concussion Flashcards
what is the huge thing that changed from one consensus to another
ACTIVITIES THAT DO NOT PROVOKE AN INCREASE in symptoms
Used to say rest until symptoms are gone
Research is now supporting initial relative physical and cognitive rest for 24-48 hour rest followed by activities that do not increase symptoms
If they have a 3/10 headache before activity, activity must not increase this headache
definition of concussion
Typically results in a rapid onset of short lived impairment and neurological dysfunction that resolves spontaneously
Commonly see resolving symptoms within_ days with proper RTL and RTP protocols
7-10 days
Clinical variables associated with prolonged recovery and the development of PCS vary across studies but may include
Younger age
Female sex
Loss of consciousness or post-traumatic amnesia at the time of injury
A previous history of concussion
ADHD and mood dis-orders
Initial headache or dizziness at the time of injury
Delayed symptom onset
Initial symptom burden
what are the 3 subtypes of post concussion disorders
physiological (blood flow dysregulation)
vestibulo-ocular
cervicogenic
TIP to help concussion symptom
- Turn the blue light off on your devices (night shift mode iphone) linked to better sleep
- wear earplug
- slant board for reading -> 22º degree angle
what are the color of glasses that are most effective
blue -> green -> red -> purple
which color is the only one that did not provide relief of symptom
yellow
Tips for Increasing Concentration
- Work at only 1 task at a time
- Reduce distractions when you are concentrating
- Give yourself more time to complete tasks
- Choose a time when your energy level is at its best
- Avoid or limit your contact with noisy or busy places
- Maintain good eye contact to stay focused during conversations
-Repeat what you heard the person say
what can you do to improve sleep hygiene
Regular sleep routine (fixed bedtime and wake time)
If you do not fall asleep within 30 minutes, get out of bed and do something relaxing. Return when you feel sleepy
After first few days after your concussion, try not to nap during the day (if nap needed 20-30 min x1)
At least 1 hour before bed do something relaxing (warm bath, reading a book, soothing music, deep breathing exercises)
Dark, quiet, cool room
Ear plugs or white noise machine/fan
Keep electronics out to the bedroom
Emotional symptoms such as sadness or depressed mood, nervousness or anxiety, irritability, fatigue, and difficulty sleeping are commonly reported among athletes and will spontaneously resolve typically within _
3-6 months
can persist for a year, 7-15% of patient with TBI
what are considered associated with development of PCS Psychiatrist outcome
Old age, female sex, premorbid psychiatric illness, anxiety sensitivity, cognitive biases and migraine headaches are considered associated with the development of PCS
what is the gold standard for psychological disorder
cognitive behavioral therapy
what is cognitive behavioral therapy
psychosocial intervention approach in which patients confront and modify the irrational thoughts and beliefs that are most likely at the root of their maladaptive behaviours.
Gold standard for psychological disorders
what is included in cognitive behavioral therapy
Self instructions (distraction, imagery, motivational self-talk)
Relaxation strategies
Biofeedback
Development of coping strategies (e.g. minimizing negative or self-defeating thoughts)
Changing maladaptive beliefs about pain
Goal setting
can CBT improve severity of symptom
It’s effect on PCS is still unclear for improving severity of symptoms
However it might be an effective treatment option for improving depression, anxiety and social integration in individuals with TBI
Cervicogenic Persistent Symptoms
Common S/S- HA, neck pain, dizziness
C0-C1 problems HA, vertigo, fatigue, poor concentration, irritability
C0-C2- often fascial connection issues
what is a cervicogenic PCS
Subtype of PCD that is mediated by isolated dysfunction of the neurological cervical spine system
Nociceptive fibers transmit important sensory information from cervical spine to the spinal cord, brainstem, and cerebellum
These interconnections form specialized reflexes including the cervicocollic, vestibulocollic, and cervico-ocular reflexes that help;
mediate head, gaze, and neck position sense, and stabilization during rapid head movements
what can cause cervicogenic post concussion disorder
Trauma or persistent muscle spasm affecting the deep and superficial cervical and sub-occipital muscles can also lead to irritation and impingement of the sensory nerves that innervate the neck and posterior scalp leading to cervicogenic headaches and occasionally occipital neuralgia
headache with cervicogenic PCD is located where
