Concussions

Question 1

What is a concussion?

Answer 1

traumatic brain injury caused by a direct blow to the head, neck or body resulting in an impulsive force being transmitted to the brain.

Initiates a neurotransmitter and metabolic cascade, with possible axonal injury, blood flow change and inflammation affecting the brain

Question 2

What are different methods of concussion impact?

Answer 2

direct contact
inertial contact (acceleration
Shear forces caused by rotational acceleration is the primary predominant mechanism of concussions

Question 3

How is a concussion mechanism determined?

Answer 3

by amount of mechanical energy from acceleration transferred to the brain and vascular tissue
Linear acceleration average concussive head impact 29.7g

Question 4

What is the physiology of a concussion?

Answer 4

Neurotransmitters are released and influx of ions ==> binding of glutamate to excitatory amino acids receptors ==> leads to further neuronal depolarization with efflux of potassium and calcium ==> the Na-K pump works in overtime to try to restore neuronal membrane ==> requires increased use of adenosine triphosphate ==> increase in glucose metabolism + diminished cerebral blood flow = cellular energy crisis

Question 5

What is the role of Calcium in concussions?

Answer 5

Impairs mitochondria and ATP production
Calcium accumulation can directly activate pathways leading to cell death
has been shown to impair neural connectivity
Seen within hours and may persist for 2-4days

Question 6

What is metabolic vulnerability?

Answer 6

Following concussive episodes, studies have shown changes in brain metabolism.
Evidence linking severity of brain injury and recovery with extent of ATP and N-acetylaspartate (NAA) decrease and recovery

Question 7

How long did it take for NAA levels to return to normal in studies?

Answer 7

Brain concentration of NAA remained profoundly depressed in 21/40 concussed athletes at 22 days but returned to normal levels at 30 days

recovery is an exponential phenomenon

Question 8

What is second impact syndrome?

Answer 8

repetitive head injury syndrome
Condition in which a person experiences a second head injury before the complete recovery of the initial injury
Often leading to death
Results from dysfunctional cerebral blood flow autoregulation leading to increased intracranial pressure
Herniation= rapid pressure develops and deterioration and leading to death within 2-5min

Question 9

How could we prevent concussions?

Answer 9

Neck strength only plays a role to a certain extent
Ability to actively engage neck muscles and resist linear and rotational acceleration is more important
Helmets: may reduce concussion severity and duration of symptoms as well as SRC odds if direct head impact
Mouthguard: conflicting results

Question 10

Should you refer a concussion to a physician?

Answer 10

All concussions should ideally be referred to a physician who has experience managing sport-related head injuries
A referral to a physician is required for all concussions with symptoms lasting more than 10 days

Question 11

What are persistent concussion symptoms?

Answer 11

up to 30% of people experience persisting post-concussive symptoms
5th CCS defines persisting post concussive symptoms as symptoms lasting 2 weeks or longer for adults and 4 weeks or longer for children
Frequently associated with mental health problems, declines in QOL and difficulties returning to sport, school work and ADLS

Question 12

What are risk factors for concussion outcomes?

Answer 12

Increased deficits and protracted recovery:
history of concussion
history of migraine
Diagnoses of learning disability
Sex (females)
Age (younger)

Question 13

What does the SCOAT6 include?

Answer 13

Symptoms, cognitive recall, blood pressure measures, cervical evaluation, neurological exam, timed tandem gait, modified VOMs

Question 14

What are the concussion clinical trajectories?

Answer 14

Vestibular
oculomotor
cognitive
post-traumatic migraine
cervical
anxiety/mood

Question 15

What is the cognitive/fatigue trajectory?

Answer 15

S/S: fatigue, decreased energy levels, non-specific headaches, sleep disturbances
Common to see symptoms increase at end of day
difficulties concentrating
increase in headache with cognitive activity
Neurocognitive testing typically reveals mild global deficits in memory, processing speed and reaction time

Question 16

What is the vestibular trajectory?

Answer 16

S/S dizziness, fogginess, nausea, feeling of being detached, anxiety, overstimulation in more complex environments
increase in symptoms in busier, more stimulating environments
Rapid head or body motion may exacerbate symptoms
Assess via a comprehensive vestibular/ocular motor screening

Question 17

What is the Ocular motor trajectory ?

