jennifer parent-nichols has no conflicts to disclose.€¢too much or too little rest •premorbid...
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• Jennifer Parent-Nichols has no conflicts to disclose.
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• Concussion understanding continues to be
modified
Sciencewatch.com
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“Its about the injury…and
who comes with the injury.”
McCrea, 2016
Postconcussionsyndromeawarenessuk.com
10-20%
of
patients
Non-
specific
definition
Symptoms vary
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• Too much or too little rest
• Premorbid dx or family hx migraine, ADHD, mood disorder, other psychiatric disorder, LD
• Poor management of acute injury
• Untreated vestibular or cervicogenic dysfunction
• Exposure to re-injury prior to full recovery
(Morgan, 2015)
• Repetitive injuries (literature conflicts concerning what this number might be)
• Younger patients
• Being female
• Type of hit or speed of hit does NOT appear to have an impact on length of recovery
Theconcussionblog.com
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Gymprofessor.com
Dailymail.co.uk
New Research: HR at which sx are first provoked,
seems to be a predictor of recovery.
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• Persistent Post Concussion Sx:
•Clinical Risk Score
• Increased: female, >13 yos, hx of migraine, prior
concussion c sx>1wk, HA, sensitivity to noise, fatigue,
answering questions more slowly, 4+ errors on BESS
tandem stance
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Injoewetrust.com.au
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• Not by typical imaging
• MRI SWI, Yuh, 2012
• Longer echo times sensitive to compounds
• Can see micro hemorrhage
• Amount seems to be correlated to longer recovery time
En.wikipedia.com
Quizlet.com
•CBF, Claussen et al, J HeadTraumaRehab, 2016
• CBF is altered in acute concussion
• See ~ 1mo p concussion
• CBF is altered in PCS
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• Brain is the only organ without a blood test
• Need to be able to detect elements of the neurometabolic
cascade
• Need right tool at right time
• Challenge in mTBI
• ? Astrocytes
• Glia predominate 10:1
• UCH- 1
• GFAP
Spectrumnews.org
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Should Include: • Specific History
• Post-concussion Symptom Inventory
• Cervical Screening
• Neurologic Exam: Coordination/Reaction Time
• Balance
• Vision/Vestibular
• Gait and Function: FGA, 3 meter tandem gait, DGI, Dual (cognitive-motor), Sports Specific
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• May send conflicting proprioceptive/visual/ vestibular info related
to balance (Brandt 2001)
• Postural screening
• PROM, AROM
• Palpation of boney landmarks and soft tissue
• Dermatomes, Myotomes
• Neck strength/Motor control: 2mm Hg x 5 2-3 sec (Schneider)
• Provocation tests
• Note: neck pain is common, especially after trauma. Look for pain
lasting longer than 7-10 day acute period.
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• Cranial nerve testing
• Reflexes
• Tone
• Global Strength
• Coordination/Reaction
Healthtap.com
Telegraph.co.uk
Blog.beamery.com
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SOT
• Look for a >30% decrement
in performance from the
static to dynamic measure Oandp.org
Ajot.aota.org
CTSIB BESS
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• Visual vergence: normal <5cm
• Visual pursuit: is it smooth?
• Visual saccades: moving from visual target to visual
target. Is it smooth, is it well timed?
• Presence of strabismus
• Photosensitivity
www.buzzle.com
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• VOR
• Stabilize visual target with head turning
• Dynamic visual acuity metronome 120 bpm (2 hz)
• 120 degrees/sec=typical ADL’s, can go up to 250 degrees/sec
• Head impulse/Head thrust
• (VOR cancellation)
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• VMS: pt report
• BPPV: Roll tests/ Dix Hallpike
•Otoconia dislodged = sx vertigo
•Not typically seen in younger populations
• head shaking nystagmus
Medical-instituion.com
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Ocular Function
1. Smooth Pursuits
2. Horizontal and Vertical Saccades
3. Near Point Convergence (NPC)
Vestibular Function
4. Horizontal VOR
5. Vertical VOR
6. Visual Motion Sensitivity (VMS)
Pts rate 0 (none) to 10 (severe) changes in: headache, dizziness, nausea and fogginess symptoms
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• Even just a head shake with a Romberg
Youtube.com
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Concussiontreatment.com
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• Remove from play
• Limit cognitive and physical activity
• Encourage pt to not participate in activities that
raise risk of second injury
• Monitor sleep and mood
• All subsequent activity is pt specific, based on
sx presentation/resolution and requires
consistent monitoring/evaluation by the team.
