Head & Brain Trauma

Basic Anatomy

Brain sits within skull, surrounded by meninges & fluid

• Cerebrospinal Fluid (CSF) floats around brain & SC for protection & nourishment

Head injuries

Brain & head injuries occur as a result of a direct blow, or sudden snapping of the head forward, backward, or rotation to the side

What head injuries result

• May result in:

  • LOC, disorientation, or amnesia

  • Motor, coordination, or balance deficits

  • Cognitive deficits

• May present as a life-threatening injury or a cervical injury (if unconscious)

Traumatic Brain Injury (TBI)

• Mild Traumatic Injuries (mTBI) are by far the most prevalent of all the brain injuries

• Concussions are a type of mTBI

• Moderate or Severe TBI include penetrating wounds, cerebral hemorrhages as a result of impact, skull fx

Signs of Mod/Severe TBI

• Prolonged loss of consciousness

• Worsening headache

• Repeated vomiting or nausea

• Slurred speech

• Seizures

• Weakness, numbness, poor coordination

• Unequal pupil size

• Brusing behind ears (Battle Sign)

• Bruising around eyes (Raccoon sign)

• Fluid exiting facial orifices

On-Field Head Trauma Protocol

Assuming ABC’s are clear

1. DO NOT let athlete move

2. With LOC, assume C-sp injury

3. Ask athlete how injury happened

4. Do sensory testing

• Scratch dermatomes distal → proximal

5. Do motor testing

• Test myotomes distal → proximal, isometric, looking for some resistance

6. Palpate for fx deformity

7. Ask orientating questions

• Name?

• Where are we?

• Date?

8. Check pupil response to light & tracking

9. Check for CSF (skull fx)

10. Ask athlete if they think they can move their head

• Allow very limited movement

11. Ask them to sit up (support them)

12. Ask to see pain free neck ROM

13. Help them off field (support them)

14. At sideline check for:

• Balance → Rhomberg Test

• Coordination → Finger to nose

15. RETEST in 10 mins

What is a Concussion?

• A temporary traumatic brain injury induced by biomechanical forces (acceleration/deceleration) that results in a transient change in brain function

• Imagine the filing cabinet of your brain has been dumped upside down

Where is the definition (concussion from)

Consensus Statement on Concussion in Sport

• Amsterdam, 2022

• Published in British Journal of Sports Medicine 2023;57:695-711

Concussion definitions

1. “May be caused by either a direct blow to the head, neck, or body with an impulsive force being transmitted to the brain.”

2. “Initiates a neurotransmitter and metabolic cascade with possible axonal injury, blood flow change, and inflammation affecting the brain.”

3. “Symptoms and signs may present immediately, or evolve over minutes or hours, and commonly resolved within days, but may be prolonged.”

4. “Results in a range of clinical symptoms and impairment of neurological function that may or may not result in a loss of consciousness.”

5. “No abnormality is seen on standard structural neuroimaging studies.

Role of PT or AT

1. Assessment & Diagnosis

• Subjective symptoms, C-sp, vision, vestibular, balance, cardiovascular/autonomic dysfunction, cognition

2. Education

• Rest & graded return to activity

• Strategies for symptom management

• Guiding return to activity (school/work/sport)

3. Treatment/Exertion

• Symptom reduction/planning & pacing, exercise prescription, cognition, visual/vestibular, balance, dual task/multiple system

1.Assessment

• Useful immediately post-injury in differentiating concussed from non- concussed

• Utility decreases 3-5 days after injury

• Symptom checklist useful for tracking recovery

• Components

• Other assessment domains not included in SCAT6 that may be

  helpful:

• Baseline testing may be useful, but not necessary for

  interpreting post injury scores

• Buffalo Concussion Treadmill Test

• Visual System

• Visual System Complexity

• Vestibular Ocular Motor Screen (VOMS)

