurological signs indicative of a more severe brain injury.

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2
Q

Definition of mild TBI

A

TBI is diagnosed when, following a bio mechanically plausible mechanism of injury one or more of the three operational definitions:
1. One or more clinical signs attributable to brain injury
2. At least two acute symptoms and at least one associated clinical or laboratory finding
3. Neuro imaging evidence of TBI

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3
Q

Mild Concussion

A

GCS = 13-15
Loss of consciousness less than 30 minutes
PTA less than 23 hours

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4
Q

Moderate concussion

A

GCS = 9-12
Loss of consciousness 30 min to 24 hours
PTA less than 24 hours

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5
Q

Severe concussion

A

GCS = 3-8
Loss of consiousness greater than 24 hours
PTA greater than 24 hours.

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6
Q

Describe the biomechanical cascade following injury

A

Time of injury you get too much glutamate released — glutamate opens ion channels — massive influx of sodium and calcium — massive efflux of potassium outside of the cell — cell doesn’t like that so wants to get back to homeostasis — requires a lot of ATP to be able to pump ions back to normal — but ATP needs glucose — but there’s already less blood flow to the brain to be able to carry the glucose.

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7
Q

What is the end result following the biomechanical cascade

A

High glucose need + low glucose delivery = ENERGY CRISIS

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8
Q

Resulting pathophysiology following energy crisis

A
  1. Mitochondrial dysfunction
  2. Atonal damage due to mechanical force
  3. Neuro chemical imbalance resulting in damage to cytoskeleton
  4. Unmyelinated nerve fibers more vulnerable to damage — really bad for kids
  5. Upregulation of inflammatory cells.
    cellular dysfunction
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9
Q

Screening and diagnosis following possible concussive event

A

Recommended for all people who experience a concussive event. Really import to have early recognition.
- need to recognize medical emergencies or severe pathology
- use of symptom checklists or rating scales

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10
Q

What are red flags

A
  1. Declining level or loss of consciousness, cognition, or orientation (GCS<13)
  2. New onset of pupillary asymmetry, seizures, repeated vomiting, or other focal neurologic signs
  3. Severe or rapidly worsening headache or neurologic deficits
  4. Signs and symptoms indicating undiagnosed skull fracture
  5. Serious cervical spine fracture, dysfunction, or pathology ( VA insufficiency, cervical ligamentous instability, signs of central cord compression)
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11
Q

What are indicators for a concussion that can be identified during the screen

A
  • Consider info from patient, family, witness
  • Alteration in mental state immediately following event
  • Physical symptoms, emotional/behavioral symptoms
  • GCS
  • Imaging if available
  • Consider possible effects of substances or medications
  • Other medical diagnoses that may explain symptoms
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12
Q

Early management of concussion

A
  1. Relative rest
  2. Typical timeframe for recovery is 7-14 days in adults. 4 weeks for kids
  3. Non linear progression of recovery.
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13
Q

Interview/history points to ask according to CPG

A
  1. Type, severity, and irritability of concussion symptoms
  2. Past medical and mental health history
  3. Injury mechanisms
  4. Any early management strategies
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14
Q

What is included in examination for concussion

A
  1. Cervical musculoskeletal function
  2. Vestíbul-oculomotor function
  3. Auto mic dysfunction/extertional tolerance.
  4. Motor function
    need to let them know the exam is going to be highly provocative of their symptoms
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15
Q

Irritability and prioritizing the exam

A
  • Frequency of provocation
  • Vigor of movement required to elicit symptoms.
  • Severity of symptom once provoked
  • Ease of provoking symptoms
  • Factors that ease symptoms
  • How much, how fast, and how completely symptoms resolve.
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16
Q

Where do you start your examination

A

Cervical spine examination — gonna be able to take a look at most of our red flags and clear that first. You’ll be moving your head a lot for the rest so check that first.

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17
Q

Vestibular examination

A

Oculomotor exam, positional testing, vestibular exam, optokinetics, outcome measure.
*proceed as tolerated — least to most provoking and prioritize based on patient’s goals

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18
Q

Autonomic/exertional testing

A
  • Identify signs and symptoms that are not present at rest
  • Positional testing of heart rate and BP in supine, sitting, and standing
  • Graded exertional testing, stationary vs. Treadmill based.
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19
Q

Motor function examination

A
  • Postural control — static, dynamic, reactive
  • Dual tasking
  • Gait
  • Motor coordination
  • Outcome measures
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20
Q

Psychological and sociological factors

A
  • Patient’s coping mechanisms or self efficacy skills
  • Social support systems
  • Risk factors for prolonged recovery
  • Patient’s beliefs about recovery
  • Equipment access and other resources
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21
Q

What are the international classification of headache disorders

A
  1. Migraine without aura
  2. Migraine with aura
  3. Headache attributed to trauma or injury to the head/neck
  4. Cervicogenic headache
  5. Vestibular migraine.
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22
Q

Describe education interventions

A

Main education piece — expectation if recovery!!
- risk for re-injury
- relative rest for 24-48 hours with gradual reintroduction of activity without symptom exacerbation
- self management strategies
- activity pacing and return to activity
- safe to initiate intervention early.

