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Neuro Eval II > Concussion/Headache > Flashcards

Concussion/Headache Flashcards

1
Q

CPG Definition of Concussion

A

Traumatic injury that affects the brain, induced by biomechanical forces transmitted to the head by a direct blow to, or forces exerted on, the body, but that does not result in an extended period of unconsciousness, amnesia, or other significant neurological signs indicative of a more severe brain injury

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2
Q

ACRM Definition of Mild TBI

A

TBI is diagnosed when, following a biomechanically plausible mechanism of injury one or more of the three operational definitions listed below are met:
1. One or more clinical signs
attributable to brain injury
2. At least two acute symptoms and at lease one associated clinical or laboratory finding
3. Neuroimaging evidence of TBI

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3
Q

Glasgow Coma Scale - Mild

A
  • GCS 13-15
  • Loss of consciousness less than 30 minutes
  • PTA less than 24 hours
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4
Q

Glasgow Coma Scale - Moderate

A
  • GCS 9-12
  • Loss of consciousness 30 minutes to 24 hours
  • PTA less than 24 hours
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5
Q

Glasgow Come Scale - Severe

A
  • GCS 3-8
  • Loss of consciousness greater than 24
  • PTA greater than 24 hours
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6
Q

What are most concussions due to?

A

Falls

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7
Q

Biomechanical Cascade

A

Excessive glutamate release –> excessive accumulation of extracellular potassium –> influx of high concentrations of sodium and calcium –> acute increase in glucose metabolism

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8
Q

End result of biomechanical cascade

A

High glucose need + low glucose delivery = energy crisis

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9
Q

Neurometabolic dysregulation

A
  • We used up the glucose and not enough is coming in
  • Problems persist for days after initial concussive event
  • Most people will. recover symptoms in 7-14 days
  • Calcium is high then crashes about day 4
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10
Q

Resulting pathophysiology of concussion

A
  • Mitochondrial dysfunction
  • Axonal damage due to mechanical force
  • Neurochemical imbalance resulting in damage to cytoskeleton
  • Unmyelinated nerve fibers more vulnerable to damage
  • Upregulation of inflammatory cells
    = CELLULAR DYSFUNCTION
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11
Q

Impairments in cerebral blood flow

A
  • 1st 48 hours = decreased cerebral blood flow
  • 8 days post = global expansion of decreased blood flow –> wide range of symptoms –> risk of re-injury
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12
Q

5 parts of screening and examination

A
  • Screening for red flags
  • Neurologic Exam
  • Cardiovascular/autonomic
  • Musculoskeletal
  • Vestibular
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13
Q

Screening/ Diagnosis

A
  • Recommended for all individuals who may have experienced a concussive event
  • Importance of early recognition
  • Recognize medical emergencies or severe pathology
  • Use of symptom checklists or rating scales
  • Refer or proceed to full examination as appropriate
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14
Q

Look at the signs and symptoms slide (14) if you want to

A
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15
Q

Red Flags

A

► Declining level or loss of consciousness, cognition,
or orientation (GCS < 13)
►New onset of pupillary asymmetry, seizures,
repeated vomiting, or other focal neurologic signs
►Severe or rapidly worsening headache or neurologic deficits
►Signs/symptoms indicating undiagnosed skull fracture
►Serious cervical spine fracture, dysfunction, or
pathology

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16
Q

Indicators for concussion

A
  • Consider information from patient, family, witnesses
  • Alteration in mental state immediately following event
  • Physical symptoms
  • Emotional/behavioral symptoms
  • GCS
  • Imaging if available
  • possible effects of substances or medications
  • Other medical diagnoses
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17
Q

Early Management

A
  • Relative Rest
  • Typical timeframe for recovery 7-14 days in adults, 4 weeks in children
  • Non-linear progression of recovery
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18
Q

Is PT Concussion Exam indicated?

A
  • Comprehensive intake interview
  • Signs of MSK, vestibulo-oculomotor, autonomic/ exertional or motor function impairments
  • Physical function goals
  • Education only?
  • Is referral to other providers indicated
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19
Q

Interview/ History

A

Type, severity, and irritability of concussion symptoms
* Past medical (and mental) health history
* Injury mechanisms
* Any early management strategies

20
Q

4 parts of examination and evaluation

A
  • Cervical Muskuloskeletal
    Function
  • Vestibul-oculomotor Function
  • Autonomic
    Dysfunction/Exertional Tolerance
  • Motor Function
21
Q

What do you prioritize the examination based on?

