Module 11 - Concussion Flashcards
What does the abbreviation SRC mean?
- Sport-related concussion
What does the abbreviation TBL mean?
- Traumatic Brain Injury
What does the abbreviation mTBL mean?
- mild traumatic brain injury
What does the abbreviation CTE mean?
- Chronic Traumatic Encepholopathy
What does the abbreviation RHL mean?
- Repetitive Head Injury
What is a contrecoup injury?
- Moving head strikes stationary object
What is a coup injury?
- Moving object impacts stationary head
What is the mechanism of a brain injury?
- Direct blow to the head (Coup or Countrecoup)
- Movement of brain results in axonal shearing
- Damage to neurons
- Death of some neurons
- Release of chemicals
What is axonal shearing?
- Axons being stretched
What are the signs and symptoms of concussions? (16)
- Headache
- Dizziness
- Nausea
- Blurred Vision
- Light/Sound Sensitivity
- Imbalance
- Ringing in the Ear
- Seeing “stars”
- Irritability
- Fogginess
- Fatigue
- Difficulty concentrating
- Poor memory
- Neck Pain
- Sadness
- Confusion
Describe the initial response to a possible concussion
- Respond immediately
- Remove from activity
- Assess for medical emergency
- Call 911 and seek medical care if red flags
What are the red flags to look for when initially assessing a possible concussion?
- Neck pain or tenderness
- Double vision
- Weakness/tingling in arms or legs
- Severe or increasing headache
- Seizure or convulsion
- Loss of consciousness
- Deteriorating conscious state
- Vomiting
- Increasingly restless, agitated, or combative
What are the steps to take if there is no medical emergency but may be a potential concussion?
Do not
- Leave the individual alone
- Let individual return to activity
- give individual any immediate medication
- Let individual leave themselves
- Let individual drive/bike
Do
- Monitor for red flags
- notify emergency contact person
What needs to be done within 48 hours of a potential concussion?
- Monitor individual
- Monitor throughout the night
- Do not wake an individual unless concerns
- Call 911 if an individual is slow to wake or RED FLAGS
- Seek medical attention is signs or symptoms present
- If no symptoms occur, monitored normal activity allowed
- Monitor for several days
When should you wake someone who has a potential concussion?
- concerns with breathing
- changes in skin colour
- Concerns with how they are sleeping
What should you do if someone with a potential concussion is slow to wake?
- Seek immediate medical care
How is a concussion diagnosed?
- Clinical judgment
Is there a test to confirm concussion?
- No diagnostic test
Do concussions show up on imaging tests like CT scans or MRI’s? Why?
NO
- There is no structural damage visible
What are the three categories of the Glasgow Coma Scale?
- Eye Opening
- Verbal Response
- Motor Response
What are the 4 ranks on the Eye Opening category of the Glasgow Coma Scale?
4 - Spontaneous Eye Opening
3 - Eye Opening to Speech
2 - Eye Opening to Pain
1 - No Response
What are the 5 Ranks of the Verbal Response Category of the Glasgow Coma Scale?
5 - Oriented verbal response
4 - Sentences
3 - Words
2 - Sounds
1 - No Response
What are the 6 Ranks of the Motor Response Category of the Glasgow Coma Scale?
6 - Obeys Commands
5 - Localizes Pain
4 - Flexion/Withdrawal to pain
3 - Abnormal Flexion to pain
2 - Extension to pain
1 - No response
What does a low score on the Glasgow Coma Scale mean?
- Coma
What does a high score on the Glasgow Coma Scale mean?
- Relatively awake, possible mild TBI
What is the concussion management protocol for the first 48 hours?
- Rest for 2 days
Why does someone with a concussion need to rest?
- Needs physical and cognitive rest to allow brain to heal
What is the concussion management protocol after 48 hours?
- Activities that do not increase heart rate or cause sweat
- Restrict strenuous work, exercise, sports, running, biking, rough play
- Limit cognitive activity: concentration/learning
- Restrict work, reading, electronics, music
How long does it typically take to recover from a concussion?
2-4 weeks
How many individuals with a concussion will experience persistent symptoms past 2-4 weeks?
15-30%
What can persistent symptoms from a concussion cause?
- long-term difficulties
What may a physician recommend if there is no improvement or worsening symptoms of a concussion past 4-12 weeks?
- interdisciplinary clinic
What can influence the recovery period of a concussion? (9)
- Previous concussions
- History of headaches, migraines
- Learning disabilities
- Mental Health Issues
- ADHD
- Use of Drugs/Alcohol
- Return to activity too soon
- Lack of family/social support
- Participating in a high-risk sport
How many stages are a part of the return to activity protocol?
