Week 3- Concussion Flashcards

(76 cards)

1
Q

PART 1: INTRO AND COGNITIVE/FATIGUE SUBTYPE

A

PART 1: INTRO AND COGNITIVE/FATIGUE SUBTYPE

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2
Q

Is a Concussion a brain injury?

A

YES, shearing of axons inside brain.

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3
Q
  • What are the 3 levels of TBI?

- What category does a concussion fall under?

A
  • Mild, Moderate, Severe

- Mild

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4
Q

Concussion Pathophysiology:

  • Concussion is a _________ brain injury.
  • Will we see anything on a head scan after a concussion? Why?
  • Disruption of cell membranes and axonal stretching leads to flux of ions through previously regulated channels → _________ effects on postsynaptic neurons. This then leads to widespread release of ____________, which causes even further ionic flux.
  • Na/K ATP-dependent pump increases membrane pumping to reestablish balance. This depletes ________ stores.

-____ energy demand + ____ blood supply → Metabolic crisis

A
  • Metabolic
  • No, because they are not structural changes, but rather metabolic.
  • depressive, neurotransmitters
  • energy stores

-**increased energy demand + decreased blood supply = metabolic crisis

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5
Q

How do we classify concussions?

A

-Based off of their primary S/Sx.

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6
Q

What are the 6 subtypes of concussion?

A
  • Cognitive/Fatigue
  • Ocular/Visual
  • Vestibular
  • Anxiety/Mood
  • Cervical
  • Post-Traumatic Migraine
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7
Q

What subtype of concussion is most often seen EARLY ON following concussion?

A

-Cognitive/Fatigue

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8
Q

What are the symptoms of Cognitive/Fatigue subtype?

A
  • Fatigue
  • HA with cognitive and physical activity
  • “End of Day” symptoms
  • Often see sleep disturbances
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9
Q

Cognitive/Fatigue Exam:

  • Is their vestibular/ocular screening normal?
  • Neurocognitive test results are mild but _______/_________, deficits across all composites.
  • Deficits with ______, ______ intact.
A
  • Yes
  • global/widespread
  • retrieval, encoding
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10
Q

What are some helpful questions to see if it is consistent with cognitive/fatigue concussion?

A
  • Do you have a generalized HA that gets worse as the day progresses?
  • Do you feel more fatigued than normal at the end of the day?
  • Do you feel more distractable?
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11
Q

Cognitive/Fatigue Treatment:

  • These patients are the ______ likely to need PT.
  • Incorporation of physical/cognitive _______ throughout the day (NOT _____!)
  • If persistent, what pharmacological agents are available?
  • _______ therapy (if symptoms linger more than a few months)
  • Monitored, structured exercise progression.
A
  • least
  • breaks (NOT naps!)
  • neurostimulants (amantadine, methylphenidate), sleep aide
  • Cognitive therapy
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12
Q

Why do we not take naps?

A

-To not cause sleep disturbances and help keep sleep schedule.

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13
Q

PART 2: OCULAR/VISUAL SUBTYPE

A

PART 2: OCULAR/VISUAL SUBTYPE

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14
Q

What are the risk factors for Ocular/Visual subtype concussion?

A

-Family/personal history of ocular dysfunction

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15
Q

Ocular/Visual Symptoms:

  • ______ HA driven by visual work.
  • Difficulties with visually-based classes, assignments, or activities.
  • _______ behind eyes.
  • Visual “_____” issues.
  • ______/_______ vision
A
  • Frontal HA
  • pressure
  • “focus”
  • blurry/double
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16
Q

How can we distinguish the difference between ocular/visual and cognitive/fatigue HA?

A

-Ocular/visual tends to be located more near the eyes while cognitive/fatigue is more general HA.

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17
Q

Ocular/Visual Exam:

  • Visual/Oculomotor Exam
      • ________, _______
    • ________ difficulties (insufficiency, spasm/excess)
    • __________ insufficiency
    • _________ visual deficits
    • __________ (tropias, phorias)
  • Neurocognitive Test Results
    • Deficits in ________ time.
    • Deficits with _______ memory. (________ rather than _______)
A
    • smooth pursuit, saccades
  • convergence difficulties
  • accommodative insufficiencies
  • binocular visual deficits
  • strabismus
  • reaction time
  • visual memory (encoding rather than retrieval)
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18
Q

_________ is the most frequent exam finding with ocular/visual subtype.

A

-Convergence

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19
Q
  • What is not frequently associated with ocular/vision subtype?
  • If this symptom is one of the main complaints, then our focus switches to which subtype?
A
  • Photosensitivity

- Migraine

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20
Q
  • What is strabismus?

