Concussion Flashcards
Acquired brain injury–> includes both TBI and non-TBI
-after birth
-adults and children
-can occur via traumatic causes such as injury or non-traumatic causes such as disease, stroke, and infection
-NON-TBI: stroke, brain tumor, hypoxia, anoxia, dementia, encephalitis
-TBI: diffuse or focal
–diffuse: concussion, diffuse axonal injury, hypoxia, anoxia
–focal: subdural hematoma, epidural hematoma
Key CDC guidelines for pediatric mTBI:
1.) do not routinely image patients to diagnose mTBI
2.) use validated, age-appropriate symptom scales to diagnose mTBI
3.) assess evidence-based risk factors for prolonged recovery
4.) provide patients with instructions on return to activity customized to their symptoms
5.) counsel patients to gradually return to non-sports activities after no more than 2-3 days rest
Concussion definitions:
-traumatic brain injury induced by mechanical forces that disrupts normal brain functioning
-It may be caused by either a direct blow to the head, face, neck or an indirect blow to the body that transmits forces to the head
- functional disturbance rather than structural injury
-may or may not result in a loss of consciousness
-Clinical signs and symptoms cannot be explained by drug, alcohol, medication use or other injuries, comorbidities, psychological factors, co-existing medical conditions
-These direct or indirect forces result in acceleration, deceleration,
and/or rotation of the brain inside the skull and the initiation of a complex
pathophysiologic process that alters neurometabolism.
Why are concussions called mTBIs?
-they are usually not life threatening
Prior concussion history makes ____ more likely to sustain a
second
3 times
Maximum score on Glasgow Coma Scale (most severe):
3 points
CATEGORIES:
-eye opening
-verbal response
-motor response
Mild TBI on the Glasgow Coma Scale score:
13-15
-can have a perfect score and still have a concussion
Moderate score Glasgow coma scale:
9-12
Severe score Glasgow coma scale:
8 or less
top three most common mechanisms of TBI:
1.) FALLS
2.) MVA
3.) OTHER: unintentionally being struck, intentional self harm, assault
Concussion risk factors associated with longer recovery or poorer outcomes:
-prior history of concussion
-female
-collegiate versus high school athlete
-posttraumatic migraine
-history of psychiatric disorders or learning disability
-dizziness on field (associated with prolonged recovery)
-cognitive deficits in the first few days
-increased severity of acute and subacute symptoms is the most consistent predictor of slowed recovery
-impact/collision sports have a greater risk –> higher risk in games than practice
General return to play guidelines:
-athletes need to be immediately removed from play when a concussion is suspected
-no athlete should be permitted to return to play on the same day as the suspected concussion
-to return, need to be symptom free and taking no symptom modifying medications
-to return, athletes should participate in a graduated return to play protocol , after which normal symptoms and no return of symptoms are confirmed
Describe the physiological mechanism of concussion:
-alteration of the neuronal membrane
-increased cellular demand for ATP
-increased glucose demand
-demand may be greater than supply—> cellular energy crisis
-leads to altered cognition and sensory interpretation
-structural damage is microscopic, cannot be seen on imaging
-exercise tolerance is impacted
-MRI should NOT be used to diagnose concussion
Concussion prognosis:
-recovery: typically within 24 hours, up to 7-10 days
-prolonged recovery: 10-30 days
-PCS: > 30 days
Dizziness and vestibular dysfunction after concussion:
-Dizziness is common after concussion and can result in a 6.4 times greater likelihood of prolonged recovery
-Dizziness can be a result of visual, peripheral and central vestibular disturbances
-imbalance and gaze stability deficits are common in athletes
- Vestibular dysfunction
manifesting as imbalance in up to 30% of those with concussion
How much greater is the risk of another concussion with a LOC on the first?
