Concussion Flashcards
A traumatic brain injury induced by biomechanical forces
Concussion
Cause of concussion
Can be due to direct blow to head/face/neck or impulsive force transmitted to the head
Acute clinical manifestations largely represent functional disturbance or structural injury
Functional disturbance
Does concussion need to involve a loss of consciousness
No
5 diagnostic criteria for mild traumatic brain injury (concussion)
- Plausible mechanism of injury
- One or more clinical signs ie. LOC, complete or partial amnesia
- Two or more acute symptoms ie. Nausea headache, dizziness
- Clinical exam findings ie. balance, cognitive or oculomotor impairments
- Imaging results rule out more severe injury
- Not better accounted for by other factors ie. other medical conditions, drug/med use, psychological conditions etc.
Key clinical impairment domains
- Cervical/musculoskeletal impairments
- Vestibular/oculomotor impairments
- Autonomic dysfunction and Exertional intolerance
- Motor function impairments (balance, dual tasking, coordination)
- Pts can demonstrate with multiple
Types of external forces applied to neuron that results in compromise to the cell membrane
- Stretching
- Twisting
- Shearing
- Compression
Neurometabolic cascade
An energy crisis that occurs 1 min after trauma and can persist for 7-10 days
- Stretch of cell membrane -> release of K+ -> influx of Ca++ -> increase ATP needed -> increase in glucose metabolism -> decrease in cerebral blood flow = energy mismatch -> indiscriminate glutamate release (gasoline to fire) -> impaired mitochondrial function
Possible concussion signs observed
- Can’t recall events prior to after a hit or fall
- Appears dazed or stunned
- Forgets an instruction, confused about an assignment or position, or is unsure of the game, score, or opponent
- Moves clumsily
- Answers questions slowly
- Loses consciousness (even briefly)
- Shows mood, behavior, or personality changes
Possible reported symptoms associated with concussion
- Headache or pressure in the head
- Nausea or vomiting
- Balance problems, dizziness, double or blurry vision
- Bothered by light or noise
- Feeling sluggish, hazy, foggy, groggy
- Confusion or concentration/memory problems
- No feeling right or feeling down
Danger signs and symptoms associated with a concussion
- One pupil larger than the other
- Drowsiness or inability to wake up
- Headache that gets worse and does not go away
- Slurred speech, weakness, numbness, or decreased coordination
- Repeated vomiting or nausea, convulsions or seizures
- Unusual behavior, increased confusion, restlessness, or agitation
- Loss of consciousness (passed out/knocked out) even a brief LOC should be taken seriously
Headache and concussion
- Cervicogenic or tension
- Post traumatic migraine: trauma may trigger migraine process in susceptible individuals who previously did not have, typically requires medical management
- Dysautonomia: autonomic nervous system malfunctions, possible fluctuation in intracranial pressure
- Rebound/medication overuse: advil 7 days/week
Dizziness
- Central vestibular impairment
- Peripheral vestibular impairment
- Autonomic impairment
- Cervicogenic origin
Central vestibular impairment and dizziness following concussion
- Brainstem or cerebellar, migraine-related
- Oculomotor abnormalities
- Visual motion sensitivity
Peripheral vestibular disorders and dizziness following concussion
- Not as common
- BPPV, labyrinthine concussion (unilateral hypo function caused by trauma)
- Temporal bone fracture, perilymphatic fistula
Autonomic impairment and dizziness following concussion
- Orthostatic hypotension or intolerance (BP doesn’t drop enough to be classified w/ OH but are symptomatic)
Key inputs for postural stability
- Vision/oculomotor function
- Vestibular function
- Somatosensory function (proprioception)
Other factors contributing to postural stability
- Musculoskeletal integrity (ROM, flexibility, muscle performance - strength, power, endurance)
- Sensory processing
- Cognition
- Behavioral factors
Cervical spine association with concussive symptoms
- Injury to cervical spine may occur as a result of the acceleration-deceleration forces applied to the head and neck
- Injuries to cervical spine have associations with headache, dizziness, imbalance and visual disturbances
- Managing neck issues
Cervical spine and association with concussive symptoms