• Smooth Pursuits

• Saccades

• Convergence

• Vestibular-Ocular Reflex (VOR) Test

• Visual Motion Sensitivity Test (VOR Cancellation)

Assessment Components

• On-Field/Neuro Assessment

• Symptom Checklist

• Cognitive Screening

• Orientation, Memory, Concentration

• Coordination & Balance

Other assessment domains not included in SCAT6 that may be helpful:

• Autonomic Dysfunction/Exercise Tolerance

• Oculomotor assessment

• C-sp assessment

• Vestibular assessment

Buffalo Concussion Treadmill Test

• A graded exercise test used after a mTBI to assesses exercise tolerance

• Identifies physiological dysfunction, autonomic symptoms

• Guides safe, individualized aerobic activity to speed recovery

Stopping Criteria (Buffalo Concussion Treadmill Test)

• 3+ increase of VAS

• RPE > 17

• Reaching 90% age-predicted HRmax

• Request to stop

Dr. Padula’s Definition of Vision:

“a dynamic, interactive process of motor and sensory function, mediated by the eyes for the purpose of simultaneous organization of posture, movement, spatial orientation, manipulation of the environment, and to its highest degree perception and thought.”

Visual System

• Visual disturbances after brain injury can be covert

• Studies show 50-90% of individuals w/ ABI demonstrated visual dysfunction

• Vision is not in the eye → it is in the brain, facilitated by the eyes

  • If the brain is damaged, high probability vision has been affected

• The visual word is a mental construction that takes a significant amount of energy from our cerebral cortex

Covert visual disturbances (visual system)

• “I have frequent headaches”

• “I don’t like to go grocery shopping”

• “I hit my head again getting into the car”

• “I just feel off sometimes”

Visual System Complexity

• 70% of our brain is involved in vision & visual processing

• 80% of all sensory processing in the entire body is directly affected by information coming in from the eyes

• More than 32 visual areas in cerebral cortex

  • More than 300 pathways between these areas

    • Consider the odds of injury / disruption with TBI

Vestibular Ocular Motor Screen (VOMS)

• Developed as a screening tool by UPMC

• Validated ages 9-40

• Need to let symptoms return to baseline b/w each test

Components (Vestibular Ocular Motor Screen (VOMS))

• Smooth pursuits

• Saccades

• Convergence

• Vestibular-Ocular Reflex (VOR) Test

• Visual Motion Sensitivity Test (VOR Cancellation)

Smooth Pursuits

• Tests ability of eyes to follow a slow-moving target

• Head stationary, only eyes move

• Side-to-side, Up-and-down, X-pattern

• “Keep your eyes fixed on target”

Saccades

• Tests ability of eyes to move quickly between targets

• Head stationary, only eyes move

• “Jump your eyes between the 2 points”

Convergence

• Measures the ability to view a near target w/o double vision

• Pt instructed to bring pencil w/ writing towards nose

• Pt instructed to stop moving target when they see 2 distinct images

• Distance from nose should be ≤ 5 cm

• “Slowly move the pencil and keep your eyes on the writing”

Vestibular-Ocular Reflex (VOR) Test

• Tests the ability to stabilize vision as head moves

• Head rotating, eyes maintain focus on target

• 180 bpm, rotate 20° each side

• “Shake your head back & forth while looking at target”

Visual Motion Sensitivity Test (VOR Cancellation)

• Tests ability to inhibit vestibular-induced eye movements using vision

• Trunk rotating, eyes maintain focus on target

• 50 bpm, rotate 80° each side

• “Turn your whole body & arm while looking at thumb”

Suspected concussion with 1 or more of the following: (Diagnosis)

• Symptoms – somatic (e.g. headache), cognitive (e.g. in a fog), and/or emotional (e.g. lability)

• Physical Signs – (e.g. LOC, amnesia, neuro deficit)

• Balance Impairment – (e.g. gait unsteadiness)

• Behavioural Changes – (e.g. irritability)

• Cognitive Impairment – (e.g. slowed reaction time)

• Sleep Disturbance – (e.g. drowsiness)

Pediatric Considerations (Diagnosis)

Children/adolescents may:

• not be fully aware of their symptoms

• not be able to articulate their symptoms or describe their effects clearly

• have pre-existing physical and mental conditions/factors that might contribute to symptoms

What is the main rule with concussions

if in doubt sit them out

2. Education

• NOT a result of brain hitting inside of skull – updated theory:

• Neurometabolic Cascade

• Rest

• How do you get out of Rest?

