Concussion and Post-Concussion Syndrome Flashcards
1
Q
Concussion:
International Consensus:
A
Complex pathophys. process affecting brain, induced by biomech forces
2
Q
Concussion:
American Academy of Neurology:
A
Clinical syndrome of biomech. induced alteration of brain function, typ affecting memory and orientation, which MAY INVOLVE loss of consciousness (does not have to)
3
Q
Concussion in terms of Severity
A
see pics
4
Q
Concussion may/may not result in…
A
loss of consiousness
5
Q
Resolution of clinical and cognitive sxs of concussion follows _____
A
sequential course
*small %→ post-concussive sxs may be prolonged
6
Q
Simply put… concussion is _____
A
A form of TBI and should NOT be taken lightly!
7
Q
Post-concussion syndrome
WHO:
A
Head injury usually suff. to result in loss of consiousness after which at least 3 of 8 common sx’s arise w/in 4wks
- Sx’s include:
- HA
- dizzy
- fatigue
- irritbility
- sleep probs
- concentration probs
- memory probs
- probs tolerating stress/emotional/alcohol
8
Q
Why should PTs care about concussion?
Lots of Overlap!!!
A
see pics
9
Q
Concussion in sports
usually…
A
High contact sports
10
Q
Concussion + military
A
common injury exp’d in US military
11
Q
Concussion and helmets
what should you remember?
A
Helmets do NOT protect from accel/decel forces→ only FOCAL injury
12
Q
Concussion Risk Factors:
A
-
Previous concussion
- Hx concussion assocd w/ 2.5-8.5x higher risk of another
-
#, Severity, Duration
- higher→ predictor of prolonged recovery
- *Dizziness→ GREATEST PREDICTOR for recovery taking >21d
- Cognitive or migraine sxs req more recovery time
-
Migraines
- hx of pre-exist migraine HA= risk factor
- MAY BE assocd w/ prolonged recovery
13
Q
Concussion risk factors
Sex
A
Females sustain more concussions
GREATER # and severity of sx’s and longer duration
14
Q
Concussion risk factors
Age
A
Youth have more prolonged recovery + more susceptible
15
Q
Concussion risk factors
sport, pos, style of play
A
Most common mech= player contact
full contact= highest risk
16
Q
Signs and Sxs Concussion
4 Categories
A
see pics
17
Q
S/S Concussion if concomitant C/S injury:
A
- Neck pain/stiff→ includes upper back
- HA
- dizzy
- tinnitus
- blurred vision
- sleep disturbs
- guarding+lmtd AROM C/S
- compensatory motions
- *sympathetic sx’s
18
Q
What should be done if concussion suspected?
McCrory et al, 2017
The CPG
A
see pics and note highlighted areas
19
Q
during-sport assess. for Concussion
A
SCAT5
20
Q
Why is removal from activity so important if concussion suspected?
A
Second Impact Syndrome (SIS) ***
- When person who has NOT fully recovered from an initial concussion sustains a 2nd impact
- 2nd impact may be of a substantially smaller magnitude and may not even be directly to the head
- may occur in mins, days or weeks after initial concussion
- 2nd injury may result in catastrophic brain swelling and can lead to marked disability or death
21
Q
Regulations in NJ for concussion:
in a nutshell…
A
- Any player exhibiting s/s concussion: LOC, HA, dizzy, confused, balance probs)→ immed. removed and not return until cleared to play
- “approp. healthcare pro” authorizes return-to-play is trained physician
22
Q
Med. Exam for concussion
A
- Neuropsych. testing useful esp if baseline testing avail
- img’ing not sensitive enough to visualize damage→ can rule out more severe BI
- exam by phys.
23
Q
Categorization of Severity: Am. Acad of Neuro Concussion Grading
A
see pics
24
Q
Relevant Outcome Measures for Concussions:
see slides 24-29
A
NOTE: SCAT5
→ immediate and follow-up versions
25
Other exam methods assocd w/ Concussion
3:
1. C/S
* given **comorbidity** of a **whiplash injury**→ screening and/or full exam of c/s warranted
1. pt may not notice sx's right away
2 and 3. Vestibular and Oculomotor Systems
* Probs here by many who sustain concussion
26
PT Exam for persons w/ Concussion:
Taking the Hx pt. 1
Be thorough!
* **Mech. of injury**
* prepared? blindsided?
