Concussion Flashcards
Primary predominant mechanism of concussions
Shear forces caused by rotational acceleration
Average concussive head impact - linear acceleration value
62.4 +/- 29.7 g force
Physiology - what happens after acceleration/deceleration injury occurs
Nerve (axon) is deformed (shearing and stretching motion)
Neurotransmitters are released and influx of ions - what happens after
binding of glutamate to excitatory amino acids receptor
What does calcium do during concussions recovery?
Impairs mitochondria and ATP production
Calcium accumulation can directly activate pathways leading to cell death
The metabolite normalization process after a concussive episode is an _______, rather _____ in the first 2 weeks, and ____ between 22 and 30 days
exponential phenomenon
slow
faster
What is a second impact syndrome?
Condition in which a person experiences a second head injury before the complete recovery of the initial injury
Cerebral herniation
Rapid pressure develop and deterioration and leading to death within 2-5 minutes
Normalization of NAA concentrations(in other words, ATP stores) may occur only after what
after the cerebral energy state has fully recovered
what preventive method is more important that neck strength?
Ability to actively engage neck muscles and resist linear and rotational acceleration is more important
Is the mouthguard a good prevention method?
Conflicting results
Is the helmet a good prevention method?
May reduce concussion severity and duration of symptoms as well as SRC odds if direct head impact
How do we define persisting post-concussive symptoms?
Symptoms lasting 2 weeks or longer for adults and 4 weeks or longer for children
Is there a gold standard for diagnosis of concussions?
NOPE, rely on symptoms report
Risk factors for concussion outcomes (protracted recovery)
- history of concussions
- history of migraines
- ADD/ADHD
- females
- younger
What acute symptom should signal a red flag and a possible longer recovery in our ax?
Dizziness
Does the SCOAT6 include blood pressure measurement?
YES
What are the 6 clinical trajectories of concussions?
Vestibular
Ocular-motor
Cognitive/fatigue
Post-traumatic migraine
Cervical
Anxiety/mood
S/S of cognitive/fatigue trajectory
fatigue
decreased energy levels
non-specific H/A
sleep disturbances
Common to see increase of symptoms at end of the day
Difficulties concentrating
Increase headache with cognitive activity
Cognitive/fatigue trajectory
What is the physiology behind the cognitive/fatigue trajectory?
Energy crisis because of the lack of ATP related to the mitochondria
Testing shows deficit in what, for cognitive/fatigue
Memory
Processing speed
Reaction time
S/S - vestibular trajectory
Dizziness, fogginess, nausea, and feeling of being detached, anxiety, and overstimulation in more complex environments
Increase in sx in busier, more stimulating environments
Rapid head or body mvt may increase sx
Vestibular trajectory
Testing shows deficit in what, for vestibular
Vestibular and ocular motor screening
S/S - ocular motor trajectory
localize, frontally based H/A, fatigue, distractibility, difficulties with visually based classes, pressure behind eyes, and difficulty with focus
Difficulties with extended time in front of computer screens or reading
Full days of work/school may increase sx vs decrease on weekends
Ocular motor trajectory
Testing shows deficits in what, for ocular motor
Convergence and/or accommodation measurements
S/S - anxiety/mood trajectory
increase in anxiety, including ruminative thoughts, hypervigilance, feelings or being overwhelmed, sadness, and or hopelessness
Report sleep disturbances, with inability to quiet minds or stop thinking and worrying
Anxiety/mood trajectory
Testing shows deficits in what, for anxiety/mood
some vestibular dysfunction testing may provoke symptoms (treat before anxiety)
S/S of post-traumatic migraine trajectory
Unilateral, moderate to severe intensity headache, pulsating quality, nausea, photosensitivity, phono sensitivity
What activities increase sx for post-traumatic migraine trajectory
Stress
Sleep dysregulation
Anxiety/emotional changes
Dietary trigger (caffeine)
How do you differentiate cervicogenic headaches from the others?
Often comes with reduced ROM of the neck, usually 1 side and increase in sx with motion of C/S or pressure
S/S - cervical trajectory
Headache and neck pain
What is important to focus on during ax of cervical trajectory?
Characterization of the headache and location
Smooth pursuit neck torsion test stimulates cervical proprioceptors or vestibular?
NOT vestibular
ONLY cervical proprioceptors
What is a +ve smooth pursuit neck torsion test
symptoms increase with head rotation in comparison to neutral position
What is the cervical joint position error test?
Laser test
Patient sitting
Have patient actively go through max neck flexion/come back neutral
Why is the cervical joint position error test important for RTP?
Because it will reflect how the muscles are able to react fast when loaded
Purpose of the flexion-rotation test
Dysfunction in the C0-C2 to help determine C/S dysfunction and cervicogenic headaches
What is a +ve flexion-rotation test?
firm resistance is encountered
pain
limited ROM
Symptoms of vestibular impairment
Unstable vision
Difficulty focusing
Motion discomfort
Difficulty in visual environments
Imbalances
Dizziness
VOMS stands for
Vestibular Ocular Motor Screening
5 domains of VOMS
Smooth pursuits
Vertical and horizontal saccades
Near point of convergence
Vestibulo-ocular reflex (VOR)
Visual motion sensitivity (VMS)
What are the 4 mains symptoms to ax?
Headache
Dizziness
Nausea
Fogginess
Review VOMS document
Read procedures
Abnormal distance in cm between the target and the tip of the nose
More than 6cm
Most common symptom in prolonged recovery
Dizziness
What is Benign Paraoxymal Positional Vertigo?
Crystals dislodged to semicircle canals interfere with normal fluid movement
Benign
is it not life-threatening
Paraoxymal
it comes in sudden or brief spells
Positional
it gets triggered by certain head positions or movement
Vertigo
a false sense of rotational movement
What is the Hallpike-Dix Test?
Patient is long sitting with head rotated 30-45d
Therapist holds head and patient goes supine with head a bit below horizontal + hold for 30-60 sec
+Ve Hallpike-Dix test
Dizziness and nystagmus
What is the goal of the orthostatic hypotension testing?
Help to differentiate causes of dizziness
Explain the orthostatic hypotension testing + what is a +Ve
Have patient lay for 15 minutes to get resting BP
Have patient stand up and take BP
+ve = if within 2-3 minutes drop of 20 mm Hg in systolic BP and/or 10 mm Hg in diastolic BP
What do you need to do before you do the head impulse test
Clear cervical spine for adequate pain free ROM and vertebral artery test
Test used to assess angular vestibular ocular reflex (aVOR)
Head impulse test
Purpose of the Buffalo Concussion Treadmill Test
Help determine how much aerobic activity is safe following a concussion (even acute)
Failed Buffalo test
Max exertion is reach or 3 point increase in Likert scale or rapid progression of symptoms or patient reports inability to continue safely
Passed Buffalo test
Patients meets their max HR (220-age) or 18-20 RPE on Borg Scale has not worsened condition before worsening of symptoms
Which type of imaging demonstrates activation patterns that correlate with symptom severity and recovery in concussion?
Functional MRI (fMRI)
What was found in early studies done with fMRI
Suggest that an increase in CVR is a response to the tissue demands that require oxygen/nutrients and removal of metabolic waste
How much time after the injury should you initially rest physically and cognitively?
24-48h
Consequence of 3+ months of concussion symptoms
Change in neuroplasticity and becomes bodies new normal
What are ‘‘The Musts’’ for concussions?
- written concussion management plan on file
- evals - from trained staff
- no same day RTP
- athletes cleared by physicians
- acknowledgement (education, reporting)
What test would also be +ve if Hall Dike test is +ve ?
Head impulse test
