Concussions Flashcards
what is a concussion?
a biomechanical force transmitted to the head (direct or indirect) that causes chemical changes in the brain
does a concussion result in an extended period of unconsciousness, amnesia, or other significant neurologic signs of severe brain injury generally?
nope
in more severe concussions, the mechanical force of the blow to the head can cause what?
stretching and permanent damage to the brain cells
t/f: though often referred to as a mild TBI, the effects of a concussion can be serious and life altering
true
what concussion population will tend to minimize their symptoms and pain?
service men and women
if a concussion pt is a service man or woman, what should we ask them?
if they were deployed, when they were deployed, and if they have been exposed to glass bc of risk for coup and contracoup injury
T/f: mTBI is primarily a fxnal injury of the CNS due to metabolic dysfxn, NT disturbance, and microstructural changes
true
does mTBI involve large structural brain changes?
nope, the changes are fxnal and maybe microstructural
does a TBI or mTBI involve structural brain changes?
TBI
what are microstructural changes?
changes at the cellular and axonal level
what is the typical GCS for a concussion pt?
13-15 (high fxning)
what must we ask about in concussion to help inform the prognosis?
the MOI
why is knowing the MOI of a concussion important in determining the prognosis?
bc some MOIs are more serious than others
t/f: a coup-contracoup injury involves linear forces
true
what are the general 3 MOIs of concussion?
coup-contracoup injury
rotational injury
stretching/shearing of axons
what MOI of concussion predicts the worst prognosis?
rotational injury
is linear or rotational MOI a better indicator of traumatic injury?
rotational
the worst concussion injuries occur with ____ injuries
rotational
how much G force is produced in a concussion? in a football impact?
concussion=100G
football impact=150G
(for reference, 3G of a space shuttle are considered significant forces and walking produces just 1 G)
does concussion generally cause temporary or permanent alteration of central regulatory systems?
temporary
what happens initially following any brain injury?
temporary alteration of central regulatory systems bc the brain shuts down for a quick second
what happens following the temporary alteration of central regulatory systems in a concussion?
rapid dynamic changes in NTs, ions, glucose metabolism, and cerebral blood flow
following a concussion, does blood flow increase or decrease? does brain energy demand increase or decrease?
blood flow decreased, but energy demand increases
what is the traumatic metabolic cascade?
the rapid dynamic changes in the brain that occur following a concussion
t/f: sx becomes clearer in concussion as the days go on
true
would traditional brain scans see abnormalities in a pt with a concussion?
nope, but blood flow scans would
what do advanced neuroimaging studies show post concussion?
reduced fMRI activation in depressed pts
gray matter loss
brain blood flow loss on CT scan
t/f: concussion results in disturbed cerebral autoregulation
true
what is the result of disturbed cerebral autoregulation (changes in ANS and CO2 regulation)?
lack of response to changes in SBP
t/f: all individuals with concussion seek medical care
false
do more male or female athletes sustain concussions every year?
more female athletes
are concussions more prevalent in sports, or non-sports populations?
non-sports populations
what is a common cause of concussion in older populations?
falls
what are common non-sport causes of concussion?
falls, MVA< high impact collisions, blunt trauma, blast/military, assault
what is the best way to differentiate concussion vs post concussive syndrome (PCS)?
by length of time to recovery
what is the typical timeline of recovery for concussion?
days to weeks
although there is no clear definition of PCS, it is generally defined as sx that persist for how long?
> 3 months
what is the typical timeline of recovery in PCS?
weeks to months
dx of concussion/PCS requires how many of the mTBI sx to be present?
3 or more
what is second impact syndrome?
when a person sustains a 2nd concussion b4 complete healing of the initial concussion (RARE)
what is the problem with second impact syndrome?
the additional rapid swelling of brain tissue after the initial impact causes significant edema that puts pressure on the BS and can cause unconsciousness and resp failure
what are the s/s of second impact syndrome?
dilated pupils
loss of eye movt
unconsciousness
resp failure
death (within 2-5 min)
what are the diagnostic criteria for a concussion dx? (don’t think we need to know these?)