The headaches are often located in occipital area, and can radiate to the temples and eyes, and are frequently exacerbated by poor posture and neck-related activities such as weight training and running
can someone with cervicogenic PCD continue aerobic activity
yes
Rehabilitation of Cervicogenic PCD
Guiding local inflammation
Decreasing muscle spasm (suboccipitals, paraspinals)
Restoring ROM
Restoring communication between cervical spine, vestibular and oculomotor systems
Manual therapy, passive and active range of motion exercises, low velocity mobilizations, proprioceptive retraining, and exercises to strengthen the deep and superficial cervical musculature
which muscle would you want to release with cervicogenic PCD
suboccipital, paraspinal
Physiological persistent concussion patients typically present with
persistent headaches, dizziness, fatigue, and sensitivity to light that are exacerbated by PHYSICAL ACTIVITY
what can be the cause of physiological persistent concussion
Studies suggest alterations in cerebral metabolism, resting blood flow, cerebrovascular reactivity and neurovascular coupling
Autonomic Nervous System dysfunction/exercise intolerance
what happened with physiological persistent concussion patient that cesse exercise
is associated with reduced blood volume and cardiac stroke volume
Body compensates by INCREASING SNS activity to maintain oxygen delivery
what is suggested to do for people with physiological persistent concussion
tailored submaximal exercise program (according to Buffalo Treadmill Test Results)
Management of Physiological PCD
Mainstay treatment is sub-maximal aerobic exercise
American Medical association defines this as 85% of the age adjusted max HR
is early controlled aerobic exercise is safe following a concussion
yes, May not always decrease symptom intensity and duration
May help to improve the psychological state resulting from social isolation and cessation of exercise
Physiological PCD patients should be prescribed
tailored sub-maximal aerobic exercise programs that target 80–90% of the heart rate achieved during graded aerobic treadmill testing, once a day for 20 min in duration, 5–6 days a week
goal of prescribing aerobic exercise in patient with physiological persistent concussion
adequate stimulation to facilitate positive physiological response
Enhance cognitive function, patient mood, enhance immune and endocrine function, restore cardiac autonomic function and CBF
T/F Previous research has suggested detrimental effect of long duration aerobic exercises, high intensity aerobic exercise, and resistance exercises for recently concussed patients when considering the physiological impairments
T
Emphasis has been placed on short duration, low intensity and moderate intensity aerobic activity
Recommended Prescription of Aerobic Exercise
Untrained individuals- 40-50% HRmax, 60-70%HRmax trained
Preferred method HRmax=208-0.7(age)
Exercise bouts of 15-20 minutes were well tolerated in athletic populations (90% completion rate) (untrained 10-15minutes)
Start in unstimulating environment to decrease vestibular ocular symptoms from be exacerbated
explain the buffalo concussion treadmill test
3.6mph (5’5” or taller), 3.2mph (5’5” or smaller)
Increase incline 1% every 1 minute
Until maximum incline of 15 degrees then increase 0.4mph every minute
Patient rate RPE and symptom severity (exacerbation of symptom or new symptom)
Terminated max exertion is reached or 3 point increase on Likert scale or rapid progression of symptoms (headache, dizziness) or patient reports inability to continue safely
which subtype of PCD is characterized by dysfunction of vestibular and oculomotor systems
vestibule-ocular persistent concussion symptom
The oculomotor and vestibular systems highly integrated systems that control
balance, postural consol and gaze stability
Affect cervical mechanoreceptors which can affect critical nucleus in your brain that affects: posture reflexes, cardiorespiratory, autonomic NS (inc. parasympathetic), digestion
T/F Improving peripheral vision can help with stress and fear
T
Clinical predictors of vestibulo-ocular dysfunction may include
female sex, pre-injury depression, and post-traumatic amnesia, dizziness, blurred vision, and difficulty focusing at the time of injury
Patients with vestibulo-ocular dysfunction can present with heterogeneous and often overlapping deficits that manifest as
objective impairments in convergence, accommodation, smooth pursuits, saccades, the VOR, or BPPV
Clinically, vestibulo-ocular PCD patients typically present with
dizziness, intermittent blurred vision or diplopia, difficulty focusing or concentrating, fogginess, motion sensitivity, postural imbalance, and headaches that are usually absent at rest but are elicited or exacerbated by prolonged periods of reading, focusing, or functioning within complex visuospatial environments
