concussion assessment Flashcards
what is a concussion
Sports Related Concussion is a traumatic brain injury caused by a direct blow to the head, neck or body resulting in an impulsive force being transmitted to the brain that occurs during sport or exercise
can abnormality is seen on standart structural neuroimaging
no
concussion impact primary predominant mechanism of concussion
Shear forces caused by rotational acceleration
concusion mechanism determined by
amount of mechanical energy from acceleration transferred to the brain and vascular tissue
High school athletes are reported to sustain between _ impacts annually, which is more than reported in collegiate athletes, who may sustain between _ and impacts annually.
High school athletes are reported to sustain between 520 and 652 impacts annually, which is more than reported in collegiate athletes, who may sustain between 257 and 438 impacts annually.
In general, impacts occurring in high school football fall on the low end of the spectrum, with _% of all impacts resulting in a linear head acceleration of _ g or less, which is far below the levels of a concussive impact.
75, 30
Following an acceleration and deceleration force transmitted to the head, a complex cascade of _ events occur
neurochemical and neurometabolic
what happen to the axon when acceleration/deceleration injury occurs
Nerve (axon) is deformed (shearing and stretching motion)
what happen physiologicaly with concussion
Increase in glucose metabolism “hyper-metabolism” + diminished cerebral blood flow
Neurotransmitters are released and influx of ions
Binding of glutamate to Excitatory amino acids (N-methyl-d-aspartate- NMDA) receptor
Leads to further neuronal depolarization with efflux of potassium and calcium
The Na+-K+ pump works in overtime to try and restore neuronal membrane
This requires increased use of adenosine triphosphate (ATP)
Cellular energy crisis
impact on calcium release in concussion
calcium in the cell impair ATP production in mitochondria, worsening energy crisis
calcium influx also cause axonal swelling and decrease axonal function
impact on increase calcium release in concusion is usually seen when
Seen within hours and may persist for 2-4days
what is metabolic vulnerability
Following concussive episode studies have shown changes in brain metabolism
Solid experimental evidence linking the severity of brain injury and recovery with
with the extent of ATP and N-acetylaspartate (NAA) decrease and recovery
metabolic recovery; at 15 day only _ concussed athlete had level return to minimal level recorde in control
Brain concentration of NAA remained profoundly depressed in _ of 40 concussed athletes at 22 days but returned to normal levels at 30 days
5 of 40
21
These data support previous findings (Vagnozzi et al., 2008), suggesting that the metabolite normalization process after a concussive episode is an
exponential phenomenon, rather slow in the first 2 weeks, when a daily increase of 0.35% is observed, and faster between 22 and 30 days, when the daily increase of the NAA/Cr ratio is 1%
what is SIS
Condition in which a person experiences a second head injury before the complete recovery of the initial injury
Results from the dysfunctional cerebral blood flow autoregulation leading to increased intracranial pressure
what is herniation and result from what
Herniation= rapid pressure develop and deterioration and leading to death within 2-5minutes
can result from SIS
The majority (80-90%) of concussions resolve in a short _ day period
7-10 days
T/F. Self-declared to have spontaneously recovered from any clinical post-concussive symptoms between 3 and 15 days after concussion, indicating a profound discrepancy between clinical self-observational return to ‘normal’ and complete metabolic recovery
T
Recent experimental studies (Signorettiet al., 2010) have shown that spontaneous re-synthesis of NAA occurs only _ therefore, it appears possible that normalization of NAA concentrations may occur only _
after recovery of mitochondrial dysfunction with consequential return to normal ATP levels;
after the cerebral energy state has fully recovered.
