TBI - 1b Mild TBI Flashcards
how is the SCAT used as a tool
eval concussion by assessing cognition, physical damage, and memory recall
what is chronic traumatic encephalopathy (CTE)
progressive degenerative disease of brain found in athletes (and others) w hx of repetitive brain trauma - including symptomatic concussions and asymptomatic concussive hits to head
what is the pathophysiology behind CTE
trauma triggers progressive degeneration of brain tissue
- including build-up of abnormal protein called tau
when is the onset of CTE in athletes w hx of repetitive brain trauma
changes in brain can begin months, years, or even decades after last brain trauma or end of active athletic involvement
what sx is the brain degeneration seen in CTE associated with (7)
memory loss
confusion
impaired judgment
impulse control problems
aggression
depression
progressive dementia
how can the presence of tau be assessed
biopsy of brain
what type of TBI is the most common of all TBIs
mild
what sports have the highest concussion incidence for males vs females
males - football
females - soccer
what is a major factor in the incidence of sports-related concussions
likely under-reported
why are sports-related concussions likely under-reported
LOC is rare (<10%)
close to 50% of athletes don’t feel sx immediately after injury -> go back on field
why would mTBIs be seen in the elderly
falls
what gender has a higher incidence of mTBI and why
males > females
may be d/t riskier behaviors
why is there a growing number of combat veterans w mTBIs
large number of IEDs and better armor
-> more veterans surviving serious attacks
not necessarily from head force, but being in close vicinity to IED that when exploded rattled the brain
what are mTBIs complicated by in combat veterans
polytrauma
PTSD
what are the 4 categories of s/sx of mTBIs
physical
cognitive
emotional
sleep
what are physical s/sx associated w mTBIs
HA, dizziness, balance disturbance, n/v
vestib/ocular disturbances
sensitivity to light/noise
what are s/sx that you should go to the ER for (11)
changes in alertness/LOC
persisting confusion
mood changes
HA persists/worsens
seizures
dizziness
walking or balance problems
unequal pupils / unusual mvmts
slurred speech
ms weakness on one/both sides
repeated vomiting
why do you want to keep someone awake or arouse at intervals after a head trauma
to check cognition
if feel sleepy and can’t stay alert -> go to ER
from pharm management - want to avoid meds w SE of drowsiness/confusion
- would rather take Tylenol over motrin bc avoid blood thinners
what are 3 components of medical management of a mTBI
greater awareness and inc dx
prevent re-injury and manage sx
rest
what is the biggest thing for PTs in terms of medical management of mTBIs
education on when to report
- coaches, ATs, athletes
baseline neurotesting for comparison
how does legislation prevent re-injury after a mTBI
protects young athletes as coaches required to screen, remove from play until medically cleared
what is the NFL doing to prevent re-injury and manage mTBI sx
“Madden rule” and funds for studying concussion & CTE
what is the current recommendation for rest after a mTBI
minimize rest to 1-2days and then guide into suitable activity
why is rest an important part of medical management of a mTBI
physical and cognitive rest will result in recovery in <2wks for the majority of people
what is the consensus post-concussion
no agreed consensus on what the appropriate amt of rest is
clear consensus that some degree of rest is important for a period of time
what was the old approach to post-concussion rest that should be avoided now
shut-down/dark closet
what is the risk of too much rest post-concussion
social isolation
anxiety
depression
looks a lot like post-concussive syndrome - dizziness, confusion, etc.
what is a likely reason for no agreed consensus on the amt of rest needed post-concussion
no RCTs evaluating rest in concussed athletes immediately following a concussion
what is relative rest
degree of activity that is reached by careful eval of sx exacerbation brought on by any particular activity
what are 3 components of continued medical management
protection
neurocognitive assessment
meds
how should protection be integrated into the medical management of a mTBI in an athlete
prevent first injury, protect against additional injury
better helmet
delayed return to play
non-impact practices
how should neurocognitive assessment be integrated into medical management of mTBIs
as soon as possible after injury
best if baseline taken preinjury
- management should begin before a pt is injured!