- What are the 2 primary types of ocular deviation?

A
  • Misalignment of the eyes/dysconjugate gaze at rest.

- Tropia and Phoria

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21
Q
  • What is tropia?
  • Exo = ________, Eso = ________
  • Hyper = ________, Hypo = ________
A
  • Tropia = over deviation of the eye
  • Exo = outward (laterally), Eso = inward (medially)
  • Hyper = upward, Hypo = downward
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22
Q

What is phoria?

A

-Phoria = ocular deviation occurs when dissociation occurs.

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23
Q

______ tend to be present all the time while _______ show up when the eyes get more tired.

A

-tropia, phoria

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24
Q

Ocular Misalignment If Severe:

  • _______
  • _____ tilt
  • Noticeable ________

Ocular Misalignment If Subtle:

  • Difficulty maintaining _____
  • Cosmetically _______
  • Ocular _______
  • ________
  • Mental dullness
A
  • Diplopia
  • Head tilt
  • Noticeable eye turn
  • Difficulty maintaining focus
  • Cosmetically normal
  • Ocular soreness
  • HA
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25
Vergence Dysfunction Symptoms: - ________: Ability of eyes to turn inward to focus on a near target - ________: Ability of eyes to move outwards to focus on a further target - Which one do we see more often?
- Convergence - Divergence - Convergence
26
What are the main complaints of with vergence dysfunction?
-Gaze instability and/or double vision
27
What are the general symptoms of vergence dysfunction? (5)
- Asthenopia (eye fatigue) when reading - Frontal headaches - Intermittent/Constant double vision - Squints/closes one eye - Letters appear to float/move on the page
28
What are (3) common vergence problems?
- Convergence Insufficiency - Convergence Excess - Convergence Spasm
29
Accommodative Dysfunction: - What is accommodation? - Reduction in ability to focus at _____. - Accommodative ______. (overfocusing at near) - Struggle to coordinate accommodation and vergence, leading to difficulty in _____________. - COMPUTERS, PHONES, NEAR WORK
- The adjustment of the optics of the eye to keep an object in focus on the retina as its distance from the eye varies. - near - spasm - spatial awareness
30
What does treatment of Ocular/Visual Subtype look like? (2)
- Ocular Motor Training | - Physical Exertion
31
PART 3: VESTIBULAR, ANXIETY, MIGRAINE SUBTYPES
PART 3: VESTIBULAR, ANXIETY, MIGRAINE SUBTYPES
32
What are the risk factors of vestibular subtype concussion?
-PMH of car sickness/motion sensitivity, migraine, anxiety
33
Vestibular Subtype Symptoms: - ________ - _________ - Nausea - Overwhelmed in ____________ environments - _______ impairments
- Vertigo - Dizziness - Nausea - Overwhelmed in visually-stimulating environments - Balance impairments
34
Dizziness Post Concussion: - Dizziness reported in __-__% of concussed athletes. - Dizziness associated with ___________ recovery. - Undiagnosed vestibular deficits may delay recovery.
- 55-80% | - protracted
35
S/Sx of Vestibular Dysfunction. (8)
- Dizziness - Blurry Vision - Nystagmus - Tinnitus - Hearing Loss - LOB and possible falls - Broad-based stance - Sweating, NV (due to ANS involvement)
36
What are some common things that cause vestibular dysfunction after a concussion? (5)
- Labyrinthine Concussion - Skull Fracture - Hemorrhage into Labyrinth - Hemorrhage into brainstem - Increased ICP
37
What is the most common vestibular injury due to TBI?
-Labyrinthine concussion
38
Labyrinthine Concussion: - Ataxia, imbalance, _______ may be present. - Most common _________ injury due to TBI.
- BPPV | - vestibular
39
Skull Fracture: - UVL or BVL (partial or complete) - ___________ hearing loss. - May have mixed _________ and ________ lesions. - Common with blows to what regions of the brain?
- Conductive - peripheral and central - occiput, temporal, parietal
40