- Injury to cervical spine may occur as a result of the acceleration-deceleration forces applied to the head and neck
- Injuries to cervical spine have associations with headache, dizziness, imbalance and visual disturbances
- Managing neck issues EARLY may reduce likelihood of delayed recovery
Cervicogenic post concussive disorder has been identified as…
A subtype of concussive injury
ANS plays a role in regulating
- Blood pressure, GI motility, body temp, metabolism, sexual responses, sleep, and glucose metabolism
- Cerebral perfusion vis controlling diameter of blood vessels
ANS impairment and concussion
- Hypothesized to impair exercise tolerance due to interference with normal cerebral blood flow regulation
- Other possible symptoms: heart rate abnormalities, OH/OI, exertional headaches, sleep disruption, mood changes, low libido
SCAT 6 sport concussion assessment tool (acute sideline screening)
- Standardized tool for assessing concussions
- Red flags, observed signs, Maddocks questions, Glasgow coma scale, C-spine assessment, coordination/balance & oculomotor assessment, symptoms evaluation
- Cognitive screen; orientation, immediate memory, concentration
- Loses diagnostic utility after 3 days *
Components to consider regarding the injury during subjective
- Loss of consciousness & duration
- Amnesia (retrograde or anterograde)
- Prepared for impact vs blindsided
- Removed from play or continued playing
- On field symptoms
Components to consider about previous history during subjective
- Mood disorders/learning difficulties
- Oculomotor impairments
- Migraine (personal/family)
- Prior concussions
Components to consider regarding symptoms during subjective
- Overall improving, static or worsening
- Headache
- Dizziness
- Visual complaints/difficulty reading
- Imbalance
- Neck pain
- Auditory complaints (fullness, pressure, tinnitus, loss)
- Fatigue and/or sleep dysfunction
- Photo/phonosensitivity
- Positional dizziness
Components to consider regarding activity level during subjective history
- School performance/tolerance
- Sense of fogginess
- Increased irritability
Components to consider regarding management since injury during subjective
- Medications; prescription vs OTC
- Other therapies or medical care
Predictors of potential prolonged recovery following concussion
- Age; occurrence in child worse than adolescent
- Migraine history
- Learning difficulties
- Repeat concussion/how many
- Female sex (neck strength, more prone to migraine, hormonal effect)
- Post traumatic amnesia
- Immediate onset dizziness
- Brief loss of consciousness
- Fogginess; predicts protraction, linked to anxiety
- Post-traumatic migraine
Vital signs to consider in exam following concussion
- BP & HR
- Positional (orthostatic) BP assessment -> assess in supine or sitting -> bring patient to sitting or standing and immediately assess BP
- Could indicate autonomic impairment or orthostatic intolerance
Orthostatic intolerance
When there is not a drop in blood pressure but the patient experiences symptoms ie. Dizziness, lightheadedness
Significant orthostatic hypotension
Drop >/= 20 mmHg systolic OR >/= 10 mmHg WITH increase in symptoms
Options for oculomotor testing and VOR following mild TBI/concussion
- Spontaneous nystagmus
- Gaze holding nystagmus
- Smooth pursuits
- Saccades
- Convergence
- VOR
- VOR cancellation
- Head impulse test (PRN only)
- Dynamic visual acuity
Importance of including oculomotor and VOR testing for concussion pts
- Need to look out for overt impairment signs with each item AND asses for symptoms reproduction
- Oculomotor deficits must be treated along with other impairments for patient to progress with recovery
King-Devick Test
- Concussion screening assessment of rapid number naming
- Requires eye movements, language function, and attention (objective measure)
- Functional assessment of saccades and to some degree cognitive processing
- Normative values: 40-60 seconds depending on population (to complete all 3)
- Minimal detectable change: 6-7 seconds
Dix Hallpike Test for BPPV
- Indicated when patient history includes true room spinning dizziness with positional component
- Incidence about 5% in concussion pts
General positional assessment for concussion pts
- Motion sensitivity quotient
- Patient performs general positional movements and rates symptoms 0-5/5
- Positions include bending over in sitting/standing, sitting to side lying, repeated sit to stand, supine rolling etc.