how should meds be integrated into medical management for mTBIs
used for sx management
- avoid meds that might effect pts mental status
- avoid anti-inflammatory pain meds bc inc bleeding risk (acetominaphens and tylenol are okay)
what are 3 standardized test/measures used in mTBIs
- standardized assessment of concussion (SAC)
- immediate post-concussion assessment and cognitive testing (ImPACT)
- Sport concussion assessment tool - 2 (SCAT-2)
what is a standardized test that can be done immediately on the sidelines of a game
SAC
what are the 4 things that the SAC assesses
immediate memory
orientation
concentration
delayed recall
what is the ImPACT
computerized neuropsychological test battery that measures effects of concussion on brain
- taken preseason for baseline scores
- post-injury scores can be compared to aid concussion dx
what 4 areas does the ImPACT assess
verbal memory
visual memory
reaction time
processing ability
who is not appropriate to take the ImPACT
if recently sustained head injury and/or currently experiencing acute sx
what is the SCAT-2
standardized method of evaluating injured athletes for concussion
what pt population is appropriate for the SCAT-2
athletes ages 13yo+
what other tests does the SCAT-2 integrate into the calculation
enables calculation of SAC score and the Maddocks questions for sideline concussion assessment
what does the SCAT-2 assess
- sx
- cog and physical eval
- cog assessment
- physical signs
- balance and coordination
- GCS
- Maddocks score
what is a balance test that can be done on the sidelines
BESS - balance error scoring system
what balance test includes high level tasks (ie dual task, coordination) and doesn’t need pre-data
HIMAT - high-level mobility assessment tool
what balance test is a self-report on confidence of steadiness/risk of fall
ABC - activity specific balance confidence scale
what balance test is a self-report on confidence in various balance activities
DHI - dizziness handicap inventory
what are 5 vestibular tests
oculomotor exam
vestib ocular reflex tests
dynamic visual acuity
positional testing
vestib/ocular motor screening (VOMS)
what are the 3 conditions of the BESS test
double leg stance (feet tg)
single leg stance (non-dom foot)
tandem stance (non-dom foot back)
how do you interpret the score from the BESS
lower score = better balance
who is the HIMAT appropriate for
assess high-level motor performance
- min mobility requirement is independent amb over 20m w/o ADs (orthoses permitted)
how do you interpret the score from the HIMAT
higher the score = better balance
what is the purpose of the mCTSIB
means to quantify postural control under various sensory conditions
- can determine reliance of systems (visual, somatosensory, vestib)
what does the DHI assess
quantify impact of dizziness on daily life by measuring self-perceived handicap
what 3 domains does the DHI assess
functional
emotional
physical
how do you interpret a DHI score
the higher the score, the greater the perceived handicap d/t dizziness
how do you interpret a ABC score
higher the score = higher the self-perceived confidence
what does the VOMS assess
looks at systems in charge of integrating:
- balance
- vision
- movement
the VOMS screening tests what 5 areas of vestib (balance) and ocular (vision) motor impairment
smooth pursuits
rapid eye movements
near point convergence
balance vision reflex
visual motor sensitivity
what are the 3 components of PT for mTBI
- on site assessment
- PT interventions - specific to sx
- return to play and activity
what is part of the PT on-site assessment for mTBI
screening
use appropriate standardized measure
remove from play if mTBI suspected
what are examples of PT interventions for mTBI (4)
endurance
vestib function
cervical dysfunction (ie cervicogenic issues)
balance
what is the return to play protocol
most able to return in 2-4wks if sustained simple concussion and asymptomatic
what type of objective tests are indicated for a pt complaining of: HAs, numbness, neck pain
ortho assessment of cervical and thoracic spine
what type of objective tests are indicated for a pt complaining of: dizziness, difficulty concentrating, visual problems, sensitivity to light
oculomotor and vestib screening tests
what type of objective tests indicated for all mTBIs
postural stability/balance tests
what is the timeline associated with the phases included in return to play protocol
