Mild Traumatic Brain Injury/ Concussion Flashcards
When diagnosing mTBI (Concussion) what is the:
- GCS score?
- LOC time length?
- PTA time length?
- Acute abnormalities on neuroimaging (yes or no?)
- GCS score: 13-15
- LOC time length: 0 - 30 min
- PTA time length: <24 hour
- Acute abnormalities on neuroimaging: no
How is a concussion clinically diagnosed?
Based on sign & symptoms
Name some common causes of Mild TBI
- Sports injures
- Military injuries
- Falls, MVA, assault
in regards to the mTBI pathophysiology:
T/F: there is a decreased cerebral metabolism and an increased cerebral blood flow
False:
- Increased cerebral metabolism
- Decreased cerebral blood flow
in regards to the mTBI pathophysiology:
T/F: Microstructural changes leading to disruption of typical neural circuits occur. And there is a dysregulation of sodium potassium pumps.
True
in regards to the mTBI pathophysiology:
T/F: There is altered neurotransmitter release and an example of this is a decrease in excitatory neurotransmitters such as glutamate.
False
- There is altered neurotransmitter release but there is an increase in glutamate
What are the 4 domain of mTBI symptoms?
- Cervical musculature impairments
- vestibule-ocular impairments
- autonomic dysfunction & exertional intolerance
- motor function impairments
Name some cervical musculature impairments
- Neck pain
- headaches
- dizziness
- Impaired postural control
- Limited proprioceptive inputs
Name some vestibulo-ocular impairments
- vertigo
- blurred vision
- light sensitivity
- headaches
- sensitivity to sound
- balance impairments
- fatigue
- tinnitus
What are some symptoms of autonomic dysfunction & exertional intolerance?
- Pounding headache
- Fatigue
- Dizziness
- Nausea
- Increasing symptoms w/ activity
Exercise intolerance is a physiological sign of (chronic or acute) concussion.
Acute
What does poor autonomic regulation present as post concussion?
- Inability to regulate HR, BP, cerebral blood flow in response to exercise/activity/positional changes
- impaired cerebral metabolism & altered cerebrovascular physiology
Name some motor function impairments
- Impairments in postural control
- limited motor coordination
- Impaired dual task motor abilites
- Increased reaction time
- Increased risk of musculoskeletal injuries
What is the typical course of prognosis of mTBI?
- Symptom resolution usually occurs within 7-10 days
- Unclear percentage of individual present with residual impairments
What is the prognosis of persistent post-concussion symptoms?
- Residual symptoms (>4 weeks in children & > 14 days in adults)
What are some baseline risk factors that might indicate a slower recovery?
- Younger
- Female
- Prior concussion history
- Migraine history
- ADHD diagnosis
- genetic factors
- Psychosocial factors
What are some injury severity factors that may indicate a slower recovery?
- PTA
- LOC
- Delayed removal from sports
What are some post injury related factors that increase recovery time?
- Vestibular-ocular findings
- Exervise intolerance/autonomic dysregulation
- Total Rest vs Relative Rest vs Acute Rehab
What are some psychological & sociological resilience factors that indicate a better recovery?
- Strong social support
- Higher SSE
- Higher educational level
- High self-efficacy
- Positive beliefs
- Resilience
- Good general health
- Positive health behaviors
What are some psychological & social vulnerabilities that indicate a slower recovery?
- Low self efficacy
- Comorbid health conditions
- anxiety
- depression
- poor coping strategies
- lower SSE
- poor health behaviors at baseline (sedentary, poor nutrition, poor sleep hygiene)
What is second impact syndrome?
- second concussion before a patient has fully recovered from the first
- can have devastating effects
What are the pathophysiological effects of second impact syndrome?
- Cerebral edema & cerebral metabolism has not returned to baseline
- Brain is unable to regulate intracranial & cerebral perfusion pressures, resulting in resulting in rapid accumulation of edema & brain herniation
what is Chronic Traumatic Encephalopathy (CTE)?
Progressive degenerative disease associated with repetitive mild brain injury
What is ImPact and what is it used for?
- Immediate Post- Concussion Assessment & Cognitive Testing
- Assessment performed to establish baseline
What are the acute management strategies for concussion?
- Remove from play/work/activity
- Bring to safe, quiet are to screen
- Monitor for acute medical emergency
- Observe for worsening function
If someone is diagnosed with a concussion is the athlete allowed to return to play the same day?
No
T/F: Someone can return to work, physical activity or school that day if diagnosed with a concussion
False
What are the goals of immediate screening for concussions?
