Concussion Introduction and Assessment Domains. UPMC Sport concussion Team. Concussion & Public Health. Concussion Incidence. Concussion Terminology

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1 Concussion Introduction and Assessment Domains Bara Alsalaheen, MS,PT University Of Pittsburgh UPMC Sport concussion Team Cara Camiolo Reddy, MD Michael Collins, Ph.D Joseph Furman, Ph.D Anthony Kontos, Ph.D Mark Lovell, Ph.D, MD Anne Mucha, PT, NCS Patrick Sparto, Ph.D,PT Susan Whitney, PT, DPT, PhD, NCS, ATC, FAPTA Bara Alsalaheen, MS,PT Concussion Incidence Most TBI injuries are mild TBI(i.e. concussion) The annual rate of mtbi is per 100,000 persons Approximately 300,000 sports-related concussions occur in the United States every year Concussion & Public Health The estimated annual cost (direct and indirect) in U.S ranges between $12-17 billion Concussion has a negative effect on psychological well being and health related quality of life (HRQOL) Concussion is linked to higher family burden and emotional distress Concussion Terminology Minor head injury Mild closed head injury The American Academy of Pediatrics Mild traumatic brain injury - (WHO) and ACRM Concussion and Sports- concussion the American Academy of Neurology and Concussion in sport group, respectively Concussion definition Until the CDC definition, no consensus on a definition Lack of consensus is problematic when reporting incidence and prevalence of symptoms Lack of consensus becomes problematic during process of care 1

2 Concussion: CDC Definition A complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces secondary to direct or indirect forces to the head. Caused by a jolt to the head or body that disrupts the function of the brain. Typically associated with normal structural neuroimaging findings (ie CT scan, MRI). Results in a constellation of physical, cognitive, emotional or sleep-related symptoms that may or may not involve a loss of consciousness (LOC). Duration of symptoms is highly variable and may last from several minutes to days, weeks, months, or longer in some cases. Centers for Disease Control, 2007 Concussion severity At least 17 grading scales None of them is evidence- based Heavily based on LOC and other markers of severity Assumed universal effects of concussion for all age and gender groups Concussion Management STANDARDIZED CONCUSSION GRADING SCALES Neurocognitive testing and comprehensive symptom evaluation INDIVIDUALIZED CONCUSSION MANAGEMENT Slide courtesy of Cara Camiolo Reddy, MD Concussion Assessment Domains Neuropsychological testing Paper & Pencil testing Computerized testing Self report symptoms Instrumented (i.e. checklists) Non instrumented (e.g. interview) Balance and postural stability Clinical testing Laboratory testing (e.g. posturography) Neuropsychological Assessment Most significant advancement in the field of sports concussion Allows for reliable and valid approach to quantify major manifestations Processing speed, reaction time, visual/verbal memory Tracks recovery Provides dependent variable to research individual factors in recovery Slide courtesy of Cara Camiolo Reddy, MD 2

3 Neuropsychological Assessment Now the cornerstone of proper concussion management Baseline testing (preseason/preinjury) Repeated post injury evaluations Computer-based models currently used: ImPACT Cog Sport Headminders ImPACT Self administered software Use a number of tests to generate 4 composite scores for different areas of cerebral functioning Visual memory Verbal memory Reaction time Processing speed Neuropsychological Assessment This is not a stand-alone instrument Must be used in conjunction with clinical interview overall symptom presentation medical/concussion history results of other diagnostic studies Recovery 80% of athletes recover spontaneously within three weeks of trauma Who does worse? Preexisting learning disability Younger age Prior concussive injury Amnesia Migrainous symptoms Over-exerters Slide courtesy of Cara Camiolo Reddy, MD Collins et al, 2006; Yang et al, 2007; Collins et al, 1999; Iverson et al, Slide courtesy of Cara Camiolo Reddy, MD Predictors of Outcome: Age Research with severe TBI suggest that children undergo more prolonged and diffuse cerebral swelling after TBI Increased risk for secondary injury More sensitive to glutamate These factors may lead to a longer recovery period and could increase the likelihood of permanent or severe neurologic deficit Field et al, 2003 Recovery Rates Vary by Age/Dependent Measure Authors Lovell et al Echemendia 2001 McCrea et al Guskiewicz 2003 Bleiberg et al Iverson et al McClincy 2006 Sample Size Population Tests Utilized 95 Pro (NFL) Paper and Pencil 29 College Paper and Pencil 94 College Paper and Pencil 94 College Balance BESS 64 College Computer ANAM 30 High School Computer ImPACT 104 High School Computer ImPACT Total Days Cognitive Resolution Total Days Symptom Resolution 1 day 1 day 2 days 2 days 5-7 days 7 days 3-5 Days 7 Days 3-7 days Did Not Evaluate 10 days 7 Days 14 days 7 Days Slide courtesy of Micky Collins, PhD 3

