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Neuro 1 > Concussions > Flashcards

Concussions Flashcards

1
Q

Concussion is a ________ brain injury. What does this mean?

A

metabolic brain injury - disruption of the symbiotic environment
- neurons are stretched but not broken, leading to cascade of events

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2
Q

What happens to neurons during a concussion? What follows this action?

A
  • neurons/axons are stretched
  • leads to an increase in neurotransmitters, leading to cell membranes working harder to balance out which increases energy demand, and decreased blood flow due to arteries being stretched and squished
  • increased energy demand + decreased blood flow leads to metabolic crisis
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3
Q

What will imaging look like after a concussion? Why?

A

normal imaging because there is no structural damage to neurons/axons (they are not broken)
- only metabolic changes which do not show up on imaging

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4
Q

What are the six subtypes of concussions?

A
  • vestibular
  • ocular
  • cognitive/fatigue
  • post-traumatic migraine
  • cervical
  • anxiety/mood
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5
Q

cognitive/fatigue is most often seen ________ following a concussion.

A

early on

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6
Q

What are the major characteristics and symptoms associated with the cognitive/fatigue subtype?

A
  • fatigue - widespread and after the smallest amount of activity
  • headache w/ cognitive and PA
  • “end of day” symptoms
  • sleep disturbances
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7
Q

What exam findings are you likely to find with the cognitive/fatigue subtype?

A

nothing abnormal in neuro screen
- normal vestibular/ocular screening

will show breakdown with neurocognitive testing

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8
Q

What are 3 helpful questions to ask a patient regarding cognitive/fatigue subtype?

A
  • Do you have a generalized headache that increases as the day progresses?
  • Do you feel more fatigued than normal at the end of the day?
  • Do you feel more distractible in school/work than normal?
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9
Q

What does interdisciplinary treatment look like for the cognitive/fatigue subtype? Where does PT get involved?

A
  • physical/cognitive breaks during the day - NO NAPS
  • medication if needed
  • cognitive therapy if symptoms linger

Typically don’t see PT unless they exercise tolerance deficits and will need a monitored, structured exercise progression

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10
Q

What risk factors exist for the ocular/visual subtype?

A

personal/family history of ocular dysfunction

- wear glasses/contacts

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11
Q

What symptoms are associated with the ocular/visual subtype?

A
  • frontal headache - gets worse as day goes on
  • difficulties w/ visually based classes/activities
  • pressure behind eyes
  • visual “focus” issues
  • blurry or double vision
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12
Q

What exam findings are you likely to find with the ocular/visual subtype?

A
    • smoot pursuit, saccades
  • convergence difficulties
  • accommodative insufficiency
  • strabismus - tropias and phorias

neurocog - deficits in reaction time and visual memory

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13
Q

What is NOT frequently associated w/ ocular visual subtype?

A

photosensitivity - sensitivity to light

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14
Q

convergence vs divergence Which is more common?

A

convergence (more common) - Ability of eyes to turn inward to focus on a near target

divergence - Ability of eyes to move outwards to focus on a further target

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15
Q

What are the general symptoms associated with vergence impairment?

A
  • intermittent/constant double vision (squint to compensate)
  • asthenopia (eye strain) when reading
  • frontal headaches
  • letters appear to float/move on the page
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16
Q

What are the 3 most common vergence problems seen with concussion?

A
  • convergence insufficiency
  • convergence excess
  • convergence spasm
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17
Q

How is eye accommodation achieved?

A

changes in the lens

- controlled by CN 2, 3 reflexive activity

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18
Q

What are the general symptoms of accommodation impairment?

A
  • reduction inability to focus at near - may need reading glasses
  • accommodative spasm - over-focusing at near
  • struggle to coordinate accommodation and vergence
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19
Q

What will the struggle to coordinate accommodation and vergence lead to?

A

difficulty in spatial awareness

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20
Q

What are the treatment strategies for ocular/visual subtypes?

A
  • ocular motor training

- exercise - make sure environment isn’t too crowded or busy

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21
Q

What risk factors exist for the vestibular subtype?

A
  • PMH of car sickness/motion sensitivity
  • migraine
  • anxiety
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22
Q

What symptoms are associated with the vestibular subtype?

A
  • vertigo
  • dizziness
  • nausea
  • overwhelmed in visually-stimulating environments
  • balance impairments
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23
Q

What is the relevance of dizziness post-concussion?

