Concussion/Headache

Question 1

CPG Definition of Concussion

Answer 1

Traumatic injury that affects the brain, induced by biomechanical forces transmitted to the head by a direct blow to, or forces exerted on, the body, but that does not result in an extended period of unconsciousness, amnesia, or other significant neurological signs indicative of a more severe brain injury

Question 2

ACRM Definition of Mild TBI

Answer 2

TBI is diagnosed when, following a biomechanically plausible mechanism of injury one or more of the three operational definitions listed below are met:
1. One or more clinical signs
attributable to brain injury
2. At least two acute symptoms and at lease one associated clinical or laboratory finding
3. Neuroimaging evidence of TBI

Question 3

Glasgow Coma Scale - Mild

Answer 3

• GCS 13-15
• Loss of consciousness less than 30 minutes
• PTA less than 24 hours

Question 4

Glasgow Coma Scale - Moderate

Answer 4

• GCS 9-12
• Loss of consciousness 30 minutes to 24 hours
• PTA less than 24 hours

Question 5

Glasgow Come Scale - Severe

Answer 5

• GCS 3-8
• Loss of consciousness greater than 24
• PTA greater than 24 hours

Question 6

What are most concussions due to?

Answer 6

Falls

Question 7

Biomechanical Cascade

Answer 7

Excessive glutamate release –> excessive accumulation of extracellular potassium –> influx of high concentrations of sodium and calcium –> acute increase in glucose metabolism

Question 8

End result of biomechanical cascade

Answer 8

High glucose need + low glucose delivery = energy crisis

Question 9

Neurometabolic dysregulation

Answer 9

• We used up the glucose and not enough is coming in
• Problems persist for days after initial concussive event
• Most people will. recover symptoms in 7-14 days
• Calcium is high then crashes about day 4

Question 10

Resulting pathophysiology of concussion

Answer 10

• Mitochondrial dysfunction
• Axonal damage due to mechanical force
• Neurochemical imbalance resulting in damage to cytoskeleton
• Unmyelinated nerve fibers more vulnerable to damage
• Upregulation of inflammatory cells
  = CELLULAR DYSFUNCTION

Question 11

Impairments in cerebral blood flow

Answer 11

• 1st 48 hours = decreased cerebral blood flow
• 8 days post = global expansion of decreased blood flow –> wide range of symptoms –> risk of re-injury

Question 12

5 parts of screening and examination

Answer 12

• Screening for red flags
• Neurologic Exam
• Cardiovascular/autonomic
• Musculoskeletal
• Vestibular

Question 13

Screening/ Diagnosis

Answer 13

• Recommended for all individuals who may have experienced a concussive event
• Importance of early recognition
• Recognize medical emergencies or severe pathology
• Use of symptom checklists or rating scales
• Refer or proceed to full examination as appropriate

Question 14

Look at the signs and symptoms slide (14) if you want to

Question 15

Red Flags

Answer 15

► Declining level or loss of consciousness, cognition,
or orientation (GCS < 13)
►New onset of pupillary asymmetry, seizures,
repeated vomiting, or other focal neurologic signs
►Severe or rapidly worsening headache or neurologic deficits
►Signs/symptoms indicating undiagnosed skull fracture
►Serious cervical spine fracture, dysfunction, or
pathology

Question 16

Indicators for concussion

Answer 16

• Consider information from patient, family, witnesses
• Alteration in mental state immediately following event
• Physical symptoms
• Emotional/behavioral symptoms
• GCS
• Imaging if available
• possible effects of substances or medications
• Other medical diagnoses

Question 17

Early Management

Answer 17

• Relative Rest
• Typical timeframe for recovery 7-14 days in adults, 4 weeks in children
• Non-linear progression of recovery

Question 18

Is PT Concussion Exam indicated?

Answer 18

• Comprehensive intake interview
• Signs of MSK, vestibulo-oculomotor, autonomic/ exertional or motor function impairments
• Physical function goals
• Education only?
• Is referral to other providers indicated

Question 19

Interview/ History

Answer 19

Type, severity, and irritability of concussion symptoms
* Past medical (and mental) health history
* Injury mechanisms
* Any early management strategies

Question 20

4 parts of examination and evaluation

Answer 20

• Cervical Muskuloskeletal
  Function
• Vestibul-oculomotor Function
• Autonomic
  Dysfunction/Exertional Tolerance
• Motor Function

Question 21

What do you prioritize the examination based on?