no activity
some light activity
light practice
“yellow shirt”
full contact practice
full contact play
each phase is 24hrs
progress to next phase if sx are improving after 24hrs
- if sx worsen regress to preceding level and wait 24hrs
what are 6 types of PT interventions for mTBIs
- pt/family ed
- gradual return to activity/sport
- vestib rehab
- sport-specific high-level balance activities
- dual task training
- modalities for HA and pain
what should you educate the pt and family on as part of a PT intervention
rest! (as tolerated)
what are the 5 typical phases of a gradual return to activity/sport protocol
- no activity and complete/relative rest
- light exercise for 10-15min
- sport-specific aerobic activity for 20-30min, no contact
- on field practice drills, no contact
- game play with contact
why should vestib rehab be included in PT interventions for mTBI
vestib impairment occurs in >1/2 of all athletes s/p concussion
what are ex of modalities for HA and pain after a mTBI
ice
heat
relaxation
biofeedback
what is the most important thing/goal that PT interventions should work toward
prevent a second injury
why is dual-task training an important component to include in PT interventions
combine cognitive and sensorimotor demands can better reveal deficits after mTBI
what is a common presentation of individuals w a mTBI when a dual task is introduced
lower gait speed
what are examples of a dual task to integrate
obstacle avoidance
verbal fluency
arithmetic
what is a common secondary injury in individuals w a mTBI and why
LE MSK injury
awareness might be off
impaired NM control
- esp higher risk for athletes
altered neurocognition
what does the literature say about “typical” recovery time
few longitudinal studies of both physio dysfunction & clinical measures
physiological dysfunction probably lasts longer than we think
how is a post-concussive syndrome dx
if 3 or more of the following sx are present beyond “usual recovery period”:
- HA
- dizziness
- irritability
- insomnia
- difficulty memory/concentration
- balance impairments
- inc/return of sx w activity
how long can sx persist in post-concussive syndrome
weeks, months, years
what are 4 negative prognostic factors that could lead to a lengthened recovery from a mTBI
hx of previous concussion
lack of sufficient rest
comorbid psych hx
comorbid physical sx
why is a hx of previous concussion a negative prognostic factor that could lead to a lengthened recovery from a mTBI
brain takes longer to heal
what comorbid psych hx are negative prognostic factors that could lead to a lengthened recovery from a mTBI (3)
anxiety
depression
substance abuse
what comorbid physical sx are negative prognostic factors that could lead to a lengthened recovery from a mTBI (5)
neck pain
HAs
TMJ pain
migraines
seizures
why is a comorbid psych hx a negative prognostic factor that could lead to a lengthened recovery from a mTBI
physiologic process in brain altered
what are risk factors for post-concussive syndrome
more common in females
inc w age
why is post-concussive syndrome more common in females
less neck ms
- dec ability to protect head from wild blows
why are sports related injuries less likely than other injuries to result in post-concussive syndrome
athletes tend to have stronger neck ms in general
what is the relationship of severity of the blow to post-concussive syndrome
not directly related
what are the 3 buckets of treatment for post-concussive syndrome and how do you choose which direction to go
physiologic
vestibulo-ocular
cervicogenic
depends on sx
what is a common MOI resulting in cervicogenic sx in post-concussive syndrome
whiplash
what causes physiologic sx associated w post-concussive syndrome
d/t continued alterations in global cerebral metabolism
what is an intervention to treat physiologic sx associated w post-concussive syndrome
sub-sx threshold aerobic activity exercise
what causes vestibulo-ocular sx associated w post-concussive syndrome
dysfunction in vestibulo-ocular system
what is an intervention to treat vestibulo-ocular sx associated w post-concussive syndrome
vestibular rehab program
what causes cervicogenic sx associated w post-concussive syndrome
dysfunction of cervical spine somatosensory system
what is are interventions to treat cervicogenic sx associated w post-concussive syndrome (3)
c-spine manual therapy
balance exercises
gaze stabilization exercises