6x greater
Second impact syndrome
- Rare but life threatening
- Results from a second injury when the brain is vulnerable
- Brain is still healing from the initial injury and is unable to regulate blood flow
- ICP builds in the brain and brainstem herniation can occur
–> due to another impact to the brain in a short amount of time - High fatality rate in young athletes–> remove them from play if there is ANY suspicion of head injury
Post Concussive Syndrome
-10% of those with concussion
-persistence of at least 3 symptoms for > 4 weeks
-Can be related to neuroinflammation and altered cerebral blood flow
-may be more likely in a setting of having previous TBIs
*the majority of those with concussion lose symptoms within 1 month
Prognosis of concussion in children:
- Graded symptom checklist reliably identified mTBI for children ages 6 and older
- Patients with AMS (altered mental status) at time of injury had increased number and severity of symptoms
- More research is needed to identify cognitive deficits and classify severity in children
-Standardized Assessment of Concussion in a Pediatric Emergency Department
Chronic Traumatic Encephalopathy
- Diagnosed after death with autopsy
- Degenerative brain disease found in athletes, military veterans and others with repeated brain trauma
- Families may report mood, behavioral or cognitive changes that progressively develop following consecutive injuries
Signs and symptoms of concussion:
-rapidly occurring, short lived
and resolve spontaneously
- Resolution of symptoms
typically follows a sequential
course, but may be prolonged
SOMATIC:
-headache
-n/v
-cervical pain
-balance problems/dizziness
-sensitivity to light/noise
-numbness and tingling
-blurred vision/diplopia/flashing lights
-tinnitus
NEUROBEHAVIORAL:
-drowsiness
-fatigue/lethargy
-sadness/depression
-nervousness/irritability
-sleeping more than usual
-trouble falling asleep
COGNITIVE:
-feeling slowed down
-feeling in a fog or dazed
-difficulty concentrating
-difficulty remembering
COMMON ACUTE SIGNS:
-impaired conscious state or brief loss of consciousness
-confusion
-vacant stare/glassy eyes
-amnesia: retrograde or anterograde
-slow to answer questions or follow directions: easily distracted/poor concentration
-poor coordination or balance; unsteady gait
-personality change; inappropriate emotion
-slurred speech
-gross observable incoordination
-n/v
-headache
-dizziness
Common sleep alterations with concussion
excessive sleep
fragmented sleep
difficulty falling asleep
BESS
Assessment of static postural stability
20-second trials in each (all with eyes closed):
-double limb support
-single limb support
-tandem stance
-double limb support on foam
-single limb support on foam
-tandem stance on foam
SCAT-5
Gold standard for assessment of individuals with concussion
AGE: 13-65 years
child SCAT can be used for children 12 and younger
-SAC- Standardized Assessment of Concussion
–best when compared to a known baseline
-measures: orientation, immediate memory, neurologic function, concentration, delayed recall
-mBESS- Modified Balance Error Scoring System
-assessment of static postural stability
The first 3 of the 6 conditions of original BESS with 20-second trials in each (all with eyes closed):
-double limb support
-single limb support
-tandem stance
-Glasgow Coma Scale
-symptom evaluation
-Maddock’s score
-cognitive and physical evaluation
-neck exam
-coordination exam
-delayed recall
How SCAT-6 is different than SCAT-5:
-modified instructions to symptoms scale
-dual task tandem gait measure added
-creating a new sequence of increasing complexity for the administration of postural control measures
-revised return-to-sport and return-to-learn progressions
-enhanced instructions and resources for clinicians
Rivermead concussion symptom scale
-self-administered
-degree of symptoms within last 24 hours
-5 point scale → total 64
-higher score→ more severe
–3 Categories:
–physical
–cognitive
–behavioral
ImPACT - Immediate Post-Concussion Assessment and Cognitive Testing
-computerized
-verbal and visual memory
-brain processing speed
-reaction time
-need to obtain baseline prior to injury
COSTS MONEY
MACE tool
Military acute concussion evaluation- 2
*Most effective when used close to
time of injury
* Can be repeated to evaluate
recovery