A

55-80% of concussed athletes

  • negative prognostic indicator
  • undiagnosed vestibular deficits may delay recovery
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24
Q

What are common signs and symptoms of vestibular dysfunction post-concussion? (9)

A
  • dizziness
  • blurry vision
  • nystagmus
  • tinnitus
  • vertigo
  • hearing loss
  • loss of balance and possible falls
  • broad-based stance (imbalance)
  • sweating, N/V - due to ANS involvement
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25
Q

Will vestibular subtype need PT?

A

YES

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26
Q

What types of TBIs will cause vestibular dysfunction? (5)

What is the most common?

A
  • labyrinthine concussion - most common
  • skull fracture
  • hemorrhage into labyrinth
  • hemorrhage into brainstem
  • increased intracranial pressure
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27
Q

labyrinthine concussion symptoms

A
  • ataxia
  • imbalance
  • BBPV
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28
Q

skull fracture concussion symptoms

A
  • unilateral or bilateral vestibular loss
  • conductive hearing loss
  • may have mixed peripheral and central lesions
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29
Q

When are skull fracture concussions common?

A

Common with blows to the occiput, temporal or parietal regions

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30
Q

hemorrhage into labyrinth concussion symptoms

A
  • post-traumatic hydrops - episodes of dizziness accompanied by noises in the ear, fullness, or hearing changes (Meniere’s type syndrome)
  • acute vertigo and unilateral hearing loss of damage to labyrinth
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31
Q

hemorrhage into brainstem concussion symptoms

A
  • oculomotor signs - poor smooth pursuit, vertigo, perception of tilt
  • damage to vestibular and oculomotor nuclei
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32
Q

increased intracranial pressure concussion symptoms

What may this cause?

A
  • fluctuating hearing loss
  • ataxia
  • imbalance

may cause peri-lymphatic fistual - leak of perilymph from the cochlea or vestibule, most commonly through the round or oval window

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33
Q

What exam findings are you likely to find with the vestibular subtype?

A
  • VOR dysfunction and suppression
    • smooth pursuits, saccades

neurocog test - difficult w/ visual motor speed, reaction time

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34
Q

What other subtypes should be tested if the patient has vestibular subtype?

A

migraine and anxiety

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35
Q

What types of pharmacological options are available for the vestibular subtype in addition to vestibular rehab therapy?

A
  • meclizine - anti dizziness
  • tricyclic antidepressants
  • melatonin
  • SSRIs (Selective Serotonin Reuptake Inhibitor) - antidepressants
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36
Q

What are the risk factors for the anxiety/mood subtype?

A

personal/family history of anxiety, migraine, vestibular issues

37
Q

What symptoms are associated with the anxiety/mood subtype?

A
  • ruminative thoughts (deep thoughts)
  • hyper-vigilant
  • fastidious (concerned about accuracy and detail)
  • easily overwhelmed
  • difficulties initiating/maintaining sleep
38
Q

What will the exam findings look like for the anxiety/mood subtype?

A

normal vestibular/ocular screen and normal neurocog test

39
Q

T/F - You should ask your patient if they have anxiety

A

false - can make patient upset and patients don’t identify with anxiety

40
Q

What are some helpful questions that you can ask to a patient to determine if they may have anxiety?

A
  • How often do you take inventory of your symptoms?
  • Do you have a difficult time turning off your thoughts?
  • Do you become symptomatic when you are thinking about your symptoms?
41
Q

What does interdisciplinary care look like for the anxiety/mood subtype? Where does PT get involved?

A
  • psychotherapy as needed
  • treat vestibular and/or migraine subtype if present
  • supervised exertion training
  • cognitive behavior training
  • regulated schedule
42
Q

What do patients who have anxiety do well with?

A

regimented schedule - may need some training to set it up but once it is set up the patients usually do very well with it

43
Q

What are the risk factors for the post-traumatic migraine subtype?

A
  • personal/family history of migraine
  • brain freeze HA
  • motion sensitivity
  • vestibular disorder
  • anxiety
44
Q

What symptoms are associated with the post-traumatic migraine subtype?

A
  • variable HA - often wakes up with HA
  • nausea, photo and/or phonophobia
  • stress, anxiety, lack of exercises
  • sleep dysregulation
45
Q

What causes migraines?

