1
Q
What is a mTBI (mild TBI)?
A
Primarily a functional (not structural) disturbance of the CNS
- d/t neurometabolic dysfunction, neurotransmitter disturbances, and microstructural changes
2
Q
What induces a mTBI?
A
Biomechanical forces that disrupt physiological brain function
- from direct blow to the head, face, or neck or an impulsive force elsewhere on the body that is transmitted to the head
3
Q
Is LOC required for mTBI diagnosis?
A
NO
4
Q
What is the neurometabolic cascade for concussion?
A
changes on cellular level that create an “energy crisis” leading to FUNCTIONAL damage
- increased permeability of cell leads to increased excitability (linked to photo/phonophobia)
5
Q
Excitatory Phase of Concussion (inital 15 min) (3)
A
- stretching/shearing of cell membrane
- permeability: K+ rushes out, CA+ rushes in
- glutamate release
6
Q
Spreading-Depression Phase of Concussion (0-10 days post) (5)
A
- brain left w/ion imbalance
- energy/ATP demand higher than norm
- leads to energy crisis
- vulnerable to a second mTBI
- inflammatory response may initiate, lead to oxidative stress > excitotoxicity
7
Q
When does the energy crisis occurs? (2)
A
7-10 days after the injury
*glucose is diminished
8
Q
Acute/Symptom associated with Ionic flux in mTBI? (3)
A
Migraine HA
Photophobia
Phonophobia
9
Q
Acute/Symptom associated with Energy Crisis in mTBI?
A
Vulnerability to second injury
10
Q
Acute/Symptom associated with Axonal Injury in mTBI? (3)
A
Impaired cognition
Slowed processing
Slowed reaction time
11
Q
Acute/Symptom associated with Impaired Neurotransmission in mTBI? (3)
A
Impaired cognition
Slowed processing
Slowed reaction time
12
Q
Acute/Symptom associated with Protease activation, altered cytoskeletal proteins, cell death in mTBI? (2)
A
Chronic atrophy
Development of persistent impairments
13
Q
How is mTBI diagnosed? (2)
A
No single diagnostic test
- Primarily review of symptoms, neuro screening
- imaging (CT/MRI) is normal
14
Q
GCS score associated w/mTBI?
A
13-15
15
Q
Recovery timeline - Acute symptomatic (3)
A
0-5 days
- Sx with activity or even at rest
- ATP stores at lowest point
16
Q
Recovery timeline - Recovering (3)
A
2-10 days
- Sx decreasing
- starting to return to normal activity
17
Q
Recovery timeline - Recovered (4)
A
7-14 days
- ATP level back to normal
- no acute symptoms
- can initiate return to activity protocols
18
Q
When you should follow up w/PCP following mTBI is sx do not subside?
A
2 weeks
19
Q
What is the SCAT6? (4)
A
Sports Concussion Assessment Tool
- Adult Version: 13 years and older
- Child Version: 8-12 years
- includes GCS and Maddocks Questions
20
Q
Per SCAT6, what are Red Flags? (11)
A
- neck pain or tenderness
- seizure or convulsion
- double vision
- LOC
- weakness or tingling/burning in more than 1 arm or in the legs
- deteriorating conscious state
- vomiting
- severe or increasing HA
- increasingly restless, agitated, or combative
- GCS < 15
- visible deformity of the skull
21
Q
What is ImPACT testing? (6)
A
FDA approved neurocognitive assessment
- attention span
- working memory
- sustained and selective attention time
- nonverbal problem solving
- reaction time
*common to be documented at baseline and post-injury
*administered by neuropsychologist
22
Q
Pre-existing factors that contribute to prolonged recovery (> 1 month)? (5)
A
- younger age: high school > college > professional
- female
- prior concussions
- psychiatric history
- migraine history
23
Q
At time of injury factors that contribute to prolonged recovery (> 1 month) (3)
A
Loss of consciousness
Delayed removal from play
Acute dizziness
24
Q
Post-injury factors that contribute to prolonged recovery (> 1 month) (4)
A
Symptoms magnitude
Acute neuropsychological changes
Vestibular s/s
Ocular s/s
25
Typical prognosis of mTBI (2)
"Average" 7-14 days
- realistically, closer to 3-4 weeks
26
What is Persisting Post Concussion Symptoms (PPCS) or Post Concussive Syndrome (PCS) (3)
Symptoms lasting > 4 weeks in adults, adolescence and children
*LOC is not a criteria
* Injury severity is not linked to developing PPCS
27
What % of concussions result in PPCS?
10-30%
28
What is second-impact syndrome?
2nd injury before recovery of 1st head injury
29
What can result from second-impact syndrome?
severe cerebral edema with potential brain herniation
30
What is Chronic Traumatic Encephalopathy (CTE)
Neurodegenerative disease linked w/repetitive mTBI
*most evidence found in boxers post-mortem
31
What are symptoms of CTE? (4)
- behavior/mood problems
- impaired cognition (memory, executive function)
- HA and dizziness
- parkinson-like motor symptoms
32
What are the 3 main domains of mTBI?
