Exam 2: Concussion Flashcards
What are the 4 diagnostic criteria for a concussion?
- GCS score of 13-15
- Loss of consciousness < 30 min
- Post Traumatic Amnesia < 24 hrs
- Lack of acute abnormalities on CT and MRI
What diagnostic imaging will show signs of concussion?
fMRI, blood flow, metabolic imaging
What percentage of concussions are associated with loss of consciousness?
< 10%
What is the pathophysiology associated with concussion?
- Disruption to neuronal circuits
- Dysregulation of K/Na pump
- Increased cerebral metabolism
- Decreased cerebral blood flow
- Increased glutamate
What are the 4 domains of concussion symptoms?
- Cervical musculature
- Vestibulo-ocular
- Autonomic dysfunction and exertional intolerance
- Motor function
What symptoms are considered to be cervical musculature impairments?
Neck pain, dizziness, impaired postural control, limited proprioceptive input
What symptoms are considered to be vestibulo-ocular impairments?
Vertigo, blurred vision, light sensitivity, headaches, sensitivity to sound, balance impairments, fatigue, tinnitus
What symptoms are considered to be autonomic dysfunction and exertional intolerance?
Poor autonomic regulation: inability to regulate HR, BP, cerebral blood flow in response to exercise and positional changes
Symptoms: pounding headache, fatigue, dizziness, nausea
What symptoms are considered to be motor function impairments?
Impaired postural control, motor coordination, motor abilities with dual task, increased reaction time, increased risk of musculoskeletal injuries
How long until symptoms of a concussion typically resolve?
7-10 days
What does PPCS stand for?
Persistent Post-Concussive Symptoms
What percentage of people with a concussion will present with PPCS?
10-20%
After what time period are concussion symptoms considered PPCS in children?
Symptoms after 4 weeks
After what time period are concussion symptoms considered PPCS in adults?
Symptoms after 14 days
What are indications for a slow recovery from a concussion?
Young age, female, prior concussion history, migraine history, history of depression and anxiety, ADHD, genetic factors, psychosocial factors
What are injury related indications for a slow recovery from a concussion?
Post traumatic amnesia, loss of consciousness, delayed removal from sport
What is Second Impact Syndrome?
A second concussion before a patient has fully recovered from the first than can have devastative effects
What is the pathophysiology of Second Impact Syndrome?
Cerebral edema and cerebral metabolism have not returned to baseline. Brain is unable to regulate pressures that results in rapid accumulation of edema and brain herniation
What does CTE stand for?
Chronic Traumatic Encephalopathy
What is CTE?
A progressive degenerative disease associated with repetitive mild brain injury
What are some conditions that professional athletes are at a higher risk for?
ALS, Parkinson’s, Alzheimers, dementia
What is involved in pre-participation testing for concussion?
Medical and family history, full neurologic assessment, SCAT6, SMHAT, ImPACT
What does the ImPACT assess?
Attention, working memory, response variability, reaction time, problem solving
What is part of the immediate screening for a concussion?
Screen for multiple-system involvement, cervical spine pathology, identify if there is a moderate or severe brain injury, administer medical attention
When should you send someone with a suspected concussion for emergency care?
- Deteriorating condition, orientation within 4 hrs
- GCS < 13
- Cervical spine injury
- Open skull fracture
- Progressive symptoms or new neurologic signs such as repeated vomiting, seizures, pupil asymmetry
How will a patient with a concussion present after a blow to the head?
Decreased orientation or alterations in cognition, physical symptoms, emotional or behavioral changes, GSC 13-15 within the first 24 hours
What are the three sideline examinations for concussion?
SCAT6, BESS, VOMS
What ages should the Child SCAT6 be administered to?
12 and under
What timeframe can the SCAT6 be administered in?
Within the first 72 hours, but as soon as possible
What is included in the SCAT6 assessment?
Neuro screen, red flag assessment, Maddock’s Rules, Modified BESS, GCS
What does BESS stand for?
Balance Error Scoring System
What does the BESS examine?
Postural control with and without shoes, with different foot positions, and on different surfaces
How is the BESS scored?
Counting the number of errors per trial
What does VOMS stand for?
Visual Ocular Motor Screen
What does the VOMS assess?
Smooth pursuits, saccades, convergence, VOR, visual motion sensitivity
What are the general recommendations after an acute concussion?
Diagnose ASAP, monitor for worsening function, no return to play, refer to medical provider, relative rest for 24-28 hrs
Describe relative rest
Reduced screen time, allowed to perform ADLs and activities that do not exacerbate symptoms
How long should you prescribe relative rest after a concussion?
24-48 hours
What four key areas should you assess when seeing a patient following a concussion?
- Cervical spine
- Vestibular system
- Exercise tolerance
- Motor function
What are examples of how to assess the cervical spine when treating a concussion?
ROM, trigger point assessment, exam of cervical dizziness, TMJ, muscle strength, endurance of cervical and scapular muscles
What are examples of how to assess the vestibular system when treating a concussion?
Smooth pursuits, saccades, vergence, accommodation, ocular alignment, etc.
What is the prognosis for vestibular systems following a concussion?
If vestibular or ocular abnormalities are still present 2-3 weeks after the concussion, it is associated with delayed recovery
Why is it important to test exercise tolerance following a concussion?
To measure autonomic dysfunction
After a concussion, will there be any abnormalities with resting HR and BP?
HR may be elevated at rest
How do you measure HR and BP following postural changes during a concussion examination?
Have patient supine for two minutes then measure their blood pressure when they transition to standing
What are the cutoffs for measuring changes in BP from supine to standing?
SBP: drop of greater than 20 mmHg
DBP: drop of greater than 10 mmHg
When assessing exercise tolerance, what change in RPE is indicative to stop the test?
+3 on the RPE
Briefly describe the Buffalo Concussion Treadmill Test
Start the speed at 3.0 mph and increase the incline by 1 degree every minute. Record patient RPE, symptoms, and HR at each minute. Once you reach max incline, start to increase speed
What are considerations for assessing motor function following a concussion?
Stead state balance, postural sway, dual task, anticipatory and reactive balance, gait activities, outcome measures
What are the two SOMs that can be used in the clinic following a concussion?
SCOAT and PCSS
When is it appropriate to use the SCOAT following a concussion?
After day 3
What is included in the SCOAT?
Assessment of cognitive function, HR and BP in two positions, cervical spine examination, neuro exam, tandem gait, dual task, modified VOMs
What does PCSS stand for?
Post Concussive Symptoms Scale
What is the PCSS?
22 item scale where patient rates their current concussive symptoms
Why is aerobic exercise important in recovery from a concussion?
Facilitates recovery through reducing symptoms, earlier return to work, improved reaction time, faster recovery, and less anger
Describe sub-symptom threshold aerobic exerciser
No more than a 2-point increase in symptoms that go away within one hour of stopping exercise. Repeat 3x per week within the HR threshold
What four factors should be considered when returning to learning following a concussion?
Environment, physical, curricular, testing
Briefly describe the return to sport protocol following a concussion
Step 2 after 24-48 hours following injury. Need to tolerate each stage without increase in symptoms. Must remain in each stage for at least 24 hours
What is the minimum time out of sport following a concussion?
One week
What is the average length of time it takes an athlete to return to sport following a concussion?
One month