4 Signs and Symptoms of Sports Concussion Signs observed by staff Appears to be dazed or stunned Is confused about assignment Forgets plays Is unsure of game, score, or opponent Moves clumsily Answers questions slowly Loses consciousness Shows behavior or personality change Forgets events before play (retrograde) Forgets events after hit (posttraumatic/anterograde) Sx reported by athlete Headache Nausea Balance problems or dizziness Double or blurry vision Sensitivity to light or noise Feeling sluggish or slowed down Feeling foggy or groggy Concentration or memory problems Change in sleep patterns Slide courtesy of Cara Camiolo Reddy, MD Sleep Alterations Difficulty falling asleep Fragmented sleep Too much/too little sleep Cognitive Symptoms Fogginess Difficulty concentrating Memory deficits Cognitive Fatigue Mood Disruption Irritability Feeling sad Anxiety Somatic Symptoms Headaches Dizziness Nausea Light/Sound Sensitivity Slide courtesy of Cara Camiolo Reddy, MD Symptom Evaluation Can be evaluated by instrumented and non instrumented methods Different checklists have been implemented Used to quantify highly subjective complaints, and to track recovery Commonly used by athletic trainers Post Concussion Symptom (PCS) Checklist Most commonly used checklist Used to track recovery in symptom resolution Patients are asked to rate their symptoms on a scale from 0 (no symptoms) to 6 (severe) The scale consists of 22 symptoms Total score is calculated by adding all the individual symptom s scores Higher scores are worse The Rivermead Post-Concussion Symptom Questionnaire Somatic Symptoms: Treatment 0 = Not experienced at all 1 = No more of a problem 2 = A mild problem 3 = A moderate problem 4 = A severe problem Somatic Symptoms Headaches Dizziness Nausea Light/Sound Sensitivity Dizziness /Balance Disorders Vestibular Therapy Headaches Musculoskeletal (manual therapy) Vascular Biochemical Cognitive Fatigue Slide courtesy of Cara Camiolo Reddy, MD 4

5 Balance and Posture Evaluation Balance deficit up to 3 days after concussion using the Clinical Test for Sensory Interaction of Balance ( CTSIB) (Guskiewicz,1996) Increased sway, and decreased balance up to 10 days after concussion via the Sensory Organization Test (SOT) Balance Error Scoring System (BESS) and force plate testing found not to be sensitive to detect the balance deficit after concussion (Guskiewicz,2004) Summary Concussion is a major public health concern 3 domains of assessment are used, none of them is stand alone Individualized treatment approach is recommended rather than using one based solely on concussion grading scales Closer look is needed when interpreting the evidence PT s Role? Are we doing enough? Concussion & Vestibular Rehabilitation Concussion & Vestibular Rehabilitation Patients usually referred to PT if they did not recover within the normal window of recovery Patients with dizziness show worse recovery in neuropsychological assessment and different self report symptoms (Chamelian et al, 2004) Sleep Alterations Difficulty falling asleep Fragmented sleep Too much/too little sleep Cognitive Symptoms Fogginess Difficulty concentrating Memory deficits Cognitive Fatigue Mood Disruption Irritability Feeling sad Anxiety Somatic Symptoms Headaches Dizziness Nausea Vomiting Light/Sound Sensitivity Numbness Numbness Tingling Visual problems Balance problems Slide courtesy of Cara Camiolo Reddy, MD 5