* Screens red flags
Screening consists of:
incident, altered consciousness or
memory, symptoms, past concussion
history, orientation, immediate
memory, speech fluency, word
finding, grip strength, pronator drift,
single leg stance, tandem gait, pupil
response, eye tracking,
concentration, delayed recall, VOMS
HiMAT- High Level Mobility Assessment Tool
Patient population: those with high-level balance and mobility problems
13 items that assess:
-walking and running
-jumping and balance
-stairs
-hopping
-skipping
cut off scores available per age and injury
Community Balance and Mobility Scale (CB&M)
-Assesses a patient’s balance and mobility with a combination of tasks that are necessary to move functionally within the community
-Patient populations: mTBI, TBI, stroke, cerebral palsy
-Max score of 96, best possible
-13 items with a maximum score of 5 on each, indicating the most successful completion
Buffalo Concussion Treadmill Test
-can be performed on a treadmill or a bike
-must obtain a resting HR, BP, VAS (visual analogue scale), RPE, then repeat RPE, VAS, and HR every minute
-1 point for worsening symptoms and 1 point for new symptoms
-start at 3.2 mph at 0% incline (alter speed if needed based on height)
-1% incline increase at 2 min
-increase the incline by 1% each min–> if a 15% incline is reached, increase speed by 0.4 every minute until stopping criteria met
BCTT stopping criteria
symptom exacerbation - an increase of 3 or more points on the VAS scale from resting VAS score
voluntary exhaustion: RPE > 17 without significant symptom exacerbation
–try to encourage the patient to keep going if they have not reached 80% of their age-predicted maximum (do not push if they are too exhausted)
rapid progression of complaints or patient appears faint or has stopped communicating or the test has progressed to a significant health risk for the patient
the patient has reached 90% or more of the age-predicted maximum without any increase in symptoms and is still reporting a low RPE
the patient requests to stop for any reason —> record the reason
VOMS - vestibular/ocular motor screening assessment
Prior to screening: assess baseline dizziness, nausea, and fogginess on 0-10
Tracking symptom provocation during various VO testing:
-visual tracking/smooth pursuit
-saccades
-near point of convergence
-VOR - horizontal and vertical
-VOR cancel - visual motion sensitivity
DHI - ADULT
25 questions (0, 2, 4 rating)
3 subtypes
-emotional, physical, functional
excellent test-retest reliability
MDC- 18 points
> 60 points: increased fall risk
categories of disability
mild: 0-30
moderate: 31-60
severe: 61-100
DHI- YOUTH
25 questions (0, 2, 4 rating)
3 subtypes
-emotional, physical, functional
excellent test-retest reliability
mild: 0-30
moderate: 31-60
severe: 61-100
VMHQ
-self-reported outcome measure
- Discriminates between those with VMH and those with vestibular disorders
Motion sensitivity is characterized by nausea, dizziness, and imbalance in response to motion of the visual environment [1]. It can develop as a sequela of a vestibular disorder and is one of the diagnostic criteria for persistent postural perceptual dizziness
COBALT - Comparison of Uninjured and Concussed Adolescent Athletes on the Concussion Balance Test
Rate athlete’s ability to complete the protocol, error rate, sway velocity, ID balance impairment
8 conditions that are evaluated:
-EO, feet apart
-EC, feet apart
-EC, feet apart, head rotation at 120 bpm
-EO, feet together in the center of force plate, arms outstretched with hands clasped and thumbs up, eyes focus on thumbs, en bloc rotation performed side to side 30 degrees in each direction to 40 bpm metronome, maintain focus on thumbs
-conditions 5-8: conditions 1 through 4 are repeated, performed on foam pad placard on top of the force plate
provide objective input recovery of balance function after concussion
PANESS - physical and neuro exam of subtle signs
-Assesses motor impairment during gait, balance, timed basic motor functions
-May be sensitive to more subtle motor deficits
-May better reflect functional improvements and speed-accuracy tradeoffs
-more-so used in a pediatric population
Healthcare professionals involved in the UPMC sports medicine concussion program
-emergency department
-pediatric practices
-certified athletic trainers