1. Physical
2. Cognitive
3. Behavioral/Emotional
33
Physical Symptoms of mTBI (12)
**HA
** Dizziness
** Neck pain
- N/V
- Balance deficits
- Fatigue
- Eye strain
- Visual difficulties
- Sleep disturbances
- Light sensitivity
- Noise sensitivity
- Hearing loss/deficit/tinnitus
34
Cognitive symptoms of mTBI (3)
- feeling confused or foggy
- difficulty concentrating
- memory disturbance
35
Behavioral/Emotional symptoms of mTBI (6)
- depression
- anxiety
- agitation
- irritability
- impulsivity
- aggression
36
What are the two associated conditions that may occur with concussion clinical profiles (trajectories)?
1. Sleep Dysfunction
2. Cervical dysfunction (exacerbate vestibular, ocular, migraine)
37
What are the 5 concussion clinical profiles?
1. Vestibular
2. Ocular
3. Migraine
4. Mood/Anxiety
5. Cognitive
38
Vestibular Profile (5)
*Dizziness
- nausea/motion sickness
- "one step behind" in their environment or if move quickly
- symptomatic in busy enviormentmenvts
- off balance
39
Ocular profile (5)
- difficulties w/visually based classes/activity
- eye strain or fatigue
- blurry or double vision
- frontal HA or report pressure behind eyes
- problems with concentrating or completing written/typed work
40
Migraine Profile (4)
- HA w/pulsating quality
- aura associated w/nausea, vomiting and sensitivity to light, sound or smell
- sleep dysregulation
- motion sickness
41
Mood/anxiety Profile (5)
- hyper vigilance of symptoms, excessive focus on their symptoms
- depression
- overwhelmed state (poor tolerance of busy environments)
- difficulty initiating and maintaining sleep (inability to turn "off: thinking)
- limited socialization - withdrawal will exacerbate sx
42
Cognitive Profile (5)
- faitgue, reduce energy
- headache with cog or physical activity
- feels best in AM, end of day sumptoms are worse
- possible sleep deficits which exacerbate
- generalized reduced cog impairments - attention, memory, time management
43
Associated Conditions - Sleep Disturbance
- difficulty initiating/maintaining quality sleep
- excessive or inadequate somnolence
- cause daytime fatigue, drowsiness
44
Associated Conditions - Cervical Strain (3)
- neck pain, stiffness, tenderness
- occipital/suboccipital HA
- UE weakness or radicular sx
45
4 main areas of PT examination (4)
- cervical-musculoskeletal
- vestibulo-oculomotor
- autonomic/exertional tolerance
- motor function
46
PMHx Considerations (4)
- ADHD
- migraine
- visual issues
- psychiatric conditions
*risk issues for prolonged recovery
47
mTBI screening red flags - cervical (2)
- instability (Alar ligament or sharp-purser)
- vascular (modified VBI)
48
mTBI screening red flags - vestibular (1)
- superior canal dehiscense (tragal pressure or valsalva)
49
mTBI screening red flags - neurologic (4)
- UMN signs (Hoffmans/Babinski)
- focal weakness/sensory
- Spurling's test
- coordination testing (RAM, FTN)
50
What is the Post-Concussion Symptom Scale (PCSS)
Test to provide initial impression of current sx and severity
- 21 items; 7-pt Likert scale
- higher score is worse sx
- 4 subscales (physical, cog, sleep, emotional)
51
What is the MCID for the Post-Concussion Symptom Scale (PCSS)?
26.5 pts
52
What is the Rivermead Post-concussion Symptom Questionnaire?
Test to measure the severity of post-concussive symptoms
- 16 items; 5-pt Likert scale
- higher is worse
- 3 domains (physical, cog, behavioral)
53
Score interpretation of the Rivermead Post-concussion Symptom Questionnaire? (2)
> 3 sx present at 3 months indicates diagnostic criteria for post-concussion syndrome (PCS)
> 35 predictive of mod-severe limitation in abilities, adjustment, and participation in daily activities
54
What are the components of a vestibular assessment for mTBI? (9)
Need to confirm central and peripheral involvement
- oculomotor
- convergence
- saccade
- smooth pursuits
- VOR cancellation
- BPPV
- Head impulse
DVA
DHI outcome
55
Are there positive central findings in the vestibular assessment for mTBI?
May be negative but still cause symptoms (HA, blurry, foggy, nausea)
56
What is purpose of the Vestibular Oculo/motor Screening (VOMS)?
Used to screen pts w/concussion for symptoms triggers/exacerbations
57
What are the 5 areas of impairment in the Vestibular Oculo/motor Screening (VOMS)?
1. Smooth pursuits
2. Saccadic or rapid-eye movements
3. Near point of convergence
4. Vestibular Ocular Reflex
5. Visual Motion Sensitivity
58
Score interpretation of the Vestibular Oculo/motor Screening (VOMS)?
> 2 on any symptom
OR
> 5cm convergence distance
*indicates cutoff for concussion
59
What is the Balance Error Scoring System (BESS)?
Assessment of static postural control in brain injury
- 6 conditions (barefoot, e/c, hands on hips 20s ea)
- timed trials but counting "errors" from starting test position
- allowed up to 10 errors per position
- score from 0-60
60
Score interpretation of the Balance Error Scoring System (BESS)?
