Week 3- Concussion Flashcards
PART 1: INTRO AND COGNITIVE/FATIGUE SUBTYPE
PART 1: INTRO AND COGNITIVE/FATIGUE SUBTYPE
Is a Concussion a brain injury?
YES, shearing of axons inside brain.
- What are the 3 levels of TBI?
- What category does a concussion fall under?
- Mild, Moderate, Severe
- Mild
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
- Metabolic
- No, because they are not structural changes, but rather metabolic.
- depressive, neurotransmitters
- energy stores
-**increased energy demand + decreased blood supply = metabolic crisis
How do we classify concussions?
-Based off of their primary S/Sx.
What are the 6 subtypes of concussion?
- Cognitive/Fatigue
- Ocular/Visual
- Vestibular
- Anxiety/Mood
- Cervical
- Post-Traumatic Migraine
What subtype of concussion is most often seen EARLY ON following concussion?
-Cognitive/Fatigue
What are the symptoms of Cognitive/Fatigue subtype?
- Fatigue
- HA with cognitive and physical activity
- “End of Day” symptoms
- Often see sleep disturbances
Cognitive/Fatigue Exam:
- Is their vestibular/ocular screening normal?
- Neurocognitive test results are mild but _______/_________, deficits across all composites.
- Deficits with ______, ______ intact.
- Yes
- global/widespread
- retrieval, encoding
What are some helpful questions to see if it is consistent with cognitive/fatigue concussion?
- 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?
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.
- least
- breaks (NOT naps!)
- neurostimulants (amantadine, methylphenidate), sleep aide
- Cognitive therapy
Why do we not take naps?
-To not cause sleep disturbances and help keep sleep schedule.
PART 2: OCULAR/VISUAL SUBTYPE
PART 2: OCULAR/VISUAL SUBTYPE
What are the risk factors for Ocular/Visual subtype concussion?
-Family/personal history of ocular dysfunction
Ocular/Visual Symptoms:
- ______ HA driven by visual work.
- Difficulties with visually-based classes, assignments, or activities.
- _______ behind eyes.
- Visual “_____” issues.
- ______/_______ vision
- Frontal HA
- pressure
- “focus”
- blurry/double
How can we distinguish the difference between ocular/visual and cognitive/fatigue HA?
-Ocular/visual tends to be located more near the eyes while cognitive/fatigue is more general HA.
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 _______)
- smooth pursuit, saccades
- convergence difficulties
- accommodative insufficiencies
- binocular visual deficits
- strabismus
- reaction time
- visual memory (encoding rather than retrieval)
_________ is the most frequent exam finding with ocular/visual subtype.
-Convergence
- 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?
- Photosensitivity
- Migraine
- What is strabismus?
- What are the 2 primary types of ocular deviation?
- Misalignment of the eyes/dysconjugate gaze at rest.
- Tropia and Phoria
- What is tropia?
- Exo = ________, Eso = ________
- Hyper = ________, Hypo = ________
- Tropia = over deviation of the eye
- Exo = outward (laterally), Eso = inward (medially)
- Hyper = upward, Hypo = downward
What is phoria?
-Phoria = ocular deviation occurs when dissociation occurs.
______ tend to be present all the time while _______ show up when the eyes get more tired.
-tropia, phoria
Ocular Misalignment If Severe:
- _______
- _____ tilt
- Noticeable ________
Ocular Misalignment If Subtle:
- Difficulty maintaining _____
- Cosmetically _______
- Ocular _______
- ________
- Mental dullness
- Diplopia
- Head tilt
- Noticeable eye turn
- Difficulty maintaining focus
- Cosmetically normal
- Ocular soreness
- HA
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
What are the main complaints of with vergence dysfunction?
-Gaze instability and/or double vision
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
What are (3) common vergence problems?
- Convergence Insufficiency
- Convergence Excess
- Convergence Spasm
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 theeyeto keep an object in focus on the retina as its distance from theeyevaries.
- near
- spasm
- spatial awareness
What does treatment of Ocular/Visual Subtype look like? (2)
- Ocular Motor Training
- Physical Exertion
PART 3: VESTIBULAR, ANXIETY, MIGRAINE SUBTYPES
PART 3: VESTIBULAR, ANXIETY, MIGRAINE SUBTYPES
What are the risk factors of vestibular subtype concussion?
-PMH of car sickness/motion sensitivity, migraine, anxiety
Vestibular Subtype Symptoms:
- ________
- _________
- Nausea
- Overwhelmed in ____________ environments
- _______ impairments
- Vertigo
- Dizziness
- Nausea
- Overwhelmed in visually-stimulating environments
- Balance impairments
Dizziness Post Concussion:
- Dizziness reported in __-__% of concussed athletes.