• Rest Recommendations

• Suggestions for Restful Activities

• Planning & Pacing

• mTBI = Altered Network Connectivity

• General Rule of Return to Play

• Natural Course of Recovery

Neurometabolic Cascade (education)

• Brain & neurons get stretched/deformed with impact and ion channels get pulled open

• Ions are exchanged across the cell membrane which excites the neurons all at once

• Rapid neurotransmitter dump causes electrical/excitatory storm

• Big use of ATP over hours/days

• Cerebral blood flow drops

• Glucose drops

• *Less blood flow to deliver less food to the brain – can take 45 days to return neurophysiology to normal*

Rest (edu)

• Evolving recommendations – no longer dark room

• Indicated for 24-48 hrs, then start activity as tolerated

• Cognitive, physical & environmental as needed

When was the last time for 1 hour you didn’t….

• Use your phone

• Watch TV

• Listen to music

• Read a book

• Work/Learn

• Study

• Talk to a friend

• Exercise

• Sleep

• Clean

How do you get out of Rest?

• Graduated return to cognitive & physical activity

• Need to educate about how & when to introduce activity and monitor

  symptoms

What not to do with rest

Don’t leave your patients in rest

Why to educate about how & when to introduce activity and monitor symptoms

• Otherwise, depression & non-compliance

• REMEMBER: they are brain injured therefore their judgement & decision making is impaired

Rest Recommendations (edu)

• Limit: TV, computer, reading, cell phone, intense physical activity, school, sports, socializing

• Allow: increased sleep, hydration, light physical activity, eating well

Suggestions for Restful Activities (Edu)

• Listening tasks (audiobooks, quiet music, radio/podcasts)

• Meditation or relaxation activities

• Anything leisure that relaxes (knitting, drawing)

• Light household tasks

• Short walks (outdoors ideally)

  • Helps improve blood flow to brain

  • If don’t start w/in first 5 days, greater chance of prolonged recovery

How does Short walks (outdoors ideally) help?

• Helps improve blood flow to brain

• If don’t start w/in first 5 days, greater chance of prolonged recovery

Planning & Pacing (Edu)

mTBI = Altered Network Connectivity

Brain is noisy & inefficient after concussion meaning:

• You can’t filter sensory stimuli

• You can’t easily maintain balance & move through environment

• You can’t use multiple systems at the same time

• You get easily fatigued

General Rule of Return to Play (edu)

The athlete needs to be symptom free for the same amount of time they have symptoms prior to returning to contact sports

• Especially youth & adolescents

Natural Course of Recovery

• 80-90% of people who experience mTBI will recovery fully

• Remaining 10-20% develop Persistent Post Concussion Syndrome (PPCS)

  • Cannot predict based on severity of injury

  • Symptoms persist longer than 4/6 weeks

3. Treatment

• Symptom Reduction

• Strategies to Help Build Tolerance

• Planning & Pacing

• Biggest Brain Drains:

• Planning & Pacing Strategies

• Pacing Points System

• Typical Point Values

• Stoplight Menu of Tasks

• The Zone of Therapeutic Benefit

• Exercise Prescription

• Cognition

• Visual System

• Visual/Vestibular System

Symptoms Reduction (Treat)

• Quiet The Noise

• Limit stimulating environment & activities & use strategies to help build Auditory & Visual tolerance