Any period of decreased orientation/loss of consciousness
Posttraumatic amnesia
Alteration in cognition or mental status (confusion, disorientation, slowed thinking, probs with attention/concentration, forgetfulness)
Physical sx: HA, dizziness, balance disorders, nausea, vomiting, fatigue, sleep disturbance, blurred vision, sensitivity to light, hearing difficulties, tinnitus, sensitivity to noise, seizure, transient neuro abnormalities, numbness, tingling, neck pain, exertional intolerance.
Emotional/behavioral sx: depression, anxiety, agitation, irritability, impulsivity, aggression
GCS 13-15
Normal brain imaging (traditional imaging, blood flowing imaging would be abnormal)
s/s not otherwise explained by drug, alcohol, or meds
Sx present that cannot be explained by preinjury hx of medical dx. If preinjury dx were present, the pt reports or is observed to demonstrate an exacerbated state of sx.
t/f: the sx, impairments, and fxnal limitations associated with concussion can be easily confused with other common illnesses or injuries
true
what are the observed signs of concussion?
Can’t recall events b4/after
Appears dazed/stunned
Forgets an instruction, is confused about an assignment/position, unsure of the game, score, or opponent.
Moves clumsily
Answers questions slowly (slowed speaking)
Loses consciousness (even briefly)
Shows mood, behavior, or personality changes
HINT will likely be normal
what are the reported symptoms of concussion?
HA/pressure in the head
Nausea/vomiting
Balance problems/dizziness or double/blurry vision
Bothered by light/noise
Feeling sluggish, hazy, foggy, or groggy
Confusion, concentration, or memory problems
Just not “feeling right” or “feeling down” (VERY COMMON)
what are the 6 clinical trajectories in the UPitt model of concussions?
vestibular
oculomotor
cognitive
post-traumatic migraine
cervical
anxiety/mood
what VOR/central issue do we often see in concussion pts in the oculomotor trajectory?
convergence/divergence issues
what are the s/s of concussion pts in the cervical MSK impairment trajectory?
neck pain
HA w/ or w/o neck pain
dizziness
diminished balance or postural control
what are the s/s of concussion pts in the vestibulo-occular impairment trajectory?
dizziness
balance problems
vertigo
blurred vision
HAs
nausea
sensitivity to light and sound
mental foginess
difficulty reading and concentrating
anxiety
fatigue
what would be a typical student presentation for concussion in the vestibulo-oculomotor trajectory?
difficulty with looking from the paper to the board (a convergence/divergence fxn), reading, or lights of the classroom
what are the s/s of a pts with concussion in the autonomic dysfxn and exertional impairments trajectory?
increased sx with physical exertion
fatigue
deconditioning
OH
what are the s/s of a pt with concussion in the motor fxn impairment trajectory?
static and dynamic balance impairments
changes in multitasking impairments
delayed motor rxn time
increased difficulty with motor coordination tasks
what is a typical student presentation of a pt with concussion in the motor fxn impairment trajectory?
hard to concentrate while taking notes and listening to the lecture
hard to balance while reading
what is the hardest concussion trajectory to assess and treat?
the concussion in the motor fxn impairments trajectory
what are the 4 domains of concussion care management that are relevant to PT practice?
cervical MSK impairment
vestibulo-oculomotor impairment
autonomic dysfxn and exertional impairments
motor fxn impairments
what factors influence recovery in concussion?
age (younger>older)
sex (females>males)
hx of concussion
ADHD
hx of migraines
genetics
considering predisposing factors, most concussed individuals recover with _____ days without intervention
7-14
if most concussed individuals will recover without intervention, why do therapy?
bc PT can improve recovery outcomes and time
bc if someone has risk factors for poor recovery, we can intervene early
what % of concussed individuals will have sx for >10 days?
10%
t/f: although sx, impairments, and fxnal limitations in concussion follow a gradual pattern of improvement, the trajectory may not be linear
true
what was the conventional approach to concussion care? why did we do this?
it used to be to encourage rest until sx resolution to alleviate discomfort, reduce energy demands, and reduce catastrophic incidence of 2nd impact syndrome
new findings show that what is better than rest for concussed individuals’ recovery?
