Concussion Flashcards
How is the Biodex used?
Given to athletes before an injury to give a baseline. Then given after injury to assess all 3 sensory feedback systems and make a return to play decision.
What are some low cost and technology concussion assessment tools used in the clinic? (
BESS (Balance Error Scoring System), Modified CTSIB , HiMAT (High Level Mobility Assessment Tool). Dynamic Gait Index, Functional Gait Assessment, Visual Acuity/Dynamic Visual Acuity using Snellen Eye Chart
What are the 4 positions of the modified CTSIB? How long is each position held?
- Eyes open, solid surface. 2. Eyes closed, solid surface, 3. Eyes open compliant surface, 4. Eyes closed, compliant surface. Hold for 30 seconds
What do higher scores on the HiMat indicate?
Better mobility performance
Physical S&S of Concussion
HA, balance problems, light/noise sensitivity, blurred vision, dizziness, fatigue, nausea, neck pain
Cognitive S&S of Concussion
foggy, difficulty concentrating, confusion, delayed processing
Emotional S&S of Concussion
Irritability, sadness, nervousness, anxiety, lability
Sleep S&S of Concussion
Drowsy, altered sleep patterns May exacerbate of symptoms: Irritability/anxiety Depression Poor concentration/attention Delayed reaction time Fatigue
APTA recognizes us for concussion management which includes…
Education
Examination/eval
H.R. 353(2) Protecting Student Athletes From Concussions Act of 2013 does what?
Mandates school district concussion management plans: Prevention ID Treatment Management
Coup-Contrecoup injury leads to
Axonal shearing/ Diffuse Axonal injury
Concussion symptoms worsen after initial axonal injury due to…
Metabolic crisis and release of large amount of neurotransmitters
Labyrinthine Concussion S&S
Ataxia, imbalance, potential BPPV
Blast Related TBI important S&S
Has the same S&S, especially noticeable are Dizziness, Balance problems, Vision Changes
In the Motion Sensitivity Quotient (MSQ) what score indicates mild impairment?
0-10
In the Motion Sensitivity Quotient (MSQ) what score indicates moderate impairment?
11-30
In the Motion Sensitivity Quotient (MSQ) what score indicates severe impairment?
31-100
Compensation is a response to a _____________ vestibular lesion.
permanent
What is compensation?
An increase in response of the remaining vestibular system in which the CNS changes to optimize function.
What are the functional goals of concussion rehab?
Decrease symptomatic complaints, Improved balance/increase gait speed/ decrease risk for falling, Improve vision during head movement, Improve quality of life
What is substitution?
Other strategies are used to replace lost or impaired function.
What are the protocols for utilizing substitution in rehab?
Progress from easy/static EO/EC to difficult/dynamic EO/EC.
What is the habituation method? How many provoking maneuvers should you chose to base your treatment on?
systematically provoke symptoms to produce reduction in those symptoms. Pick 2 or 3.
What are some convergence exercises?
Pencil Push Ups
Brock String
Arrow Chart/Dot Card
What are some cervical proprioceptive exercises?
Head Laser with Targets
Combine with Saccades
Eyes Closed awareness
What are the 6 stages to return to play?
Stage 1- Complete physical and cognitive rest
Stage 2- Light aerobic exercise (Monitored vital signs,
Stage 3-Sport Specific exercise
Stage 4-Non contact Training Drills
Stage 5-Full Contact after medical clearance
Stage 6-Normal Game Play
What is the purpose of vestibular ocular/motor screening?
Identify impairment and recognize the need for referral.
Bony section of the Labyrinth
3 semicircular canals, the cochlea and the vestibule
Membranous section of the Labyrinth
membranous portions of the canals and utricle and saccule.