• Take breaks to recharge brain

  • Mindfulness & meditation

Quiet the noise (Symp-red)

• Address sleep issues → focus on sleep hygiene

• Sleep & wake at same time

• Make bedroom dark & cool

• Limit caffeine after 1pm

• Access morning sunlight

• Use bed for sleeping only – no work or TV

• Exercise but not right before bed

Strategies to Help Build Tolerance (Treat)

• Auditory Strategies

• Visuals Strategies

Auditory Strategies (Building tolerance)

• Noise cancelling headphones (Airpods)

• Loop Earplugs

• Graduated noise exposure

Visual Strategies (building Tolerance)

• Block part of page to reduce visual input

• Blue light blockers

  • Night shift on devices

  • Glasses with tint

• Reduce sunlight

  • Sunglasses

  • Hat with a brim

• Timer for shorter more frequent chunks of reading

  • 3x10 min better than 1x30 min

• Palming

• Use voice to text

• Use “reader” view to reduce clutter & ads

Planning & Pacing (Treat)

• Right level of activity in ACUTE phase:

• Right level of activity in CHRONIC phase:

• Requires a huge lifestyle change

• Many of our “Type A” personality patients struggle with limiting tasks and setting limits

• The most common pt I see in my office with PPCS: Type A Women w/family

  • Still need to care for kids

  • Try to do it all

Right level of activity in ACUTE phase: (P&P)

• Aiming for pts to participate in ALL activities BELOW the level of symptoms

• Stop activities prior to symptom onset

• Re-introduce activities in a graded and gradual way

Right level of activity in CHRONIC phase: (P&P)

• Same principles of graded & gradual activity, but messaging slightly different

• Pt can have a bit more leeway to go into symptoms before stopping activity

• General Guide:

  • Symptoms can increase 2-3/10 on intensity scale and return to baseline in less than 1 hour

Biggest Brain Drains:

• Talking

• Visually stimulating environments

• Driving

• Any activity requiring “filtering”

• Cognitive tasks

• Physical activity

Talking (brain drains)

Particularly in crowded environments w/ multiple conversations

Visually stimulating environments (Brain drains)

Bright, colourful, moving (think Walmart)

Driving (Brain Drains)

Even as passenger

Any activity requiring “filtering” (Brain Drains)

Noise in background, takes energy to filter

Cognitive tasks (Brain Drain)

Reading, crosswords

Physical activity (Brain Drain)

Need to keep HR down to not bring on symptoms, you are not efficient, so simple task is now exhausting

Planning & Pacing Strategies (Treat)

• Use a timer

• Make a plan

• Chunk your activity & schedule it throughout the week

• Pacing Points System

• Stoplight Menu of Tasks

Pacing Points System (Treat)

• Every activity has a points value calculated by:

• You get a maximum number of points per day

• Start at 15-20pts

  • Provides a simple, structured way to limit & track tasks

Typical Point Values (Treat)

Stoplight Menu of Tasks (Treat)

• Red tasks are hardest, Yellow tasks are medium, Green tasks are easy

• Get 1 red task, 2-3 yellow tasks, and unlimited green tasks per day

When you don’t plan & pace…(P&P)

When you do plan & pace… (P&P)

The Zone of Therapeutic Benefit (Treat)

When doing activities consider:

• How quickly symptoms increase

• How long it takes to settle them back down

Good Rule of Thumb:

• Symptoms can go up by 2-3/10

• Need to be able to settle them w/in 30-60 mins

Exercise Prescription (Treat)

• Well-trained or conditioned patients:

  • 60%-70% of HRmax x 15-20 min

• Untrained or deconditioned patients:

  • 40%-50% of HRmax x 10-15 min depending on tolerance

• Can likely safely initiate exercise on day 3 post-injury

  • Yoga often well-tolerated by mTBI patients

• Buffalo Concussion Treadmill Test w/in 1st week

Cognition (Treat)

