Concussion - Physical Therapy Exam and Intervention Flashcards by Owen Honroth

what are the four domains to guide PT exam and interventions

MSK (cervical and thoracic spine)
vestibulo-oculomotor
autonomic
motor function

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what typical examination aspects are crucial in SRC populations

red/yellow flags
current meds
sleep
hydration
eating habits
concussion hx
past medical history

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what would MSK examination include

ROM
strength
endurance
palpation
joint mobility / positioning

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what subjective reports would indicate MSK screening

neck pain
HA
dizziness
fatigue
balance issue
difficulty visually focusing

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what would a vestibulo-oculomotor exam include

ocular alignment
smooth pursuits
saccades
vergence / accommodation
dynamic visual acuity
motion sensitivity
BPPV testing (vertigo)

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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)

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what would an autonomic examination include

symptom guided graded exercise test
orthostatic hypotension assessment

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what does autonomic exam really mean

exertion tolerance testing

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what subjective report would indicate an autonomic examination

exertional intolerance
dizziness/HA
desire to return to high-level exertional activities

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what does a motor function examination indicate

static/dynamic balance
coordination
multi/dual tasking

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what subjective reports would indicate motor function exam

imbalance
difficulty multitasking

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interventions associated with cervical MSK impairment

strengthening
ROM
sensorimotor integration
manual therapy of cervical/thoracic spine

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interventions related to vestibulo-oculomotor impairments

vestibular rehab (vestib/oculo dysfunction)
habituation (vertigo)
BPPV = positioning maneuvers

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interventions for exertional intolerance impairments

symptom guided
progressive aerobic exercise program

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interventions related to motor function impairments

static/dynamic balance
motor coordination
dual/multitasking

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what is the VOMS

oculomotor exam that combines with symptom exacerbation during eye/head movements

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what are the components of the VOMS

smooth pursuits
saccades (horizontal/vertical)
convergence
VOR (horizontal and vertical)
visual motion sensitivity

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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

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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