L16 Mild TBI Flashcards
mTBI is synonymous with
concussion
mTBI
injury that affects the brain, induced by biomechanical forces, that does not result in extended period of unconsciousness, amnesia, or other significant neuro signs
Two guiding documents for exam and treatment of mTBI
- Concussion CPG
- Consensus statement on concussion in sport
Epidemiology mTBI
1.6 to 3.8 million per year
many do not seek medical care, underestimate
MOI of mTBI
sports
falls
MVA
military
Medical management of mTBI
-rest for 24 to 48 hours
-limit activities that require high mental load
-limit PA that causes S/S
slowly progress back to normal load, without triggering symptoms
avoid ibuprofen and aspirin
S/S after mTBI
headache
fatigue
balance issues
sensitivity
vomiting
feeling foggy
memory problems
irritability
sadness
drowsiness
Natural course of recovery
lots of variability
usually 7-14 days
not a linear progression
Chronic Traumatic Encephalopathy
linked to buildup of proteins that damage brain tissue and cause cell death
associated with long term exposure t repeated hits to head
can only be confirmed by autopsy
S/S of CTE
problems with thinking, emotions, mood
sucidial thoughts
behaviors that interefere with normal life
Component 1 of CPG
process for determining appropriateness of PT concussive event/exam
helps to triage to be sure pt is appropriate for PT
patient must not have emergent S/S, needs to have S/S of concussion, and msk, VOM, autonomic dysfunction
Should a patient continue with PT if there is alar ligament pathology present?
NO. This is determined to be an emergent situation because they cervical spine is unstable
Component 2 of CPG
PT exam and eval processes for pts after a concussive event
determining probable movement related impairments and levels of irritability
evaluating cervical MSK, movement related impairments, and VOM, hypotension to determine how to best treat patient
if patient reports neck pain
test for cervical musculoskeletal impairments
If patient reports dizziness or headache
test for cervical MSK, VOM, and orthostatic hypotension
If patient does not report headache, dizziness, or neck pain
test for movement related impairments
Component 3 of CPG
develop and implement a PT POC for patients after concussive event
should be based on findings from PT clinical exam in combo with patient and family needs
involves education about self management, activity levels, rest, pacing, reassurance of recovery, referrals for other HCP
For VOM impairments, test
-BPPV with dix-hallpike
-Ocular alignment
-Vergence and accommodation
-visual motion sensitivity
-smooth pursuits
-saccades
-gaze stability
For motor function impairments, test
static balance
dynamic balnce
dual task
motor coordination
For autonomic dysfunction, test
heart rate
BP in different positions
For cervical MSK impairments, test
ROM
muscle MMT
tenderness
passive motion of spine
(all have poor/expert opinion level)
Strong Evidence for testing
Dix-hallpike
ocular alignment
HiMat
developed as outcome measure to quantify motor performance in individuals with high level balance and mobility impairments
must have at least independent walking over 20 m without ADs, can use orthoses before test
What does HiMat test?
walking, running
jumping
balance
stairs
skipping
items are scored using 5 point scale, with higher score meaning better performance. 54 is the highest
Buffalo Treadmill Test
assesses the degree of exercise tolerance
identifies the HF at which concussion specific symptoms occurs
establish safe level of exercise
help differentiate between concussion and other diagnoses
identify variables associated with exacerbation of S/S and patient’s level of recovery
Tests of autonomic/exertional tolerance
Dix-Hallpike
Orthostatic Hypotension
BCTT
VOMS
Tests of Vertigo/Dizziness
Dix-Hallpike
Supine Rol
BCTT
Gaze holding nystagmus
oculomotor screen
VOR screen
DHI, ABC
Prognosis of mTBI is influenced by
pre-injury factors
injury-related factors
post-injury factors
psychosocial factors
early concussion mgt
Pre-injury factors
hx of prior concussion
ADHD
hx of migraines
Injury-related factors
LOC
amnesia
delayed removal from sport
Post-injury factors
perceived competence
tenacity
tolerance
acceptance
Early concussion mgt factors
strict rest vs relative rest vs active rehab
VOM impairments tx
Canalith reposition
individualized VOM rehab
Motor function impairment tx
different types of balance
motor coordination
dual tasking
use progression to help pt towards goal
Autonomic dysfunction impairments tx
progressive aerobic exercise
education
delaying exertional testing until pts s/s stabilize
Cervical musculoskeletal impairment tx
ROM, strength, posture
sensorimotor function
manual therapy
all low grade evidence
Communication and Education (CPG)
- must education about S/S, functional limitations, stress, and recovery
- must educate about self-management, importance of rest, safe return, pacing, exertional signs, following up with HCP
For movement-related impairments,
- should design intervention plan that is personalized
- should refer patients for follow-up
(3. Not as important to triage patients into has movement impairment vs does not)
For cervical msk,
should implement interventions aimed at addressing dysfunction of spine
For VOM
- should use canalith repositioning
- should implement VOM rehab
- Individualizied VOM habituation plan
Exertional tolderance and aerobic exercise
- Use symptom guided aerobic exercise
- (Don’t focus too much on deconditioning)
Documenting/monitoring pts
level F evidence = monitoring and documenting, using outcome measures as needed or indicated
Sports Related Concussion
TBI caused by direct blow to head resulting in impulsive force being transmitted to brain that occurs in sports
possible axonal injury, inflammation, altered blood flow
S/S onset is immediate, commonly resolves in days
no abnormal imaging
may or may not result in loss of consciousness
11 Rs of sports related concussion
recognize
reduce
remove
refer
re-eval
rest
rehab
recover
return to sport
reconsider
residual effects
Who should be evaluated for concussions in sport?
- any player with concussive event or suspected concussion
- SCAT=6 should be used on sidelines
- SCOAT-6 is a follow up
- S/S longer than 4 weeks should be evaled with clinical assessment
SCAT 6
sidelines and up to first 72 hours
standardized tool for those 13 and older
helps decide if individual needs to be removed from play and if they need immediate care
includes immediate and off-field assessment
Immediate assessment of SCAT
-observation
-glasgow coma
-cervical spine assessment
-coordination and ocular motor screeen
-memory assessment
Off-field assessment
symptoms
cognitive screen
coordination and balance
dual task (opt)
Questions in SCAT indicating immediate care
yes to any indicates for immediate care
- positive observable signs
- glasgow coma scale <15
- neck pain, tenderness, changes in ROM
- Coordination or ocular motor screen abnormality
- Memory <5?
SCOAT-6
designed to better guide eval and management in an office setting from 72 hours after injury and for serial evals
intential overlap with SCAT-6
What does SCOAT-6 include?
History
Symptom Eval
Verbal/Cognitive Tests
Orthostatic/Vital Signs
Cervical Spine Assess
Neuro Exam
Gait
VOM
Emotional
Sleep
Return to Sport Steps
- Daily activities that do not result in more than mild exacerbation
- School activities
- Return to school part time
- Return to school full time
- Symptoms limited activity
- Aerobic Exercise
- Sport Specific Exercise
- Non-contact training drills
- Full contact practice
- Return to game play