A

insufficient vascular supply of trigeminal nerve
- causes cortical spreading depression - wave of sustained depolarization (neuronal inactivation) moving through intact brain tissue

46
Q

Migraine vs tension HA characteristics - how long do they last?

A

migraine - 4-72 hours

HA - 30 min - 7 days

47
Q

Migraine vs tension HA characteristics - location

A

migraine - unilateral location (half of face)

HA - bilateral (across forehead)

48
Q

Migraine vs tension HA characteristics - sensation

A

migraine - pulsating

HA - pressure or tightening sensation around head

49
Q

Migraine vs tension HA characteristics - pain

A

migraine - moderate to severe pain

HA - mild to moderate pain

50
Q

Migraine vs tension HA characteristics - reaction to PA

A

migraine - aggravated by PA

HA - not aggravated by PA

51
Q

Migraine vs tension HA characteristics - N/V

A

migraine - accompanied by N/V

HA - No N/V

52
Q

Migraine vs tension HA characteristics - sensitivity to light

A

migraine - sensitive to light and/or sound

HA - sensitive to either light or sound

53
Q

What will typically preced a migraine? What type is the most common to least common?

A
  • transient neurological symptoms and 1/3 will have aura

visual aura (squiggly line/lightning bolts - most common), sensory (tingling), language (difficulty speaking), motor (motor disturbance - least common)

54
Q

What examination findings will you see with post-traumatic migraine subtypes?

A

normal vestibular/ocular screen

neurocog - verbal and visual memory deficits

55
Q

T/F - You can treat a patient who is having a migraine.

A

False - Do not treat - send them home

56
Q

What are the risk factors for the cervical subtype?

A
  • prior c-spine injury
  • high velocity injury
  • strong rotational component to injury
57
Q

What symptoms are associated with the cervical subtype?

A
  • neck pain, stiffness, soreness
  • HA radiating forward from upper cervical spine - aggravated by specific neck movements or postures
  • horn like HA presentation - LA Rams helmets - starts at ears and loops around to back of neck
58
Q

What examination findings will you see you with the cervical subtype?

A

normal vestibular/ocular and normal neurocog testing

    • cervical screen
59
Q

What are the most commonly reported symptoms post sports-related concussion?

A
  • headache
  • feeling slowed down
  • difficulty concentrating
  • dizziness
  • fogginess
  • fatigue
  • visual blurring/double vision
  • light sensitivity
  • memory
  • balance
60
Q

Describe the typical recovery timeline of concussions. Who will need PT?

A
  • most get better on their own in first 10-14 days with newer research says 21-28 days
  • recovery takes ~ 4 weeks

People who have objective signs and symptoms (vestibular and ocular) are more likely to need PT

61
Q

Why is early identification of impairments important in concussion rehabilitation?

A

aids in return to activity/sport w/o prolonged sequelae

62
Q

What are predictors of prolonged recovery post-concussion?

A
  • initial symptoms
  • sex (females slower than males)
  • age
  • loss of consciousness
  • post-traumatic amnesia
  • premorbid comorbidities
63
Q

What are the general recommendations for early management of concussion?

A
  • rest - not more than 3 days
  • low-stimulus activity
  • consider temporarily removing from school/work
  • limit reading, computer, texting
  • avoid busy environments
  • no exertional activity
64
Q

What are the general return to physical activity guidelines from the international conference on concussion in sports?

A
  • rest during acute phase (24-48)
  • gradual progression of physical and cognitive activity staying below symptom-exacerbation thresholds
  • activity level should not bring on or worsen symptoms
  • avoid vigorous exertion while recovering
65
Q

Describe the progression recommended for the return to sport strategy.

A

1 - symtpom limited activity - daily activities that don’t provoke symptoms
2 - light aerobic exercise - slow-medium pace; no resistance training
3 - sport-specific exercise - running; no head impact activities
4 - non-contact training - hard training drills; progressive resistance training
5 - full contact practice - normal training activities w/ medical clearance
6 - return to sport - normal game play

66
Q

Goal of each step to return to sport

A

1 - symptom-limited activity - gradual reintroduction of work/school activities
2 - light aerobic exercise - increase HR
3 - sport-specif exercise - add movement
4 - non-contact training drills - exercise, coordination and increased thinking
5 - full contact practice - restore confidence and assess functional skills by coaching staff
6 - return to sport

67
Q

Describe the progression recommended for the return to school strategy.