* linear vs. rotation forces
* **Sx's**
* Immed, delayed, still present
* **Immediate removal from act? or return right away?**
* **Hx of prev concussions**
* *More than 3 predicts _slower recovery_*
27
PT Exam for persons w/ concussion:
Taking the Hx part 2:
* **Mood disorders**
* anxiety/depression
* **Learning disorders**
* ADHD
* **Migraine hx**
* pre-injury dx in 14% concussed athletes\*\*
* Report of more _migraine-type sx's_→ correlates w/ more protracted (takes longer) recovery
* **Hx of visual impairs**
28
Problem Inventory w/ Concussion
3 to particularly **focus on:**
1. **Dizziness**
1. If _on-field dizziness_→ 6.34x \> likelihood protracted recovery AND post-concussion syndrome
2. **Amnesia**
1. If _on-field amnesia_→ 10x \> likelihood poorer outcome **3 days post concussion\***
2. If _on-field anterograde amnesia_→ 4x \> likelihood poorer outcome **3 days post concussion\***
1. **anterograde= cannot form new memories after trauma**
3. **Loss of Consciousness**
1. SOME evidence that _brief LOC_ (\<30s) NOT predictive of poorer outcome
29
Top 11 Sx's of **protracted recovery** w/ Concussion:
1. Fogginess
2. Diff concentrating
3. Vom
4. Dizzy
5. Nausea
6. HA
7. Slowness
8. Imbalance
9. Lt. Sensitivity
10. Noise Sensitivity
11. Numbness\*
30
Clinical Trajectories: **6**
6 Clinical trajectories ID'd that describe **common clusters and s/s exp'd by people who sustain concussion**
1. **Cognitive/Fatigue**
2. **Vestibular**
3. **Ocular**
4. **Post-Traumatic Migraine**
5. **Cervical**
6. **Anxiety/Mood**
31
Clinical Trajectory:
**Cognitive/Fatigue**
32
Clinical Trajectory:
## Footnote
**Vestibular**
see pics
33
Clinical Trajectory:
## Footnote
**Ocular**
see pics
34
Clinical Trajectory:
## Footnote
**Post-Traumatic Migraine HA**
see pics
35
Clinical Trajectory:
## Footnote
**Cervical**
see pics
36
Clinical Trajectory:
## Footnote
**Anxiety/Mood**
see pics
37
Clinical Trajectory:
NOT PART OF ORIG. 6:
**Autonomic Sx's**
* **Typical Sx's**
* Ex. intolerance
* Cog. intolerance
* **Questions to Ask**
* Does ex provoke sx's?
* Does concentrating or focusing provoke sx's?
38
During Observation and the Exam:
We are looking @ 3 things in particular:
1. Eye appearance
1. strained/squints
2. glassy/bloodshot
2. Eye position
1. @ rest
2. cover/uncover test
3. Head/neck pos.
1. head tilt
2. FHP
39
Oculomotor Exam:
What CN's are “eye stuff”
3, 4, 6!!!
3: Oculomotor
4: Trochlear
6: Abducens
40
Oculomotor Exam:
Components?
* CN III, IV, VI
* smooth pursuit
* convergence
* accommodation
* King-Devick Test
\***NOTE:** Dysfunction on oculomotor exam, **particularly _saccades and smooth pursuit,_** are HIGHLY PREDICTIVE of **poor recovery and dev. of post-concussion syndrome**
41
Tests and Measures:
## Footnote
**UPMC Vestibular/Ocular Motor Screening (VOMS)**
* Includes exam (0-10) of HA, Dizzy, Nausea and Fogginess during _several conditions:_
* @ Rest
* Smooth pursuit (vert/horiz)
* following finger smoothy
* Saccades (vert/horiz)
* following something then “snap” eyes back to place
* Convergence (dist. also)
* follow to nose like crossing eyes
* VOR
* move head but eyes stay focused on one thing
* NAJEEEEB Hockey Game!!!
* Visual motion sensitivity
* like “car sickness”
* These will **differentiate those w/ and w/out concussion**
* **HIGHER SCORES= poorer recovery/dev. of post-concussion syndrome\*\*\***
42
Tests and Measures:
**Vestibular Assess.**
* Differentiate **CAUSES of dizziness**
* some occur. BPPV in concussion (~5%)
* Include tests of **cervicogenic dizziness**
* **C/S!!!**
43
Tests and Measures:
**Balance and Gait**
***We do what we can to _induce the problem_*****_\*\*_**
* Probs w/ **postural control** may persist longer than week *after injury* even when there are **no signs of unsteadiness**
* Assess balance w/ **visual motion conflict** → may be more sensitive measure
* EXAMPLES:
* **Dynamic posturography**
* **BESS/MBESS**
* **DGI or FGA**
44
Tests and Measures:
**MSK**
*Examine like a _whiplash injury_*
* UQS
* C/S and T/S ROM + Jt. mobility
* C/S mm strength and flex.
* *Deep Neck Flexors*
45
Tests and Measures:
**CV Status**
* RHR may be elevated post-concussion
* **Autonomic dysf.** may result in **sympathetic dysreg.**
* EXAMPLES:
* **TM tests**
* **Tilt table tests**
* **observe during Valsalva maneuver**
46
Tests and Measures:
**Buffalo Concussion TM Test**
***see canvas!!***
* Mod. version of Balke Protocol
* Safe + reliable
* *Very high Sn for ID'ing sx exacerbation*
* Measures ex. tol.