Answer 17

S/S localized, frontally based headaches, fatigue, distractibility, difficulties with visually based classes, pressure behind eyes, difficulty with focus
difficulty with extended time in front of computer screen or reading
Characterize headaches
most likely the ocular motor dysfunction will be evident with near convergence and/or accommodation measurements

Question 18

What is the anxiety/mood trajectory?

Answer 18

S/S: increase in anxiety, including ruminative thoughts, hypervigilance, feelings of being overwhelmed, sadness, and/or hopelessness
report sleep disturbances with inability to quiet minds or stop thinking and worrying
symptoms may manifest through headache, fogginess, dizziness, or fatigue
Some vestibular dysfunction testing may provoke symptoms (must be treated before treating anxiety)

Question 19

What is the post migraine trajectory?

Answer 19

described as unilateral moderate-to-severe intensity headache following a head trauma with a pulsating quality that is associated with nausea and photosensitivity and/or phono sensitivity and is often aggravated by physical activity
Exacerbated by stress, sleep dysregulation, anxiety or emotional changes, dietary trigger

Question 20

What is the cervical trajectory?

Answer 20

S/S headache and neck pain
Important to focus on characterization of headache as well as location
Ask about onset and course of ADL to help determine triggers
Assess cervical spine for ROM, strength, instability tests and flexibility of musculature

Question 21

What are the different components of VOMS?

Answer 21

Smooth pursuits
Saccades
Near point convergence
VOR
VMS

Question 22

What are some tests to determine if C/S causing headache?

Answer 22

Smooth pursuit neck torsion test
Cervical joint position error test (target laser)
Flexion rotation test (45 degrees rotation)

Question 23

What is Benign Paroxysmal positional vertigo?

Answer 23

Benign: non life-threatening
Paroxysmal: comes in sudden brief spells
Positional: triggered by certain head positions
Vertigo: false sense of rotational movement

Question 24

What is the hallpike-Dix test?

Answer 24

Patient long sitting with head rotated 30-45 d

Therapist holds head and patient is then assisted into supine position with head slightly below horizontal plane and position maintained for 30-60sec

Question 25

What is the orthostatic hypotension test?

Answer 25

Take pressure when sitting
stand up and take BP again
if drop of 20mmHg in systolic and/or 10mmHg in diastolic then positive

Question 26

What is the head impulse test?

Answer 26

Used to assess angular vestibular ocular reflex (aVOR)

Pt fixes eyes on target (examiner’s nose)
Explain to pt they need to try not to blink and relax neck muscles
Explain you will complete small but rapid head movements
Examiner will develop a rapid head movement (10 degrees) and assess for a corrective or compensatory saccade response

FIRST: clear C/S for adequate pain free ROM and vertebral artery test

Question 27

What is the buffalo concussion treadmill test?

Answer 27

Used to help determine how much aerobic activity is safe following a concussion (even acute concussion)

Warm up- 2.5mph for 2 min 0% incline
3.6mph (5’5” or taller), 3.2mph (5’5” or smaller)
Increase incline 1% every 1 minute
Until maximum incline of 15 degrees then increase 0.4mph every minute

Patient rate RPE and symptom severity (exacerbation of symptom or new symptom)
Terminated (fail) 3 point increase on Likert scale or rapid progression of symptoms (headache, dizziness) or patient reports inability to continue safely
Terminated (pass) Max exertion, patient meets their max HR (220-age), Or 18-20 on Borg scale has not worsened condition before worsening of symptoms

Question 28

How much rest is too much rest?

Answer 28

for the first 24-48hours physical and cognitive rest has been strongly encouraged

Studies do not support 6 days of bed rest
No evidence on optimal time period of rest

Question 29

What are some neuroplasticity changes after a concussion?

Answer 29

when injured brain tries to use a different area to do same thing
overtime brain gets tired and uses more energy and blood supply to use this more difficult and inefficient pathway
3+months of concussion symptoms = change in neuroplasticity and becomes new norm