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23
Q

self management components

A
  • minor symptoms
  • good social support
  • few to no negative risk factors
  • good health literacy and self-efficacy
  • patient preference
  • access to resources/equipment
  • education on symptom management strategies.
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24
Q

What are C spine interventions

A
  1. ROM
  2. STM
  3. Strengthening
  4. Modalities
  5. Posture
  6. Sensorimotor
  7. Neck pain CPG guidelines
    intensity still driving progression
25
Q

What are vestíbulo-ocular motor interventions

A
  1. Oculomotor training
  2. Canalith repositioning maneuvers as indicated
  3. Gaze stabilization
  4. Gaze shifting
  5. Habituation strategies
    Referral as indicated for oculomotor impairments
26
Q

Autonomic/exertional tolerance interventions

A
  1. Progressive, symptom guided monitored aerobic exercise
    referral as indicated
27
Q

Motor function interventions

A
  1. Static and dynamic balance
  2. Motor control and coordination
  3. Dual tasking — esp. cognitive dual task
  4. Task specific
28
Q

What are the special considerations in pediatrics

A

Validated measures: graded symptom checklist (6+), post concussion symptom scale (high school)
- Most will fully recover within 1-3 months
- Balance testing may have less utility in children, but more useful in older adolescent athletes
- Collaboration with school and sport recommended progressions and appropriate activities including educational supports and accommodations.

29
Q

What are risk factors for delayed recovery

A

Mental health and/or substance use disorders
— IN PEDS: mTBI, learning difficulties, psychiatric disorders, family or social stressors, more symptoms or more severe symptoms.
- Patient perspective/understanding towards recovery plus access to resources and equipment to support recovery.

30
Q

What should we emphasize with our patients

A

EMPHASIZE MOST SYMPTOMS AND IMPAIRMENTS WILL IMPROVE.

31
Q

What is post concussive syndrome

A

Presence of any symptom that cannot be attributed to a preexisting condition and that appeared within hours of a mTBI, that is still present every day 3 months after the trauma, and that has impact on at least one sphere of a person’s life.

32
Q

What are risk factors for prolonged recovery

A
  • female sex
  • younger age (teens)
  • increased severity of acute and subacute symptoms
  • loss of consiousness
  • mental health symptoms — depression and ADHD
  • personal history of migraines.
33
Q

What is recovery in this population

A

Resolution of symptoms and exam findings, and return to usual activities
— Physiologic recovery may extend beyond the period of symptom resolution.

34
Q

What are the risks of multiple lifetime concussions

A
  1. Post concussive syndrome
  2. Chronic traumatic encephalopathy
    — chronic progressive disorder
    — only diagnosed post-Mortem
  3. Alzheimer’s
  4. Other degenerative neuro disorders - but mixed evidence on this one.
35
Q

Timeframe for recovery in adults vs. Children

A

Adults: 7-14 days
Children: 1-3 months

36
Q

What test has a high sensitivity for detecting concussion

A

Vestibular/ocular motor screening (VOMS) Assessment.
— this is good for diagnosing the likelihood of concussion.

37
Q

VOMS Assessment

A
  1. Valid for use in ages 9-40 years old
  2. 2 point symptom increase in any domain is considered to demonstrate increased likelihood of concussion.
  3. Clinical use — diagnosis, goal setting, plan of care.
38
Q

Components of VOMS Assessment

A
  1. Smooth pursuit
  2. Saccades - horizontal and vertical
  3. Convergence
  4. VOR - horizontal and vertical
  5. Visual motion sensitivity test
39
Q

Smooth pursuit from VOMS Assessment

A
  1. Patient rates symptoms
    2.Target is 3 feet from patient
  2. Move target 1.5 ft to the R and L from midline.
  3. Complete 2 full reps R->L and then up->down
  4. Ask patient to re-rate symptoms —Record
    eyes should stay locked on the target. We don’t care too much about the smoothness of the eye movement, here we wanna see how much this affects their symptoms
40
Q

Saccades from VOMS Assessment

A

Same spacing as smooth pursuit: 3 feet from patient. 1.5 ft to each side.
1. Pre-rate symptoms — Complete 10 reps of horizontal saccades — re-rate symptoms and record
2. Pre-rate symptoms — complete 10 reps of vertical saccades — re-rate symptoms and record.
we use saccades way more in the real world than smooth pursuit. So can def be a big trigger

41
Q

Convergence from VOMS Assessment

A

Want to make sure patient’s eyes stay locked on the target as they bring it in towards their nose. Okay for it to get blurry but once it doubles you stop.
(Normal is 6cm or less)
if one of patient’s eyes falls off target then you tell them to stop. Otherwise patient stops moving the object on their own once it doubles
1. Pre-rate symptoms — do convergence 3xs — measure distance each trial — re-rate symptoms and record.

