Concussion Flashcards
Categories of Traumatic Head Injury
Mild Traumatic Head Injury or Concussion
Moderate Traumatic Head Injury
Severe Traumatic Head Injury
Defintition of Concussion / Mild TBI
Any period of observed or self-reported transient confusion, disorientation, impaired consciousness, dysfuciton of memory around the time of injury, or loss of consciousness lasting less than 30 minutes
Alternate Definition of Concussion / Mild TBI
Alteration of consciousness for 24 hours
Testing Concussions / Mild TBIs
Post Traumatic Amnesia for less than 24 hours
Alteration of concsiousness for 24 hours to 7 days
Glasgow Coma Scale of 13-15 at 30 minutes
Glasgow Coma Scale
Gold Standard for Head Trauma
Implemented at 1st Eval and assessed in people with Moderate to Severe TBI
Distinct Differences between Concussion and Moderate to Severe TBI
Concussion
-No structural brain changes (Minimal Cell Death)
-No Medical Intervention
Moderate to Severe TBI
-Structural Brain Injury with Cell Death
-Medical intervention or hospitalization
CDC Statistics
(Don’t think it will be important)
7/10 ER visits are kids for sports-related concussions
Higher proprotion of females have concussions
1.4 to 3.8 million concussions per year
Concussion Etiology
Concussion or MIld TBI caused by a bump, blow, or jolt to the Head or by a hit to the body that causes the head and brain to move rapidly back and forth
Brain bouncing or twisting in the Skull creates chemical changes in the brain and sometimes stretches and damages Brain Cells
What kind of Injury is a Concussion?
A Diffuse Cortical Injury
Combination of insult and chemical changes in the Brain
Results of MRI or CT Scans in Concussion
The MRI or CT scan will often be normal in persons with mild TBI or Concussion
THIS DOES NOT MEAN THAT BRAIN FUNCTION IS NORMAL (careful brother)
Direct Impact Injury
Brains are smacked
Acceleration-Deceleration Injury
Sudden decelleration causes the Frontal Lobe to hit the Anterior Skull
Blast Injury
Sound Waves affect numerous areas of the brain
What age groups show the greatest risk for Concussion?
10-14 years and 15-17 years are at the highest risk
The risk stedily increases as you age due to the increased number of falls in the elderly
Signs to watch for after a Concussion
Problems may arise over the first 24-48 hours
The individual should not be left alone and must to go to a hospital if signs and symptoms may worsen over time
Specific Signs after a Concussion
-A headache that increases
-Very drowsy or can’t be awakened
-Can’t recognize people or places
-Have repeated vomiting
-Behave unusually or seem confused (irritable)
-Have seizures (arms & legs jerk)
-Have weak or numb arms and legs
-Unsteady on feet and slurred speech
Additional Red Flags for a Concussion
-Worsening dizziness or vertigo
-Worsening disequilibrium
-Worsening of headache
-Loss of coordination
-Double Vision
-Loss of Coordination
What do you do when your patient has Red Flags?
STOP THE ACTIVITY
Take to Emergency Room
When do mild TBI symptoms typically improve?
Most symptoms improve over 7-14 however the changes can be subtle
If issues persist after 3 weeks seek medical assistance
Mild TBI: Behavior
Irritability
Anxiety
Sadness
Inability to Sleep
Mild TBI: Environment
Lights
Loud Sounds
Mild TBI: Cognitive
Memory Loss (New Memories)
Concentration and Attention
Cognitive Fatigue: Reading/Computer
Mild TBI: Motor
Loss of Dexterity/Coordination/Speed
Balance
Visual and Ocular Function
Pathophysiology of Concussions
Axonal Damage
-May or may not occur
Neuroinflammation
-Microglia activation and excitotoxicity leads to cell damage/death
Ionic Dysfunction
-Glutamate release and ions dysfunction
Energy Crisis
-Mitochondrial dysfunction (energy)
-Oxidative Stress
Concussion Pathology
-Reduced information processing efficiency
-Increased Brain metabolic activity
-Inability to processing information efficiently
-Dual Task reductions
-Reduced divided attention
Metabolic Activity in Post-Concussion MRI
Post-Concussive Brain
-Larger area of brain activity with the same tasks
Mild TBI (Over Two Weeks)
How does it change processing?