A

1 - daily activites at home that do not give the child symptoms
2 - school activities - HW, reading or other cognitive activities outside of classroom
3 - return to school part-time - gradual introduction to schoolwork w/ partial day or increased breaks
4 - return to school full time - gradual progression until full day tolerated

68
Q

Goal of each step for return to school

A

1 - daily activities at home that do not give the child symptoms - gradual return to typical activities
2 - school activities - increase tolerance to cognitive work
3 - return to school part time - increase academic activities
4 - return to school full time - return to full academic activities and catch up on missed work

69
Q

Where should PT be considered on the recovery timeline post-concussion?

A

after about 2 weeks (14 days)

70
Q

How does the time to pull from sport impact recovery?

A

the early someone is removed after a concussion the shorter the average injury duration is

71
Q

What are the common signs of symptoms that come with cervical injury post-concussion?

A
  • pain
  • loss of ROM
  • dizziness
72
Q

What are the signs & symptoms of vertebral artery compromise?

A

5 D’s and 3 N’s

  • dizziness
  • dysarthria
  • dysphagia
  • diplopia
  • drop attack
  • nystagmus
  • nausea
  • numbness - ipsi facial
73
Q

What are the signs and symptoms associated with cervical dizziness?

A
  • dizziness
  • nausea
  • neck pain
  • referred pain
  • abnormal cervical afferent input - subjective “wobbly, heavy head”
74
Q

How do we measure cervicogenic dizziness?

A
  • head-neck differentiation test
  • smooth pursuit neck torsion test
  • joint position error test
75
Q

head-neck differentiation test

A

patient sits on stool w/ eyes closed and therapist holds head still while patient rotates

  • looking for them to tell you when they are dizzy – stretching neck proprioceptors
    • test if patient has symptoms during or immediately after test
76
Q

smooth pursuit neck torsion test

A

smooth pursuit test w/ body twisted and head is forward

- rules in or out smooth pursuit cause for dizziness vs cervicogenic dizziness

77
Q

joint position error test

A

laser on forehead and have patient close eyes and therapist moves head off center and patient must re-center laser on target
- tests cervical muscles proprioception

78
Q

Describe the general intervention focuses for cervical impairment post-concussion

A
  • cervical, scap strengthening - strengthen around impacted muscles (SCM, suboccipitals, levator) to unload them
  • stretching program
  • proprioceptive/kinesthetic training
  • address secondary balance issues
79
Q

What are the three most common visual impairments seen post-concussion?

A
  • misalignment
  • vergence
  • spatial disorientation or balance issues
80
Q

misalignment interventions

A
  • EOMs - smooth pursuits, gaze stabilization

- can use external aides and activity mods if persistent

81
Q

vergence interventions

A
  • convergence/divergence exercises

- activity and environmental mods if persistent

82
Q

spatial disorientation or balance issues interventions

A
  • dynamic balance activities

- treat underlying vergence/accommodation issues

83
Q

What is meant by visual memory? Why does it matter for our concussion patients?

A

Your brain will remember words or things you have seen before which is why you can read a sentence with multiple misspelled words
- matters for concussion patients because it will be impaired because vision is also a brain thing

84
Q

visual impairment S & S

A
  • diplopia
  • objects appear to move
  • poor concentration and attention
  • staring behavior
  • poor visual memory
  • photophobia (glare sensitivity)
  • asthenopic symptoms (tired eyes)
85
Q

Objective findings for visual impairments

A
  • oculomotor-based reading difficulties
  • difficulty w/ balance, coordination, and posture
  • increased sensitivity to visual motion
  • difficulty judging distances
  • inability to tolerate visual complex environments
86
Q

Why is proprioception such a problem post-concussion? Most common injuries?

A

increased risk for MSK injury especially LE

  • lateral ankle sparins
  • knee injuries
  • general LE muscle strains
87
Q

How can we measure functional reaction time?

A
  • drop stick
  • stroop test
  • functional assessment - gait, drop jump, single leg hop, anticipated/unanticipated cut
88
Q

What are the major dimensions of neurocognitive performance in the sport performance context? (5)

A
  • visual attention
  • self-monitoring - focus on proprioceptive/kinesthetic feedback
  • agility/fine motor skill
  • processing speed/reaction time
  • dual-tasking

Neuro 1 (11 decks)

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