A
  • Irritability
22
Q

irritability

A
  • Frequency of provocation
  • Vigor of movement required to elicit symptoms
  • Severity of symptom once provoked
  • Ease of provoking symptoms
  • Factors that ease symptoms
  • How much, how fast and how
    completely symptoms resolve
23
Q

Cervical Spine Examination

A
  • Standard MSK exam
  • Elements of Vestibular Exam – positional testing, DVA, head shaking
  • Joint Position Error Testing
  • Outcome Measures
  • Proceed as Tolerated
24
Q

Vestibular examination

A
  • Oculomotor Exam
  • Positional Testing
  • Vestibular Exam (VOMS)
  • Optokinetics
  • Outcome Measures
  • Proceed as Tolerated – least to most provoking and prioritized based on patient’s goals
25
Q

Autonomic/Exertional Testing

A
  • Identify signs/symptoms that are not present at rest
  • Positional testing of heart rate and BP in supine, sitting, standing
  • Graded exertional testing: stationary vs treadmill
26
Q

When to stop exertion test

A

When there has been a three point or greater increase in any symptom

27
Q

How do you get target heart rate?

A

whatever their HR is when you stop the test, their target HR is 80% of that

28
Q

Motor function examination

A
  • Postural Control – static, dynamic, reactive
  • Dual Tasking
  • Gait
  • Motor coordination
  • Outcome Measures
29
Q

Psychological and Sociological Factors

A
  • Patient’s coping mechanisms or self-efficacy skills
  • Social support systems
  • Risk factors for prolonged recovery
  • Patient’s beliefs about recovery
  • Equipment access and other resources
30
Q

International Classification of Headache Disorders

A
  • Migraine without aura
  • Migraine with aura
  • Headache attributed to trauma or injury to the head and/or neck
  • Cervicogenic Headache
  • Vestibular Migraine
31
Q

Interventions - Education

A
  • EXPECTATION IS RECOVERY
  • Risk for re-injury
  • Rest x 24-48 hours with gradual reintroduction of activity without symptom
    exacerbation
  • Self-management strategies
  • Activity pacing and return to activity
  • Safe to initiate intervention early
32
Q

Self Management

A
  • Minor symptoms
  • Good social support
  • Few to no negative risk factors
  • Good health literacy and self-efficacy
  • Patient preference
  • Access to resources/ equipment
  • Education on symptom management
33
Q

Interventions in cervical spine

A
  • ROM
  • Soft tissue mobilization
  • Strengthening
  • Modalities
  • Posture
  • Sensorimotor
  • Neck Pain CPG guidelines
34
Q

Interventions - Vestibulo-occular motor

A
  • Oculomotor training
  • Canalith repositioning manuevers as indicated
  • Gaze Stabilization
  • Gaze Shifting
  • Habituation strategies
  • Referral as indicated for oculomotor impairments
35
Q

Interventions - Autonomic/Exertional Tolerance

A
  • Progressive, symptom guided monitored aerobic exercise
  • Referral as indicated
36
Q

Interventions - Motor Function

A
  • Static and dynamic balance
  • Motor control/coordination
  • Dual Tasking
  • Task specific
37
Q

Validated measures for pediatrics

A
  • Graded symptom checklist (6+)
  • Post concussion symptom scale (high school)
38
Q

time frame for recovery in peds

A

1-3 mo

39
Q

Is balance training good for children?

A
  • probs not but its useful in older adolescent athletes
40
Q

Prognosis

A
  • Coping Strategies
  • Support Systems
  • Risk factors for delayed recovery: mental health and/or substance use disorders
  • Patient perspective/ understanding towards recovery
  • Access to resources and equipment to support recovery
41
Q

Pediatric risk factors

A
  • Pediatrics: history of mTBI, learning difficulties, psychiatric disorders, family or social stressors, more symptoms or more severe symptoms
42
Q

Post concussive syndrome

A

Presence of any symptom that cannot be attributed to a preexisting condition and that appeared within hours of an mTBI, that is still present every day 3 months after the trauma, and that has an impact on at least one sphere of a person’s life.

43
Q

Risk factors for prolonged recovery

A
  • Female Sex
  • Younger age (teenage years)
  • Increased severity of acute and subacute symptoms
  • Loss of consciousness
  • Mental health symptoms (depression, ADHD)
  • Personal history of migraine
44
Q

Recovery

A
  • Resolution of symptoms and exam findings, and return to usual activities
  • Physiologic recovery may extend beyond the period of symptom resolution
45
Q

Risk of Multiple lifetime concussions

A
  • Post-Concussive Syndrome
  • Chronic Traumatic encephalopathy (Chronic progressive disorder –> only diagnosed definitely post-mortem)
  • Alzheimer’s Disease
  • Other degenerative neurologic disorders have mixed evidence

Neuro Eval II (16 decks)

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