Concussion - Physical Therapy Exam and Intervention Flashcards
what are the four domains to guide PT exam and interventions
MSK (cervical and thoracic spine)
vestibulo-oculomotor
autonomic
motor function
what typical examination aspects are crucial in SRC populations
red/yellow flags
current meds
sleep
hydration
eating habits
concussion hx
past medical history
what would MSK examination include
ROM
strength
endurance
palpation
joint mobility / positioning
what subjective reports would indicate MSK screening
neck pain
HA
dizziness
fatigue
balance issue
difficulty visually focusing
what would a vestibulo-oculomotor exam include
ocular alignment
smooth pursuits
saccades
vergence / accommodation
dynamic visual acuity
motion sensitivity
BPPV testing (vertigo)
what subjective reports would indicate a vestibulo-oculomotor examination
dizziness
vertigo
nausea
balance problems
visual motion sensitivity
blurred vision
difficulty focusing (stable or moving targets)
what would an autonomic examination include
symptom guided graded exercise test
orthostatic hypotension assessment
what does autonomic exam really mean
exertion tolerance testing
what subjective report would indicate an autonomic examination
exertional intolerance
dizziness/HA
desire to return to high-level exertional activities
what does a motor function examination indicate
static/dynamic balance
coordination
multi/dual tasking
what subjective reports would indicate motor function exam
imbalance
difficulty multitasking
interventions associated with cervical MSK impairment
strengthening
ROM
sensorimotor integration
manual therapy of cervical/thoracic spine
interventions related to vestibulo-oculomotor impairments
vestibular rehab (vestib/oculo dysfunction)
habituation (vertigo)
BPPV = positioning maneuvers
interventions for exertional intolerance impairments
symptom guided
progressive aerobic exercise program
interventions related to motor function impairments
static/dynamic balance
motor coordination
dual/multitasking
what is the VOMS
oculomotor exam that combines with symptom exacerbation during eye/head movements
what are the components of the VOMS
smooth pursuits
saccades (horizontal/vertical)
convergence
VOR (horizontal and vertical)
visual motion sensitivity
what is something to keep in mind when conducting the VOMS (compared to normal oculomotor exam)
want patient to do the tests as fast as possible
–> more so looking for symptom reproduction or lack thereof
–> still note abnormalities
oculomotor exam looks at the quality of the system not symptoms
what is done to test vergence?
near point convergence
≥ 6 cm from tip of nose is abnormal
what is a common subjective report with abnormal convergence
difficulty reading or looking at things close up
treatment for vergence abnormalities
brock string exercises
pencil push ups
dosage of vergence exercises
baseline = duration until mild symptoms or blurriness occurs
repeat multiple times after symptoms subdue
explain saccade habituation
- possible progressions
- possibly HEP
saccade between objects
- faster speed
- postural control
- dual task and or busy background
possible word searches
HART charts
card games
explain smooth pursuit habituation
ability to smoothly pursue without symptom exacerbation
progressions related to smooth pursuit habituation
duration and then speed on a plain back ground
tests for vestibular hypofunction
Head Impulse Test
Dynamic Visual Acuity
–> both will determine if VOR is off
if head movement elicits symptoms but does not cause VOR abnormality, how do you proceed
habituation program
how to intervene for visual motion sensitivity
consider provoking symptoms with head movement
- progression to more complicated movement, dual task of inclusion of aerobic component
if visual motion sensitivity on the VOMS is symptom provoking, what else can be used to formulate interventions?
motion sensitivity test or modified MST
standard intervention scheme for VMS habituation
- exercises
- reps
- considerations
3 moderately provoking exercises
3-5x per day
rest until symptoms resolve
how to assess for autonomic intolerance
buffalo concussion treadmill test
– bike version
data driven method
age predicted method
explain the goal of the buffalo concussion treadmill test
determination of heart rate threshold
explain the structure of the buffalo concussion test
based off of modified Balke protocol
incline is increased by 1° a minute with a consistent speed
if 5’10” = 3.2 mph, if over = 3.6
what is the heart rate threshold (HRt)
– any caveats to this measurement?
HR at point of symptom exacerbation
– if max exertion is achieved without symptoms limiting the test, then cardio/cerebrovascular physiology has recovered
with the HRt found, what does that information allow us for intervention
dosage of exertion needed for interventions
– can differentiate symptoms due to exertion vs other causes
safety considerations of buffalo concussion test
2 people to monitor
ability to engage in conversation
postural control
– bike method may be applicable
when is the buffalo concussion treadmill test not indicated
within first 24 hrs
if patient has symptoms of ≥ 7/10
stopping criteria of BCTT
symptom exacerbation of ≥ 3 on VAS
voluntary exhaustion = RPE ≥ 17
rapid progression of complaints/signs of distress
> 90% of age predicted max w/o symptom increase
safe level of exercise is considered
at or below 90% of HRt
explain the buffalo concussion bike test
same thing but on a bike
– will need bodyweight in KG to convert to power/watt chart
intervention for exertional intolerance
5 min warm up, 90% of HRt for 20 min, 5 min cool down
6-7 days a week
how to progress exertional intolerance interventions
increase HR by 5-10 bpm every 3-7 days or re-test
what indicates physiological recovery
can get to voluntary exhaustion at >80% of age predicted max HR for 20 min
for several days in a row w/o symptom exacerbation
general trend in mode of exercise throughout exertional intolerance intervention
move from something stationary to more dynamic
will include more sport-specific activity as well as increased head movement (stress on vestibular sys)
hydration education related to volume of water
1/2 oz per ever 1lb of body weight
