Concussion

What is concussion classified as?

mild traumatic brain injury

Concussion Definition

complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces secondary to DIRECT OR INDIRECT forces to the head

What causes concussion?

jolt to the head or body that disrupts the function of the brain

Concussion imaging

normal structural neuroimaging findings - CT/MR are insensitive to concussion

CONCUSSION IS CLINICAL DIAGNOSIS

Concussion symptoms + symptoms duration

constellation of physical, cognitive, emotional or sleep-related symptoms that may or may not involve LOC

duration highly variable last various amounts of time

Concussion pathophysiology

axons stretch --> K+ leaks out of neurons and Ca2+ influxes into neurons ---> metabolic dysfunction--> energy crisis --> vulnerable neuron that could die or undergo irreversible serious cell damage with further injury or stress

what type of brain injury is a concussion?

metabolic rather than structural

What do biomarkers and advanced imaging not show?

when concussion occurred

when individual healed from concussion

all done clinically

Diagnosis of concussion and recovery monitoring

sideline/acute assessment

sx assessment *****

neurocognitive testing

vestibular/ocular testing

balance testing

Acute management of concussion (0-3 days)

remove from risk

moderate (do not want increased energy demand with decreased blood supply --> metabolic crisis) physical and cognitive activity (DO NOT ELIMINATE) as needed - accommodations as needed

REST BASED IS NOT PRESCRIBED

are there "playing through" a concussion consequences?

yes - continuing to play DOUBLED recovery time

better to sit out for shorter period than risk sitting out longer if play now

does the initial hit matter?

not a reliable predictor of concussion or concussion severity

what on field signs/symptoms are most important in predicting recovery after concussion? what is the ding ding ding predictor?

Post Traumatic Amnesia

Retrograde Amnesia

Confusion

Dizziness ************** - this is the predictor of longer recover

Headache

Loss of Consciousness - protective faster healing

Numbness

Visual Problems

Balance Problems

Fatigue

Personality Change

Light/Noise Sensitivity

Vomiting - protective faster healing

pre-existing risk factors to include in evaluation

Sex (female)

Age (Adolescents and

Older Adults)

Migraine Hx

Vision Dysfunction

Mood Disorders

Concussion History

Learning Disabilities/ADHD

injury-specific risk factors to include in evaluation

Removal from Play

On Field Dizziness

post injury risk factors to include in evaluation

Migraines

Vision Dysfunction

Anxiety/Mood Disorders

High Symptom Burden

*Multiple Areas Involved

Post-acute management

active treatment

early physical activity at appropriate level and treatment of specific deficits

identify clinical profiles to assist in tx prescription.

are all concussions the same?

no they are heterogenous and have different clinical presentations - like snowflakes :)

primary concussion profiles

vestibular

ocular

cognitive

anxiety/mood

post-traumatic migraine

rarely occur in isolation - but find key drivers to start managment

vestibular profile common features

Dizziness

Nausea/Motion sickness

"One-step behind"

Symptomatic in busy environments

Off-balance

ocular/visual profile common features

more of a motor problem

Frontal headache w/ visual work

Difficulties with visually based classes & activity

Pressure behind the eyes

Visual "focus" issues

Blurry vision

Double vision

anxiety/mood profile common features

Hypervigilence, rumination

Overwhelmed (poor tolerance of busy environments)

Difficulty initiating sleep (unable to turn thoughts off)

Difficulty maintaining sleep

Excessive focus on/inventory of symptoms

Limited socialization

post-traumatic migraine profile common features

Variable headache and intermittently severe

Often wake with headache

Nausea, photo and phonophobia

Stress, anxiety, lack of exercise

Sleep dysregulation

May also present with Vestibular Migraines

cognitive/fatigue profile common features

Fatigue, reduced energy

Feels best in am; headache w/ cognitive & physical activity

"End of day" symptoms

May have sleep deficits

Cognitive impairment - generalized

components of concussion evaluation

symptoms/history

cognitive

vestibular

ocular/visual

cervical

exertion

problem with symptom checklists

sx checklists are self reported ranks of 0-6 and completed before eval but they are under-reporting and magnification are common

purpose of neurocognitive testing

Assists in determining presence/severity of concussion and establishing recovery from concussion

most useful when have baseline testing for comparison - do not use alone

example of computerized neurocognitive testing

imPACT test

keys to successful concussion

recognition

removal

eliminate from risk exposure (but do not only rest)

evaluate

manage based on clinical profile

manage with multidisciplinary approach

ACTIVE TREATMENT IS KEY

what are the most common profiles?

anxiety and migraines

VOMS - what is included

scaled down version of vestibular exam to measure distinct constructs and helps diagnose concussion through screening mechanisms

includes:

pre-test symptom assessment

horizontal and vertical pursuits and saccades

near point convergence - average 3x

horizontal and vertical VOR

visual motion sensitivity (VOR cancellation - normal but looking for sx reproduction)

following each assessment rate symptoms

VOMS in the control group

minimal to no symptoms compared to the large symptom reproduction of concussed individuals

interpreting VOMS for an individual with a concussion

VOMS symptom (dizziness, headache, nausea, fogginess) scores >2 and NPC distance >5cm represent clinically useful cut-offs for identifying a concussion

are hypermetric saccades associated with concussion?

no they are abnormal but not associated with concussion but rather cerebellar

convergence spasm findings

spontaneous convergence

pupillary constriction

inability to abduct eyes with gaze testing

what is accommodation?