Webmd.com
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Need to choose the right treatment at the right time…
Anitabrooks.com
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Always monitor and assess symptoms
• Must have objective baseline
measurements for comparison
Always education
Process is SLOW: decreased
speed, decreased reps,
decreased sensory stimulation
Use good sense: early
exercise is monitored.
Too much=bad, Too
little=bad.
Famalii.com
Bunkiechamber.net
Br J Sports Med 2014, Schneider:
intervention with PT
Rx group 10x more
likely to be returned
to sport than in the
control group.
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• Melatonin
• Meds
• Biofeedback
• Sleep hygiene
• Sun exposure
• MSK!
• ROM
• TPI
• Mobs
• STM
• Dry needling
• Taping
Sportsrehabcenter.com
Cchirosw.com
123rf.com
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• Oculomotor Training
• Progressive VOR training (vertical and horizontal)
• Progressive visual sensitivity training
•Can change speed, number of reps, complexity
• Pt symptoms will be the guide
Fitnessgaming.com
Binbpt.com
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• Pursuit: tracking tubes
• Saccades: Suduko, crossword puzzles, increase font
size, line grids
• Convergence: Brock String
• Eye Strain/HA: apps for rest breaks, colored tints for
computer screen
• Vestibular
• Progressive accommodation
• Moving toward function. Visionhelp.wordpress.com
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• Early exercise after mTBI = noted decrease in plasticity (Greisbach, 2004)
• BUT…
• Strict Rest=No benefit, sx influenced by rest (Thomas et al,
2014)
• Well timed ex =decrease in recovery time, improved sx,
and increased tolerance to ex over time. (Leddy et al, 2010,
Gagnon et al, 2015)
O-connecta.ca
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• Restriction of activity NOT removal
• Sx should be manageable, not necessarily abolished
• Gagnon, et al, 2016.
• Historically: rx at 4 weeks post
• Now: data suggesting potential benefits from
beginning at 2 weeks post.
Activerehab.com
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• Aerobic component: ? Use of BCTT
• 5 min warm up
• Exercise to 80% max HR 20 min/day
• Increase HR by 5 bpm every week.
• Sports Specific Activity
• Mental Imagery
• Education
• Prolonged ssx can be anxiety provoking
and isolating
• Time to sx provocation recorded
• Iverson, et al 2012.
Hub.jhu.edu
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• Return to Play = Return to Risk
• Significant increase in time to recovery if 2nd
injury before 1st resolved
• Look at Sx burden
• determine where we are and where we’re going
• PRACTICAL AND LOGICAL
• Stratified care: look at degree of disability and
determine strategy
Nike.com
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Blog.mioglobal.com
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• Use exercise tolerance as proxy
• Brain Function is DIFFERENT in concussed individuals.
Wang Y et al., J Neurotrauma 2015 epub
Meier TB, et al.,
JAMA Neurol 2015
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• Abnormally
phosphorlated/degenerates
• Seems pathogenic/different from
aging
• Makes tau sticky
• Dose dependent
• Seen with concussion
• Correlates with axonal injury
• But eventually seen all over
• Administration of antibody targeting
of cis tau seems to prevent/limit
functional deficits…in mice
Vectorchildrenshospital.org
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• The better is the enemy of the good. Voltaire
• Berlin…2016
Twitter.com
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References
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• Alsalaheen, B. A., Mucha, A., Morris, L. O., Whitney, S. L., Furman, J. M., Camiolo-Reddy, C. E., ... & Sparto, P. J. (2010). Vestibular rehabilitation for dizziness and balance disorders after concussion. Journal of Neurologic Physical Therapy, 34(2), 87-93.Brandt, T., & Bronstein, A. M. (2001). Cervical vertigo. Journal of Neurology, Neurosurgery & Psychiatry, 71(1), 8-12.