24-48 hours of rest followed by phased activity progression for early, gradual return to activity
t/f: early intervention for concussion is safe and may facilitate faster recovery
true
do we use graded severity for concussions (is grade 1, 2, 3, etc)?
no, we are moving away from this and towards evaluation fo clinical trajectories of impairment
why do we want to ID tests and outcomes that provoke sx in concussion pts?
to ID clusters of sx and limitations
for triangulation of subjective and objective outcomes
are most concussed individuals one type of dysfxn or multiple types of dysfxn?
multiple types of dysfxn
what is involved in concussion management?
immediate removal from the sport and activity
medical evaluation
physical and cognitive rest 24-48 hours
school modifications as needed
therapies as needed
RTP (return to play)/RTL (return to learning)
sideline assessments
what are the 3 sideline assessments we can use for concussion?
SCAT5
sideline ImPACT testing
concussion symptoms inventory
what is involved in impact testing?
verbal memory
visual memory
processing speed
rxn time
sx scale
demographic hx
what is the big limitation of ImPACT testing?
submarining (literally not a clue what this means)
what concussion sx are predictors of prolonged recovery?
dizziness at the time of injury
HA
migraine
depressive sx
if sx of concussion are worsening over time, is this the typical progression we expect to see?
definitely not
what characteristics of concussion sx should we be paying attention to?
the frequency, intensity, type, and irritability of the sx
what conditions with concussion would limit/serve as contraindications to PT?
respiratory dysfxn
unstable VS
personality changes
changes in consciousness
unstable sx (large swings)
(+) sharp purser test of the c spine
what questions should we ask about PMH with a concussion pt?
previous concussions
ADHD
mood disturbances
migraine hx
what subjective questionnaires can we use at intake to cluster sx?
clinical profile screening tool (UMPC)-CP screening tool
post concussion symptoms scale
dizziness handicap inventory (DHI)
neck disability index (NDI)
HA disability index (HDI)
ABC
what does the clinical profile screening tool (CP screening tool) tell us?
it tells us about the last 24 hours of sx with specific questions to be aligned with specific concussion trajectories so we can classify them
when would we want to screen for emergent situations?
GCS<13
pupillary asymmetry, repeated vomiting, seizures
severe or rapidly worsening HA or neuro deficits (risk for hemmorhage)
undiagnosed skull fx
c spine fx or ligamentous instability
what is the proposed order of the objective exam for concussion?
cervical spine
dizziness/HA
motor fxn
t/f: we should proceed in our objective concussion exam in order of anticipated least to most irritable tests
true
what are the emergent screening items in the cervical MSK exam for concussion?
alar lig testing
sharp purser testing
what is involved in the cervical MSK exam for concussion?
alar lig testing
sharp purser testing
cervical AROM
manual passive jt mobility
trigger point assessment/tenderness to palpation
craniocervical flexion testing
cervical flexion rotation testing
cervical jt position error
thoracic spine testing
how do we perform a craniocervical flexion test?
use a PBU cuff at 20mmHg
have pt activate their deep neck flexors (DNFs) to increase to pressure by 2 mmHg, then 2 more, then 2 more until they can’t hold it or start using SCMs
how do we perform a cervical flexion rotation test?
have the pt max flex their neck then add rotation in to highlight any tightness
what info are we trying to gain from the craniocervical flexion test?
DNF endurance
how do we perform the cervical joint position error test?
place a target 90 cm away at the pt’s head height and have them align a head laser with the bullseye center of the target
with their EC ask them to turn their head one way and then try to realign with the target with eyes still closed
measure the distance from the laser to the center
do 3 trials in each direction and record the best score
what does the cervical joint position error test tell us?
the proprioceptive kinesthetic sense of the neck
t/f: the VOMs (vestibulo-ocular motor screen) is a replacement for a robust vestibular and ocular assessment
false
what is the VOMs (vestibulo-oculomotor screen)?
a test for 5 areas of self reported sx provocation
smooth pursuits, horizontal/vertical saccades, convergence, horizontal/vertical VOR, visual motion sensitivity
t/f: the VOMS lacks objective assessment
true
what sx does the VOMs track?