5
What are the stages of the return to activity concussion protocol?
Stage 1 - Initial Rest
Stage 2 - Prepare to Return to Activity
Stage 3 - Increase your activity
Stage 4 - Gradually Resume Daily Activity
Stage 5 - Full Return to Activity
Explain Stage 1 of the return to activity protocol for concussions
Initial Rest
- Stay Home
- Quiet and Calm Environment
- Brief Social Visits
- Sleep as much as needed
- Maintain regular sleep schedule
When would you move from stage 1 of the return to activity concussion protocol to stage 2?
- When symptoms start to improve
- After 2 days rest
Explain stage 2 of the return to activity concussion protocol
Prepare to Return to Activity
- Simple familiar tasks
- Less than 30 minutes of activity with regular breaks
- Go for walks/other light physical activity
- minimum day time bed rest
When would you move from stage 2 of the return to activity concussion protocol to stage 3?
- When you tolerate simple, familiar tasks
Describe stage 3 of the return to activity concussion protocol
- Gradual return to usual activity
- Gradual decrease in rest breaks
- Start with less demanding activities
- Jogging, light weights, non-contact sports drills, etc.
- Return to work/school on part-time basis
When would you move from stage 3 of the return to activity concussion protocol to stage 4?
- When they tolerate further increases in level of activity
Describe stage 4 of the return to activity concussion protocol
- Resume challenging activities
- Energy and capacity should improve
- Students/workers may require accommodations
What accommodations might students or workers require when returning post-concussion?
- Reduced Hours
- Reduced Workload
- Extra time for assignments
- Access to quiet distraction-free work environment
When would someone move from stage 4 to stage 5 of the return to activity concussion protocol?
- When individual tolerates partial return or usual activities
Describe stage 5 of the return to activity concussion protocol
- full class/work schedule (no rest break/accommodations)
- Student-athletes no return to sport until full return to school
- Only return to contact sport/dangerous job when cleared by doctor
What happens if there are worsening or new symptoms at any stage of the return to activity protocol?
- Go back to the previous stage for at least 24 hours
- Do not push through symptoms
- Decrease activity level
What might happen during the recovery process of the return to activity concussion protocol?
- May need to move back a stage more than once
How many stages are in the return to sport concussion protocol?
6
What are the stages of the return to sport concussion protocol?
Stage 1 - No Sporting Activity
Stage 2 - Light Aerobic Exercise
Stage 3 - Sport-Specific Exercise
Stage 4 - Non-contact drills
Stage 5 - Full-contact practice
Stage 6 - Back in the Game
What do the return to activity/sport/work protocols not replace?
- Medical Advice
Describe stage 1 of the return to sport concussion protocol
No Sporting Activity
- Physical and cognitive rest
When would you transition from stage 1 of the return to sport concussion protocol to stage 2?
- Symptoms start to improve
- Resting for 2 days
Describe stage 2 of the return to sport concussion protocol
Light Aerobic Exercise
- walking/swimming/stationary cycling
- No resistance training
- Pace (still able to converse)
- Increase heart rate
When should you move from stage 2 to stage 3 of the return to sport concussion protocol?
- No new or worsening symptoms for 24 hours
Describe stage 3 of the return to sport concussion timeline
Sport-Specific Exercise
- Skating drills (ice hockey), running drills (soccer)
- No head-impact activities
- Add movement to activities
When would you transition from stage 3 to stage 4 of the return to sport concussion timeline?
- No new or worsening symptoms following stage 3 sport-specific exercises
Describe stage 4 of the return to sport concussion timeline?
Non-contact drills
- complex training drills (ex. passing)
- start resistance training
- Exercise coordination, cognitive load
When would you move from stage 4 to stage 5 of the return to sport concussion timeline?
- When symptom-free for 24 hours following stage 4
- Requires medical clearance
Describe stage 5 of the return to sport concussion timeline
Full-Contact practice
- normal training activities
- Restore confidence: assess functional skills
When would you move from stage 5 to stage 6 of the return to sport concussion timeline?
- Symptoms free for 24 hours following stage 5 return to full-contact practice
Describe stage 6 of the return to sport concussion timeline
Back in the Game
- Normal game play
What stage of the return to sport concussion timeline requires medical clearance?
- Stage 5
What can happen if there is a premature return to contact sport?
- Can cause significant setback in recovery
What happens if there are new or worsening symptoms during the return to sport concussion timeline?
- Move back to previous stage for minimum 24 hours
- may occur more than once during recovery
What should be completed before return to sport concussion timeline?