Answer 21

• Irritability

Question 22

irritability

Answer 22

• Frequency of provocation
• Vigor of movement required to elicit symptoms
• Severity of symptom once provoked
• Ease of provoking symptoms
• Factors that ease symptoms
• How much, how fast and how
  completely symptoms resolve

Question 23

Cervical Spine Examination

Answer 23

• Standard MSK exam
• Elements of Vestibular Exam – positional testing, DVA, head shaking
• Joint Position Error Testing
• Outcome Measures
• Proceed as Tolerated

Question 24

Vestibular examination

Answer 24

• Oculomotor Exam
• Positional Testing
• Vestibular Exam (VOMS)
• Optokinetics
• Outcome Measures
• Proceed as Tolerated – least to most provoking and prioritized based on patient’s goals

Question 25

Autonomic/Exertional Testing

Answer 25

* Identify signs/symptoms that are not present at rest * Positional testing of heart rate and BP in supine, sitting, standing * Graded exertional testing: stationary vs treadmill

Question 26

When to stop exertion test

Answer 26

When there has been a three point or greater increase in any symptom

Question 27

How do you get target heart rate?

Answer 27

whatever their HR is when you stop the test, their target HR is 80% of that

Question 28

Motor function examination

Answer 28

* Postural Control – static, dynamic, reactive * Dual Tasking * Gait * Motor coordination * Outcome Measures

Question 29

Psychological and Sociological Factors

Answer 29

* Patient’s coping mechanisms or self-efficacy skills * Social support systems * Risk factors for prolonged recovery * Patient’s beliefs about recovery * Equipment access and other resources

Question 30

International Classification of Headache Disorders

Answer 30

- Migraine without aura - Migraine with aura - Headache attributed to trauma or injury to the head and/or neck - Cervicogenic Headache - Vestibular Migraine

Question 31

Interventions - Education

Answer 31

* EXPECTATION IS RECOVERY * Risk for re-injury * Rest x 24-48 hours with gradual reintroduction of activity without symptom exacerbation * Self-management strategies * Activity pacing and return to activity * Safe to initiate intervention early

Question 32

Self Management

Answer 32

* Minor symptoms * Good social support * Few to no negative risk factors * Good health literacy and self-efficacy * Patient preference * Access to resources/ equipment * Education on symptom management

Question 33

Interventions in cervical spine

Answer 33

* ROM * Soft tissue mobilization * Strengthening * Modalities * Posture * Sensorimotor * Neck Pain CPG guidelines

Question 34

Interventions - Vestibulo-occular motor

Answer 34

* Oculomotor training * Canalith repositioning manuevers as indicated * Gaze Stabilization * Gaze Shifting * Habituation strategies * Referral as indicated for oculomotor impairments

Question 35

Interventions - Autonomic/Exertional Tolerance

Answer 35

- Progressive, symptom guided monitored aerobic exercise - Referral as indicated

Question 36

Interventions - Motor Function

Answer 36

* Static and dynamic balance * Motor control/coordination * Dual Tasking * Task specific

Question 37

Validated measures for pediatrics

Answer 37

- Graded symptom checklist (6+) - Post concussion symptom scale (high school)

Question 38

time frame for recovery in peds

Answer 38

1-3 mo

Question 39

Is balance training good for children?

Answer 39

- probs not but its useful in older adolescent athletes

Question 40

Prognosis

Answer 40

* Coping Strategies * Support Systems * Risk factors for delayed recovery: mental health and/or substance use disorders * Patient perspective/ understanding towards recovery * Access to resources and equipment to support recovery

Question 41

Pediatric risk factors

Answer 41

* Pediatrics: history of mTBI, learning difficulties, psychiatric disorders, family or social stressors, more symptoms or more severe symptoms

Question 42

Post concussive syndrome

Answer 42

Presence of any symptom that cannot be attributed to a preexisting condition and that appeared within hours of an mTBI, that is still present every day 3 months after the trauma, and that has an impact on at least one sphere of a person’s life.

Question 43

Risk factors for prolonged recovery

Answer 43

* Female Sex * Younger age (teenage years) * Increased severity of acute and subacute symptoms * Loss of consciousness * Mental health symptoms (depression, ADHD) * Personal history of migraine

Question 44

Recovery

Answer 44

* Resolution of symptoms and exam findings, and return to usual activities * Physiologic recovery may extend beyond the period of symptom resolution

Question 45

Risk of Multiple lifetime concussions

Answer 45

* Post-Concussive Syndrome * Chronic Traumatic encephalopathy (Chronic progressive disorder --> only diagnosed definitely post-mortem) * Alzheimer's Disease * Other degenerative neurologic disorders have mixed evidence