HA, dizziness, nausea, and fogginess of the movts (smooth pursuits, saccades, convergence, VOR, visual motion)
with the standard ocular exam, we are typically looking to differentiate a central vs peripheral issue, so what is its role in concussion, when we know there is a central issue?
to see what things provoke their sx
what is normal convergence?
<6cm
what is normal smooth pursuits/saccades distance?
30 deg each direction about 36 inches from the nose
would we expect to see vertical eye movts in the cover/uncover test with concussion?
no, bc even though it is a central sign (and concussion is a central issue), this is more indicative of a cerebellar issue
t/f: vergence and accomodation (reshaping of the lens with contraction/relaxation) are often dysfxnal in mTBI
true
what indicates abnormal performance of visual/vestibular fxn?
hypometric and slowed movts
what things are involved in the vestibulo-ocular exam?
cover/uncover test
saccadic eye movt
vergence
accomodation
DHT
roll test
spontaneous nystagmus test
HIT
head shaking nystagmus
DVA
gaze evoked nystagmus
VOR
VOMs
VORc
what is the king devick test?
saccades, vergence, and accomodation based reading assessment that takes about 3 min to complete mostly as a sideline assessment
what is the difference bw reactive saccades and anticipatory saccades?
in reactive saccades, the examiner is cueing the pt when to look from one target to another
in anticipatory saccades, the pt looks bw the targets at expected times (told to look bw the targets as quickly as they can)
t/f: the king devick test has high specificity and sensitivity to detect concussion
true
how can we increase the sensitivity of the kind devick test?
by performing the test after exertional testing
t/f: cerebellar connections help maintain calibration of the VOR and contributes to posture during static and dynamic activities
true
a large % of pts with mTBI may complain of what central vestibular complaint?
vertigo
a lot for interventions for concussion are _____ based
habituation
what is the MSQ (motion sensitivity quotient)?
an assessment of dizziness and motion sensitivity by having the pt move in various positions
the scale of the MSQ is from 0-5 with 0 meaning what? 5 meaning what?
0=no sx
5=severe sx
if a pt scores a 0% on the MSQ, what does this mean? what if they score 100%?
0%=no dizziness
100%=severe dizziness
what are some of the movt included in the MSQ?
supine to sit, sitting to nose to right knee, turns, etc
what is the mMSQ (modified motion sensitivity quotient)?
a quicker assessment of dizziness and motion sensitivity that involved more aggressive position changes
what are some of the movts included in the mMSQ?
head turns, trunk bends, turns, VORc
t/f: there is a clear set of motor fxn measures to assess motor fxn impairment in concussion
false
what aspects of motor control can be affected by concussion?
postural control
dual tasking/divided attention tasks
response time
static/dynamic balance
what are commonly used tests for motor fxn impairment in concussion?
BESS test
FGA
SOT
HiMAT
what is the BESS test?
the clinical analog to the SOT to ID integration of sensory info contributing to balance
what are two common factors for each condition of the BESS test?
EC
20 sec long
in the BESS test we count the number of errors, but what counts as an error?
moving the hands off the iliac crests
opening the eyes
step, stumble, or fall
abd/flexion of the hip beyond 30 deg
lifting the forefoot or heel off the testing surface
remaining out of the proper testing position for >5 sec
what is the max total # of errors for each condition of the BESS test?
10
t/f: if the pt can’t establish a position for any condition of the BESS test, it automatically counts as the max 10 errors for that condition
true
if more than one error occurs simultaneously during the BESS test, how many errors does this count as?
just 1
what are the 6 conditions of the BESS test?
EC, firm surface, NBOS
EC, firm surface, SLS (on good leg)
EC, firm surface, tandem stance (good leg fwd)
EC, foam, NBOS
EC, foam, tandem stance (good leg fwd)
EC, foam, SLS (on good leg)
what is a highly recommended, but very long TBI edge recommended outcome for motor fxn in concussion?