Ampulla
contain the cupula (hair cells) which convert displacement into neuro firing thru bending of hair cells to detect linear/angular motion
Otolith Organ (Utricle/Saccule)
contain calcium carbonate crystals called otoconia. Shift in these crystals set off neuro firing detecting gravity and acceleration
ratio of eye to head movement
1:1
Vestibular input sends information to:
cerebellum
vestibular nuclear complex
Why are cerebellar strokes commonly missed?
mimics an episode of vertigo
Vestibular Ocular Reflex (VOR)
generates eye movements to produce clear vision during head motion
Vestibular Spinal Reflex (VSR)
compensatory body movement in order to maintain head and postural stability–prevents falls
Vestibular Collic Reflex (VCR)
stabilizes head in space
3 Vestibular Ocular Reflexes
Angular
Linear/Translational
Ocular Tilt Reflex
cervicoocular reflex (COR)
proprioception/somatosensory
innervation C1-C2 dorsal nerve roots
cervicocollic reflex (CCR)
head stability
contracts to align head
Cervicospinal Reflex (CSR)
postural stability through limb activation
Balance
The ability to control the Center of Gravity over the base of support in a given sensory environment
Postural Stabilization System
body in balance while an individual stands and actively moves in daily life
Gaze Stabilization System
maintains gaze direction of the eyes and visual acuity during activities involving active head and body movements
Benign Paroxysmal Positional Vertigo (BPPV)
brief episodes of vertigo when head is moved in certain positions
Concussion Symptoms
Dizziness Vertigo Tinnitus Lightheadedness Blurred vision/Double vision Photophobia Disruption in gaze stabilization
Cranial Nerves Controlling the Eye Movements
III Superior Rectus III Medial Retus III Inferior Oblique IV Superior Oblique VI Lateral Rectus
oculomotor n. responsibilities
saccades
pursuit
fixation (fast and slow objects)
Vergence System Function
moves eyes in opposite directions
Convergence
Both eyes fixing on one near object
Vergence triad
convergence causes accomodation which causes pupil constriction (blinking)
convergence insufficiency
reduced vergence > 6cm from nose
Vergence Spasm
increased vergence response
Vergence Symptoms
Asthenopia
Frontal Headaches
squinting/closure single eye
floating letters on page
convergence insufficiency
double vision
frontal headaches
“pulling sensation” on eyes
4 kinds of strabismus
exotropia - beats out
esotropia - beats in
hypertropia - beats up
hypotropia - beats down
Tropia
Overt deviation of the eye (exo, eso, hyper, hypo)
Phoria
ocular deviation occurs when dissociation occurs
Cranial Nerve Screen
o I: smell coffee
o II: read eye chart
o III: PEARL, tracking penlight
o IV: look inferiorly
o V: light touch to face, jaw MMT, jaw jerk reflex
o VI: look laterally
o VII: make facial expressions, taste food
o VIII: feel and hear tuning fork, balance with eyes closed
o IX/X: check gag reflex/swallowing, practice speech
o XI: Traps and SCM MMT
o XII: stick out tongue
Joint Position Error (JPE)
o Patient begins seated with crown of head 90cm from target with laser pointer on forehead
o (Right rotation x3 reps, left rotation x3 reps, extension x3 reps) – done with eyes open and closed
o Error >4.5 degrees are likely significant for head and neck proprioception deficit
Vertebral Artery Test
Supine, Extension, Rotation
Red Flag if diaphoresis, dysphagia, dysarthria, drop attacks, or diploplia
Saccadic Gaze System
for rapid eye movement to bring object into view of foveo
Vestibulo Gaze System
keeps image steady on fovea during movements
Vergence Gaze System
keeps image on fovea when moved closer
Spontaneous Nystagmus
nystagmus while holding head still and pt then looks straight ahead
Fixed Gaze Nystagmus
nystagmus while holding head still at 30 degrees left, right, up, and down from center
Convergence
ability to focus on finger from 2 feet away to 5-8cm from brow
Smooth Pursuits
Finger moving slowly at 2-3 feet from patient and taken to 60 degree total arc to avoid end range nystagmus
Saccades Test
o Rapid conjugate movements of the eyes to pace the object of interest on the fovea