concussion prevention
Neck strength only plays a role to a certain extent
Ability to actively engage neck muscles and resist linear and rotational acceleration is more important (Viano et al 2007)
Neuromuscular warm up programs completed at least 3x/week have been associated with lower concussion rates in rugby players
can helmet help concussion prevention
Helmets- may reduce concussion severity and duration of symptoms as well as SRC odds if direct head impact
does headgear help with concussion prevention
no statistical significance
do monthguard help with concussion prevention
conflicting results. Hockey has shown a 26% reduction rate in ice hockey across all age groups. More research needed for non-helmeted contact and collision sports
In some cases of concussions, symptoms may take up to _ days to develop and/or evolve
5
Therefore, CAT(C)s should remain in touch with the injured athlete and/or individual monitoring the athlete, especially during the first _ hours. It is essential to watch for any possible red flags to ensure that appropriate follow-up is made
48-72h
A referral to a physician (versed in concussion management) is required for all concussions with symptoms lasting more than _ days
10
Up to _% of children and adults with SRC experience persisting post-concussive symptoms
30
5th international conference on concussions in Sport defines persisting post-concussive symptoms as symptoms lasting _ weeks or longer for adults and _ weeks of longer for children
2 week adults, 4 weeks children
Persistent Concussion Symptoms is frequently associated with
mental health problems, declines in QOL and difficulties returning to sport, school work and ADLs
is their a gold standard for diagnosis of concussion
no, relie on symptom report
Risk Factors for concussion outcomes;Increased deficits and protracted recovery
History of migraine
Diagnoses of learning disability of attention deficit hyperactivity disorder
Sex (i.e. females)
Age (i.e. younger)
_ appear to be risk factors for persistent symptoms
Preinjury mental health problems and prior concussions
does ADHD and learning difficulties increase risk of prolonged recovery
ADHD and learning difficulties may require more careful planning for RTL but do not consistently increase risk of prolonged recovery
The _ years might be a particularly vulnerable time for having persistent symptoms—with greater risk for girls or boys ?
teenage year, girl
T/F. Greater acute and subacute symptoms are a consistent predictor of worse clinical outcome.
T
_ has been reported in some studies as having a 7 fold increase in risk of PCS
Dizziness
Sport Concussion Office Assessment Tool (SCOAT6/Child SCOAT6)
Does not replace clinical acumen but provides a _ that can be adapted to help inform clinical evaluations
standardized framework
Sport Concussion Office Assessment Tool (SCOAT6/Child SCOAT6) can be use with who and what does it provide
Identifies areas for potential individualized interventions, direction for the specialist, possible referral avenues and monitoring recovery
Child= 8-12
Adult=13+
what is include in the new SCOAT6 and child SCOAT6
Symptoms, cognitive recall, blood pressure measures, cervical evaluation, neurological examination (cranial nerves and spinal), timed tandem gait, modified VOMs
_ symptoms in the first week need special attention**
Dizziness at time of injury and migraines
_% of patients report headaches with concussion
75
S/S of cognitive/fatigue trajectory
fatigue, decreased energy levels, non-specific H/A, sleep disturbances
Common to see symptoms increase at end of day
Difficulties concentrating
Increase headache with cognitive activity
Neurocognitive testing typically reveals mild global deficits in memory, processing speed, and reaction time
if i have sleep disturbance, my symptome increase at end of day, i have trouble concentrated, fatigue and increase headache with cognitive activity which trajectory it is
cognitive/fatigue
S/S vestibular trajectory
dizziness, fogginess, nausea, and feeling of being detached, anxiety, and overstimulation in more complex environments
Increase in symptoms in busier, more stimulating environments
Rapid head or body movements may exacerbate symptoms
Note the triggers for increased symptoms as well as activities that do not trigger a vestibular reaction
Assess via a comprehensive vestibular/ocular motor screening
if i am dizzy, have feeling to be detached, my symptom inrease in more stimulating environement, fogginess and rapid head mpvement exacerbate my symptom which trajectory is affected
vestibular
S/S of ocular motor trajectory
S- localize, frontally based headaches, fatigue, distractibility, difficulties with visually based classes, pressure behind eyes, and difficulty with focus
Difficulties with extended time in front of computer screens or reading
Full days at work or school may intensify symptoms, with decrease in symptoms on the weekend
Characterize headache- frontal pressure sensation or behind eyes? Or increased headache with reading or computer time?
