Persistent Concussion Mgmt

Clinical examination for persistent concussion: History include PMH, MOI, sxs from

Self-report measures (Post Concussion Symptom Inventory, Post Concussion Symptom Scale, Health & Behavior Inventory)

Symptoms should NOT be the sole guide for intervention

Clinical examination for persistent concussion: systems review including

cardiovascular system, MSK, neurologic, communication (word retrieval, body language), affect, learning, cognition (neuropsychologist referral)

Clinical examination for persistent concussion: red flags

Declining level of cognition, orientation, or consciousness

GCS < 13

new onset pupil asymmetry

seizures, repeated vomiting

focal neurologic signs

severe or rapidly worsening HA

signs of undiagnosed skull or C-spine fx

signs of VBI, cervical ligamentous instability, SC compression

Clinical examination for persistent concussion: physical examination of cardiovascular status

HR & BP in sitting & standing (orthostatic or exaggerated to position changes)

Exercise Intolerance→ Su-bsymptom Exercise Tolerance Test: Buffalo Concussion Treadmill Test which is Safe & reliable that can Quantify clinical severity of concussion & Develop exercise prescription

during Buffalo Concussion Treadmill Test what do you monitor?

BP/HR every 1 min

RPE/sx every 1 min

during Buffalo Concussion Treadmill Test when do you terminate the test?

Sx >3/10

RPE 18-20

HR at termination→ threshold HR (HRt)

Clinical examination for persistent concussion: Vestibular Assessment must assess for

BPPV via Dix-Hallpike

Impaired dynamic gaze stabilization: Head Impulse Test to assess VOR (high velocity), Dynamic Visual Acuity (functional), VOR Cancel (motion sensitivity)

Motion Sensitivity (MSQ)

Clinical examination for persistent concussion: Oculomotor Assessment must assess for

Smooth pursuit

Saccades

Convergence/Divergence

Gaze/alignment

Clinical examination for persistent concussion: Balance & Gait Assessment

FGA

ABC

mCTSIB

BESS test

Clinical examination for persistent concussion: Cervical Spine Assessment

Craniocervical ligament tests: Sharp Purser, Alar ligament stability test

VBI assessment

Cervical AROM

Cervical Passive Accessory Intervertebral Motion

Cervical Muscle Strength: Craniocervical flexion test

Clinical examination for persistent concussion: Mood/Psychological Assessment

Ask about prior history

Ask about any emotional disturbance related to concussion sxs

Clinical examination for persistent concussion: Headache Assessment

Ask about presence of HA

Ask about history or family history of HA or migraine

Clinical examination for persistent concussion: Sleep Assessment

Ask about difficulty w/ sleep, components of difficult sleep

Clinical examination for persistent concussion: Cervicogenic Dizziness is a dx of

exclusion

Dizziness, imbalance, unsteadiness related to mvmts or position of C-spine OR occurring w/ a stiff or painful neck

abnormal afferent signals (whiplash, or fear of mvmt/sxs → c-spine mechanics) can lead to have sensations of altered orientation in space → sensation of dizziness

PT intervention for concussion: Education on

Initial relative rest (24-48h) → 20 min daily walk

Symptom-guided activity (no sx ↑ over 2/10 from baseline)

Importance of normal sleep schedule & diet

Communication about symptoms (eye strain → limit screen time; 20min screen → 20s break → 20ft look away)

Red flag symptoms

what is a negative prognostic factor for concussion?

prolonged rest (mvmt is important for neuroplasticity)

Concussion cognitive Rehab involves SLP &/or Neuropsych

Aerobic Exercise Training is prescribed based on

on 60-80% of threshold HR x10-15 min→ progress time & intensity based on sxs response

Can use any modality

concussion vestibular rehab incudes

Gaze stabilization: Improves VOR, Vary speed, support surfaces, backgrounds, patient position, Implement into task specific training

Treat BPPV w/ CRM

concussion cervical rehab follows ortho guidelines

Balance Training includes

Static→ dynamic, firm→ compliant, task-specific training, dual task w/ cognitive exertion

concussion visual training will need to tolerate some visual exercises before gaze stabilization exercises.

Smooth pursuit tracking (30° in each direction)

Saccades (2 targets, various planes, 12-16” apart)

Visual fixation w/ gait & mvmt

Start w/ 15-30s each direction, 2-3 x/day, ↑ to max of 2 min if asymptomatic

Can progress w/ varying speeds (start slow), support surfaces, visual backgrounds, dual task