KNES 505 Midterm 2

Given the heterogenous nature of concussion, what kind of approach is warranted to treat concussions?

Interdisciplinary approach including a variety of health care professionals

Who is included in a collaborative team approach to treat concussions and optimize care?

• Sport medicine physicians

• Physiotherapists

• Family physicians

• Physician specialists

• Psychologists

• Athletic therapists

• Neurologists

• Neuropsychologists

• Other health care professionals

What is physiotherapy?

Treatment to restore, maintain, & make the most of a patient's mobility, fx, & wellbeing

What does physiotherapy incorporate?

• Physical rehab

• Injury prevention

• Health & fitness

Physiotherapists get you involved in your own recovery.

How are physiotherapists an integral part of the interdisciplinary team?

They possess a unique skillset that can inform recognition of concussions on the field of play, inform differential diagnosis of concussions, early management, re-evaluation & rehabilitation of physical ramifications of concussions across the continuum of care in the clinic & facilitate return to sport & school

What does the precise role of the physiotherapist depend on?

Locations

Expertise & competency that the physiotherapist has in each context (specializations)

What ensures a coordinated & comprehensive approach to care?

Working collaboratively w the treating physician & other health care professionals

What is the vital first step in developing a relationship w a patient?

Structured history

Gain a clear understanding of the injury, the level of risk for persistent symptoms, & to develop a hypothesis driven examination

What must be thoroughly investigated in terms of hx?

Patient's past medical, social, & prior concussions hx

What are the principal goals when understanding the current concussion?

The mechanism of injury, the initial & ongoing symptom presentation, what medical mgmt has been recommended, & any risk or prognostic factors that may contribute to a prolonged recovery

What is the emerging research of physiotherapy mgmt for dizziness post-concussion?

Positive outcomes of the cervical spine & vestibular/balance systems

Participants who received an individualized multimodal cervical & vestibular physiotherapy mgmt were how much more likely to be medically cleared to return to sport by 8 weeks than those treated w the control intervention?

3.91 times

(95% CI 1.34 to 11.34)

What are some of the causes of dizziness?

• Underlying migraine/tension headaches

• Cervical issues

• Vestibular impairments

• CNS/autonomic impairments

• Psychogenic

• Vascular/CBF challenges

• Medication complications

• More than 1 cause & multiple diff subcategories

What is the vestibulo-ocular reflex (VOR)?

Responsible for maintaining stable vision during head motion

Important in sport settings

Can be impaired following concussions

What is peripheral vestibular hypofx?

Relative imbalance of input from peripheral vestibular apparatus leads to relative excessive input to intact side of vestibular nucleus results in vertigo & imbalance

• 10% show peripheral vestibular hypofunction (trauma to labryth)

What is the head thrust test (HTT)?

• Slight nod

• Unpredictable

• Small amount of rotation only

Neg: eyes stay on the target (GOOD)

Pos: corrective saccade observed toward the side of the thrust (eyes move with head, then correct)

What does the HTT assess?

Eye tracking w head movement

What is dynamic visual acuity (DVA)?

Slight nod

ETDRS chart

Metronome set at 2 Hz

20 degrees rotation

13 feet from the target

Static visual acuity: lowest line read w head still

DVA: lowest line read w head moving

What is the Hallpike-Dix test?

Patient long sitting

Head rotated 45 degrees

Examiner assists to bring head & trunk into supine position with head handing at 30 degrees

• head in line with tested canal = feel vertigo

• only 1-3 treatments

• for BPDP (crystals dislodged into semicircular canals)

What does the Hallpike-Dix test assess for?

Benign paroxysmal positional vertigo (BPPV)

What can be predictors of PPCS?

Positive tests for dizziness/neck pain/ocular motor fx

What is the #1 symptom reported after concussion?

Headaches

How many patients experience headaches post concussion?

25-90%

What is the lifetime prevalence post-traumatic headache (PTH)?

4.7% in men & 2.4% in women

How many ppl experience persisting PTH following concussion?

15-75%

How many ppl w headaches still experience headaches at 4 yrs post-injury?

Up to 20%

What are the 6 types of heaches?

1. Cervicogenic

2. ANS/tension

3. Migraine

4. Occipital neuralgia

5. Ocular

6. Medication overuse (rebound)

What is a cervicogenic headache?

• Often associated w neck tension, neck pain, & a pulling/whiplash feeling (damage radiating up neck)

• Most often felt in posterior portion of the head

• may present in MRIs (bulging/herniation)

What is an ANS/tension headche?