Concussion leads to:
Reduced processing
Loss of brain efficiency
Fatigability
Signs and symptoms increase with envrionmental interactions (personal, light, sound, reading)
Oculomotor and Vestibular Issues in Concussion
The vestibular systems takes input to monitor two major major activities:
ROTATION OF THE HEAD
SPEED / ANGULAR ACCELERATION
Cranial Nerves of the Ocular Motor Systems
CN III: Oculomotor
CN IV: Trochlear
CN VI: Abducens
Vestibular Tract Functions with a Concussion
Vestibular Tracts send information
Lateral Vestibular Tract: LEGS
Vestibulocerebellar Tract: COORDINATION
Medial Vestibular Trunk
Concussion and the Vestibular Ocular System:
Visual Pathway
Visual Pathway spans the length of the Brain and is susceptible to injury
Abnormalities or impairments to the VOR rReflex and Oculomotor system are frequently reported in mTBI populations with rates ranging from 29-69%
Vestibulo-Ocular Reflex Gaze Response
VOR uses information from the Vestibular nucleus to generate movements that stabilize gaze during Head movements
Vestibulo-Ocular Reflex Gaze Response
AFTER A CONCUSSION
The Vestibular and Ocular Motor System undergo Chemical Disruption, thus disrupting the timing
Dizziness, Vertigo, and Walking Difficulties
Balance and the Vestibular System:
Dizziness
Caused by host of problems:
(Light Headed, Woozy, Off Balance)
Caused by host of issues:
(Orthostatic, Alcohol, Not Sleeping, Dehydration)
Balance and the Vestibular System:
Vertigo
World is spinning (specific type of dizziness) inner ear
Balance and the Vestibular System:
Oritentation
Medial Vestibular Pathway
-Sends information to control Cervical and Thoracic musculature
-Helps generate msucle activity with movement of the head and ocular muscles
Lateral Vestibular Pathway
-Sends information to control LE Motor Units to control balance
-Extensor and Flexor musculature
What is Post-Concussion Syndrome?
Concussion signs and symptoms lasting over 6 weeks
-20% of concussion have s/s over 6 weeks
-Effects of Concussion in 3 domains (Motor, Behavior, Cognitive)
-Higher risk for Post Concussion Syndrome with repeated concussions
-Most common findings are headaches
Post-Concussion Syndrome - Symptoms
Central Issue: Continued Neuroinflammation Brain Changes
Symptoms may remain for months to years
Lower Hippocampal Volume (Memory)
Increased Risk of Cell Death
Smaller Thalamus (unable to process sensory)
Risk of Limbic Atrophy
Women are at higher risk
Post-Concussive Syndrome
Cluster of Symptoms from Concussion
-Headache
-Dizziness
-Fatigue
-Anxiety
-Depression
-Reduced Sleep
Over-Exertion and Mental Activity can increase symptoms
Post-Concussive Headache
Local vs. Global
May be related to neuroinflammation, neurochemical changes, increased pain sensitivity, trigeminal nerve activation
Associated with light and noise sensitivity
Post-Concussive Headache:
Migraine vs. Tension
Migraine
-Only one side
Tension
-Bilateral (BAND)
Cervical Muscular Injury and Headaches
Cervical Injury or Whiplash Associated Syndrome
-Associated headaches
-Neck Pain
-Memory and Concentration
-Tinnitus
Symptoms of Vestibular Problems
Disequilibrium or Dizziness
-40-60% of individuals show vestibular signs and symptoms
Vestibular Problems:
Peripheral Processes
18% of the individuals are Peripheral
BPPV (dislodgement of the Otoliths)
Vestibular Problems:
Central Processes
Dysfunction arises with microscopic hemorrhage
-Nausea, Vomiting
-Nystagmus, exacerbated by Rapid Head Movements
Vestibular compensation: 2 months
Ocular Motor Deficiencies
Deficiencies in initiation in Saccades
-Due to reduction of Sensory Motor Integration after a concussion
-Impaired Organization of Sensory Processes (Visual)
Loss of Ballistic Saccade Accuracy
Voluntary Gaze Movements has marked slower speeds
Loss of Visual Motor Symmetry
Reductions in Postural Control
Combo of Visual, Vestibular (Central & Peripheral) and Poor Integration
Individuals with concussion can walk, but lack adaptation to changes in the envrionment
Unable to turn quickly, adjust postural control, and integrate sensory input to postural adapt changes
Autonomic Nervous System Changes
Blood Pressure:
Loss of Autoregulation (Global and Regional)
Leads to:
Vaso-Restriciton of Blood Flow
Exercise Intolerance/Headaches
Creates:
Anxiety/Depression/Irritability
Sleep Loss and Confusion
Behavioral/Cognitive Factors
- Autonomic System & Loss of Perfusion/Blood Flow
- Energy Crisis
Loss of Energy Sources: Mitochondria