6 Somatic Symptoms Headaches Dizziness Nausea Vomiting Light Sensitivity Sound Sensitivity Numbness Numbness Tingling Visual problems Balance problems Headache The most common symptom after concussion Prevalence of initial headache between 43% to 86% of patients Persistent headache is also reported in a period up to three months after concussion Study Mean age (years) Outcome measure % report initial Time of follow up % reporting (sample size) headache (mean headache at follow severity) up (mean severity) Blinnman et al, (116) 14.1 PCS 71.6 (2.7) 2-3 weeks 31.8 (1.8) Collins et al, (109) 15.8 PCS NS 1 week 33.0 (2.7) Faux et al, (100) 33.6 RPQ month 3 months 30.4 (NR) 15.4(NR) Lannsjo et al 3months (2523) 31 RPQ (2.6) Lovell et al, (52) 16.8 PCS 88.5 Between 1 &4 weeks 32.7(NR) Headache Headache at time of admission to the ER is associated with development of post concussion symptoms at 1& 6 months after injury Individuals with headache have worse neurocognitive and balance testing, and were found to report more symptoms than individuals who do not have headache after concussion Savola et al, Modified 4 weeks (37) 33.7 version of 65 38(NR) PRQ Headache Individuals with headache (> 3 hours) have a prolonged return to play (RTP) compared to athletes w/o headache (>3 hours) after sport related concussion. Individuals with migraine headache have greater neurocognitive deficits compared to individuals with other forms of headache and individuals with no headache Dizziness Frequent symptom after concussion 23-81% of persons post concussion report dizziness in the first days Of the 61% who reported dizziness in one study, the severity breakdown is 41% mild 16% moderate 4% severe 6

7 Study (n) Blinmann et al, (116) Broglio et al (32) Lovell et al, (52) Lannsjo at al, (2523) Savola et al, (37) Prevalence of dizziness Mean Outcome measure % report initial Time of follow up age dizziness (mean (years) severity) % reporting dizziness at follow up (mean severity) 14.1 PCS 60.3(2.7) 2-3 weeks 27.0 (1.6) 19.7 PCS 28.1(.75) NS NA 16.8 PCS 78.8 Between (NR) and 4 weeks 31 PRQ 31 3 months 16 (2.6) 33.7 Modified 49 4 weeks 43(NR) version of RPQ Dizziness More symptomatic, and have worse psychosocial functioning 6 months after injury Dizziness at ER is associated with severity of post concussion symptoms at 1 and 6 months after injury linked to psychological distress at 6 months after injury Independent factor for failure to return to work after mild to moderate head injury Study (sample size) Balance Problems Mean age (years) Outcome measure % report initial Time of follow up symptoms (mean % reporting symptom at follow Rationale for vestibular rehabilitation post- concussion severity) up (mean severity) Post- traumatic dizziness associated with impairments in the vestibular system Blinmann et al, 14.1 PCS 60.3(2.6) 2-3 weeks 25.4(1.5) Broglio et al, 19.7 PCS 34.4 (.75) NS NA (32) Post- Concussive balance disorders may be attributed to dysfunction in sensory integration system Lovell et al, PCS 55.8 Between 1 and (NR) Vestibular rehab dizziness & imbalance (52) weeks Vestibular/ Balance Rehabilitation For concussion Evidence for vestibular rehab postconcussion Vestibular/ balance evaluation Evidence for Vestibular Rehabilitation Gurr et al, 2001 Graded exposure to head and body movements Anxiety management Coping strategies and education Results: reduced complaints of vertigo and dizziness, and improved balance of individuals standing on an unstable surface Hoffer et al, 2004 Somatosensory exercises combined with aerobic activity, vestibuloocular reflex, and cervico ocular reflex activities Results: reduced the complaints of dizziness and accelerated return to work 7

8 Subjects 114 patients (67 F/47 M) 84 patients received vestibular Rehabilitation Therapy Median number of visits:4 (2-13) Median Duration: 7 days(2-181) Oculomotor abnormalities Cover/uncover 8 subjects Convergence 7 Smooth Pursuit 7 VOR Cancellation 6 VOR 4 Saccades 3 Dynamic visual acuity 3 Results/Self Report Outcome Measure Pre-treatment Post-treatment Dizziness Severity 21(22) 12 (18) ABC 64 (27) 84 (17) DHI 49 (21) 30 (22) All measures are statistically significant, P <.05 Results/Performance Outcome Measure Pre-treatment Post-treatment DGI 20 (3) 23 ( 1) FGA 22 (5) 28 (3) Gait Speed 1.02 (.28) 1.28 (.23) TUG (sec) 9.7 (2.5) 7.8 (1.8) Results (Age effect) Outcome measures Children Adults DHI FGA TSTS s s FTSTS( Sec) 13.1 (6) 9.7 (5) SOT (Composite) 48 (19) 71 (13) All measures are statistically significant, P <.05 8