• Sudoku, Crosswords, Wordle

• Card sorting games

• Alphabet game

• Duolingo

Visual System

• Bi-Nasal Occlusion (BNO) glasses

• Wall Clock Saccades

• Vision Worksheets

• Brock String

• Rainbow Bean Bag Toss

• Walking & Looking

• Infinity Walk

• Infinity Walk

• Dishwasher

• PQBD Exercise

• Padula Cube

Bi-Nasal Occlusion (BNO) glasses

• Decreases visual noise

• Use for reading or busy environments

• Helpful for Pursuits, Saccades, Convergence

Smooth Pursuits (1.) {visual systems}

Saccades (2.) {visual systems}

Near/Far fixation exercises (3.0) {visual systems}

Pencil pushup’s for convergence insufficency (4.) {visual systems}

Gaze Fixation/Stabilization (5.) {visual systems}

Peripheral Awareness Exercises (6.) {visual systems}

Wall Clock Saccades (visual systems)

• Stand in front of a wall

• Place 12 visual targets in a circle like a clock

• Place an X in the middle of the clock.

• Move your eyes as quickly as you can from each post it note to the centre X moving in a clockwise and then counter-clockwise direction

Vision Worksheets (visual systems)

• Stand in front of a wall

• Place a # sheet and a letter sheet on wall

• Find & touch the letters & numbers in order (A-1, B-2, C-3)

Brock String (visual systems)

• Hold the string at a 20° angle down from your nose

• Bring your attention to the furthest bead; it will be in focus and all other beads will either be doubled or out of focus

• Switch your focus to the next bead on the string and keep moving your eyes to closer beads until you cannot focus on a bead

• If double vision occurs, focus or relax eyes until you can see bead, but do not try to hold for longer than 5 seconds

Rainbow Bean Bag Toss (Visual systems)

• Keep head still and eyes on the bean bag

• Lightly throw the bean bag from one hand to the other in the shape of a rainbow

• Your eyes should follow the path of the bean bag

• To make it harder: Move head and eyes together to follow bean bag

Walking & Looking (visual systems)

• Pt is walking towards therapist with their eyes fixed on them

• Pt turns head, but keeps eyes fixed on therapist

• Then allow eyes to follow

• Return to centre, repeat same thing in opposite direction

• To make it harder: move eyes first, then head

Infinity Walk (visual systems)

• Walk at a comfortable but continuous pace

• Look at visual target on the wall

• Walk in a sideways figure of 8 or infinity symbol while maintaining visual target

• When you are turning around, bring head and eyes back to the target as quickly as possible

• Repeat several times as symptoms allow

180° Chair Spins (Visual systems)

• Spin your chair 180° to the right and stop and fixate on the target

• Let any dizziness or disturbance settle then spin chair 180° back to the left

• Once again focus on the visual target and let any dizziness or disturbance settle

• Repeat this sequence as tolerated

• To make it harder: rotate same direction every time, so turning 360°

Dishwasher (Visual systems)

• Find and touch the letters & numbers in order (A -1, B-2, C-3…) on the coloured worksheets

• Move your head and neck together quickly as you turn and bend down to touch the letter or number on the seat

• Then return your head and neck to the starting position quickly and find next letter/number on coloured sheet on wall

PQBD Exercise (Visual systems)

• Consider the vertical line of the letter as your midline

• Where the "loop" of the letter is positioned designates which body part you are going to move

• Top loops are upper extremities, bottom loops are lower extremities

  • p = Right hand

  • q = Left hand

  • b = Right foot

  • d = Left foot

Padula Cube (Visual systems)

• Patient keeps a soft focus on centre of cube

• Ask them what square is forward (red or green)

• They then try to flip the cube so that the opposite colour is forward, then flip it back

Visual System (diagram)

Visual/Vestibular System (Visual systems)

Can make any task more difficult by altering: