Concussions Flashcards
Concussion is a ________ brain injury. What does this mean?
metabolic brain injury - disruption of the symbiotic environment
- neurons are stretched but not broken, leading to cascade of events
What happens to neurons during a concussion? What follows this action?
- 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
What will imaging look like after a concussion? Why?
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
What are the six subtypes of concussions?
- vestibular
- ocular
- cognitive/fatigue
- post-traumatic migraine
- cervical
- anxiety/mood
cognitive/fatigue is most often seen ________ following a concussion.
early on
What are the major characteristics and symptoms associated with the cognitive/fatigue subtype?
- fatigue - widespread and after the smallest amount of activity
- headache w/ cognitive and PA
- “end of day” symptoms
- sleep disturbances
What exam findings are you likely to find with the cognitive/fatigue subtype?
nothing abnormal in neuro screen
- normal vestibular/ocular screening
will show breakdown with neurocognitive testing
What are 3 helpful questions to ask a patient regarding cognitive/fatigue subtype?
- 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?
What does interdisciplinary treatment look like for the cognitive/fatigue subtype? Where does PT get involved?
- 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
What risk factors exist for the ocular/visual subtype?
personal/family history of ocular dysfunction
- wear glasses/contacts
What symptoms are associated with the ocular/visual subtype?
- frontal headache - gets worse as day goes on
- difficulties w/ visually based classes/activities
- pressure behind eyes
- visual “focus” issues
- blurry or double vision
What exam findings are you likely to find with the ocular/visual subtype?
- smoot pursuit, saccades
- convergence difficulties
- accommodative insufficiency
- strabismus - tropias and phorias
neurocog - deficits in reaction time and visual memory
What is NOT frequently associated w/ ocular visual subtype?
photosensitivity - sensitivity to light
convergence vs divergence Which is more common?
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
What are the general symptoms associated with vergence impairment?
- intermittent/constant double vision (squint to compensate)
- asthenopia (eye strain) when reading
- frontal headaches
- letters appear to float/move on the page
What are the 3 most common vergence problems seen with concussion?
- convergence insufficiency
- convergence excess
- convergence spasm
How is eye accommodation achieved?
changes in the lens
- controlled by CN 2, 3 reflexive activity
What are the general symptoms of accommodation impairment?
- reduction inability to focus at near - may need reading glasses
- accommodative spasm - over-focusing at near
- struggle to coordinate accommodation and vergence
What will the struggle to coordinate accommodation and vergence lead to?
difficulty in spatial awareness
What are the treatment strategies for ocular/visual subtypes?
- ocular motor training
- exercise - make sure environment isn’t too crowded or busy
What risk factors exist for the vestibular subtype?
- PMH of car sickness/motion sensitivity
- migraine
- anxiety
What symptoms are associated with the vestibular subtype?
- vertigo
- dizziness
- nausea
- overwhelmed in visually-stimulating environments
- balance impairments
What is the relevance of dizziness post-concussion?
55-80% of concussed athletes
- negative prognostic indicator
- undiagnosed vestibular deficits may delay recovery
What are common signs and symptoms of vestibular dysfunction post-concussion? (9)
- 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
Will vestibular subtype need PT?
YES
What types of TBIs will cause vestibular dysfunction? (5)
What is the most common?
- labyrinthine concussion - most common
- skull fracture
- hemorrhage into labyrinth
- hemorrhage into brainstem
- increased intracranial pressure
labyrinthine concussion symptoms
- ataxia
- imbalance
- BBPV
skull fracture concussion symptoms
- unilateral or bilateral vestibular loss
- conductive hearing loss
- may have mixed peripheral and central lesions
When are skull fracture concussions common?
Common with blows to the occiput, temporal or parietal regions
hemorrhage into labyrinth concussion symptoms
- 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
hemorrhage into brainstem concussion symptoms
- oculomotor signs - poor smooth pursuit, vertigo, perception of tilt
- damage to vestibular and oculomotor nuclei
increased intracranial pressure concussion symptoms
What may this cause?
- 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
What exam findings are you likely to find with the vestibular subtype?
- VOR dysfunction and suppression
- smooth pursuits, saccades
neurocog test - difficult w/ visual motor speed, reaction time
What other subtypes should be tested if the patient has vestibular subtype?
migraine and anxiety
What types of pharmacological options are available for the vestibular subtype in addition to vestibular rehab therapy?
- meclizine - anti dizziness
- tricyclic antidepressants
- melatonin
- SSRIs (Selective Serotonin Reuptake Inhibitor) - antidepressants
What are the risk factors for the anxiety/mood subtype?
personal/family history of anxiety, migraine, vestibular issues
What symptoms are associated with the anxiety/mood subtype?
- ruminative thoughts (deep thoughts)
- hyper-vigilant
- fastidious (concerned about accuracy and detail)
- easily overwhelmed
- difficulties initiating/maintaining sleep
What will the exam findings look like for the anxiety/mood subtype?
normal vestibular/ocular screen and normal neurocog test
T/F - You should ask your patient if they have anxiety
false - can make patient upset and patients don’t identify with anxiety
What are some helpful questions that you can ask to a patient to determine if they may have anxiety?
- 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?
What does interdisciplinary care look like for the anxiety/mood subtype? Where does PT get involved?
- psychotherapy as needed
- treat vestibular and/or migraine subtype if present
- supervised exertion training
- cognitive behavior training
- regulated schedule
What do patients who have anxiety do well with?
regimented schedule - may need some training to set it up but once it is set up the patients usually do very well with it
What are the risk factors for the post-traumatic migraine subtype?
