Concussion Flashcards
What are definitions of concussion?
Biomechanically induced neurological injury resulting in an alteration of mental status…which may or may not result in a loss of consciousness
A complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces
What is pathophysiology of brain injury?
Necrosis: tissue death
Axonal injury: death of the electrical wires of the brain
Apoptosis: programmed cell death
Demyelination: loss or destruction of the nerves myelin coating in the CNS
Microgliosis: presence of microglia (immunological cells) in nervous tissue secondary to injury
Neuro-regeneration: regrowth of repair of nervous tissues, cells, or cell products
How are PTs involved in concussion management?
Acute on field evaluation: sports, military
Sub-acute assessment: balance/vestibular/neurologic screen
Rehab/return to play/activity: balance/vestibular therapy, management of co-existing cervicogenic issues related to HA/dizziness, return to exertion
What are symptoms of concussion?
Headache Feeling slowed down Difficulty concentrating Dizziness Fogginess Fatigue Visual blurring/double vision Light sensitivity Memory dysfunction Balance problems
What 3 symptoms of concussion come from vestibular system?
Dizziness, visual blurring/double vision, balance problems
What are cognitive/fatigue complaints in concussions?
Headache of 0/10 in morning, worsens progressively
Increasing fatigue at day goes on
Distractibility, poor attention
Symptoms with physical activity
May have sleep deficits
*If we see these it’s a sign of cognitive issue and they either needs to rest or do things to get brain going
What are cervical subjective complaints?
Neck pain/soreness
Limited cervical ROM
Symptoms worse with prolonged sitting/reading postures
Headaches (occipital)
C/O dizziness and visual symptoms related to cervical ROM
May have generalized balance complaints
What are ocular subjective complaints?
Frontal headache or pressure behind eyes brought on by visual activities
Problems in high visual and cognitive demand classes (math/science)
Blurry vision, double vision, difficulty maintaining visual focus
Fatigue, distractibility
What are anxiety/mood subjective complaints?
Hypervigilance, rumination
Overwhelmed (poor tolerance of busy environments)
Difficulty initiating sleep (unable to turn thoughts off)
Difficulty maintaining sleep
Excessive focus on/inventory of symptoms
Limited socialization
What are subjective complaints for post traumatic migraines?
Variable headache and intermittently severe
Often wakes with headache
Nausea, photo, and/or phonophobia
Stress, anxiety, lack of exercise
Sleep dysregulation
May also present with vestibular migraine symptoms
What are common vestibular findings?
Dizziness, nausea, one step behind, overwhelmed/anxious in busy environments, off balance
What are details of injury you should ask about in the subjective?
LOC (duration) Amnesia Prepared for impact vs blindsided Removed from play/activity vs continue to participate On field symptoms include dizziness
What should you ask about in prior history during the subjective?
Migraines: personal and family history
Prior concussion: length of recovery, complete recovery
Mood disorders
Learning disabilities
Ocular motor problems: strabismus, lazy eye, amblyopia
During subjective what should you ask about current symptoms?
headache, dizziness, visual complaints/difficulty reading, imbalance, neck pain, auditory system complaints, fatigue, sleep dysfunction
What are the key factors related to recovery ?
Age: younger takes longer to recover
Exertion: athletes who engaged in high levels of activity in weeks following concussion had increased symptoms
Migraine: athletes with post traumatic migraines had significantly lower cognitive performance
Amnesia: presence was most predictive of post injury difficulties
Dizziness: when reported as on field symptom it led to 6.4x increased risk of protracted recovery
Repetitive injury: multiple concussions may be risk factor for future
What symptoms scales are used in concussions?
Post concussion scale
Sport concussion assessment tool 3
Post concussion symptom scale
ImPACT: immediate post concussion assessment and cognitive testing
Graded symptom check list
Rivermead post concussion symptoms questionnaire
Neurobehavioral symptom inventory: military specific
Are positional tests done after concussion?
Testing for BPPV
In concussion, incidence of BPPB low
May be more prevalent in mild/moderate TBI
What balance tests are done post concussion?
BESS (balance error scoring system) test DGI FGA Dual cognitive task paradigms Five time sit to stand TUG
What are parts of the BESS test?
3 stance postures: double support, single leg, tandem)
Firm and foam surfaces
Eyes closed
Scored based on # postural corrections in 20 sec trial
Developed specifically for concussed athletes
What are parts of the oculomotor testing?
Ocular ROM
Smooth pursuit: maintain stable gaze at slow speeds
Spontaneous nystagmus: differences in tonic firing rate between the vestibular nuclei
Saccades: quick movements of eyes between targets
What do people with smooth pursuit/saccades problems experience?
Patients are often highly symptomatic
Unable to read or watch TV without headaches
Video games, computer (scrolling) bothers
Driving is difficult
What are examination components of vestibulo-ocular reflex?
Slow VOR: maintain fixed gaze with head movements
Head thrust test: small amplitude, quick movement and observe corrective saccades; peripheral signs- UVL or BVL
Head shake test: move head at rate of 2Hz with 30 deg neck flexion and observe nystagmus; horizontal nystagmus- peripheral sign; vertical nystagmus- central sign
VOR cancellation: saccades or nystagmus is a central sign
Dynamic visual acuity test: move head at 2 Hz and if patient loses >3 lines it indicates hypofunction
What are symptoms of vergence system deficits?
Trouble reading, focusing Trouble focusing from far to near Blurred vision Headaches Eye strain Sensitivity to light (w/ excessive vergence response) Pulling sensation around eyes Avoidance of reading Comprehension deficits over time
What are PT treatments for concussion?
Balance training
Aerobic training
Oculomotor training
Multi disciplinary effort
Gradual return should be implemented once the following conditions are satisfied…?
Completely asymptomatic presentation, normal neurocognitive evaluation, off medications
What are guidelines for return to play?
Restrictions are temporary and gradual return to cognitive and physical activity allowed as symptoms persist.
Managed individually based on neuro cognitive recovery, symptom report, normalization of balance and other vestibular deficits.
Patient should be assessed regularly during recovery to determine when to implement changes
What are some symptoms scales used with concussions (claude)?
Dizziness handicap inventory
Headache disability index: more sensitive to changes
HIT-6
What are balance tests used with concussions (claude)?
mCTSIB: feet on/off foam with eyes open/closed
FGA over DGI
Sharpened Romberg: tandem stance with eyes open/close
Single leg stance eyes open and eyes close
What are some vision things you should consider with concussion (claude)?
convergence
accommodation: insufficiency can lead to headache and light intolerance
Tropia: misalignment of two eyes when looking forward
Phoria: appears when binocular viewing is broken and the two eyes are no longer looking at the same object
What are vestibular exercises after concussion?
Gaze stability: viewing X1, viewing X2
Saccades eye movement only, eyes and head movement
Smooth pursuit
What are two pathways that people think affect concussion?
Magnocellular: magnocells- where we see objects in relation to ourselves and how we guide movements in relation to those objects
Parvocellular: parvocells- help process visual info about shape, size, color, contrast
