L1 Mild TBI Flashcards
define concussion/mild TBI
- observed/self report of confusion, disorientation, impaired consciousness, memory dysfx around time of injury, loss of consciousness lasting < 30 min
- alteration of consciousness for 24 hrs (GCS)
- post traumatic amnesia <24 hrs
- GCS 13-15 30 min post injury
glasgow coma scale is used when?
after a TBI or head trauma
to assess level of consciousness for inpatient setting and track changes
components of GCS
eye response
motor response
verbal response
GCS scoring: eye
- eyes open spontaneously
- open eyes to verbal command
- eyes open to pain
- no eye opening
GCS scoring: motor
- obeys commands
- localizes pain
- withdraws from pain
- flexion response to pain
- extension response to pain
- no motor response
GCS scoring: verbal
- oriented
- confused
3, inappropriate words - incomprehensible sounds
- no verbal response
structural damage of mild TBI
no structural changes and minimal to no cell death
as opposed to mod/severe which has structural brain injury and cell death
girls vs boys in sports concussions
girls more likely to report
girls more likely to have mental health, severe, or long lasting symptoms
fewer research on girls and concussions
fewer ATs available at games for care of young female athletes
may be more prevalent due to weaker cervical stabilizers in girls
CDC definition of mild TBI
caused by blow/jolt to head, causing brain to move back and forth
creates chemical changes and stretches/damages brain cells in more mod injury
imaging results of mild TBI
normal MRI or CT
does not mean brain function is normal
causes of TBI
direct: local injury
coup/contracoup: acceleration/deceleration injury affecting front and back of brain, stretching in the middle
blast injury with diffuse injury
what age groups are most likely to get concussion
10-17 y/o
risk also increases after 70 y/o due to falls
red flags after a concussion
headache that worsens
drowsiness, can’t be awakened
can’t recognize people/place
repeated vomiting
confusion/irritability
seizures
weak/numb arms and legs
unsteadiness/slurred speech
worsening dizziness
worsening disequilibrium
double vision
all are possible signs of a brain bleed
timeline for improvement in concussion symptoms
7-14 days
maybe 3 weeks
s/s of concussion
irritability
anxiety
sadness
inability to sleep
sensitivity to lights and sound
memory loss
concentration and attention decreased
cognitive fatigue from reading
loss of coord/speed/dexterity
balance, ocular function impairment
metabolic pathology of concussion
- axonal damage
- neuroinflammation
- ionic dysfunction of glutamate
- energy crisis
axonal damage in concussion
may or may not be present
recovers with remyelination over time
generates lots of the recovery seen after TBI
neuroinflammation in concussion
microglia activated by injury, create inflammation
creates excitotoxicity leading to cell damage
ionic dysfunction in concussion
membrane homeostasis is disrupted, leading to excess glutamate release
increased excitation reduces brains ability to inhibit when needed
energy crisis in concussion
excess excitation leads to mitochondrial dysfunction and energy depletion or oxidative stress
hypermetabolism with more brain areas active than needed
creates fatigue
effects of increased brain metabolic activity after concussion
reduced efficiency
reduced information processing
reduced dual tasking
reduced divided attention
increased fMRI brain area activation
increased fatigue
increased sensitivity to environmental stimuli
vestibular system takes what input?
- angular acceleration/rotation
- head position relative to gravity
3 cranial nerves of oculomotor system
3oculomotor
4trochlear
6abducens
lateral vestibular tract gets info from:
primarily LE
medial vestibular tract gets info from
cervical and thoracic muscles
vestibulocerebellar tract control:
coordination
Why is visual pathway likely to be injured in concussion?
How many patients % have VOR deficits?
long pathways likely to be stretched with movement of the brain
VOR impairments in 29-69% mTBI
VOR is?
gaze response - vestibulo-ocular reflex
uses vestibular nucleus to move eyes to stabilize gaze while the head is moving
allows the eyes to stay focused on objects while the body and/or head it moving by adjusting position
dizziness vs vertigo vs disequilibrium
dizziness: light headed feeling/off balance caused by OH, alc, not sleeping, dehydration
vertigo: world/room is spinning, caused by inner ear dysfunction
disequilibrium: vestibular issue
post concussion syndrome
how many %, who is it most common in?
symptoms lasting > 6 weeks (motor, cognitive, behavioral)
about 20% of concussions
more common in women
most common post concussion syndrome symptom
headaches that reoccur
physiological effects of post concussion syndrome
neuroinflammation causing brain changes
lower hippocampal volume
increased cell death
smaller thalamus
limbic atrophy
s/s of post concussion syndrome
headache
dizziness
fatigue
concentration poor
anxiety
depression
irritability
reduced sleeo
light/noise sensitivity
blurred vision
inability to habituate enviro stimuli
exertion worsening symptoms
migraine headache
bilateral pain with thorbbing/pulsating
tension headache
UL headache
vestibular symptoms post concussion
disequilibrium, peripheral or central
BPPV - peripheral
nausea/vomiting/nystagmus - central
VPR symptoms post concussion
impaired saccade initiation
impaired saccade accuracy
slower gaze movements
decreased visual motor symmetry
autonomic symptoms post concussion syndrome
BP: losses autoregulation
reduced exercise tolerance from vasocontriction
+ anxiety, depression, irritability, sleep loss, memory impairments
areas to include in initial concussion examination
VOR
autonomic
C spine dysfunction
once these 3 areas are clear pt can start sport specific training
history after concussion
MOI: twist, impact, accel/decel, direction of impact and speed
loss of cx
post traumatic amnesia
loss of orientation after event
loss of postural control
physical/cervical assessment with mTBI
What are you assessing in cervical exam?
if pt has cervical whiplash and headache
neck pain/headache
cervical injury causing proprioception/balance issue
visual oculomotor assessment after mTBI
eye symmetry: saccades, tracking/reading
vision: convergence, accommodation
vestibular assessment after mTBI
VOR
what direction, velocity, head position provokes symptoms
function assessment after mTBI
attention level
concentration ability
postural control in walking, head movements
autonomic function
rule out cervical injury after concussion
extension/rotation exam
palpate for cervical muscle tenderness
facet dysfunction
accomodation
ability of eye to adjust lens to focus vision at varying distances from the eye
vergence
movement of the eyes in synch and symmetrical to track objects
convergence
ability of eyes to move medially towards nose to center vision on close objects
Should concussion patient push through symptoms?
No! Stop activity when symptoms start
pushing through will only exacerbate the energy crisis/metabolic inefficiency
Rivermead self report scale for concussion: assesses what?
assesses physical, cognitive, and behavioral symptoms over time to assess post concussion syndrome
King Devick
rapid naming numbers
assess eye movement, attention, language, general brain function
compare before/after times injury and treatment
graded exertional tolerance exam for post concussion syndrome
performed to determine if exertion provokes symptoms such as poor endurance due to autonomic symptoms
graded aerobic exercise with incrememtnal increases, marking time, mode and symptoms onset
BESS
balance error scoring system
used in post concussion syndrome to assess postural control
a form of modified CTSIB with 6 positions, 3 firm ground 3 foam, count errors for 20 s each position
