Concussion Basics

1. Concussion Basics Sarah Brittain, MS CCC-SLP Kate Smulligan, PT, DPT

2. HealMyConcussion.com 303.932.2030

3. Objectives At the end of this presentation, you will be able to: • Describe the basic mechanism of a concussion • Identify signs and symptoms of a concussion • List 3 similarities between symptoms of a concussion and a whiplash injury • Discuss why early referral for concussion treatment is critical • Understand the implications of imaging in concussion • Gain an appreciation for all disciplines required to treat concussion

4. Concussion Tell us what you’ve heard about concussions!

5. Concussion?

7. Concussion Myths

8. Concussion Myths https://www.hshlawyers.com/articles/concussions-emerging-from-a-dark-room-after-a-traumatic-brain-injury/

9. Concussion Myths https://www.theatlantic.com/health/archive/2016/02/super-bowl-football-helmet-concussion/460092/

10. Concussion Myths https://www.newsobserver.com/sports/soccer/article29643220.html

11. Concussion Myths https://www.nytimes.com/2014/08/07/sports/soccer/premier-league-concussion-protocol-could-force-injured-players-from-games.html

12. Concussion Myths https://www.shutterstock.com/image-vector/cartoon-man-running-on-treadmill-office-155801495

13. Concussion Myths https://beta.washingtonpost.com/opinions/trump-said-i-alone-can-fix-it-how-wrong-he-was/2018/01/20/c2802e1a-fe05-11e7-a46b-a3614530bd87_story.html?noredirect=on

14. What is a Concussion?

15. Traumatic Brain Injury A disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or a penetrating head injury.

16. Concussion - CDC Definition • A type of traumatic brain injury caused by a blow to the head OR a hit to the body • Often described as a “mild” traumatic brain injury • Effects are serious

17. American Congress of Rehab Medicine (ACRM) Definition • Traumatic force to brain leading to disruption of brain function EITHER by direct blow to the head OR by acceleration/deceleration movement. • Manifested by AT LEAST one of the following: • Any period of LOC of 30 minutes or less: GCS 13-15 • Any loss of memory for events immediately before or after the event (must not exceed 24 hours) • Any alteration in mental status at time of event • Focal neurological deficit

18. Mild does not mean mild!!

20. Concussion Signs • Appears confused • Answers questions slowly • Appears clumsy • Moves slowly/holds furniture • Closes one eye • Wears sunglasses inside Symptoms • Headache • Nausea • Balance impairment • Dizziness • Light and/or noise sensitivity • Blurry vision • Memory impairment/confusion • Sleep disturbance/fatigue • Emotional changes

21. Concussion Signs/Symptoms - 4 Categories • Physical • Cognitive • Emotional • Sleep

22. Physical • Headache • Neck pain • Dizziness • Nausea • Blurry vision • Impaired balance

23. Cognitive • Attention • Memory • Problem solving • Executive functioning

24. Emotional • Depression • Anxiety • Irritability • Emotional lability

25. Sleep • Difficulty falling asleep • Difficulty staying asleep • Sleeping too much • Sleeping at inappropriate times • Excessive fatigue

26. Epidemiology • Annual Incidence of mTBI - approximately 3.8 million • WHO: TBI will surpass many diseases as the major cause of death and disability by the year 2020 • 2013: 2.8 million TBI-related ED visits, hospitalizations and deaths in the U.S., with TBI-related deaths of approx. 50,000 people • 75 percent of TBIs each year assessed as mTBIs https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm596531.hm

27. How concussions happen - cellular level

28. Brain Basics https://en.wikipedia.org/wiki/Neuron

30. What Happens in Concussion • Axonal Shearing Forces - Axonal Swelling/Edema • Disruption of neural membrane • Outflux K+, Influx Na+, Increase Ca2+ • Elevated Ca2+, increase in cerebral metabolic rate with increased energy requirement but decrease in cerebral blood flow • Impaired metabolism, decreased mitochondrial function, increase lactate, decreased ATP, impaired neuron functioning • Glutamate (excitatory neurotransmitter) released without discretion • TAKE AWAY: Cellular Damage and Disconnection of Neural Circuits

32. Concussion Implications of this Mechanism • Symptoms might not appear on day one • Energy crisis in the brain where glucose and blood flow are impacted

33. When does someone sustain a concussion • There is no threshold • Studies using accelerometers looking at both • Linear Acceleration • Rotational Acceleration • Determine probability of concussive event

34. Risk Factors • Prior history of TBI • Prior psychological history • Prior history of migraine • Prior history of ADD/ADHD • Gender differences?

35. Subconcussive blows - who cares • Data to suggest that even subconcussive blows are risky • Implications for athletes, or people sustaining frequent blows to the head • Are these people more likely to sustain injury in a single event such as an MVC?

36. How are Concussions Diagnosed? • Imaging • Subjective Data • Objective Data

37. Imaging • CTs/Traditional MRIs will typically not show a concussive injury • Rule out more serious conditions • 3T MRI showing some promise for identifying micro hemorrhaging • Imaging studies DO NOT change evaluation or treatment of a concussion • DTI helpful for visualizing white matter tracts - not routinely used • SPECT - not specific • fMRI - used in research

38. Subjective & Objective Data Subjective Data • patient reported symptoms Objective Data • Data from screening measures such as • VOMs • BESS • Tandem Gait • Cognitive Testing

39. Deep dive into the physical 4 main areas for concussion assessment in physical therapy: • Cervical spine • Oculomotor • Vestibular • Exertional testing

40. A concussion almost always involves an injury to the cervical spine.

41. Cervical Spine: PT evaluation Orthopedic: • Upper C-spine ligaments • C-spine ROM • C1-C2 rotation • C-spine segmental mobility • Cervical strength/endurance • 1st rib mobility • Upper T-spine ROM/mobility Neurologic: • Cervical joint position sense error • Head/neck differentiation test (cervicogenic dizziness) • Smooth pursuits neck torsion • ULTT

42. Cervical Joint Position Error • Neck reposition sense (cervical JPE) • Abnormal cervical afferent input

43. Cervical Joint Position Error • Target distance = 90 cm • Errors > 4.5 degrees = significant Skillworks.biz

44. Cervicogenic Dizziness • Neck pain accompanied by dizziness and disequilibrium • May resolve with cervical spine treatment • May also require vestibular treatment

45. Head-Neck Differentiation Test Cheever 2016

46. Smooth Pursuit Neck Torsion • Differentiate between dizziness related to cervical injury vs. vestibular or oculomotor deficits Cheever 2016

47. Whiplash versus Concussion

48. Whiplash versus Concussion You cannot differentiate between whiplash and concussion based on symptoms alone. Cheever et al 2016

49. Whiplash versus Concussion Proper identification of the source of symptoms is crucial for timely recovery!

50. What do you do with patient whose primary complaint is neck pain, but they are not responding to orthopedic treatment?