HiMAT
what is involved in testing autonomic/exertional impairments in concussion?
the Buffalo concussion treadmill test (BCTT) or Buffalo concussion bike test (BCBT)
what is the BCTT?
a standardized, progressive exercise test that can be utilized to dx physiologic dysfxn following mTBI
what is the protocol for the BCTT (long ass answer)?
Obtain HR after 2 min rest b4 getting pt on treadmill
Set treadmill to 3.2mph for pts up to 5’10” and 3.6mph for pts 5’10” and above
Start incline at 0
HR stage o is HR when pt is standing on treadmill b4 starting BCTT and not during 2 min rest
After 1 min at this pace, treadmill incline increased by 1 deg and pt is asked to rate their sx severity (VAS) and RPE at the beginning of each stage
HR also recorded at the beginning of each stage
Procedure repeated each minute while treadmill is inclined at a rate of 1deg/min
1 point given for any worsening sx and 1 point for any addition of new sx
Once treadmill reaches max incline (15 deg), speed is increased by 0.4mph each min in lieu of increased incline
Once test is terminated, speed is reduced to 2mph and incline reduced back to 0 for 2 min cool down (if pt is able)
HR, RPE, VAS, plus any additional comments (if needed) are recorded after the 2 min cool down
how do we interpret the results of the BCTT?
the max HR achieved at sx exacerbation (HR threshold) gives us info to provide subsymptom physical activity
in the BCTT, if the pt is able to exercise to voluntary exhaustion w/o any inc in sx but isn’t cleared to return to play bc of sx at rest of physical exam impairments, then the pt can perform what kind of exercises?
aerobic exercise at any HR up to the max achieved or at 85% of age-appropriate max
what are the stopping criteria for the BCTT (long ass list)?
Sx exacerbation (inc of 3 or more points on the VAS scale from resting VAS score)
Voluntary exhaustion (RPE>17 w/o sig sx exacerbation)
Examiner notes a rapid progression of complaints or pts appears faint or has stopped communicating or continuing the test constitutes a sig health risk for the pt
Pt has reached 90% or more of age predicted max w/o any inc in sx and still reporting low RPE
t/f: if pt in the BCTT hasn’t reached at least 80% of age predicted max (220-age), the examiner should encourage the pt to try and keep going but shouldn’t push if they are too exhausted
true
t/f: concussion pts demonstrate normal HR response and higher RPE
false, they demonstrate mild blunted HR response, altered HR variability, and higher RPE
t/f: evidence suggests that moderate levels of physical activity within the first week after injury can reduce sx (earlier return to activity).
true
how does exercise help with concussion recovery?
exercise promotes neuron growth and repair through brain dervied neurotrophic factor (BDNF)
what level of exercise can be cognitively protective and associated with greater levels of BDNF, which is involved in neuron repair after injury, as well as greater hippocampal volume and improved spatial memory?
moderate aerobic exercise (60% HRmax performed for 150min/week)
what are indications for referrals according to the mTBI CPG?
Persistent migraine type HAs or chronic HAs (often need to be managed with meds)
Vision impairments
Auditory impairments
Mental health sx
Sleep disturbances
Cognitive impairments
what is involved in concussion interventions?
early mobilization to tolerance (after 24-48 of rest) using the 2 point sx rule
what is the 2 point sx rule?
Monitor sx and if they change by 2 VAS points, stop
t/f: matching targeted and active tx to clinical profiles may improve recovery trajectories after concussion
true
what is involved in pt education in concussion?
concussion sx expectations
self management
prognosis
risks of subsequent injury
return to activity progressions
referrals
cervical interventions should aim to do what for concussion?
improve cervical and thoracic spine strength, ROM, postural position, and sensory motor fxn
t/f: stronger neck ms and anticipatory cervical ms activation reduces risk for future concussion
true
are there clear guidelines for cervical interventions post concussion?
nope, so base them on the clinical presentation and fxn limitations and use the CPG for neck pain as guidance
what are commonly used strategies for cervical MSK interventions for concussion?