- Screen multi-system involvement (cervical spine pathology)
- Identify individuals who may present with moderate-severe brain injury & get these individual emergency medical attention
- Perform as early as possible
During acute management of concussion when should you send someone for emergency care?
- Deteriorating cognition (within 4 hours post injury)
- GCS <13
- Cervical spinal injury
- Open skull fx or signs of one
- Progressive sx or new neurologic signs
- Severe or rapidly worsening headache
What are some progressive symptoms or new neurological signs that may indicate they need to be sent to emergency care?
- Repeated vomiting (more than 2x)
- Seizures
- Pupil asymmetry
A concussion diagnosis can be made when a patient has a direct force to the head, face, neck followed by what signs/symptoms?
- Decreased orientation or LOC
- PTA
- Alteration in cognition
- physiological symptoms
- Emotional or behavioral changes
- GCS 13-15 in first 24 hours
What are some physiological symptoms that may indicate a concussion diagnosis?
- Headache
- Dizziness
- Balance problems
- Tonic posturing
- Nausea
- Vomiting
- Fatigue
- Blurred vision
- Sensitivity to light/noise
- Seizure
Name some sideline evaluation screening tools
- Sports Concussion Assessment Tool (SCAT6)
- Balance Error Scoring System (BESS)
- Visual Ocular Motor Screen (VOMS)
T/F: SCAT 6 can be used for all ages
False
- Ages 13 & up use SCAT 6
- 12 and under use Child SCAT 6
What does the SCAT 6 include?
- On field & Off field testing
When is the optimum utility for SCAT 6?
First 72 hours
Where does the SCAT 6 Off Field assessment need to take place?
Distraction free environment
What does the visual ocular motor screen examine?
- Smooth pursuits
- Saccades
- Convergence
- VOR
- Visual motion sensitivity
What are the recommendations after an acute concussion?
- Diagnose ASAP
- Monitor for worsening function
- Do not return to play on same day
- Refer to medical provider
- Relative rest 24-48 hours
- Communication with patient encouraging positive prognosis
T/F: After 24-48 hours naps are highly discouraged
True
What activities are permitted during relative rest?
- ADLs & activities that do not exacerbate symptoms
- Reduce screen time for first 48 hours
How long should relative rest last post concussion?
24- 48 hours
Why is relative rest prescribed to patients?
Excessive physical or cognitive activity in this period may prolong rehab
What is the role of a PT in mild TBI/ concussion?
- Perform thorough exam
- Provide recommendations & interventions for balancing rest & activity
- Refer as needed
- Guide return to life
When examining a patient after mild TBI/ concussion what should the environment be like and what should be expected?
- Environment: Consider low light, quiet room, less visually complex environments to minimize sx
- Expect patient sx & limit repetition of testing
Why is it important to examine the cervical spine if a patient comes to you post concussion?
- No significant separation of symptoms
- Ocular motor dysfunction, headache, & autonomic dysfunction is observed in whiplash injuries too
What should be included in a cervical spine examination?
- ROM, trigger portion assessment, cervical reproduction of dizziness, TMJ
- Muscular strength & endurance
- Proprioceptive awareness
- NDI or Headache Disability index
What are some examination procedures for the Vestibular system?
- Smooth pursuits
- saccades
- vergence, & accomadation
- ocular alignment
- VOR (gaze stability)
- HIT
- BPPV exam
- visual motion sensitivity
- VOR cancellation
- dynamic visual acuity test
- Parts of VOMS
What are the symptoms that might indicate vestibular system issues?
- Headache
- Dizziness
- Vertigo
- Fatigue
- balance problems
- Nausea
- Blurred vision
- Dizziness handicap inventory
What is the prognosis when there is vestibular/ocular abnormalities after concussion?
2-3 weeks after concussion associated with delayed recovery
How can autonomic dysfunction be measured?
- Take BP & HR at rest
- Then take BP & HR with positional changes
If a patients has exercise intolerance what may you see?
- May not see appropriate increase in HR (>20mmHg drop in SBP or > 10 mmHg DBP)
- Longer recovery time
Describe the Buffalo Concussion Treadmill Test
- Systematically evaluates exercise tolerance to guide rehab
- Pt wears HR monition & speed starts at 3 mph
- Each minute the treadmill incline is increased by 1 degree
- Pt rates effort & sx each min & record HR
- Once treadmill reaches maximal treadmill incline, speed is increased
What should you look at when examining motor function?
- Balance
- Coordination
- Reaction time
When is Sport Concussion Office Assessment 6 used?
After day 3
What does the Sport Concussion Office Assessment (SCOAT) include?
- Cognitive function
- BP & HR
- Cervical spine exam
- Neuro exam
- Tandem gait & dual task
- Modified VOM