• Can be associated w imbalance of sympathetic & parasympathetic innervations (band around head)

• Often felt as a band around the head & can be linked w challenges in neurovascular coupling

• may be due to blood flow in the head

What is a migraine?

• Typically presents as an extreme, stabbing pain on 1 side of the head (or the other), generally near the top of the head

• Often seen in individuals who have a predisposition to (or family history) of migraines

• Can occur w & w/out 'aura' (warning sign of migraine such as seeing spots/flashing lights)

What is an occipital neuralgia headache?

• Often an undiagnosed cause of head & neck pain that can occur from whiplash &/or concussion

• Can have severe stabbing pain in the greater occipital nerve region (back side of head)

• Can be diagnosed & treated w an occipital nerve block

What is an ocular headache?

• Often felt as a pounding, pulsing or throbbing pain behind the eye

• Can be associated w sensitivity to light, noise &/or odours

• related to hypertension/ANS headaches

What is a medication overuse (rebound) headache?

• Typically caused by patients taking too many analgesic medications

• As medication wears off, the headache pain increases & this may be unrelated to the concussion

• If suspected, medication detoxification should occur

What links most headaches?

Neurovascular coupling

In terms of involvement of cervical spine in headaches, what types of symptoms may be experienced?

Neck pain

Cervicogenic headaches

Cervicogenic dizziness

In terms of involvement of cervical spine in headaches, what may be the source of pain/dysfx?

Joint

Myofascial

Nerve

Sensorimotor

Neuromotor control

Higher centres

Psychological distress

What does a typical ax of the cervical spine include?

Biomech exam

Cervical flexor/extensor endurance test

Cervical flexion rotation test

Joint position error

Head & neck position sense

Head perturbation test

Craniocervical flexion test

How is sensorimotor control assesed?

Cervical proprioception

Postural control

Eye movement control

How is cervical proprioception assessed?

Joint position sense

Cervical movement accuracy

How is postural control assessed?

Standing balance

Dynamic & fx'al movement

What are 3 tests for the pos prediction rule - facet joint mediated pain?

Manual spinal exam (MSE)

Palpation - segmental tenderness (PST)

Extension rotation test

What is included in a multifaceted ax?

Symptoms

Neurological screen

Cognition

Cervical spine

Vision

Balance/vestibular

Exertion

What are 9 tests that measure cervical, vestibular, dynamic balance w tasks of divided attention?

Cervical flexor endurance

Cervical flexion rotation test

Cervical rotation side flexion test

Head perturbation test

Clinical DVA

Computerized DVA

Fx'al gait ax

Walk while talk test

What are the 5 R's for concussion mgmt?

Rest

Rehab

Refer

Recovery

Return to sport

What do multifaceted ax's lead to?

Targeted treatment in a multidisciplinary collaborative setting

What does the evidence say for concussion mgmt?

Multimodal approach

Manual therapy & exercise

Specific exercises

Sensorimotor

What is vestibular rehab?

1. Canalith repositioning maneuvers (mechanical problem)

2. Habituation exercises (desensitize the brain with specific movements)

3. Gaze stability retraining (vestibulooccular reflex training)

4. Static & dynamic balance retraining

5. Substitution

What does progressions for concussion mgmt consider?

Repeated exposures

Deliberate practice

Context specific

What did Kathryn Schneider describe the progressions for concussion mgmt as?

Plain background

Busy visual environment (plaid/polka dots, TV screen, crowds)

Distracted environment (carry on conversation, problem solving)

Alter afferent input (eyes closed, unsteady ground, smaller base of support)

Combinational

What does the 2023 CISG say about dizziness, neck pain, &/or headaches?

Cervicovestibular rehab for individuals who have sustained an SRC & reports symptoms for longer than 10 days

• Vestibular rehab, active rehab, & collaborative care for adolescents with persisting symptoms following SRC

What are intrinsic risk factors for concussions?

Previous concussion

Pre-existing symptoms

Player weight

Sex

Age

Neuromuscular control

What are extrinsic risk factors for concussions?

Psycho-social

Sport

Session type

Equipment

Rules of the game

Level of play

Position

What do physiotherapists focus on?

Not only on the evidence around sensitivity & specificity of diagnostic concussion tests, but also on the best evidence around assessment & targeted treatment of the relevant domains that may be impaired

What is the physiotherapy community a major part of?

The catalyst for a paradigm shift in our conceptual & practical framework of concussion mgmt, in all its complexity

What are the conclusions of current research comparing strict rest vs usual care following a concussion?

Strict rest offers no benefits over current usual care

Symptoms lasted longer for individuals following strict rest as compared to usual care for all 10 days post injury

What was a limitation for current research comparing strict rest vs usual care following a concussion in adolescents?

Adolescents' symptom reporting may be influenced by restricting activity (limiting screen time)

In 1783, what did Alexander Monro say about the brain?

• The brain was enclosed in a non-expandable case of bone

• The substance of the brain was nearly incompressible

• The volume of the blood in the cranial cavity was therefore constant or nearly constant

• A continuous outflow of venous blood from the cranial cavity was required to make room for the continuous incoming arterial blood

What are the measurements of CSF, blood, & brain parenchyma volume?

• CSF: 150 mL (10%)

  • replaced every 8hrs

• Blood: 150 mL (10%)

  • can change most rapidly

• Brain parenchyma: 1400 mL (80%)

What are ventilatory thresholds?

2 points during exercise where the rate of ventilation increases significantly

What happens to the ventilatory thresholds post-concussion?

Decreases

What is 1 of the main factors contributing to symptom exacerbation during submaximal exercise post concussion?

Initial increase in CBF during mild to moderate exercise intensity and then decreases during moderate to heavy exercise intensity

• decreases later due to hyperventilation = vasoconstriction

Why are symptoms exacerbated during exercise post concussion?

The amount of incompressible fluid in the skull increases during initial exercise to reduce the amount of space available to make symptoms worse

What is the effect of moderate-vigorous physical activity on concussion?

Can exacerbate symptoms and delay recovery

• more time spent in MVPA during the first 3 days following concussion diagnosis is associated with a greater time to medical clearance to RTP

What does the concussion exercise curve recommend?

Too little & too much exercise delays recovery

Like Goldilocks, there is an ideal sweet spot

What is the proposed mechanism for PPCS?

• Concussion-induced mechanical changes coupled w neurometabolic alterations can affect fx'al cerebral circulation & combined w post-TBI autonomic dysfx

• Cerebral autoregulation & CBF are disturbed post-concussion, potentially explaining why symptoms reappear or worsen

What do the alterations to neurovascular coupling following SRC reveal?

More nutrients and resources are required to accomplish the same task prior to injury

• greater increase in PCAv and total activation indicating more nutrients are required to accomplish the same task

Why is CBF an important issue in adolescents?

Abnormal CBF is reported for weeks after injury despite reported resolution of resting symptoms

What is the cause of abnormal regulation of CBF?

Altered autonomic nervous system (ANS) fx &/or altered carbon dioxide regulation post-concussion

What is one of the primary regulations of CBF

CO2 tension in the blood

Where is the control center for the primary ANS?

In the brainstem

• may be damaged in concussion, particularly with rotational force applied to the upper cervical spine

What happens in concussed athletes with altered ANS balance vs controls?

Higher HR during steady-state exercise

What causes altered autonomic regulation after TBI?

Changes in the autonomic centers in the brain &/or an uncoupling of the connections b/w the central ANS, the arterial baroreceptors, & the heart

• Proportional to TBI severity & improves during recovery

What does emerging data suggest about how exercise improves brain fx?

Via favorable effects on brain neuroplasticity as early as 6-8 weeks of exercise

What is the mechanism of exercise improving brain fx?

May not involve exercise influence on cerebrovascular disease risk, but rather improved neuronal fx

What are the effects of exercise on the brain?

Cognitively protective & is associated w greater levels of brain-derived neurotrophic factor (BDNF), which is involved in neuron repair after injury, greater hippocampal volume, & improved spatial memory (energy metabolism, synaptic fx & plasticity, neurotransmitter modulation)

• Improved regulation of CBF

• Angiogenesis & vascular health

• Neurogenesis & cell survival

Pros of exercise with concussion

Moderate aerobic exercise (60% of maximum HR performed for 150min/wk) is cognitively protective and is associated with greater levels of brain- derived neurotrophic factor (BDNF), which is involved in neuron repair after injury, as well as greater hippocampal volume and improved spatial memory.

• Another salutary effect of regular exercise is improved regulation of CBF.

What is the relationship between concussions & deconditioning?