CNS screening for concussion pts
- Cranial nerves
- DTRs
- Test of cerebellar function (finger to nose, tandem gait)
- Increased tone (spasticity) PROM followed by quick stretch
Cranial nerve screen
Raise eyebrows, frown, smile, stick out tongue, say ahhh, resistance to tongue in check, resistance to shoulder elevation, gross hearing assessment, smell coffee grounds
Outline for cervical examination with concussion patients
- Posture
- Goni measurements (ROM)
- Muscle strength
- Cervical spine proprioception
- Upper cervical ligamentous stability
- Palpation
- Special tests
Cervical ROM in concussion pts
- Look at flexion, extension, rotation, lateral flexion
- Assess for symptoms and any significant asymmetry in lateral flexion or rotation
-Extension ROM commonly limited in this group
Cervical muscular assessment in concussion pts
- Ability to perform upper cervical flexion (longus colli/capitus mm.) look at control and endurance
- Ability to isolate contraction of mid/lower traps without excessive upper trap activation
- MMT of scapular stabilizers (if indicated)
- Core/abdominal strength testing may be appropriate
Deep neck flexor activation and endurance test
- Consider using when hearing complaints of wobble/bobble head
- Patient performs chin tuck (avoiding SCM and scalene mm. Use)
- Examiner assists pt to place head 1 in off table surface & pt asked to hold position
- Time stops when control of chin tuck is lost
- Adults: F: 29 sec M: 39 sec
- Adolescents: F: 30 sec M: 34 sec
Cervical proprioception/test of joint position error
- Assesses accuracy of cervical proprioceptive input by testing the ability to relocate the head to a starting neutral position after maximal rotation
- Normal deviation </= 4.5 degrees
Cervical palpation for concussion pts
- Muscles: cervical paraspinal and suboccipital mm, upper trap and elevator scap mm, SCM’s, massager and temporalis mm.
- Intersegmental mobility: locate transverse and spinous processes, feel for alignment asymmetries, segmental hyper/hypo mobility
- Monitor symptoms; dizziness, nausea, headache, symptoms relief
Cervical flexion rotation test
- Used to identify mobility impairment at C1/C2 segment
- Less complicated than other forms of cervical joint mobility testing
- Passively flex pts neck -> passively rotate -> assess for symmetry and symptoms
Normal ROM: 40-45 degrees
Smooth pursuit neck torsion test
- Tests effect of cervical proprioceptive input on smooth pursuit function by stimulating cervical receptors but not the vestibular system (assesses smooth pursuit function with head in neutral and in rotated positions, 45 degrees)
- Patient sits upright and performs smooth pursuits -> repeat smooth pursuits testing in rotated position -> observe for changes in pursuit quality and symptoms in rotated position (demand on oculomotor system should be the same)
System involved in balance (need to screen all of these)
- MSK: adequate ROM, strength, ankle strategies
- Somatosensory: proprioceptive info to cerebellum & cortex
- Vestibular: peripheral components & vestibular nuclei & associated pathways
- Visual: input to vestibular nuclei & brainstem to cerebellum
Static balance measures
- Romberg eyes closed and tandem: should be able to hold for 60 seconds
- Modified clinical test of sensory integration for balance: hold for 30 sec each position documenting time to LOB
Balance error scoring system (BESS)
- Designed for concussed population
- 3 stance postures performed on and off foam with EYES CLOSED; feet together, single leg, tandem stand
- Hold for 20 sec, count balance errors
- Norms: 11-14 points in pts </= 50
Errors involved in BESS test
Moving hands off of iliac crests, opening eyes, step or fall, abduction or flexion of hip beyond 30 degrees, lifting forefoot or heel off testing surface, remaining out of proper testing position for >5 seconds
Gait measures used in concussed pts
- Dynamic gait index; 8 components <19/24 =fall risk
- Functional gait assessment; 10 components <22/30 =fall risk
Exertional intolerance in concussed pts
- Due to altered central regulatory systems; autonomic nervous system & cerebral blood flow
Persistent post-concussive symptoms may be result of…
Auto regulatory mechanisms not returning to normal
- Possible increase in resting HR levels
Cerebral blood flow following concussion
- Is automatically regulated & may be augmented following injury resulting in increased flow and increased symptoms
Buffalo concussion treadmill test
- Starting speed of 3.3-3.6 mph at 0% grade
- Increased grade by 1% every minute
- Assess RPE every minute & HR/BP every 2 min
- If max incline is reached begin to increased speed by 0.4 mph every min
- Note BP & HR at time of stopping (represents threshold)
Stopping criteria: 1. increase in any symptoms >/= 3/10 VAS from baseline 2. Pt reaches exhaustion (RPE of 19/20)
Aerobic exercise recommendation for concussed pts
Patient can perform gentle exercise daily 20 min at 80-90% of threshold HR (measured during treadmill test)
Absolute contraindication to performing the BCTT
- Pt unwilling to exercise
- Increased risk for cardiopulmonary disease as defined by the American college of sports medicine
- Focal neurological deficit
- Significant balance deficit, visual deficit, or orthopedic injury that would represent a significant risk for walking/running on a treadmill