Glucose Hypometabolism
First 5 to 10 days post injury
Inneffective Source of Energy - Neuroinflammation
Directly correlates with Signs and Symptoms - Axonal Loss
Only in some individuals
Environmental Factors:
Sensory Input
Especially noted is Electronic Devices
-Especiallly smaller screen watching combined with Auditory stimulation
Lights
-Natural Lighting and Artifical (problematic)
Auditory
-Unable to habituate background noise
Concussion Examination and Assessment
- Ocular Motor
- Saccades: Reaction
- Functional Vision Tasks: Reading
- Light Sensitivity - Vestibular
- Vestibular Ocular Reflex VOR
- Postural Control (Quick turns)
- Dizziness - Symptoms
- Management of s/s of Fatigue
- Headache
- Cervical Pain
- Dysautonomia
- Noise Sensitivity
Assessment Basics
After each exam ask if the symptoms have been provoked. If positive, this is the activity for treatment
Assessment Basics: Visual Symptoms
Smooth Pursuits
- Horizontal, Vertical, H Figure
- Assessment of Visual, Motor/Symmetry
- Record any symptoms (HA, Dizziness, Fog Brain)
Concussion History
History is Critical
1. What’s the Mechanism of Injury
- Twisting, Direct Impact, Acceleration
- Direction (Flex/Ext: Lateral one side or both)
- Speed of Impact
- Loss of Consciousness
- Able to Remember Event: Amensia
- Dizziness / Confusion with loss of orientation
- Loss of Function - Postural Control
- Questionnaires for Symptoms
PT Physical Exam for Mild TBI:
Physical
- Whiplash associated syndrome
- Muscular Neck Pain which may be associated with Headaches, Cervical Proprioception
- Balance Static
PT Physical Exam for Mild TBI:
Visual-Oculomotor
- Eye muscular synchronization with Vestibular System: Saccades, Tracking, Reading
- Vision: Tracking, Convergence, Accomodation
PT Physical Exam for Mild TBI:
Vestibular
- Vestibular System: Direction, velocity, head position (dizziness, nausea, walking)
- Vestibular Ocular System: Movement & Vision
PT Physical Exam for Mild TBI:
Function
- Attention/Concentration
- Postural Control: Dynamic, walking with dynamic head movements
-Autonomic System: Exercise tolerance, sleep disturbances, changes in BP, fatigue with and without exercise
Ruling out a Cervical Injury for a mTBI
- Extension rotation exam of the C-Spine (Cervicogenic Headache)
- Palpation for Cervical Musculature tenderness overt the facet joints
- Cervical Facet Dysfunction (ExaM0: Post and Ant force over C2-C& over the articular pillars
- A positive test if pain greater than 3/10, resistance to motion is moderate in rotation or manual spine exam. If all three are positive is highly predictive
Other Cervical Exams for mTBI
- Joint Proprioception test using a laser pointed headlamp
- 4.5 degree error is considered Whiplash disorder
Oculomotor: Terms
- Accomodation
- Verg
- Convergence
Oculomotor: Accomodation Definition
The ability of the eye to make adjustments of the lens to focus on objects at various distances
Oculomotor: Vergence
Movement of the eyes synchronously and symmetrically to track objects
Accomodation and vergence work synchronously to be able to focus clearly and quickly on objects at difference distances
Oculomotor: Convergence
The ability of the eyes to move medially, towards the nose, which allow for single vision of closer objects
CROSSING YOUR EYES
Vision Susceptibility for Concussion
The visual system involves about helf of the brain’s circuits
After a concussion, there may be deficits in:
Convergence
Accomodation
Ocular Muscle Balance
Saccades
Pursuit
Visual:
Saccades Horizontal and Vertical
Moving the eyes from one point to another quickly
PT will note symmetry and speed 10 repetitions
Visual:
Convergence
Move target (14 point font) towards patient’s nose
Patient indicates when double vision occurs or when PT notes eye deviation
PT measures distance from nose to object: Abnromal greater than 5 cm
Ocular / Vestibular Integration
Rapid, accurate eye movements are necessary to fixate and stabilize an image in the eye, which is critical during head and body movement
Ocular / Vestibular Integration:
Neuromuscular Connection
Neuromuscular connection to the extraocular muscles has an event, activation of ocular muscles are off set and lose efficiency, “endurance” and “strength”.
Due to injury, greater effort is required to move the eyes medially, which causes eye-strain and pain, just like with any other muscle injury
Vestibular Ocular Motor Screening (VOMS)
What is it?