Hemorrhage Into Labyrinth: - May create post traumatic hydrops (Meniere’s type syndrome). - Damage to labyrinth, may create acute ________ and ________ hearing loss. - Labyrinth damage may present with S/Sx similar with acute __________ vestibular damage.
- acute vertigo and unilateral hearing loss | - peripheral vestibular damage
41
Hemorrhage Into Brainstem: - _________ signs, poor smooth pursuit, vertigo, perception of tilt. - Damage to ________ and _________ nuclei.
- Oculomotor | - vestibular and oculomotor nuclei
42
Increased ICP: - Fluctuating _______ loss, ataxia, imbalance. - May cause peri-lymphatic ________.
- hearing loss | - fistula
43
Vestibular Subtype Exam: - Vestibular/Ocular Screen - VOR dysfunction (_________ and/or _______) - VOR _________ - Can see + ___________/________ - *Not significant + skew - Neurocognitive Test Results - Difficulty with visual motor ______, _________ time
- vertical and/or horizontal - suppression - smooth pursuit/saccades -speed, reaction time
44
Why will we typically not see a + test of skew with Vestibular Subtype?
-It is sensitive for brainstem involvement, which is usually ok with this subtype.
45
What 2 other subtypes does Vestibular Subtype coexist with frequently?
- Migraine | - Anxiety
46
Vestibular Treatment: - _______! - Pharmacological as needed (Meclizine, Tricyclic antidepressants, Melatonin, SSRIs)
-Vestibular Rehab Therapy (VRT)!
47
What are the risk factors for Anxiety/Mood subtype concussion?
- Personal/Family Hx of anxiety - Migraine - Vestibular disorders
48
Anxiety/Mood Subtype Symptoms: - __________ thoughts - ______-vigilant - _________ - Easily overwhelmed - Difficulties initiating/maintaining __________
- Ruminative thoughts - Hyper-vigilant - Fastidious - Difficulties initiating/maintaining sleep
49
What population is Anxiety/Mood Subtype common in and why?
- Athletes | - These are a bunch of driven individuals who are being told that they cant work out and need to take breaks.
50
Anxiety/Mood Subtype Exam: - Vestibular/Ocular Screen - _________ - Neurocognitive Test Results - _________
- normal | - normal
51
Anxiety/Mood Subtype Treatment: - Treat _______ and/or _________ subtype, if present. - Supervised ________ therapy. - Cognitive behavior training. - Regulated ___________ (sleep, exercise, diet, hydration, etc.). - Psychotherapy/Pharmacology (antidepressants, benzodiazepines).
- vestibular and/or migraine - exertion - regulated schedule
52
What are the risk factors for Migraine Subtype?
- Personal/family Hx of migraine - "ice-cream headache" - Motion sensitivity - Vestibular disorder - Anxiety
53
Migraine Subtype Symptoms: - Variable ___ (often wakes with HA) - Nausea, _______ and or ______phobia - Stress, anxiety, lack of exercises - Sleep dysregulation
- Variable HA | - photo and/or phonophobia
54
- Migraine Subtype is 1 of 2 subtypes which can have HA when the patient ______ ___. - What is the other subtype? How is it different?
- Wakes up | - Cervical Subtype, if they wake up with HA and neck pain
55
Post-traumatic Migraine Subtype: - What is a migraine? - __/__ patients will experience preceding aura. What is the most common aura that makes up about 50% of all cases?
- Neurovascular event involving failure of central modulation of trigeminovascular system. - 1/3, visual aura most common (followed by sensory, language, and motor)
56
Migraine Subtype Exam: - Vestibular/Ocular Screen - __________ - Neurocognitive Test Results - ______ and ________ memory deficits.
- normal | - Verbal and visual memory deficits.
57
Migraine Subtype Treatment: - Medications (pain, sleep regulation) - Diet - Stress Management - Avoid migraine "________" (alcohol, caffeine, poor sleep
-"triggers"
58
When will we as PTs not treat Migraine Subtype patients?
-When it is in isolation from other subtypes.
59
PART 4: CERVICAL SUBTYPE, OUTCOME MEASURES, PROGNOSIS
PART 4: CERVICAL SUBTYPE, OUTCOME MEASURES, PROGNOSIS
60
What are the risk factors for Cervical Subtype?
- Prior c-spine injury - High-velocity injury - Strong rotational component to injury
61
Cervical Subtype Symptoms: - _____ pain, stiffness, soreness - HA radiating forward from upper cervical spine (precipitated/aggravated by specific ______ movements or sustained _______)