9 Conclusion Significant treatment effect for vestibular rehabilitation Age effect for some balance measures Interaction effect for dizziness severity only Meaning vestibular rehab can be used for both population(i.e. adults and children) Vestibular Rehab & Whiplash In a review, it was found that vestibular rehab reduces handicap and improves postural control Goals of VR After Concussion Reduce dizziness, imbalance, headache and other symptoms Improve balance performance Improve gaze stability and eye-head coordination Offer entry point to exertion program for athletes Concussion Evaluation Three domains: Neuropsychological performance Balance performance Self report symptoms (Somatic, mood, sleep, and cognitive) Concussion Evaluation History of concussion Mechanism of injury Date of Injury On field symptoms Present symptoms and dysfunctions Somatic symptoms (Keep in mind other clusters: mood, sleep, and cognition) Duration & severity of symptoms Exacerbating and relieving factors Post concussion symptom checklist (PCS) 22 symptom severity 7- point likert scale 0 (no symptom) - 6 (severe) Add up the scores Used by athletic trainers and neuropsychologists Acute phase 9

10 Vestibular Evaluation for concussion Assessment of symptoms (dizziness, headache) Assessment of Eye-Head coordination Balance assessment Assessment of dizziness/ vertigo Spontaneous or provoked If provoked, precipitating factor? All directions or Dix-Hallpike Characteristics Onset, duration, effect of repeated head movement Presence/ type of nystagmus Provoked dizziness Are you dizzy when? Looking up Walking in supermarket aisle Reading Turning over in bed Bending over Lying down Getting out of bed Cervicogenic Dizziness A non-specific sensation of altered orientation in space, and dysequilibrium originating from abnormal afferent activity from the neck (Furman and Cass, 1996) Associated with cervical flexion/extension (whiplash) injuries and head trauma Symptoms Ataxia Unsteadiness of gait Postural instability Associated with neck pain, limited neck ROM or headache Illusionary sense of motion Cervicogenic Dizziness Chief Complaint Dizziness or Vertigo History of neck pain, injury or pathology Diagnostic Criteria Complaints of ataxia, unsteadiness of gait, postural imbalance, and illusory sensation of movement Close temporal relationship between neck pain or headache and symptoms of dizziness Previous neck pain or pathology Elimination of other causes of dizziness Onset of symptoms may be sudden or gradual and occur days to weeks following the injury Symptoms are usually episodic and last minutes to hours yes BPPV, vestibular disorder, and/or cervicogenic dizziness Dix-Hallpike yes no Positive test Posterior canal BPPV Canalith abnormal results repositioning Maneuver Vestibular disorder Neck pain associated with dizziness Vestibular disorder, and/or cervicogenic dizziness Treat neck appropriately and refer to MD for vestibular testing no Cervicogenic dizziness unlikely Treat neck appropriately and refer to MD for dizziness normal results Cervicogenic dizziness likely Co-treat or refer to VR-PT Co-treat or refer to VR-PT 10

11 Cervicogenic Dizziness Suggested Treatment in Literature Cervical collar Cope and Ryan, 1959 Cervical traction Mayoux et al, 1951; Jongkees, 1969 Neck manipulation Stoddard, 1952; Ledru, 1955 Cold spray and local anesthetic Weeks and Travell, 1955 Local anesthetic injection and massage Gray, 1956 May also benefit from vestibular rehabilitation for residual space and motion discomfort or balance impairments Assessment of Eye Head Coordination Eye Head (E-H) coordination plays a role in gaze stabilization and balance Dysfunction in E-H coordination can lead to dizziness and /or imbalance By improving E-H coordination, post concussion dizziness/ imbalance can be improved Perception of Eye-Head movement Signals from labyrinth give info about head movement in space Info is integrated with somatosensory and visual input Whenever asymmetry in vestibular function occurs, brain interprets it as continuous movement of head May cause spinning even when head is not moving Vestibulo-Ocular Reflex (VOR) Stabilize visual image on retina during head movement Produces an eye movement of equal velocity but in opposite direction to the head movement VOR Gain = Eye velocity/ head velocity = 1 Normal VOR When head moves to right Excites Rt horizontal SCC Inhibit Lt horizontal SCC Drives eyes to left at same velocity of head movement Impaired VOR With Rt Unilateral peripheral vestibular hypofunction Head stationary No discharge of horizontal SCC Normal resting discharge of Lt horizontal SSC Difference indicates head movement (to lt in this example) Nystagmus? 11

12 Impaired VOR (con t) When false Lt head movement is indicated Eye will move slowly to Rt (slow phase) When eyes get to end range, they will move back quickly to Lt (fast phase) Left beating nystagmus VORx1 Evaluation Negative findings: Gross abnormalities Symptom provocation VOR x 1 VOR x 1 12

13 VOR X 2 VOR cancellation If we want to move eye in same direction with head, VOR must be suppressed. Eyes moves in the same direction as the moving object Convergence testing Convergence spasm Convergence insufficiency 13

14 Smooth Pursuit & Saccade Smooth pursuit: Visually pursue a slow moving object without moving head Maintain gaze on moving target Saccade: Rapid eye movement to allow refoveation of stationary targets (e.g. reading) Impairments Indicate brain problem Dix-Hallpike test? Positive findings -Negative findings Head Thrust test? BPPV Balance Assessment Gait assessment Balance Error Scoring System Objective findings vs. symptoms provocation? Clinical outcome measures Self Report measures: Activities Specific Balance Confidence Scale(ABC). Dizziness Handicap Inventory(DHI) Dizziness Rating (0-100) Self report symptoms checklist Performance measures: Dynamic Gait Index (DGI) Functional Gait Assessment (FGA) Five Times Sit to Stand (FTSTS) Timed UP &GO (TUG) Gait Speed Sensory Organization Test (Posturography) Activities Specific Balance Confidence Scale (ABC) 16 questions scale 0 No confidence 100 Full confidence e.g. Walk around the house? Walk across the parking lot to a mall? Walk in a crowed mall where people rapidly walk past you? Dizziness Handicap Inventory (DHI) Individual s handicap due to their dizziness 25 items 3 components: physical, emotional, and functional domains Maximum score 100 Higher score = Worse performance 14

15 Dizziness Rating & Descriptions Verbal scale (0-100) Higher score = more severe Dizziness descriptions: Spinning Lightheadedness Off balance Nausea Sensation of motion Others. Performance Measures Dynamic Gait Index (DGI) Functional Gait Assessment (FGA) Five Times sit to Stand (FTSTS) Timed UP &GO (TUG) Gait Speed Sensory Organization Test (Posturography) Dynamic Gait Index (DGI) DGI: 8 items Questions are rated on 0-3 scale 0 = severe impairments 3 = Normal Maximum score 24 ( higher score is better) Functional Gait Assessment (FGA) 10 items test 7 items from DGI in addition to: Gait With Narrow Base Of Support Gait With Eyes Closed Ambulating Backwards Maximum score 30 ( higher score is better) TUG (Sec) TUG & FTSTS Subject stands from a chair, walks three meters at their normal walking speed, and returns to the chair FTSTS (Sec) Subject stands-up and sits down from a standard height chair five times as quickly as possible. Dynamic Computerized Posturography (SOT) Tests sensory integration between the visual, somatosensory, and vestibular systems 1) eyes open, fixed support 2)eyes closed, fixed support 3)sway-referenced vision, fixed support 4) eyes open, sway-referenced support 5) eyes closed, sway-referenced support 6) sway-referenced vision and support surface 15

16 SOT SOT Evaluation Guidelines Perform the least number of tests possible ( testing intolerance) Evaluation may take more than one visit Rule out/ Treat BPPV first Pure BPPV V.S not pure? Re-eval oculomotor testing every few visits Selection of appropriate measures Self report vs. performance Expected ceiling effect in young adults Validity and test retest reliability in young adults Normative reference values, and Minimal clinical important difference(mcid) 16

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