Concussion

Question 1

What is LYSTEDT LAW?

Answer 1

Any youth athlete showing signs of concussion must be evaluated by licensed HCP before return to play *coaches, parents and athletes require some education

Question 2

What is the definition of a CONCUSSION?

Answer 2

TBI induces by biomechanical forces

Question 3

Who has a higher incidence of concussion (younger vs older, men vs women)? Which of these groups are more likely to have slower recovery?

Answer 3

In comparative sports females have higher incidence, are more severe and have slower recovery Younger athletes have higher incidence, and slower recovery (brain is more vulnerable)

Question 4

Does CT or MRI show structural abnormalities after concussion?

Answer 4

No, unless it is more than a mild injury. *may show ultrastructural changes (fine structures, especially within a cell)

Question 5

What is the proposed pathophysiology of concussion?

Answer 5

-Angular and rotational forces = neuronal shearing -Linear acceleration-deceleration = macroscopic damage

Question 6

What is the primary neurochemical cause of concussion?

Answer 6

Increased permeability of neuronal membranes (from stretching, damage of axons) = increase glutamate production (interferes with cell communication), K+ release, NA+ influx = causes axon dysfunction or death

Question 7

What is SECOND IMPACT SYNDROME?

Answer 7

Occurs with a 2nd head injury after previously having one without symptoms returning to baseline Results in impaired consciousness and death from cerebral edema (occurs within a few days)

Question 8

What are some PHYSICAL symptoms of concussion?

Answer 8

Headache, nausea, vomiting, balance, dizziness, visual impairment, light/sound sensitivity

Question 9

What are some SLEEP related symptoms of concussion?

Answer 9

Drowsy, difficulty falling/staying asleep, less/more sleep than usual

Question 10

List some EMOTIONAL symptoms related to concussion.

Answer 10

Increased emotion, irritability, sadness, nervous, anxious

Question 11

List COGNITIVE symptoms related to concussion.

Answer 11

“Foggy”, difficulty concentrating or remembering, confusion, recall challenges

Question 12

What is the STRONGEST predictor of slow recovery post concussion?

Answer 12

The severity of initial symptoms after injury

Question 13

What is a way to help with tracking recovery post concussion?

Answer 13

Baseline testing: neuropsychologic, balance, PMH pertinent to concussion(includes those that may overlap with post concussive symptoms - depression, fatigue, HAs, learning disability etc)

Question 14

What are some different TESTS that can be used to assess for CONCUSSION?

Answer 14

Balance Error Scoring System (tests static balance - part of SCAT) King -Derick test (eye movement - speed - rapid number naming) Vestibule-ocular tests (smooth pursuits, VOR, convergence)

Question 15

What are some things you can EDUCATE the athlete on regarding CONCUSSION ?

Answer 15

• Significance of injury - Recognition and management - Equipment (helmets, mouth guards) don’t decrease incidence - State regulations regarding RTP process * there is no single tool for guaranteed diagnosis or RTP clearance

Question 16

Can co-morbidities play a role in CONCUSSION MANAGEMENT?

Answer 16

Yes - example, hx of ADHD = 3 days longer to return to baseline

Question 17

What test is utilized to assess the athlete for concussion on the sideline?

Answer 17

SCAT5 - Sport Concussion Assessment Tool Guides testing -> red flag assessment, S+S to give info about injury, memory assessment, Glasgow coma scale, C/S assessment

Question 18

What are some immediate tests that can be performed to determine if an athlete is concussed?

Answer 18

• get background, S+S - cognitive screening (orientation, immediate memory and concentration) - brief neuro screen and delayed recall assessment *periodic testing should be perform to ensure athlete stabilizes

Question 19

What are your recommendations for an athlete and their family post concussive event?

Answer 19

-Educate on S+S to monitor -Give copy of SCAT5 for reference -review importance of sleep, hydration and rest from stressful activities -recommend follow up with physician

Question 20

What are some important factors with regards to early management of concussion?

Answer 20

-rest is IMPORTANT (avoid too little and too much - can result in persistence or exacerbation of symptoms) - recommend against early med use (except previous prescriptions) - SLOW and GRADUAL activity progression (return to full school before full activity) - must be SYMPTOM FREE along each step

Question 21

What is typical RETURN TO PLAY for young individuals with concussion?

Answer 21

Approximately 14-28 days

Question 22

What are some predictors of POOR or DELAYED prognosis for athletes with concussion?

Answer 22

Dizziness (6x more likely for protracted recovery), post trauma migraines, depression, ADHD, cognitive deficits, difficulties with oculomotor function

Question 23

What impairment DOMAINS should the SCS inquire about when assessing sport related concussion?

Answer 23

Cervical, Headaches, Vestibular, Oculomotor, Sleep, Affective, Cognitive, Cardiovascular

Question 24

What are CERVICAL IMPAIRMENTS related to concussion?

Answer 24

Neck pain, impaired proprioception, cervicogenic dizziness *these aren’t directly involved with changes in brain

Question 25

What are some common findings with CERVICOGENIC HEADACHES?

Answer 25

-unilateral pain, headache -HA increased with sustained positions and neck movement -decreased ROM, strength, endurance, coordination

Question 26

What are some basic treatments to be performed with both the ACUTE and SUBACUTE cervicogenic headache patient?

Answer 26

Acute = gentle C1-C2 SNAGS Subacute = manual therapy -> cervical manip, mob

Question 27

List some tests that can be performed to assess CERVICOGENIC HEADACHES and DIZZINESS.

Answer 27

-Cervical Joint Reposition Error Test -Smooth Pursuit neck torsion test -Cervical flexion-rotation test -Craniocervical flexion test -Deep neck flexor endurance test

Question 28

What is Post-Concussive Syndrome? What increases the likelihood that an athlete will experience this?

Answer 28

• persistent symptoms beyond normal course of recovery (majority resolve quick; 1/3 have symptoms >10 days) - if VESTIBULO-OCULAR DYSFUNCTION post concussion = increased likelihood

Question 29

What is VOR? What is VSR?

Answer 29

• Vestibulo-ocular reflex = images stabilized during head movement (eye movement opposes head movement) - Vestibulo-spinal reflex = vestibular input stabilizes body/maintains posture *if these are affected = increased likelihood of LE injury

Question 30

What are the possible CAUSES of dizziness?

Answer 30

• cervicogenic (possible with neck pain; not likely without) - vestibular disorder (includes otolith issue - BPPV) *assessment should drive intervention! (may find - impaired balance, VOR, fixation, and convergence; +ve saccades)

Question 31

What are some TREATMENT options for vestibular dysfunction post concussion?

Answer 31

-BPPV habituation -Balance Training -Dynamic head-neck stabilization and proprioception -Gaze stabilization exercises (VOR) -Manual Therapy (C-spine dysfunction) *A combination = is more effective when treating RTP athletes

Question 32

What is a common TREATMENT for OCULOMOTOR impairments post concussion?

Answer 32

-eye-head coordination exercises (e.g., VOR x1, convergence)

Question 33

What effect can OCULOMOTOR impairments POST CONCUSSION have on the student athlete and their ability to return to school?

Answer 33

-visual issues can interfere with: reading, ability to see the board, walking stairs etc.

Question 34

What are some of the possible effects of concussion on: EXECUTIVE FUNCTION?

Answer 34

-decreased attention, impaired memory, impaired concentration, slow recall *should assess these weekly to look for changes (SCAT5 diagnostic utility decreases after 5 days) *symptoms > 2 weeks = refer (neuropsychologist, SLP, CBT)