- neck pain | - specific neck movements or sustained postures
62
What is a good way to remember the HA pattern with cervical subtype?
-LA Rams helmet
63
Cervical Subtype Exam: - Vestibular/Ocular Screen and Neurocognitive Test Results are _______. - ...but + ________ screen.
- normal | - + cervical screen
64
Cervical Subtype Treatment: - Obtain _________. - Cervical ____________ exercises. - Medication (muscle relaxants, anelgesics) - Injection/nerve block - Massage, acupuncture
- imaging | - stabilization
65
10 Most Commonly Reported Symptoms in Post Concussive Athletes.
1. ) HA (71%) 2. ) Feeling Slowed Down (58%) 3. ) Difficulty Concentrating (57%) 4. ) Dizziness (55%) 5. ) Fogginess (53%) 6. ) Fatigue (50%) 7. ) Visual Blurring/Double Vision (49%) 8. ) Light Sensitivity (47%) 9. ) Memory Dysfunction (43%) 10. ) Balance Problems (43%)
66
What are (5) commonly used Sideline Concussion Assessments?
- SCAT5 - Sideline Impact Test - NFL Sideline Tool - Standardized Assessment of Concussion (SAC) - King-Devick Test
67
What is the gold standard test in determining exercise tolerance in post concussive patients?
-Buffalo Concussion Treadmill Test
68
Buffalo Concussion Treadmill Test: Purpose: - To investigate exercise tolerance in patients with post-concussive symptoms > __ weeks. - To help establish appropriate levels of exercise to aid in return to play/activity. - To aid in __________ between possible diagnoses for concussive symptoms. - To identify physiological variables associated with exacerbation of symptoms and the patient’s level of recovery.
- 3 weeks | - differentiating
69
Buffalo Concussion Treadmill Test Stopping Criteria: 1. ) Symptom exacerbation (defined as an increase in ___ or more points on the VAS scale from resting VAS score). 2. ) Voluntary exhaustion (defined as an RPE of >___ without significant symptom exacerbation). 3. ) Patient demo's rapid progression of complaints, patient appears faint, has stopped communicating, or continuing the test constitutes a significant health risk for the patient. 4. ) Patient reaches ___% or more of age-predicted HRmax (with or without any increase in symptoms and still reporting low RPE).
- 3 or more - >17 RPE - 90% HRmax
70
Do we still usually perform Buffalo Concussion Treadmill Test if patient has a resolve in symptoms? Why?
-Yes, because sometimes it will bring on the symptoms.
71
BCTT Exercise Prescription: - ___% of the maximum heart rate reached without symptom exacerbation. - ___ minutes daily without exceeding the time or HR constraints. - Swimming, walking or stationary cycling – _______ attempt resistance training. -If any post-concussion symptoms return along the progression, the patient must do what?
- 80% - 20 minutes - DO NOT attempt resistance training -Return to the previous asymptomatic stage/maximum HR
72
What is the VOMS?
- Vestibular/Ocular-Motion Screening | - Go to on field and clinic layout for the vestibular and ocular exam. Great use acutely for screening.
73
What are the (5) things measured with the VOMS?
- Smooth Pursuits - Saccades (vertical and horizontal) - Convergence (near point) - VOR (vertical and horizontal) - Visual Motion Sensitivity Test
74
What is the difference between performing these tests for the VOMS and just a regular screen?
The VOMS looks at symptoms in regards to HA, Diziness, Nausea, and Fogginess on a scale from 0-10.
75
Concussion Typical Recovery: - 85-90% Concussions show signs of recovery in first __-__ days… but newer research says it may be more like __-__ days for full biophysiological process. - Recovery from sports-related concussion in children is approximately __ weeks. - Early identification of impairments aids in return to activity/sport without prolonged ___________.
- 10-14, 21-28 - 4 weeks - sequelae
76
What are the predictors of prolonged recovery with concussions? (6)
- INITIAL SYMPTOMS - Sex - Age - LOC - Amnesia - Premorbid comorbidities (psych dx, migraines, vestibular dysfunction)