Lower scores indicate better balance and less errors
61
What are the Exertional/Aerobic Assessments?
Buffalo Concussion Treadmill Test
Modified Buffalo Concussion Bike Test
62
What is the Buffalo Concussion Treadmill Test? (4)
Test to assess physical activity tolerance post-concussion
- screen for health/function of autonomic nervous system
- HR, RPE< and symptoms recorded at baseline, every min while progressively inclining the TM by 1% every min
- static speed in maintaining and determined by the person's heigh
63
When is the Buffalo Concussion Treadmill Test terminated? (3)
Max HR or RPE of 19 reached
OR
symptoms increase greater than 3 pts on VAS
OR
new symptoms start
64
When would you use the Modified Buffalo Concussion Bike Test?
Option if vestibular sx are too severe
65
What are the components of a cerivcal assessment for mTBI? (5)
NDI outcome
AROM
Passive upper cervical mobility (OA: flex/ext and slight lateral flex; AA: rotation)
Soft tissue palpation (UT, parascapular, sub-occipital area)
Postural assessment
66
What are Cervical spine functional PT exams? (2)
1. Deep Cervical Flexor Endurance Test
2. Joint Position Error Test
67
Norms for Deep Cervical Flexor Endurance Test
M: 39s
F: 29s
68
Norms for Joint Position Error Test
< 7 cm
69
What are the tests for Cervicogenic Dizziness? (3)
- Cervical Torsion Tests
- Smooth pursuit neck torsion test
- head-neck differentiation test
*performed on a swivel stool
70
How to perform cervical torsion test?
E/c, head is still w/45 deg trunk/body rotation
(+) if pt reports dizziness, visual disturbances
71
How to perform smooth pursuit neck torsion test?
smooth pursuit performed w/trunk/body rotated to R and L
(+) if pt reports dizziness in torsion position
72
How to perform head-neck differentiation test?
E/C, head still with alternating 45 deg body turns
(+) if pt reports dizziness, vision changes
73
Mood Outcomes (3)
- Hospital Anxiety and Depression Scale
- Beck Depression Inventory
- Generalized Anxiety Disorder-7 Scale
74
Cut off for MOCA (cognitive changes in older adults)
< 26
75
MDC for MOCA (cognitive changes in older adults)
4 pts (in mixed conditions)
76
How is convergence insufficiency trained?
Brock's string or pencil push-ups
77
Can you train saccades and smooth pursuits?
Yes
78
Aerobic training guidelines
20 min on treadmill at 80% of threshold HR
5x/week
*progressively increase intensity by 5 to 10 beats per/min every 2 weeks as long as sx do not worsen
79
Sleep Dysfunction Strategies (6)
- avoiding daytime naps
- regulating wake time and bedtime to allow for 7-9 hours of sleep
- relaxation strategies
- restricting caffeine
- avoiding technology, exercise, and other stimulation before bedtime
- regulating the temperature set for a cool room
80
For the Return-to-sport (RTS) strategy, ea step typically takes how long?
1 day
81
What is step 1 of Return-to-sport (RTS) strategy?
Symptom-limited activity
*daily activities that do not exacerbate symptoms
82
What is step 2 of Return-to-sport (RTS) strategy?
Aerobic exercise
2A - light (up to ~55% maxHR) than,
2B - moderate (up to ~70% maxHR)
83
What is step 3 of Return-to-sport (RTS) strategy?
Individual sport-specific exercise
*may need medical clearance prior to initiation of this step
*away from the team environment
84
When should steps 4-6 of Return-to-sport (RTS) strategy begin?
After the resolution of any symptoms, abnormalities in cog function, and any other clinical findings related to condition
85
What is step 4 of Return-to-sport (RTS) strategy?
Non-contact training drills
86
What is step 5 of Return-to-sport (RTS) strategy?
Full contact practice
87
What is step 6 of Return-to-sport (RTS) strategy?
Return to sport
88
How to determine if someone is appropriate to progress to next step in Return-to-sport (RTS) strategy?
Complete prior step for at least 24 hours
*If symptoms in step 1, complete for additional 24 hours
NCS
flashcards
Decks in class (26)
# Cards
-
Parkinsons Disease114
-
Cerebellar Dysfunction106
-
Spinal Cord Injury I100
-
Neuro Anatomy59
-
Disorders of the Basal Ganglia84
-
Multiple Sclerosis89
-
Spinal Cord Injury II100
-
Spinal Tracts58
-
Spinal Cord Injury Interventions96
-
Vestibular Systems I88
-
Vestibular Dx and Interventions95
-
Brain Injury I132
-
Brain Injury II47
-
Concussion88
-
Brain Tumors53
-
Brain Infection22
-
Psychiatric Disorders, Alzheimer's, and Dementia33
-
ALS64
-
Stroke I108
-
Stroke II102
-
Polio and Demyelinating Diseases70
-
Orthosis and Prosthesis88
-
Wheelchair Seating and Mobility73
-
Muscle Diseases87
-
Pediatrics67
-
Outcome Measures51