A series of six exams incorporating ocular and vestibular screening
Assesses: Vision, Ocular Motor, and Visual vestibular
Vestibular Ocular Reflex Testing
Horizontal VOR and Vertical VOR
Patient moves approximately 20 degrees
180 beats per minute (timing)
10 repetitions
Keep eyes stable while turning head or vertical movement
Visual Motion Sensitivity
(VOR Cancellation)
Moving the Head (Vestibular) and vision together to follow your thumb
- Tests visual motion sensitivity and inhibits the vestibular induced eye movements
- Wide Range of Movement (80 degrees)
- Patient moves to metronome 50 bpm
- Five repetitions (back and forth)
Specific Vestibular Exams
(Not typically used)
BPPV does occur in mild TBI: about 5-18% of concussions
Dix-Hallpike - 5% of persons are positive in concussion: Nystagmus or vertigo
Head Thrust Test: Vestibular Ocular (Be careful as cervical spine may be injured) Screen the c-spine first
Common Symptoms After Concussion
- Headaches
Tension type headaches: Frontal Lobe, associated with N/V and occur with Noise/Light sensitivity - Dizziness
Peripheral vs. Central Disorder - Fatigue
Related to overexertion of brain activity - Irritiability
- Anxiety
- Insomnia
- Loss of Concentration and Memory
- Ringing in the Ears
- Blurry Vision
- Noise and Light Sensitivity
Behavioral Symptoms of a Concussion
Irritability
Frustration/Anxiety
Sensory Symptoms of a Concussion
Blurry Vision
Photophobia
Ringing Ears
Environmental Symptoms of a Concussion
Light
Busy, Crowded, Noisy
Attention Symptoms of a Concussion
Memory
Concentration
Headache Symptoms of a Concussion
Nausea/Vomiting
Tension
Fatigue Symptoms of a Concussion
Exercise
Brain
Overstimulation during Assessment of Concussion:
Attention Exercises
Reading or Visual Attention
Overstimulation during Assessment of Concussion:
Exercise
Stop assessment when symptoms start
Overstimulation during Assessment of Concussion: Environmental Stimulation
Crowded Areas, Bright Lights, Background Noise
Self-Report Scale for Concussion:
Rivermead
Assesses 3 domains:
Physical, Cognitive, Behavioral
Greater than 3 symptoms listed after three months is indicative of post concussion syndrome
Provides mean scores for 1, 6 months, and 12 months post injury
Self-Reporting Scale:
King Devick
Examine Pre-Injury and Post-Injury
Examine Post-Injury and with Treatment
King-Devick scale measures the speed of rapid number naming (reading aloud single-digit numbers)
Assesses eye movements, attention, language, and other correlates of suboptimal brain function
Used in atheltics to provide information on changes in visual language and attention
Self-Inventory Questionnaires / Symptoms
Used to discover symptoms and show symptom reduction
Dizziness Handicap Index
Post Concussion Symptom Scale
Neurobehavioral Symptom Inventory
Reduces PT Q&A
Endurance/Autonomic:
Graded Exertional Tolerance Exam
Do not perform with individuals with symptoms at rest
Endurance/Autonomic:
Graded Aerobic Exercises
Treadmill or Stationary Bike
Note time, mode, and symptom onset
(Dizziness, fatigue, headache, nausea)
Monitor BP, HR, RPE to assess Autonomic symptoms.
If vestibular system involved, use stationary bike
Autonomic Nervous System:
Graded Aerobic Exam
Treadmill or Stationary Bike
Buffalo Concussion Treadmill Test
Start at 3.3 mph with no incline
1 minute increase incline to 2 percent
Each subsequent minute increase 1 percent
Monitor HR, BP,RPE each minute
Stop at the onset of any concussion s/s
Balance Exams:
Balance Error Scoring System (BESS)
Specific for Inidividuals with mTBI to assess postural control
Count the number of errors in posture
Functional Assessment
Balance Exams:
Modified CTSIB
Sensory Based Assessment
Used in GBMC brotha
Balance Exams:
Computerized Posturography
Bertec SOT Testing
Bertec Cobalt
Balance:
BESS Test
Specifically designed for concussion in athletes
Evaluates posture in Six Positions:
Romberg, Single Leg Stance, and Tandem
Eyes open and closed
Score is Observational:
Points added for loss of balance, hip or trunk sway, foot touching surface
Other Assessments for Balance in Mild TBI
Dynamic Gait Index
Functional Gait Assessment
There are useful as they are functional exams that combine head turning, tandem gait and balance
More appropriate for adults and non-sport related injuries
Clinical Decision Making
Symptom List
1. Which test provoked the greatest symptom
2. Postural Control which sensory is the worst
3. Remember to include environmental triggers
Collaborate with patient to request which symptom is the most troublesome
Goals of Concussion Treatment
Consider goals in 2 week intervals
Tolerate 30 min of electronic device with no sympt
Maintain HR and BP stability w/ 15 min light aerobic activity with no symptoms
Demonstrate reading for 10 minutes with the onset of symptoms
Perform convergence accomodation activity x 10 without symptoms
Demonstrate unilateral standing for 10 second without trunk or hip sway