Ability of the eyes to focus properly on a near target

age-dependent (normal to have issue >30)

accommodation insufficiency

Amplitude of accommodation is lower than expected for the patient's age

how to test accommodation?

one eye test - bring 14 point font in until they report sustained blur

<30 should achieve at least 15cm

what happens to ocular misalignment after concussion?

decompensates these alignments - does not create them

characteristics of post-traumatic BPPV

more complex - more than one place and more than one ear

abnormal VOR x1

Unable to maintain eye position on target as head moves

Target becomes blurry, unreadable, or does not stay stationary with head motion

concussion VOR x1

symptomatic - provokes dizzy, nausea, and other abnormal sx but can keep target in focus

is visual motion sensitivity central or peripheral problem?

central - abnormal sensitivity with visual/vestibular interaction

what does visual motion sensitivity coexist with?

migraine and/or anxiety

VOR x1 with sx but able to maintain view on target - peripheral or central

central

goals of vision therapy

1. Improve eye coordination (binocular vision), important for depth perception, reading, and preventing diplopia.

2. Enhance smooth and accurate saccades and pursuits essential for reading, sports, and other activities

3. Strengthen eyes to maintain focus (accommodation), especially during near tasks like reading and computer work

4. Enhance visual processing critical for reading,

writing, and cognition.

we try first before ophthalmologist

who benefits the most from vision therapy?

patients with normal ocular alignment or phoria

PT exercises for convergence insufficiency

Pencil Pushups

Brock String

3 Dot/Barrel Cards

Eccentric Circles

Lifesaver Cards

PT exercises for oculomotor dysfunction (pursuits, saccades)

HART chart - column jump

reading

spot the difference - for pediatrics

PT exercises for accommodative insufficiency

HART Chart -near far

what is exertion therapy

Closely monitored exercise regimen to allow patient to actively recover to limit negative effects of rest

An individualized program specific to patient needs and impairments

pathophysiology to support exercise post concussion

mTOR: Facilitates cell growth and protein synthesis

BDNF: Facilitates synaptic plasticity

PGC 1a: increases the aerobic function of the cell and facilitates mitochondrial biogenesis

moderate to vigorous physical activity affects on recovery

More moderate to vigorous physical activity (70-100% max heart rate) time was associated with faster symptom resolution time

aspects of exertion therapy evaluation

History - MOI, HPI, risk factors, sx, work/school demands, physical activity since injury (do not want straight up rest)

Cardiorespiratory Screen - BP/HR

Cervical Screen

Exercise Testing

Education

HEP

is ANS response trainable?

yes - why physical activity is so important after concussion

concussions affect on central autonomic nervous system and the heart

Reduced ability to maintain and adjust cerebral blood flow

Difficulty regulating blood pressure, and/or heart rate in response to increases and decreases activity

signs of ANS dysfunction

changes in temp, light exposure, level of alertness, response to eating, postural changes, regulating blood pressure, GI movement and secretion, body temperature and metabolism

consensus for early physical activity for concussion

24-48 hours as tolerated light activity

walking or stationary cycling while avoiding risk of contact, collision or fall

based on heart rate threshold

does not elicit more than lid and brief sx exacerbation

what does the Buffalo Concussion Treadmill Test give us?

heart rate threshold

goals of vestibular training

Habituation Training

Gradual exposure to provocative interventions

progressions of treatment for mood

TREATMENT SHOULD BE AGGRESIVE

Minimal attention to symptom reports

Exposure/recovery model

Exertion is key

AVOID AVOIDANCE BEHAVIORS - SHOW THEM ITS OK

goals of training for mood

Return to prior activities

Return to prior social engagements

DO NOT reinforce avoidance behaviors

exercise and migraines

Aerobic exercise is an effective management strategy for episodic and chronic migraine

migraine training goals

Gradual exposure to provocative interventions

Sub-migraine threshold

• Low- moderate level physical activity can be migraine

preventative

• High intensity level physical activity may be migraine

trigger

cognitive/fatigue training goals

Gradual exposure to provocative activities

ocular training goals

Return to prior level of physical activity ASAP

chicago blackhawks test

bike first, plyometric seconds

was able to determine those who were asymptomatic who were not ready for return to sport

standardized assessments for return to play used at UPMC

ImPACT-Neurocognition

VOMS- Vestibular and Ocular function

PCSS-Symptoms

EXIT- physical readiness to return to play

abnormal EXIT test

ANY change in symptoms with testing

if start with sx but these don't change - normal response