-primary care physicians
-vestibular/physical therapy
-radiology
-behavioral
-neuro-optometry
-neurosurgery/orthopedic surgery
History and symptoms to focus on - concussion
mech of injury
time since injury
symptom reporting
context
Warning signs that warrant immediate referral to emergency care:
➢ Cervical instability/fracture
➢ Neurologic signs:
▪ spasticity
▪ reflex changes
▪ ataxia
▪ weakness
▪ sensory changes
▪ CN abnormalities
▪ Seizures
➢ Prolonged LOC
➢ HA that is progressing
➢ Altered mental status beyond the acute stage or deteriorating mental status
➢ HTN
➢ Autonomic dysregulation
❖ One pupil larger than the other –> could indicate stroke, dural tear, brain bleed
❖ Is drowsy or cannot be awakened
❖ A headache that gets worse and does
not go away
❖ Weakness, numbness, or decreased
coordination
❖ Repeated vomiting or nausea
❖ Slurred speech
❖ Convulsions or seizures
❖ Cannot recognize people or places
❖ Becomes increasingly confused, restless
or agitated
❖ Has unusual behavior
❖ Loses consciousness
Systems/domains to examine or treat:
-C spine
* Cervicogenic dizziness, HA, neck pain, altered afferent input
-vestibular-oculomotor
* Difficulty with gaze
stabilization and/or
* Increased symptoms with
visual activities
* Visual Motion Sensitivity
-balance
*sensory vs motor contributions
-BPPV
-symptoms with exertion
C spine exam
- Palpation
- Ligamentous/stability testing
- Flexibility
- Mobility testing
- Cervical strength testing
- Upper quarter screen
- Cervicogenic dizziness testing
–Smooth Pursuit Neck Torsion Test (SPNTT) - tests proprioceptive function
—-> head is turned 45 degrees, track object with eyes while keeping the head steady
—-> positive if dizziness in torsion position compared to neutral
– Joint Position Error Test (JPET)
– Head-Neck Rotation Test (you hold their head stable and they rotate their body–> indicates that the dizziness is a result of neck (cervical afferent) impairment)
——> isolated stimulation of cervical afferent nerves
Things to think about if head motion provokes dizziness:
-if the target slips or blurs:
* VOR deficit
* Caused by vestibular/inner ear origin such as hypofunction, OR
* Caused by central dysfunction
-if the target is stable (VOR intact) but the dizziness is perceived
* Determine whether this is caused by vestibular or cervical misinformation
* Cervical origin -> + SPNTT, + JPET, + Head Neck Rotation test -> treat neck first, may include cervical proprioception/kinesthetic training
* Vestibular hypofunction -> treat with VOR exercises for recalibration and for habituation to symptoms
Exam for cervicogenic dizziness:
+ with head neck rotation test–> dizziness experienced with body-on-head motion
smooth pursuit neck torsion test
—-> head is turned 45 degrees, track object with eyes while keeping the head steady
—-> positive if dizziness in torsion position compared to neutral
Joint position error test- neck proprioception/kinesthesia
endurance of long neck flexors and extensors –> necessary for postural control and stability
Pain, ROM, muscle imbalance, strength of the c-spine
joint position error test
- Laser mounted to headband/hat
- Patient asked to focus on natural resting head position sitting 90 cm away from the wall with a target placed
- With eyes closed, move head one direction,
then return to resting position (R, L, up, down; repeat 3 times in each direction) - Repeat this with additional head movements
- Meaningful error: 7.1cm, 4.5 degrees
SPNTT
- Visual tracking, observing for smooth pursuit, neck in
neutral, followed by smooth pursuit assessment with the
head rotated 45 degrees to each side - Assess for abnormalities in tracking when head is rotated
- Assess for symptom provocation
- Simplify this for intervention, using clinic and home
exercise programs, then progress
-tells you the cervical spine is involved if dizziness provoked —> cervicogenic dizziness
** start with a blank background
Head neck rotation testing
- Patient is seated on a rotational stool
- Therapist holds shoulders and body stable while patient rotates head to one side, then repeat to the other side
-note if this provokes dizziness
-if this is positive: symptoms are arising from the cervical spine
Differentiate inner ear vs Cervical spine involvement
When would intervention be unsuccessful?