Most likely the ocular motor dysfunction will be evident with near convergence and/or accommodation measurements
if i have pressure behind eyes, feel fatigue, difficulty with extended time in front of computer screen or reading. I have decreased symptom in the weekend and increase with full day at school which trajectory is affected
ocular motor trajectory
common visual complain of ocular motor trajectory
I get tired when trying to read
When I turn to quickly, I get dizzy
I feel like its difficult to find things
I am seeing double
I am skipping lines when reading
My vision is blurry
My depth is off
common functional complain of ocular motor trajectory
Hard time paying attention in class
Cant read for more than 5 minutes at a time
Lights frorm computer and phone is bothersome
Hard time following recipes, skips steps
Get dizzy and disorientated when tying shoes
Hard time putting make up on
S/S of anxiety/mood trajectory
increase in anxiety, including ruminative thoughts, hypervigilance, feelings or being overwhelmed, sadness, and/or hopelessness
Report sleep disturbances, with inability to quiet minds or stop thinking and worrying
Ask about family history of anxiety
Symptoms may manifest through headache, foggy, dizzy or fatigued
If symptoms present with down time/alone consider anxiety
Some vestibular dysfunction testing may provoke symptoms (must be treated before treating anxiety)
i have sleep disturbance, inability to stop thinking, hypervigilance feeling, sadness which trajectory is affected
anxiety/mood
International Headache society defines post-traumatic migraine as
unilateral, moderate to severe intensity headache following a head trauma with a pulsating quality that is associated with nausea and photosensitivity and or/phono sensitivity and is often aggravated by physical activity
post traumatic migraine trajectory is exacerbated by
stress, sleep dysregulation, anxiety or emotional changes, dietary trigger (caffeine)
what is a vestibular migraine
nervous system problem that causes repeated dizziness
which type of migraine is associated with Dizziness, sensitivity to light, sound, motion intolerance with head, eyes, and body movement (potentially causing vertigo, nausea, vomiting), confusion/altered
vestibular migraine
what is cervicogenic headache
Secondary headache
Referred pain caused by dysfunction of the cervical spine
which type of headache is associated with Increased symptoms with motion of C/S or pressure placed on neck, Often reduced ROM of the neck, usually 1 side of dysfunction
cervicogenic headache
what is a post-traumatic headache
Headache that develops within 7 days of injury or after re-gaining consciousness
- Most common resembles a migraine
which type of headache is associated with C1-3 cervical afferents and trigeminal nerve in face lead to referred hemi cranial pain
post-traumatic headache
what is important to focus on with cervical trajectory
Important to focus on characterization of the headache (i.e. dull, throbbing, pressure) as well as location (frontal, temporal, occipital)
Ask about onset and course of ADL to help determine triggers
Assess cervical spine for ROM, strength, instability tests and flexibility of musculature
Cervical injury that affects somatosensory affects
arising from the muscle spindles, joint and pain receptors, or nerve roots of the cervical spine contribute to cervicogenic headache, and vertigo or dizziness
smooth pursuit neck torsion test stimulate and look at what
Looking at the cervical spine influence verses vestibular issues
Stimulates the cervical proprioceptors but not the vestibular
Shown potential to identify abnormal cervical afferent input as the cause of sensorimotor control disturbances
how do you test smooth pursuit neck torsion and what is a positive
Test: complete smooth pursuit in neutral then repeat in 45 degree left and right rotation
Positive: symptoms increase with head rotation in comparison to neutral position (if they increase in left rotation=left side problem)
cervical joint position error test look at
proprioceptive abilities
purpose of flexion-rotation test
Purpose: dysfunction in the C0-C2 to help determine C/S dysfunction and cervicogenic headaches
Cervicogenic headache is a chronic headache that arises from the atlanto-occipital and upper cervical joints and perceived in one or more regions of the head and/or face
what is a positive flexion-rotation test
Flexion c/s fully and rotate to one side then the other
Normal 45 degree rotation
If firm resistance is encountered, pain provokes, and range is limited before suspected ROM, test is positive
_% of athletes report dizziness as a symptom in first few days
50
Symptoms of vestibular impairment
Unstable vision, difficulty focusing, motion discomfort, difficulty in visual environments, imbalance and dizziness
what is Used to assess vestibular and ocular impairments after a concussion
Help to guide impairments for rehabilitation goals
VOMS
what are the 5 domains of VOMS
Smooth pursuits
Vertical and horizontal Saccades
Near point of convergence
Vestibulo-ocular reflex (VOR)
Visual motion sensitivity (VMS)
how do you perfom smooth pursuit
The patient is instructed to maintain focus on the target as the examiner moves the target smoothly in the horizontal direction1.5 ft to the right and 1.5ft to the left of midline. One repetition is complete when target moves back and forth to the starting position and 2 repetitions are performed
Horizontal: Target is moved at a rate of 2 seconds for each direction (right to left and left to right).