42
Q

VOR from VOMS Assessment

A
  1. Pre-rate symptoms — move head horizontal at a rate of 180 beats/minute for 10 reps — re-rate symptoms and record.
  2. Do the same thing but 10 reps of vertical movement at same speed.
43
Q

Visual Motor Sensitivity from VOMS Assessment

A

Aka VOR cancellation
1. Pre-rate symptoms — trunk rotation 80 degrees to the R and L at a speed of 50 beats/minute for 5 reps — re-rate symptoms and record.

44
Q

What are concussion specific examination - vestibular outcome measures

A
  1. Dizziness handicap inventory - DHI
  2. Dynamic visual acuity testing - DVA
  3. Neurobehavioral symptom inventory - NSI
  4. Post-concussion symptom scale - PCSS
  5. Sport concussion assessment tool - SCAT
45
Q

Post concussion symptom scale (PCSS)

A

Self report scale
Rating 0-6 (none to severe)
includes physical, mod, and cognitive symptoms

46
Q

Sport concussion assessment tool (SCAT)

A

For athletes 13+
Incorporates symptom evaluation, standardized assessment of concussion and modified balance error scoring system

47
Q

What are some concussion specific interventions for vestibular symptoms

A
  1. Gaze stabilization
  2. Gaze shifting
  3. Habituation
  4. Compensation.
  5. Convergence training (pencil push ups and Brock’s strings)
48
Q

What is involved in the C spine examination

A

Positional testing, DVA, head shaking, joint position error testing

49
Q

What is joint position error testing

A
  1. Patient seated with back support and fitted with laser headpiece centered over nose.
  2. Target placed on wall 90 cm from patient.
  3. Patient self selects neutral positioning and we put the center of the target there.
  4. Vision is occluded and patient is told to perform max or submax rotation and return to neutral.
  5. Perform 6 or more trials and calculate average for best reliability.
50
Q

Outcome measures for C spine

A

Neck disability index. NDI
Headache impact test-6 - HIT6

51
Q

Interventions for C spine

A

MSK interventions
Proprioceptive training to reduce sensory mismatch.

52
Q

What are concussion specific exam components for autonomic/exertional part

A
  1. BP/HR assessment in supine and standing
  2. Buffalo concussion treadmill test
53
Q

What is buffalo concussion treadmill test

A

A graded exercise test to assess symptom provocation and physiologic response
1. Start at 3.6 mph and 0% incline
2. At 2 minutes start increasing include by 1% each minute until max incline
3. Increase speed 0.4mph each minute after max incline achieved
4. Monitor RPE and symptoms with VAS each minute and HR/BP every 2 minutes
test is complete when RPE is 19-20 or symptom increase of >/equal to on VAS

54
Q

What is the bike protocol

A

Used if treadmill can’t
1. Start pedaling at 60rpm for 4 minutes
2. Increase by 15W every time after
3. Rate symptoms on VAS and RPE every minute and monitor HR and BP
4. Test is complete when RPE is 19-20 or symptom increase of >/equal to VAS

55
Q

Autonomic/exertional interventions

A
  • Submax aerobic training
  • 20 min/day at sub-threshold intensity (80% of threshold HR)
  • Increase HR target by 5-10 bpm every 2 weeks if patient responding well
  • Consider retesting every 2-3 weeks
  • Resolution achieved when patient has ability to exercise at 80-90% of age predicted maximum HR.
56
Q

Concussion specific motor function exam

A
  1. Postural control — static and dynamic : use CTSIB
  2. Dual tasking — TUG cog and walking while talking
  3. Gait — 10MWT
  4. Motor coordination — BESS, HiMat, FGA
57
Q

HiMat. High Level Mobility Assessment Tool

A
  1. Less of a ceiling effect compared to FGA/DGI
  2. Patients allowed to practice once prior to performing scored trials
    excellent reliability in TBI population
58
Q

Balance Error Scoring System. BESS

A

Normative values based on age
Used more frequently in sports populations

59
Q

Motor function interventions

A

Task specific
Intensity levels based on irritability
Specific to the PT diagnosis and impairments from exam.

Neuro 2 (8 decks)

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