Concussion/Headache Flashcards
CPG Definition of Concussion
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
ACRM Definition of Mild TBI
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
Glasgow Coma Scale - Mild
- GCS 13-15
- Loss of consciousness less than 30 minutes
- PTA less than 24 hours
Glasgow Coma Scale - Moderate
- GCS 9-12
- Loss of consciousness 30 minutes to 24 hours
- PTA less than 24 hours
Glasgow Come Scale - Severe
- GCS 3-8
- Loss of consciousness greater than 24
- PTA greater than 24 hours
What are most concussions due to?
Falls
Biomechanical Cascade
Excessive glutamate release –> excessive accumulation of extracellular potassium –> influx of high concentrations of sodium and calcium –> acute increase in glucose metabolism
End result of biomechanical cascade
High glucose need + low glucose delivery = energy crisis
Neurometabolic dysregulation
- 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
Resulting pathophysiology of concussion
- 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
Impairments in cerebral blood flow
- 1st 48 hours = decreased cerebral blood flow
- 8 days post = global expansion of decreased blood flow –> wide range of symptoms –> risk of re-injury
5 parts of screening and examination
- Screening for red flags
- Neurologic Exam
- Cardiovascular/autonomic
- Musculoskeletal
- Vestibular
Screening/ Diagnosis
- 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
Look at the signs and symptoms slide (14) if you want to
Red Flags
► 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
Indicators for concussion
- 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
Early Management
- Relative Rest
- Typical timeframe for recovery 7-14 days in adults, 4 weeks in children
- Non-linear progression of recovery
Is PT Concussion Exam indicated?
- 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
Interview/ History
Type, severity, and irritability of concussion symptoms
* Past medical (and mental) health history
* Injury mechanisms
* Any early management strategies
4 parts of examination and evaluation
- Cervical Muskuloskeletal
Function - Vestibul-oculomotor Function
- Autonomic
Dysfunction/Exertional Tolerance - Motor Function
What do you prioritize the examination based on?
- Irritability
irritability
- 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
Cervical Spine Examination
- Standard MSK exam
- Elements of Vestibular Exam – positional testing, DVA, head shaking
- Joint Position Error Testing
- Outcome Measures
- Proceed as Tolerated
Vestibular examination
- Oculomotor Exam
- Positional Testing
- Vestibular Exam (VOMS)
- Optokinetics
- Outcome Measures
- Proceed as Tolerated – least to most provoking and prioritized based on patient’s goals
Autonomic/Exertional Testing
- 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
When to stop exertion test
When there has been a three point or greater increase in any symptom
How do you get target heart rate?
whatever their HR is when you stop the test, their target HR is 80% of that
Motor function examination
- Postural Control – static, dynamic, reactive
- Dual Tasking
- Gait
- Motor coordination
- Outcome Measures
Psychological and Sociological Factors
- 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
International Classification of Headache Disorders
- Migraine without aura
- Migraine with aura
- Headache attributed to trauma or injury to the head and/or neck
- Cervicogenic Headache
- Vestibular Migraine
Interventions - Education
- 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
Self Management
- 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
Interventions in cervical spine
- ROM
- Soft tissue mobilization
- Strengthening
- Modalities
- Posture
- Sensorimotor
- Neck Pain CPG guidelines
Interventions - Vestibulo-occular motor
- Oculomotor training
- Canalith repositioning manuevers as indicated
- Gaze Stabilization
- Gaze Shifting
- Habituation strategies
- Referral as indicated for oculomotor impairments
Interventions - Autonomic/Exertional Tolerance
- Progressive, symptom guided monitored aerobic exercise
- Referral as indicated
Interventions - Motor Function
- Static and dynamic balance
- Motor control/coordination
- Dual Tasking
- Task specific
Validated measures for pediatrics
- Graded symptom checklist (6+)
- Post concussion symptom scale (high school)
time frame for recovery in peds
1-3 mo
Is balance training good for children?
- probs not but its useful in older adolescent athletes
Prognosis
- 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
Pediatric risk factors
- Pediatrics: history of mTBI, learning difficulties, psychiatric disorders, family or social stressors, more symptoms or more severe symptoms
Post concussive syndrome
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.
Risk factors for prolonged recovery
- 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
Recovery
- Resolution of symptoms and exam findings, and return to usual activities
- Physiologic recovery may extend beyond the period of symptom resolution
Risk of Multiple lifetime concussions
- Post-Concussive Syndrome
- Chronic Traumatic encephalopathy (Chronic progressive disorder –> only diagnosed definitely post-mortem)
- Alzheimer’s Disease
- Other degenerative neurologic disorders have mixed evidence