➢ Poor education provided to the patient
➢ Incorrect diagnosis/classification
➢ Lack of specificity of program
➢ Overloading the system
➢ Not persistent enough
➢ Premorbid sensory dysfunction
➢ Disorder is too great for CNS adaptation or substitution
➢ Fluctuating pathologies
➢ Multiple causes/insults
➢ Depression/Anxiety
Interventions for neck impairments associated with concussion
MOVEMENT CONTROL:
-Use a headband and laser pointer to track a maze or target
90 cm away from wall
–Follow the image; focus on smoothness and accuracy
–Assess symptom reproduction
–Want to stay 4/10 or less on NPRS scale
–Progress over time
–Increase speed, accuracy, and monitor symptoms
FLEXIBILITY:
-ROM
-Stretching
-Soft tissue mobilization
STRENGTH:
-progressive resistance
HYPOMOBILITY:
-mobilizations, manipulations (after acute period)
suboccipital HA:
-suboccipital release
cervicogenic dizziness:
-May have +SPNTT, +JPET, + Head Neck Rotation Test
Treat the neck first, may include proprioception/kinesthetic training
-Proprioceptive training
-Oculomotor and balance retraining
-Mobilizations AFTER acute period
patient education
-Adherence to physical therapy
-Patient needs to learn to habituate
observation of neck movement during balance tasks
–observe head righting and neck motion
Where can I find details of VOMS testing?
NM STUDY GUIDE
vestibulo-oculomotor impairment interventions:
SMOOTH PURSUIT
Progress from seated to standing or from blank to busy background
Progress or regress intervention based on the patient’s symptom reproduction
SACCADES
Progress intervention by incorporating a busy background, focusing on improved speed and accuracy of movement
Provide patient education on why this exercise is being performed
Can be prescribed for home exercise
NEAR POINT CONVERGENCE
Use of brock string
Green far, yellow middle, red at tip of nose
–V for near
–X for middle
–Inverted V for far
Practice focusing on each of the balls back and forth
Move the yellow ball as needed to progress
Tie end of string to door
Quantify reproduction of symptoms
CONVERGENCE AND DIVERGENCE PENCIL PUSHUPS
-Convergence on the pencil from arms length and bringing to the tip of your nose
–Stop when you notice the pencil turned double
–Rest eyes
–Bring focus back to the pencil and try to focus so double vision resolves
VOR
Vertical or horizontal head movement at 1-2 Hz while focusing on target
–Goal is to keep the target in focus during head movement
–Note symptom reproduction throughout
–Use larger targets, progressing to smaller targets
–Assess accuracy of movement
–Progress for intervention (smaller target) in clinic and at home
DOSING:
–Don’t go above a 4/10 on exercises
–Perform exercise 4-10 times in a given day
–May give 2-3 exercises for the home program
VOR CANCELLATION
–Rotation of head/eyes/trunk with arms as a unit
–Change background to increase difficulty
–Perform on a compliant surface to progress
–Perform while walking a hallway
–Perform with one eye at a time
Balance interventions
BESS loses the ability to detect balance problems after their 3rd day of recovery
Use BESS, CTSIB, SOT, MiniBEST, FGA, DGI, CB&M, HiMAT→ assess balance after concussion and determine deficits in: dynamic, reactive, and anticipatory balance
Tailor specific balance POC from deficits in these assessments
Compare your findings to norms of people their age
Exertional testing and training
Gradually build up CV endurance if symptomatic with CV activity
Monitor HR during exertional training
Exercise dosing/guidelines post concussion
24- 28 hour rest period after acute concussion
Detrimental effects of rest after 2 weeks
–Deconditioning
–Increased anxiety and depression
Exercise benefits
–Increased BDNF, improves mood, improves cerebral blood flow and o2 delivery, provides a sense of control
–Performed at subsymptom threshold
—->Especially for cardiovascular training
Jake snakenberg youth concussion act in Colorado
Senate Bill 40