- Dizziness associated with ___________ recovery.
- Undiagnosed vestibular deficits may delay recovery.
- 55-80%
- protracted
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)
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
What is the most common vestibular injury due to TBI?
-Labyrinthine concussion
Labyrinthine Concussion:
- Ataxia, imbalance, _______ may be present.
- Most common _________ injury due to TBI.
- BPPV
- vestibular
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
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
Hemorrhage Into Brainstem:
- _________ signs, poor smooth pursuit, vertigo, perception of tilt.
- Damage to ________ and _________ nuclei.
- Oculomotor
- vestibular and oculomotor nuclei
Increased ICP:
- Fluctuating _______ loss, ataxia, imbalance.
- May cause peri-lymphatic ________.
- hearing loss
- fistula
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
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.
What 2 other subtypes does Vestibular Subtype coexist with frequently?
- Migraine
- Anxiety
Vestibular Treatment:
- _______!
- Pharmacological as needed (Meclizine, Tricyclic antidepressants, Melatonin, SSRIs)
-Vestibular Rehab Therapy (VRT)!
What are the risk factors for Anxiety/Mood subtype concussion?
- Personal/Family Hx of anxiety
- Migraine
- Vestibular disorders
Anxiety/Mood Subtype Symptoms:
- __________ thoughts
- ______-vigilant
- _________
- Easily overwhelmed
- Difficulties initiating/maintaining __________
- Ruminative thoughts
- Hyper-vigilant
- Fastidious
- Difficulties initiating/maintaining sleep
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.
Anxiety/Mood Subtype Exam:
- Vestibular/Ocular Screen
- _________
- Neurocognitive Test Results
- _________
- normal
- normal
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
What are the risk factors for Migraine Subtype?
- Personal/family Hx of migraine
- “ice-cream headache”
- Motion sensitivity
- Vestibular disorder
- Anxiety
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
- 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
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)
Migraine Subtype Exam:
- Vestibular/Ocular Screen
- __________
- Neurocognitive Test Results
- ______ and ________ memory deficits.
- normal
- Verbal and visual memory deficits.
Migraine Subtype Treatment:
- Medications (pain, sleep regulation)
- Diet
- Stress Management
- Avoid migraine “________” (alcohol, caffeine, poor sleep
-“triggers”
When will we as PTs not treat Migraine Subtype patients?
-When it is in isolation from other subtypes.
PART 4: CERVICAL SUBTYPE, OUTCOME MEASURES, PROGNOSIS
PART 4: CERVICAL SUBTYPE, OUTCOME MEASURES, PROGNOSIS
What are the risk factors for Cervical Subtype?
- Prior c-spine injury
- High-velocity injury
- Strong rotational component to injury
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
What is a good way to remember the HA pattern with cervical subtype?
-LA Rams helmet
Cervical Subtype Exam:
- Vestibular/Ocular Screen and Neurocognitive Test Results are _______.
- …but + ________ screen.
- normal
- + cervical screen
Cervical Subtype Treatment:
- Obtain _________.
- Cervical ____________ exercises.
- Medication (muscle relaxants, anelgesics)
- Injection/nerve block
- Massage, acupuncture
- imaging
- stabilization
10 Most Commonly Reported Symptoms in Post Concussive Athletes.
- ) HA (71%)
- ) Feeling Slowed Down (58%)
- ) Difficulty Concentrating (57%)
- ) Dizziness (55%)
- ) Fogginess (53%)
- ) Fatigue (50%)
- ) Visual Blurring/Double Vision (49%)
- ) Light Sensitivity (47%)
- ) Memory Dysfunction (43%)
- ) Balance Problems (43%)
What are (5) commonly used Sideline Concussion Assessments?
- SCAT5
- Sideline Impact Test
- NFL Sideline Tool
- Standardized Assessment of Concussion (SAC)
- King-Devick Test
What is the gold standard test in determining exercise tolerance in post concussive patients?
-Buffalo Concussion Treadmill Test
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
Buffalo Concussion Treadmill Test Stopping Criteria:
- ) Symptom exacerbation (defined as an increase in ___ or more points on the VAS scale from resting VAS score).
- ) Voluntary exhaustion (defined as an RPE of >___ without significant symptom exacerbation).
- ) 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.
- ) 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
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.
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
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.
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
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.
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
What are the predictors of prolonged recovery with concussions? (6)
- INITIAL SYMPTOMS
- Sex
- Age
- LOC
- Amnesia
- Premorbid comorbidities (psych dx, migraines, vestibular dysfunction)