what is dynamic visual acuity
ability to see object clearly while in motion
what is contrast sensitivity
ability to judge subtle difference in contrast and detect a target in various lighting conditions
what is visual stamina
ability to keep both eyes accurately working together under high speed and under physically and mentally stressfull conditions
which test will be affect if your dynamic visual acuity is affected
smooth pursuit
what is gaze stabilization
Ability to maintain visual acuity while the body/head is in motion
what is postural stability
Ability to maintain upright posture, balance and equilibrium in response to body movements
what is motion sensitivity
information about the position and movement of the head in space
what is the Brock string
Vision therapy tool
Focus on convergence
Learn to use eyes together more effectively
Fixate on 1st bead
Close eyes then fixate on next
Can change angle of string and modify support surface
Vestibulo-Ocular Motor Screen as Rehab + parameter
Smooth pursuits
Saccades
Near point of convergence
Vestibulo-ocular reflex (VOR)
Visual motion sensitivity
Assessing for (0-10)
Headache
Dizziness
Fogginess
Nausea
Complete each exercises for 1 minute
2-3x/day
It is okay to feel some dizziness or slight nausea after the exercise but this should subside
distance and rate of the target during smooth pursuit
target at 3ft from patient
move target in horizontal 1.5ft to the right and midline and 1.5ft to left
rate: 2s
explain near point convergence test
Examiner sits in front of the patient and observes their eye movement during this test. Patient focuses on a small target (approximately 14 font size) at arm’s length and slowly brings it toward the tip of their nose
The patient is instructed to stop moving the target when they see two distinct images or when the examiner observes an outward deviation of one eye
what is an abnormal distance for point convergence
> to 6cm
what is the amplitude of movement with VOM and VOR
VOMS - > 80 degree to each side
VOR -> 20 degree to each side
VOR assess what
ability to stabilize vision as the head move
visual motion sensitivy test what
Test visual motion sensitivity and the ability to inhibit vestibular –induced eye movements using vision
explain the visual motion sensitivity test
Patient stands with feet shoulder width apart, facing a busy area of the clinic/field/court (guard patient appropriately)
Patient holds arm outstretched and focuses on their thumb
Maintaining focus on their thumb, the patient rotates together as a unit, their head, eyes and trunk at an amplitude of 80 degrees to the left and 80 degrees to the right
Use a metronome to ensure the speed of rotation is maintained at 50 beats/min (one beat in each direction)
Vestibular rehabilitation is an exercise program aimed at
reducing dizziness and vertigo and improving gaze stabilization, postural stability, and overall functional abilities
main component of vestibular rehabilitation
Gaze stabilization exercises (to retrain VOR function-eyes stable when head moves)
Balance retraining (to retrain VSR function-reflex body movement that maintains your posture and stabilizers your body)
Conditioning exercises (to improve overall fitness)
If indicated, habituation or canal repositioning maneuvers (to reduce position- or motion induced dizziness or vertigo)
which system can detect movement of 6000º/sec
vestibular
oculomotor system can detect movement of what degree
<60/sec
Decreases in visual acuity can occur with as little a _º of error (termed retinal slip)
1
Chicago Blackhawks Test and Gapski-Goodman Test stress what
Stresses heart rate variability, positional changes. Multidirectional movements, dynamic muscle activation
which test is the gold standard for managing blood flow dysregulation with its steady-state cardio approach
buffalo treadmill test
Chicago Blackhawks Test and Gapski-Goodman Test is performed when
after athlete had fulfilled the RTP criteria
if I present with Neck pain and stiffness
Fatigue
Fogginess
Dizziness is also a common complaint among these patients and is usually absent at rest but elicited by activities that require prolonged neck stabilization or movement with headache in occipital region what type of PCS do I have
cervicogenic
if I present with dizziness, intermittent blurred vision or diplopia, difficulty focusing or concentrating, fogginess, motion sensitivity, postural imbalance, and headaches that are usually absent at rest but are elicited or exacerbated by prolonged periods of reading, focusing, or functioning within complex visuospatial environments which type of PCD do I have
vestibule-ocular