2004- In 2004 Jake Snakenberg, a freshman high school football player died of second impact syndrome due to his sport
2011-In response, in 2011 in Colorado Senate Bill 40 was signed into law requiring that coaches get education on concussion and that athletes with signs and symptoms of concussion must be removed from play
REQUIRES:
-notification of parent/guardian
-medical clearance for RTP
CLEARANCE BY:
-physician
-neuropsychologist
-NP
-PA
-PT with training in neurology or concussion evaluation and management
Colorado House bill 19-1208 - 2019
Stated that physical therapists with training in pediatric neurology or concussion evaluation and management are considered healthcare providers for ensuring compliance with required head trauma guidelines in organized youth sports
RTP COLORADO
no symptoms for at least 24 hours
attending full days of school with return to learn in place
tolerating a full academic workload
off any medications started for concussions
–not including previous ADHD or antidepressants
cannot return to play on the same day as the injury
Colorado High School Activities Association Bylaws:
Bylaw 1790.21
“If at anytime during participation, a student is removed from participation due to head trauma, the student athlete must obtain a written release from a license practitioner before participating again. A school or school district may impose stricter standards.”
Bylaw 1620.9
“All athletic coaches must annual complete one of the following: the online NFHS concussion course or a school organized sports medicine review that includes a head trauma/concussion component and emergency evacuation procedures.”
Sideline assessment
-remove from play
RED FLAGS SCREENING
-neck pain or tenderness
-double vision
-weakness or tingling or burning in arms or legs
-severe or increasing headaches
-seizure or convulsion
-loss of consciousness
-deteriorating conscious state
-vomiting
-increasingly restless, agitated or combative
-perform SCAT 5 or child SCAT
OBSERVABLE SIGNS
-lying motionless on the field
-balance, gait difficulty, motor incoordination, disorientation or confusion, inability to respond appropriately to questions, blank or vacant look, facial injury after head trauma
Return to Learn
-24 -48 hour rest period
-gradual return to activity
-subsymptom daily activities ok
-reduce screen tme, reading , homework, etc
-quality nutrition and hydration
-avoid meds that may mask
-working with school counselor to aide with return to learn
RTP MEDI CLEARANCE
cannot return to play on the same day as the injury
complete Post Concussion Symptom Inventory or Graded Symptom Scale Check List
must have medical clearance at stage 3 to progress to stage 4
each stage is sport specific
must have clearance from a PA or MD
communication with AT regarding stages 4-6
a PT can only clear at stage 6
Criteria to progress RTP
decline in symptoms
able to remain symptom free during aerobic conditioning
tolerating increasing resistance with strengthening exercise
dual task and reaction-time based training progression
return to running, sprinting, and agility without symptom exacerbation
Exercise dosage
CERVICAL STRENGTH
begin light resistance
start 2x10→ 3x20 for endurance
VESTIBULAR
6x20sec/day
BALANCE
3x30 seconds
add vestibular perturbations, cervical strengthening, dual task
add reaction time training
CARDIO CONDITIONING
perform BCTT→ find max HR→ calculate 90% of HR threshold
–start conditioning at 80-90% of submax HR below symptom exacerbation
–20 min/day, 6-7 days/week
–increase by 5-10 bpm every 1-2 weeks
–will need to repeat BCTT as cardiovascular conditioning improves → adjust training as necessary
RTP objective tests
Mile run (complete return to run/sprint
progression)
* Clean exam without elevated heart rate
* Tandem gait with dual task
* Y balance
* Tuck jump assessment
* SL squat test
* Hop testing
* Multi directional cutting analysis
* Cervical Handheld Dynamometry