- personal/family history of migraine
- brain freeze HA
- motion sensitivity
- vestibular disorder
- anxiety
What symptoms are associated with the post-traumatic migraine subtype?
- variable HA - often wakes up with HA
- nausea, photo and/or phonophobia
- stress, anxiety, lack of exercises
- sleep dysregulation
What causes migraines?
insufficient vascular supply of trigeminal nerve
- causes cortical spreading depression - wave of sustained depolarization (neuronal inactivation) moving through intact brain tissue
Migraine vs tension HA characteristics - how long do they last?
migraine - 4-72 hours
HA - 30 min - 7 days
Migraine vs tension HA characteristics - location
migraine - unilateral location (half of face)
HA - bilateral (across forehead)
Migraine vs tension HA characteristics - sensation
migraine - pulsating
HA - pressure or tightening sensation around head
Migraine vs tension HA characteristics - pain
migraine - moderate to severe pain
HA - mild to moderate pain
Migraine vs tension HA characteristics - reaction to PA
migraine - aggravated by PA
HA - not aggravated by PA
Migraine vs tension HA characteristics - N/V
migraine - accompanied by N/V
HA - No N/V
Migraine vs tension HA characteristics - sensitivity to light
migraine - sensitive to light and/or sound
HA - sensitive to either light or sound
What will typically preced a migraine? What type is the most common to least common?
- 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)
What examination findings will you see with post-traumatic migraine subtypes?
normal vestibular/ocular screen
neurocog - verbal and visual memory deficits
T/F - You can treat a patient who is having a migraine.
False - Do not treat - send them home
What are the risk factors for the cervical subtype?
- prior c-spine injury
- high velocity injury
- strong rotational component to injury
What symptoms are associated with the cervical subtype?
- 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
What examination findings will you see you with the cervical subtype?
normal vestibular/ocular and normal neurocog testing
- cervical screen
What are the most commonly reported symptoms post sports-related concussion?
- headache
- feeling slowed down
- difficulty concentrating
- dizziness
- fogginess
- fatigue
- visual blurring/double vision
- light sensitivity
- memory
- balance
Describe the typical recovery timeline of concussions. Who will need PT?
- 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
Why is early identification of impairments important in concussion rehabilitation?
aids in return to activity/sport w/o prolonged sequelae
What are predictors of prolonged recovery post-concussion?
- initial symptoms
- sex (females slower than males)
- age
- loss of consciousness
- post-traumatic amnesia
- premorbid comorbidities
What are the general recommendations for early management of concussion?
- 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
What are the general return to physical activity guidelines from the international conference on concussion in sports?
- 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
Describe the progression recommended for the return to sport strategy.
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
Goal of each step to return to sport
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
Describe the progression recommended for the return to school strategy.
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
Goal of each step for return to school
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
Where should PT be considered on the recovery timeline post-concussion?
after about 2 weeks (14 days)
How does the time to pull from sport impact recovery?
the early someone is removed after a concussion the shorter the average injury duration is
What are the common signs of symptoms that come with cervical injury post-concussion?
- pain
- loss of ROM
- dizziness
What are the signs & symptoms of vertebral artery compromise?
5 D’s and 3 N’s
- dizziness
- dysarthria
- dysphagia
- diplopia
- drop attack
- nystagmus
- nausea
- numbness - ipsi facial
What are the signs and symptoms associated with cervical dizziness?
- dizziness
- nausea
- neck pain
- referred pain
- abnormal cervical afferent input - subjective “wobbly, heavy head”
How do we measure cervicogenic dizziness?
- head-neck differentiation test
- smooth pursuit neck torsion test
- joint position error test
head-neck differentiation test
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
smooth pursuit neck torsion test
smooth pursuit test w/ body twisted and head is forward
- rules in or out smooth pursuit cause for dizziness vs cervicogenic dizziness
joint position error test
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
Describe the general intervention focuses for cervical impairment post-concussion
- cervical, scap strengthening - strengthen around impacted muscles (SCM, suboccipitals, levator) to unload them
- stretching program
- proprioceptive/kinesthetic training
- address secondary balance issues
What are the three most common visual impairments seen post-concussion?
- misalignment
- vergence
- spatial disorientation or balance issues
misalignment interventions
- EOMs - smooth pursuits, gaze stabilization
- can use external aides and activity mods if persistent
vergence interventions
- convergence/divergence exercises
- activity and environmental mods if persistent
spatial disorientation or balance issues interventions
- dynamic balance activities
- treat underlying vergence/accommodation issues
What is meant by visual memory? Why does it matter for our concussion patients?
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
visual impairment S & S
- diplopia
- objects appear to move
- poor concentration and attention
- staring behavior
- poor visual memory
- photophobia (glare sensitivity)
- asthenopic symptoms (tired eyes)
Objective findings for visual impairments
- oculomotor-based reading difficulties
- difficulty w/ balance, coordination, and posture
- increased sensitivity to visual motion
- difficulty judging distances
- inability to tolerate visual complex environments
Why is proprioception such a problem post-concussion? Most common injuries?
increased risk for MSK injury especially LE
- lateral ankle sparins
- knee injuries
- general LE muscle strains
How can we measure functional reaction time?
- drop stick
- stroop test
- functional assessment - gait, drop jump, single leg hop, anticipated/unanticipated cut
What are the major dimensions of neurocognitive performance in the sport performance context? (5)
- visual attention
- self-monitoring - focus on proprioceptive/kinesthetic feedback
- agility/fine motor skill
- processing speed/reaction time
- dual-tasking