AROM/PROM
manual therapy/massage/mobs
postural re-ed, ther ex
craniocervical flexion/deep neck flexor strengthening
joint position error training
tx and assessment in VT (vision therapy) should include what things?
Vergence (most common)
Accommodation fxn (most common)
Eye movt fxn (smooth pursuits, saccades)
what are the primary goals of vestibular interventions post concussion?
to reduce dizziness and improve gait and balance fxn
t/f: it is possible for there to be a transient increase in sx during vestibular training post concussion
true
what is involved in vestibular intervention post concussion?
central VOR activity
habituation
motion tolerance training
BPPV tx (Eply for posterior canal, BBQ/Gufoni for horizonal canal)
gaze stabilization
visual motion sensitivity
balance retraining
what gaze stabilization exercises may be used post concussion for vestibular interventions?
VORx1, VORx2, gaze shifting, and remembered targets with progression in speed, distance, duration, balance demand, background disturbance, reps, and task specificity
Start at 15-30sec to 2 min max
Best place to start-sitting with blank background
the goal of gaze stabilization training is normally to increase VOR gain, what is the goal of gaze stabilization in concussion intervention?
to restore tolerance to dynamic head movt
What is habituation?
Reeducation in response to repeatedly performed movt
What are the protocol for habituation training in post concussion?
Find provoking activities from the MSQ, VOR, or clinical assessment and use 3 of those as your intervention
Hold the provoking position 30 sec or until sx abate
Perform 2-3x/day, 3-5x each exercise
T/f: habituation exercises are designed to reproduce dizziness
True
What interventions are often used as the primary intervention when there is a centrally driven dysfunction?
Habituation
When do we habituate?
When the pt is intolerant to motion
When there is a central vestibular problem
What is the aim of exertional tests and aerobic exercise?
To help speed recovery and get faster rate of return to PLOF
The protocol for aerobic exercise interventions are primary guided by what?
Symptoms
What are the benefits of aerobic training post concussion?
Reduced reconditioning
Promotes fxnal brain healing
Promotes non-pharmaceutical improvement to mental health
T/f: we should choose mild to moderately provocative items to work on with post concussion pts
True
If a post concussion pt fits into multiple trajectories, how do we decide what interventions to use?
Using the piece meal method
15 min of intervention in one trajectory, then the next, then the next
What assessment should we use to guide aerobic activity interventions?
The BCTT, or BCBT
How do we determine sub symptom threshold training?
Take the HR at stopping criteria on the BCTT and use 80% of this, 20min/day, for 3-5 days/week
How do we progress sub symptom threshold training?
Increase 5-10 bpm of their target HR every 2 weeks and retest the BCTT
Make progressions to more moderate activities like jogging and agility drills
There is physiologic recovery once a pt reaches what % of their age predicted HRmax?
85-90%
What motor interventions can we use post concussion?
Static and dynamic balance
Motor coordination and control
Dual/multitasking
Work/school/recreation/sports specificity
What is the primary goal of motor function interventions post concussion?
To improve balance fxn and dual task activities
T/f: motor functions interventions involved a gradual progressive return to higher level motor fxn tasks and challenges, including return to work ad return to sport/activity
True
What stages of return to sport is PT involved most in?
Stages 2-4
What is stage 2 of RTS?
Light aerobic exercise (walking, stationary bike at slow to medium pace)
No resistance training
What is the goal of stage 2 RTS?
Increase HR
What is stage 3 RTS?
Sport specific exercise (running/skating drills)
No head impact activities
What is the goal of stage 3 RTS?
Add movt
What is stage 4 RTS?
Non-contact training drills (passing drills)
May start progressive resistance training
What is the goal of stage 4 RTS?
Exercise, coordination, increased thinking
How long do to have to spend in each stage of the RTS progression?
At least 24 hours
When does RTS progression begin?
After the initial 24-48 relative rest period
If any sx worsen during a stage of the RTS progression, what do we do?
Go back to the previous step in the progression
What are the 3 school modifications we can use post concussion if absolutely necessary?
Temporary academic adjustments
504 plan (5 weeks-4 months)
IEP (>6 months)