* Assists in diff. dx
* **lack of sx exacerbation** indicates **presence of some other cond.**
* cervicogenic HA/dizzy
* migraine
* PTSD
* Objective measure of recovery
47
Med. Mgmt Concussion:
**Common S/S to look for:**
* Migraine HA
* Sleep disturb
* Mood disorders
* Cognitive deficits
48
Med. Mgmt:
Meds\*
* often prescribed for HA pain, but result in **rebound HAs**
* NSAIDs and aspirin should be **Avoided** during acute stages→ **due to risk of hematoma**
49
Commonly prescribed meds
Focus on the “**what for”**
* Amantadine
* **cog. fatigue and HA**
* Amitriptyline (Elavil)
* **depression + irritability**
* Meclizine
* **Vestib suppressant/anti-emetic**
50
Interdisciplinary Team Mgmt:
2 things to consider:
1. Return to **Sport or Play**
2. Return to **School or Work**
51
Return to **Sport** or **Play**
## Footnote
**Progressions**
see pics
52
Return to **School/Work**
## Footnote
**Progressions**
see pics
53
PT Mgmt
**Modified Return to Play/Work Protocols:**
* Vestib rehab + Oculomotor exercise
* addresses **dizziness, balance, HA**
* **\*HA may be vision-induced**
* Manual Tx
* HA, neck pain, strength impairs
* Progressive Aerobic Act→ INCs cerebral bloodflow
* addresses **decond. and DECd cerebral blood flow**
54
Vestibular Rehab
## Footnote
**Main Goals to Improve:**
**Consists of:**
* Main Goals:
* dizziness, balance, oculomotor function, overall act. lvl
* May Consist Of:
* gaze stab.→ focus eyes
* oculomotor ex→ ROM/accuracy eye mvmts
* Balance retraining
* Canalith repos. or other techs
* addresses vestib system itself\*\*\*
55
Manual Therapy
## Footnote
**Main Goals:**
**May Consist of:**
* Main Goals:
* ROM/Jt mobility
* DEC cervical and HA pain
* improve neck strength
* improve somatosensory input from c/s
* May Consist Of:
* Jt mobs/soft tissue work
* focus on c/s & t/s
* examine + address issues w/ C1
* strengthen deep neck flexors and cervical ext's
* strengthen scapular mm's
56
Why are PTs Key Providers?
see pics
Experiment:
* **Control Group:** traditional concussion rehab\*
* postural-ed
* ROM ex
* phys/cognitive rest until asymptomatic
* graded exertion
* **Intervention Group:**
* control intervention *+ c/s and vestib tx*
57
Aerobic Activity
## Footnote
**Main Goals:**
**May Consist Of:**
* Goals:
* endurance and aerobic capacity
* restore **homeostasis** by balancing autonomic functions
* Consists Of:
* Progression of lt aerobic activity based on symptom response
* consider modality
* monitor HR
* start w/ short act. (~15mins work) and work to longer durations
* Progress to more moderate act.
* walk/jog → all jog
* trampoline/agility
* add head/body mvmt
* \*\*\*Early on, **oculomotor training should _precede aerobics_, but should be moved to _AFTER_ when able to perform mod. activities sx free**
58
Aerobic Activity:
When to progress??
\*MONITOR CAREFULLY!!!
Not Enough Rest
vs.
Too Much Rest
59
Recovery from Concussion
see pics
* Not yet clear
* Even after substantial amt of time, with sx inventory and fMRI resolutions
* pts were still only 80% and 90% recovered, respectively→ shows that there are still lingering sx's OR post-concussion syndrome
60
Recovery from Concussion
## Footnote
**Factors that affect Recovery:**
**3**
1. Prev. concussion
1. **Hx of _3 or more_ prev. concussions→ prolonged recovery**
2. Sex
1. **Bio. girls/women have _longer recovery pd._**
1. smaller head, lower cervical strength, hormones
3. Age
1. **_Younger_ athletes have _longer_ recoveries**
2. Need to consider whether return to play is _approp._ for children under 10yo?????
3. _Conservative approach_ is warranted in _younger pts_
61
**Chronic Traumatic Encephalopathy**
\*Form of **neurodegen.** that is believed to result from **rep'd head injuries**
62
**Chronic Traumatic Encephalopathy:**
**Clinical Presentation**
* **Stage 1→** HA + loss of attn
* **Stage 2→** Depression, anger outbursts, STM loss
* **Stage 3→** Exec. dysf. and cog. impairs
* **Stage 4→** Dementia, aggression, word-finding diffs