• Clausen, M., Pendergast, D. R., Willer, B., & Leddy, J. (2016). Cerebral blood flow during treadmill exercise is a marker of physiological postconcussion syndrome in female athletes. The Journal of head trauma rehabilitation, 31(3), 215-224.
• Gagnon, I., Grilli, L., Friedman, D., Iverson, G. (2016). A pilot study of active rehabilitation for adolescents who are slow to recover from sport-related concussion. Scand J Med Sci Sports, 26(3), 299-306.
• Griesbach, G. S., Hovda, D. A., Molteni, R., Wu, A., & Gomez-Pinilla, F. (2004). Voluntary exercise following traumatic brain injury: brain-derived neurotrophic factor upregulation and recovery of function. Neuroscience,125(1), 129-139.
• Iverson, G., Gagnon, I., & Greisbach, G. S. (2012). Active rehabilitation for slow-to-recover children. Mild traumatic brain injury in children and adolescents: From basic science to clinical management, 281.
• Kondo, A., Shahpasand, K., Mannix, R., Qiu, J., Moncaster, J., Chen, C.-H., Lu, K. P. (2015). cis p-tau: early driver of brain injury and tauopathy blocked by antibody. Nature, 523(7561), 431–436. http://doi.org/10.1038/nature14658
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• Leddy et al. (2016). In press.
• Leddy, J., Hinds, A., Sirica, D., & Willer, B. (2016). The role of controlled exercise in concussion management. PM&R, 8(3), 91-100.
• Leddy, J. J., Kozlowski, K., Donnelly, J. P., Pendergast, D. R., Epstein, L. H., & Willer, B. (2010). A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clinical Journal of Sport Medicine, 20(1), 21-27.
• Leddy, J. J., & Willer, B. (2013). Use of graded exercise testing in concussion and return-to-activity management. Current sports medicine reports, 12(6), 370-376.
• Meier TB, Bellgowan PF, Singh R, Kuplicki R, Polanski DW, Mayer AR. Recovery of Cerebral Blood Flow Following Sports-Related Concussion. JAMA Neurol.2015;72(5):530-538.
• Mucha, A., Collins, M. W., Elbin, R. J., Furman, J. M., Troutman-Enseki, C., DeWolf, R. M., & Kontos, A. P. (2014). A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions preliminary findings. The American journal of sports medicine, 0363546514543775.
• Schneider, K. J., Meeuwisse, W. H., Nettel-Aguirre, A., Barlow, K., Boyd, L., Kang, J., & Emery, C. A. (2014). Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. British journal of sports medicine, bjsports-2013.
• Wang, Y., Nelson, L. D., LaRoche, A. A., Pfaller, A. Y., Nencka, A. S., Koch, K. M., & McCrea, M. A. (2015). Cerebral blood flow alterations in acute sport-related concussion. Journal of neurotrauma.
• Yuh, E. L., & Gean, A. D. (2012). Structural neuroimaging. Brain Injury Medicine: Principles and Practice, 194.
• Zemek, R., Barrowman, N., Freedman, S. B., Gravel, J., Gagnon, I., McGahern, C., ... & Craig, W. (2016). Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED.JAMA, 315(10), 1014-1025.
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• CTSIB/SOT: clinical test of sensory integration on balance
• BOT-2: Bruininks-Oseretsky test of motor proficiency 2
• BESS: balance error scoring system
• DHI: dizziness handicap inventory
• DGI: dynamic gait index
• FGA: functional gait assessment
• 5 Times Sit to Stand/ 30 seconds sit to stand
• (Alsalaheen2010)
• Romberg/ sharpened
Romberg
• Single leg stance
• Star Test
• Line walking
• Timed up and go
• Berg Balance Scale
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Buffalo Concussion Treadmill Test
• Ex to sx tolerance
• RPE>18=RECOVERED
• Push to increase sx, then back
off
• Ask pt every 60 seconds if
increase in sx or new sx= 1
point
• 3 points=stop
• ? Starting RTP from here
Buffalo.edu
Leddy, et al (2013).
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• ImPACT, HeadMinder, CogSport
• Above are baseline and for comparison
• Post Concussion Symptom Inventory
• King Devik
• Rivermead Post-Concussion Symptoms
Questionnaire
Kingdevik.com
Impacttest.com