- Return to School timeline
How many stages are there in the return to school concussion timeline?
- 6
What stage of the return to school concussion timeline has two parts?
- Stage 2 (a and b)
What are the different stages of the return to school concussion timeline?
Stage 1 - Physical & Cognitive Rest
Stage 2 - Light Cognitive Activity
Stage 3 - Back to School Part-time
Stage 4 - Part-time School
Stage 5 - Full-time School
Stage 6 - Full-time school
Describe stage 1 of the return to school concussion timeline
Physical and Cognitive Rest
- At home
- Rest
- Board games, crafts, talk on phone
- No activities that increase heart rate/sweat
- Limit computer, TV, Texting, Video Games, reading
- No: school work, sports, work, driving
When should you switch from stage 1 to stage 2a of the return to school concussion timeline?
- Symptoms improve
- Rest max 2 days
Describe Stage 2a of the return to school concussion timeline
Light Cognitive Activity
- Gradual increase in cognitive activity (up to 30min)
- Frequent breaks
- Read/TV/Drawing okay
- Limited peer contact/social networking
- Contact school for return plan
- No: school attendance, sport or work
- Gradually add schoolwork at home
When would you transition from stage 2a to stage 2b of the return to school concussion timeline?
- When 30min cognitive activity tolerated
Describe stage 2b of the return to school concussion timeline
- Introduce schoolwork
- Communicate with school about student’s progression
- No: school attendance, sport, or work
What stages of the return to school concussion timeline occur at home?
- Stage 1
- Stage 2a
- Stage 2b
When would you transition from stage 2b to stage 3 of the return to school concussion timeline?
- When 60min of schoolwork in 2 30min intervals tolerated
Describe stage 3 of the return to school concussion timeline
- part-time school attendance (with max accommodations)
- Schoolwork at school
- No: PE, physical activity at lunch/recess, homework, testing, sport, assemblies, field trips
- Communicate with school on student’s progression
- School work only at school
When should you transition from stage 3 to stage 4 of the return-to-school concussion protocol?
- When 120 minutes of school work in 30-45 min intervals is tolerated
Describe stage 4 of the return to school concussion timeline
- Increase school time
- Moderate accommodations
- Homework (up to 30min/day)
- Testing with adaptations
- No: PE/physical activity at lunch/sports/standardized testing
- Communicate with school on student’s progression
When would you switch from stage 4 to stage 5 of the return to school protocol?
- When 240min of cognitive activity tolerated in 45-60min intervals
Describe Stage 5 of the return to school concussion timeline
- Full days at school (minimal accommodations)
- increase homework to 60min/day
- Limit testing to 1/day (with adaption)
- No: PE/ P activity at lunch/ sport/ standardized tests
When would you switch from stage 5 to stage 6 on the return to school concussion protocol?
- When tolerating full-time school with no learning acommodations
Describe stage 6 of the return to school concussion timeline
Full-time school
- full days, no accommodations
- All classes
- All homework
- Full extracurricular
- All tests
- No: full participation in PE unit return to sport completed and medical clearance
- full academic load
What does it mean if someone is tolerating an activity?
- when symptoms are not exacerbated
How many stages are in the return to work concussion timeline?
6
What are the stages of the return to work concussion timeline?
Stage 1 - physical and cognitive rest
Stage 2 - Light activity
Stage 3 - Prepare for work (a: at home/b: at work)
Stage 4 - Gradual return to work
Stage 5 - Regular work hours (modifications)
Stage 6 - Full Return to Work
Describe stage 1 of the return to work concussion timeline
Physical and Cognitive Rest
- At home
- Rest (quiet calm environment)
- Low aggravation activities (quiet music/colouring)
- Sleep as much as needed
- Limit social visits/screen time
- Avoid sports/physical activity that increase HR or sweating
What should be discussed with a medical professional during stage 1 of the return to work concussion timeline?
- Driving
When should you transition from stage 1 to stage 2 of the return to work concussion timeline?
- When symptoms improve
- 2 days rest
Describe stage 2 of the return to work concussion timeline
- simple gradual increase in cognitive activity
- Walks or other light physical activity
- Frequent rest periods
- Brief periods of activity (<30min)
- Communicate with workplace about return to work plan
When should you switch from stage 2 to stage 3a of the return to work concussion protocol?
- When 30 min activity is tolerated
Describe stage 3a of the return to work concussion timeline
- increase cognitive activity
- Return to pre-injury physical activity
- Contact workplace for tailored return to work plan
- Attempt commute to work (assess aggravation of symptoms)
- Regular sleep schedule
- Work up to 2 hour activity with breaks
- Prepare for return to work
When should you switch from stage 3a to stage 3b of the return to work timeline?