Vertical: Repeat at the same rate (2 seconds) moving the target vertically 1.5 ft above and 1.5ft below midline for 2 complete repetitions up and down.
how do you perform sacade
Horizontal: Examiner holds two single points (fingertips/targets) Horizontally at a distance of 3 ft from patient and 1.5 ft to the right and 1.5 ft to the left of midline so that the patient must gaze 30 degrees to the left and 30 degrees to the right. Once repetition is complete when the eyes move back and forth to the starting position. 10 repetitions are to be completed
Vertical: Repeat the test with 2 points held vertically at a distance of 3 ft from the patient and 1.5 ft above and 1.5 ft below midline so that the patient must gaze 30 degrees upward and 30 degrees downward
how do you perform near point convergence
Examiner sits in front of the patient and observes their eye movement during this test. Patient focuses on a small target (approximately 14 font size) at arm’s length and slowly brings it toward the tip of their nose
The patient is instructed to stop moving the target when they see two distinct images or when the examiner observes an outward deviation of one eye
what is an abdnormal near point convergence distance
ABNORMAL >to 6cm)
VOMS assess what
Assess the ability to stabilize vision as the head moves
visual motion sensitivity test what
Test visual motion sensitivity and the ability to inhibit vestibular –induced eye movements using vision
Cervicogenic dizziness=caused by dysfunction in
upper cervical spine
what is bening paroximal positional vertigo
Crystals dislodged to semicircle canals and interfere with normal fluid movement
what is hallpike-dix test
Therapist holds head and patient is then assisted into supine position with head slightly below horizontal plane and position maintained for 30-60sec
positive with dizziness and nystagmus -> beningn paroximal positional vertigo
what is orthostatic hypotension testing
Help to differentiate causes of dizziness
Have patient lay for 15 minutes to get resting BP
Have patient stand up and take BP
Within 2-3 minutes of standing a drop of 20mmHg in systolic BP and/or 10mmHg in diastolic BP is a positive test
what is head impulse test
Used to assess angular vestibular ocular reflex (aVOR)
Test
Pt fixes eyes on target (examiner’s nose)
Explain to pt they need to try not to blink and relax neck muscles
Explain you will complete small but rapid head movements
Examiner will develop a rapid head movement (10 degrees) and assess for a corrective or compensatory saccade response
what do you first need to assess before doing head impulse test
clear C/S for adequate pain free ROM and vertebral artery test
absolute contraindication of BCTT
unwilling to exercise, increase risk fro cardiopulmonary disease
focal neurologic deficit
significant balance deficit, visual deficit, orthopedic injurury
relative contraindication to performing BCTT
beta-blocker use, major depression, don’t understand english
minor balance deficit, visual deficit or orthopedic injury. SBP > 140 mmHg or DBP > 90 mmHg
obsesity: BMI > 30 kgm
T/F Brain CT (or MRI) contribute a lot to concussion evaluation but should be used whenever suspicion of an intracerebral or structural lesion (i.e. hematoma or fracture)
false, little
T/F Functional MRI (fMRI) demonstrate activation patterns that correlate with symptom severity and recovery in concussion
T
what is use to assess cerebral blood flow
PET scan
Early studies are suggesting that an increase in CVR is a response to
the tissue demands that require oxygen/nutrients and removal of metabolic waste
why In the initial days following injury, physical and cognitive rest has been strongly encouraged (24-48 hours)
Neurometabolic crisis= increase energy demand may hinder recovery
Vulnerability of second injury= overlapping injury=greater damage to axons
Decrease in neuroplasticity biomarkers
Neuroplasticity changes after concussion
Overtime the brain gets tired and uses more energy and blood supply to use this more difficult and inefficient pathway
3+months of concussion symptoms=change in neuroplasticity and becomes bodies new norm
what can be a breach of duty with concussion
Failure to warn, educate,
train
Premature return to play
Mismanagement/misdiagnos
Failure to Evaluate/Test/Monitor
Failure to refer
To prove negligence, the athlete must be able to substantiate ALL of the following
Conduct by the AT
Existence of duty
Breach of duty
Causation
Harm/damage
what do you MUST do with concussion
Written Concussion management plan on file
Evals- from trained staff
No same day RTP
Athletes cleared by physician
Acknowledgement (education, reporting)
what do you need to documented with a concussion
Document ALL pertinent information
Document communication with athlete
Document the “negatives” (things not observed)
If it is not documented, it didn’t happen!!