Physical deconditioning of the cardiovascular system due to prolonged rest is common post concussion

• Deconditioning is associated w reduced CBF, whereas exercise training has beneficial effects on CBF control, which may relate to restoration of autonomic balance &/or sensitization of the autoregulatory system to gradual increases in systemic BP w controlled exercise.

What is the Buffalo Concussion Treadmill/Bike Test (BCTT/BCBT) based off of?

Balke cardiac treadmill test that requires a gradual increase in workload safe for patients w cardiac & orthopedic problems

• The HR and BP recorded at the threshold of symptom exacerbation become the basis for the individualized exercise prescription for patients with PPCS.

How does the BCTT work?

• Starting speed is ~ 5 km/h at 0% incline for the 1st minute (adjust for height & activity levels)

• Incline increased by 1% at minute 2 & by 1% each minute while maintaining the same speed until the max incline (15%) is reached or the patient cannot continue

• Once max incline is reached, speed increases ~ 0.5 km/h

• Rating of perceived exertion (RPE, Borg Scale) & symptoms are assessed every minute

• HR by HR monitor & BP by automated cuff (not mandatory) are measured at every stage

What are the contraindications of the BCTT/BCBT?

• Same as the contraindications of a cardiac stress test

• History: unwilling to exercise, increased risk for cardiopulmonary disease, beta blocker use, major depression, does not understand English

• Physical exam: focal neurologic deficit, significant/minor balance deficit, visual deficit, orthopedic injury, BP > 140/90, BMI > 30

• Symptoms increase by >2pt (skip a phase) and don’t do test if rated between 7-10

What parts of the BCTT/BCBT become the basis for the individualized exercise prescription for patients w PPCS?

HR & BP recorded at the threshold of symptom exacerbation

When is the BCTT/BCBT stopped?

When there is a 2 point increase in overall condition

• dont do test between 7-10

What are other cut-off criteria for the BCTT/BCBT?

• RPE > 18 on Borg (6-20) Scale

• HR > 180 BPM

• Voluntary exhaustion

How does the BCBT work?

Starting speed is 60 rpm & resistance is increased every 2 minutes based on the patient's mass

When is the individual not allowed to begin the BCTT/CCCT?

When their overall condition is at least a 7/10

Stop: >2pt increase from the pre-exercise baseline symptoms level or HR reaches 90% of HRmax

What has the BCTT also been adapted to?

A physiologically informed cycle ergometer protocol (Calgary Concussion Cycle Test - CCCT)

What is the starting wattage for females & males?

F: 0.11 times body weight (kg)

M: 0.14 times body weight (kg)

What do the BCTT/BCBT/CCCT help determine?

If symptoms present following concussion are physiological in nature

Why is buffalo concussion bike test not accurate?

• Does not match treadmill 

• “takes longer to reach physiological steady state on cycle ergo vs. treadmill” - stage on treadmill = 1min, on cycle each stage = 2min

  • doesn’t take longer 

  • >VT1 = won’t reach steady state

• USE Calgary Concussion Cycle Test and Calgary Adapted aRm Ergometer

What symptoms are we expecting and want an increase in following exertion testing?

• feeling slowed down

• fatigue/low energy

How has exercise been used as treatment for other conditions in the past?

• Passive cycling was used in the ICU w/in the first 72 hours

• Severe TBI

What was the effect of passive cycling on rehab periods?

• Improved patient outcomes

• Reduced hospital stay times

• Helped patients get back to as good a life as possible & as soon as possible

What are the cardiovascular effects of exercise?

• Decreased HR

• Increased SV

• Antioxidants

Which systems does exercise benefit?

All systems & aspects

What is the progression of concussion mgmt?

1. Concussion injury

1.1. Pre-existing factors

2. Neurometabolic cascade

2.1. Pre-existing factors

3. Deficits/ dysfx

4. Assess & manage:

4.1 Symptoms

4.2 Motor

4.3 Cognitive

4.4 Vestibular/occular

4.5. Other

5. Recovery

5.1. Non-recovery.

Why do we want to engineer treatment?

To move people from the non-recovery group to the recovery group

Similar to observations w severe TBIs, what is the effect of exercise as treatment in patients w PPCS?

Positive recovery trajectories

What exercise treatments lead to the best outcomes?

Prescribed exercise thresholds based upon individualized symptom thresholds

What do prescribed exercise threshold programs utilize?

BCTT or CCCT

What are the exercise prescriptions?

20 mins/day

Once/day

6-7 days/week

80-90% of the threshold HR RESERVE