- At work: When 120 min activity tolerated with rests
Describe stage 3b of the return to work concussion timeline
- Set Work accommodations
- Arrange Graduated return to work plan
- Work your way up to an additional 2 hours of activity. with breaks
- Plan to leave work if symptoms worsen, return to stage 2
What accommodations can be set up at work for a return to work concussion plan?
- Flexible hours
- Reduced workload
- Extra time for task
- Access to quiet, distraction-free work space
When should you transition from stage 3b to stage 4 of the return to work concussion timeline?
- When 4 hours of activity is tolerate, with breaks
Describe stage 4 of the return to work concussion timeline
- Return to work based on plan set
- Start with less demanding activities
- Gradually increase hours and difficulty
- Work with accommodations
When would you switch from stage 4 to stage 5 of the return to work concussion timeline?
- When ready for regular work hours with accommodations
Describe stage 5 of the return to work concussion timeline
- decrease accommodations as energy/capacity increases
- Accommodations phased out in ‘trial’ periods
- Monitor energy levels (participate in activities after work)
When would you switch from stage 5 to stage 6 of the return to work concussion timeline?
- When regular work hours are tolerated with minimum accommodations
Describe stage 6 of the return to work concussion timeline
- Full regular work hours
- usual expectations of productions
What requires medical clearance in stage 6 of the return to work concussion timeline?
- Return to Job-duties that have safety implications
- Ex. heavy machine operation, heights, driving
How many people get post-concussion syndrome?
30-80% of patients with mild-moderate brain injuries
Does the severity of the TBI relate to the occurrence of PCS?
- NO (not clearly correlated)
What are the symptoms and signs of Post Concussion Syndrome? (8)
- Headache
- Dizziness
- Irritability
- Anxiety
- Sleep Impairment
- Fatigue
- Loss of memory / concentration
- Noise Sensitivity
What are some possible structural changes that occur in post concussion syndrome?
- Regional Voluem loss
Do the structural changes that occur during post-concussion syndrome correlate with symptoms?
- No
What are some possible psychogenic factors that can contribute to post-concussion syndromes?
- Limited Social Support
- Poor Coping Skills
- Negative Perceptions
- Depression
- Anxiety
- Panic
- PTSD
Describe the treatment for someone with post-concussion syndrome
Individualized
- Cognitive and physical rest
- Headache management
- Management of sleep/wake disorders
- Psychological support and education
What are some ways to manage headaches for someone with post-concussion syndrome?
- physical therapy
- pharmaceutical intervention
What are some ways to manage sleep/wake disorders for someone with post-concussion syndrome?
- Behavioural changes
- Pharmacological intervention
What is second impact syndrome?
- Catastrophic injury due to a second impact while still symptomatic from prior concussion
What is diffuse cerebral edema?
- Increase intracranial pressure
When can a diffuse cerebral edema occur?
- Second Impact Syndrome
What can second impact syndrome lead to?
- Death
- Permanent disability
Who is more at risk for second-impact syndrome?
- people under 20 years old
Where have all cases of second impact syndrome been seen?
Males
- Associated with American Football
What is a risk factor for sport-related concussions?
- Past sport-related concussions
What are multiple Sport-related concussions associated with?
More
- Physical
- Cognitive
- Emotional
Symptoms before participation in sporting season
What is predictive of worse symptoms or prolonged recovery? is this a clear connection?
- Loss of consciousness
- Retrograde amnesia
- Post-traumatic amnesia
UNCLEAR RELATIONSHIP
What may be helpful for neuropsychological assessments related to sport-related concussions? Why? When?
What?
- Baseline testing pre-season
Why?
- Assist in Return-to-play
When?
- Multiple concussion situations
What is CTE?
Chronic Traumatic Encephalopathy
- progressive/fatal brain disease
When might CTE occur?
- Repeated traumatic brain injuries
How many cases of CTE have been reported?
- only 300
Why is CTE hard to diagnose?
- Only diagnosed post-mortem
What happens to the brain from CTE?
- Patchy distribution of tau deposits throughout the brain
What are tau deposits?
- Neurofibrillary tangles
What are some other possible features of CTE aside from patchy distributions of tau deposits?
- Amyloid-B(AB)
- Transactive DNA-binding protein 43 (TDP43)
- Degeneration of Axons
Why is CTE controversial?
- Many people get mTBI, yet CTE uncommon
- Dismissal of repetitive head injury in sport does not increase understanding of CTE