o Have patient look between 2 targets approximately 15 degrees apart
o Normal is
Cover Uncover Test
test for tropia - perform cover test first on each eye; if no movement of uncovered eye tropia is not present
Alternate Cover Test
test for phoria - measures magnitude of phoria and tropia by covering one eye at a time and observing for phoria in contralateral eye
Maddox Rod Test
o Cylindrical slot testing looking at horizontal and vertical alignment
o Room is dimmed and Maddox rod is placed over one eye. Pt is asked to note pen lights position in relation to red line on rod. If the light is not right on the line, a multilevel prism is used as a treatment and the change in diopter is noted as the prescription to fix the malalignment of the eye
Head Thrust Test
tilt patient’s head down 30 degrees and start moving the head side to side while they focus on your nose, gradually increasing speed, repeat in vertical plane
Visual Acuity
snellen eye chart done both statically and dynamically
Tragal Pressure
pressure that is applied to the cartilage at the front of the ear, closing the canal and increasing pressure on the tympanic membrane
Positive if nystagmus or increased dizziness
Modified Balke Protocol
test used to assess threshold for aerobic activities
Neurocom
high tech tool used to assess balance
Skull Fx TBI S&S
UVL/BVL (partial/complete)
Conductive hearing loss
Mixed peripheral and central lesions
Hemorrhage into labyrinth TBI S&S
Post traumatic hydrops
Acute vertigo
Unilateral hearing loss
Hemorrhage into brainstem TBI S&S
damage to vestibular and occulomotor nuclei
CN III signs
poor smooth pursuit
vertigo
perception of tilt
Increased ICP
TBI S&S
Fluctuating hearing loss
Ataxia
Imbalance
Oscillopsia
“bouncing” or blurred vision
Primary Injury of Blast
caused by Barotrauma
Affects hollow organs:
Lungs, abdomen and middle ear
Potential to affect great vessels in neck and inner ear and brain
Post concussion dizziness:
Peripheral related
BPPV Labyinthine Concussion Perilymphatic Fistula (SCD)
Post concussion dizziness:
Central related
Post traumatic migraine
Brainstem concussion
Post concussion dizziness:
Non Vestibular causes
Ocular Motor Problems
Autonomic/orthostatic
Cervicogenic Dizziness
Dix Hallpike Test
Pt in long sitting Head rotated 45* to side of testing Neck ext to 20-30* in supine Hold for 30-60 sec Observe for nystagmus
Results for Dix Hallpike
Post. canal BPPV: upbeating nystagmus
Ant. canal BPPV: downbeating nystagmus
60 sec = Cupulolithiasis
Roll Test for Horizontal Canal BBPV
Pt supine
Turn head 90* and hold to observe nystagmus on both sides
Determine which side the nystagmus is worse and the direction of it
Roll Tests for Horizontal Canal Results
Canalithiasis: Geotrophic (with gravity) involved side stronger nystagmus
Cupulolithiasis: Ageotrophic (against gravity) involved side weaker nystagmus
Modified Epley/ Canal Repositioning Technique
Pt long seated head 45* rotation to affected side Supine neck extended 30* Head rotates 45* opposite direction Roll to Sidelying same as head Short sitting EOB
Initial ____ are better severity predictors after Sport-related concussions than _____ .
- Symptoms (dizziness, HA, etc.)
2. Age, sex, LOC, amnesia etc.
Differential Dx of Concussions
More serious TBI Peripheral vestibular involvement Migraine Anxiety Other mood disorders Behavior, malingering, physiologic responses Cervical pathology
Post Concussion Syndrome
Essentially the same S&S but last longer than a month
Persistent HA, Fogginess and Dizziness when standing may warrant Vestibular Therapy
Second Impact Syndrome
Occurs when an initial head injury doesn’t resolve before another head injury is acquired
Often fatal or involves serious impairments
Imaging for mTBI
CT (SPECT) for blood flow
PET scan for brain metabolism
fMRI for real time blood flow and metabolic changes
SCAT 3 AND Child SCAT 3
Acute testing with 7 Subsets
Child = 5-12 y.o.
Use for on-field assessment
King Device Test
Assess eye movement is used as baseline and compares on field exam against it, quick, affordable, easy with online data management
ImPACT Testing
Neurocognitive computerized exam used for baseline and return to play protocols
