Concussion Flashcards
what is a concussion
TBI caused by a direct blow to the head, neck or body resulting in an impulsive force being transmitted to the brain that occurs during sport or exercise
concussion impact types
direct contact
inertial contact (acceleration)
shear forces caused by rotational acceleration (primary predominant mechanism of concussion)
primary mechanism of concussions
shear forces caused by rotation
concussion mechanism determined by
amount of mechanical energy from acceleration transferred to the brain and vascular tissue
which population sustains more concussions
high school athletes > college
physiology of concussion
acceleration/deceleration = injury
nerve is deformed = shearing and stretching motion
physiology cascade of events
- neurotransmitters are released and influx of ions
- binding of glutamate to excitatory amino acids receptor
- leads to further neuronal depolarization with efflux of potassium and calcium
- the Na+ K+ pump works in overtime to try and restore neuronal membrane
- this requires increased use of ATP
- increase in glucose metabolism “hyper-metabolism” + diminished cerebral blood flow = cellular energy crisis !
most important part of physiology
energy crisis
what impairs the mitochondria, ATP production, and neural connectivity
calcium
what does calcium accumulation do
can directly activate pathways leading to cell death
what are changes in the brain metabolism following a concussive episode called
metabolic vulnerability
second impact syndrome
second head injury (hit) before the complete recovery of the initial injury
second impact syndrome physiology
results from the dysfunctional cerebral blood flow autoregulation leading to increased intracranial pressure
herniations = rapid pressure develop and deterioration and leading to death within 2-5min
concussion prevention
neck strength
ability to actively engage neck muscles and resist linear/rotational acceleration (neuromuscular training)
helmets and mouthguards
may help but more research is needed
symptoms of concussion may develop within
48-72 hours
% of people who experience persistent symptoms
up to 30% of children and adults
how much time do persistent symptoms last on average
2 weeks + for adults
4 weeks+ for children
what are persistent concussion symptoms associated with
mental health problems
declines in QOL
difficulties returning to sport, school and ADLs
risk factors for concussion outcomes
history of concussions
history of migraines
diagnosis of learning disability or ADHD
sex ( more females)
age (younger)
does a SCOAT6 replace a clinical assessment
no
what does the scat 6 include
symptoms
cognitive recall
BP
cervical evaluation
neuro exam
timed tandem gait
modified VOMs
what is the most commonly reported symptom during clinical assessments?
75% of patients experience headaches.
dizziness at time of injury AND migraines in the first week post injury BOTH require special attention
how do you evaluate symptoms
combination of self reported questionnaires and clinical interview questions
what do you categorize symptoms into
trajectories
what are the different trajectories
vestibular
ocular-motor
cognitive
post-traumatic migraines
cervical
anxiety/mood
S/S - cognitive
fatigue
decreased energy levels
non-specific H/A (increase with cognitive activity)
sleep disturbances
difficulty concentrating
symptoms increase at the end of the day
vestibular - S/S
dizziness
foggines
nausea
feeling of being detached
anxiety
overstimulation
what increases vestibular S/S
busy environments
rapid head and body movements
Ocular motor -S/S
localize
frontally based headaches
fatigue
distractibility
difficulties with visually based classes
pressure behind the eyes
difficulty with focus
what can intensify symptoms - ocular motor
full days of work or school
common complaints
anxiety mood - S/S
anxiety
ruminative thoughts
hypervigilance
feelings or being overwhelmed
sadness
hopelessness
sleep distrubances
headaches
dizziness
fogginess
fatigue
what needs to be treated before anxiety
vestibular symptoms
post traumatic migraine -S/S
unilateral headache
pulsating
photo/phono sensitivity
increased with physical activity
what exacerbates symptoms with post traumatic migraine
stress
sleep dysregulation
anxiety
emotional changes
caffeine
differentiating headaches - vestibular migraines
NS problem that causes repeated dizziness
may have H/A
differentiating headaches - cervicogenic
secondary H/A
referred pain caused by cervical spine dysfunction
reduced ROM of neck
increased S/S with movement of the C/S
differentiating headaches - concussion
H/A that develops within 7 days post injury or after regaining consciousness
resembles a migraine
C1-3 and trigeminal nerve lead to referred hemi cranial pain
cervical - S/S
headache and neck pain
can have a concussion without C/S affected
yes but very rare
tests to help differentiate C/S injury from concussion
cervical joint reposition error test
smooth pursuits neck torsion
flexion-rotation test
head-neck differentiation test
motor control
purpose of smooth pursuits neck torsion test
test cervical spine
stimulates cervical proprioceptors NOT vestibular
+ve smooth pursuits neck torsion
symptoms increase with head rotation in comparison to neutral position
(rotation side is side of the problem)
purpose of cervical joint position error test
looks a proprioceptive abilities
purpose of flexion rotation test
dysfunction in the C0-C2 to help determine C/S dysfunction and cervicogenic headaches
+ve flexion rotation test
firm resistance
pain
limited ROM
common impairment following concussion
vestibular and ocular motor
symptoms of vestibular impairement
unstable vision
difficulty focusing
motion discomfort
difficulty in visual environments
imbalance and dizziness
VOMS
smooth pursuits
vertical and horizontal saccades
near point of convergence
vestibulo-ocular reflex (VOR)
visual motion sensitivity (VMS)
note changes in ___ with VOMS
headaches
dizziness
fogginess
nausea
abnormal distance for near point convergence
> 6cm
benign
not life threatening
paroxysmal
comes in sudden, brief spells
positional
it gets triggered by certain head positions or movement
vertigo
a false sense of rotational movement
benign paraoxymal positional vertigo
crystals dislodged to semicircle canals and interfere with normal fluid movement
hallpike-dix text
patient long sitting with head rotated 30-45º
therapist holds head and pt is then assisted into supine position with head slightly below horizontal plane and position maintained for 30-60s
orthostatic hypotension testing
helps differentiate causes of dizziness
take BP after 15 min of resting
take BP standing
+ve test for orthostatic hypotension testing
2-3 min of standing a drop of 20 mmHg in systolic and/or 10 mmHg in diastolic
Head impulse
assess angular vestibular ocular reflex
buffalo concussion treadmill test
conventional neuroimaging is what with concussions
90% normal
brain CT of MRI
contribute little to concussion eval
should be used when suspicion of an intracerebral or sturctural lesion
Functional MRI
demonstrates activation patterns that correlates with symptoms severity and recovery
how much rest is too much
normal 24-48 hours
no optimal time yet
neuroplasticity of the brain after concussion
injured brain tries to use another area for the same thing
after 3 months of concussion symtoms still experienced, what occurs in the brain?
changes in neuroplasticity and becomes the body’s new norm