Relative contraindications to performing the BCTT
- Beta-blocker use
- Major depression
- Does no understand English
- Minor balance deficit, visual deficit, or orthopedic injury that increases risk for walking/running on a treadmill
- SBP >140 mmHg or DBP >90 mmHg
- Obesity: BMI >/= 30 kg/m2
Buffalo/Manitoba approach
- Aimed at managing pts with persistent symptoms
- States standardized concussion assessment tools alone are not sufficient for pts with persistent post-concussion syndrome
- Suggest assessment of cranial nerves, motor/sensory function, reflexes, cerebellar, gait, and balance testing, vestibular/oculomotor testing, cervical eval, pupillary function and visual field testing
Physiologic post-concussion disorder
- Persistent alteration in neuronal depolarization, cell membrane permeability, mitochondrial function, cellular metabolism, and cerebral blood flow
- Symptoms include HA exacerbated by physical and cognitive activity, nausea, intermittent vomiting, photo/phono phobia, dizziness, fatigue, difficulty concentrating, slowed speech
- Exam; no neuro deficits, may have elevated resting HR, exertion intolerance
- Management: rest, school/work accommodations, sub-threshold aerobic exercise (graded return to activity)
Vestibule-ocular post-concussion disorder
- Impairment within vestibular and/or oculomotor systems
- Symptoms include dizziness, vertigo, nausea, lightheadedness, gait and postural instability at rest, blurred or double vision, eyes strain, HA with vestibular/ocular tasks ie. Reading
- Exam: impairments on standardized balance and gait testing, impaired VOR, smooth pursuits, convergence, horizontal and vertical saccades
- Management: vestibular rehab, school/work accommodations, consider aerobic exercise
Cervicogenic post concussion disorder
- Muscle trauma/inflammation, impaired cervical proprioceptive function
- Symptoms include neck pain, stiffness, occipital HA not aggravated with physical/cognitive activity, lightheadedness, imbalance
- Exam: decreased cervical ROM, muscle tenderness, impaired head-neck position sense
- Management: manual therapy, proprioceptive re-training, balance and gaze stabilization exercise, consider aerobic exercise
Early goals for cervical treatment following concussion
- Restore ROM (manual techniques/therapeutic exercise)
- Manage pain (manual techniques, ther-ex, modalities)
Restoring/retraining cervical proprioceptive function following concussion
- Isometric exercise w/w/o visual feedback ie. Neck clock
- Position sense training
Cervical/postural strengthening following concussion
- Deep neck flexor muscle
- Scapular strengthening
Treatment for oculomotor and vestibular dysfunction following concussion
- Smooth pursuits: tracking ie. Moving finger/pen, roll/toss ball, ball pendulum on string
- Saccades: eyes movements between 2 targets, eye-head movement substitution, number search on blank or complicated sheet
- Convergence: eye pushups, near/far point fixation, Brock’s string
- VOR: VORx1, VORx2 with backgrounds
Progressions for oculomotor/vestibular exercises
- Begin seated, quiet environment, plain backgrounds
- Move to stand with hand support -> 1 hand support -> no hand support -> narrow base of support -> compliant surface -> complex backgrounds -> integrate movement
- Progress to functional activities based on demands of patient occupation/interests
Balance retraining following concussion
- Focused on sensory reintegration
- Consider findings on mCTSIB; find their threshold and make it challenging
- Vary postures/sensory inputs/head movements
- Be creative but targeted
Post-traumatic migraine symptoms
Photo/phonosensitivity, intense activity limiting pain, not usually localized to posterior occiput, may be unilateral
Note: HA around eyes do not necessarily indicate this
- No testing, based on subjective information
Treatment for post-traumatic migraine
- Medical management*
- Slow exposure to vestibular activity, HA diary, salt/caffeine limitation
Influence of mood/mental health conditions and concussion
- Meanness, aggression, and psychoticism associated with increased incidence of sports-related concussion
- Baseline traits of irritability, illnesses, family hx or psychiatric illness, and significant life stressors associated with worse symptomatology after sports-related concussion
- Pre-existing psychiatric illnesses, family hx and significant life stressors associated with increased risk of developing post-concussion syndrome following sports-related concussion
Differential diagnosis of post-concussion syndrome includes
- Factitious disorder
- Anxiety disorder
- Chronic fatigue syndrome
- Chronic pain syndrome
- Look for aphysiologic balance strategies, more complicated social histories
- Make/suggest appropriate referral if warranted
Messaging for successful outcomes following concussion
Focus on gain of function and symptom improvement NOT symptom resolution
Graduated return to sport strategy
- Initial period of physical/cognitive rest (24-48 hours) then begin a graded program of exertion before returning to activity
- Students may require temporary absence from school after injury
- Children/adolescents should NOT return to sport until they have successfully returned to school
