Concussion and mild TBI Flashcards
(205 cards)
1
Q
____ have the highest concussion rates.
A
Adolescents and young adults (15–24 years)
2
Q
Highest Rates: why?
A
High participation in contact sports
Risk-taking behaviors
Developing brain may be more susceptible to concussion effects
3
Q
As of the end of 2022, the DOD has reported over ___ cases of TBI among U.S. service members
A
463,000
4
Q
The majority of TBIs reported are classified as ___, often referred to as ____.
A
mild
concussions
5
Q
Common Causes of TBI in Military Settings:
A
Combat-related incidents: Exposure to blasts, gunshot wounds, and other combat injuries.
Training accidents: Injuries sustained during rigorous physical training exercises.
Motor vehicle accidents: Both on and off-duty vehicular incidents.
Falls: Particularly among older service members or in challenging terrains.
Sports and recreational activities: Participation in contact sports or other high-risk activities.
6
Q
The majority of TBIs are mild, emphasizing the need for ____
A
effective concussion management protocols.
7
Q
TBIs result from a variety of incidents, not solely combat, highlighting the importance of ____
A
comprehensive prevention strategies.
8
Q
Types of Traumatic Brain Injury Mechanisms:
A
Direct Impact Injury
Acceleration-Deceleration Injury
Blast Injury
9
Q
Direct Impact Injury =
A
cause = Blow to the head
injury type = Focal (coup/contrecoup)
features = Localized deficits, contusions, skull fractures
10
Q
Acceleration-Deceleration Injury =
A
cause = Rapid head movement
injury type = Diffuse (DAI)
features = Loss of consciousness, widespread impairments
11
Q
Blast Injury =
A
cause = Explosive forces
injury type = Complex (primary to quaternary)
features = Combination of pressure effects, shrapnel wounds, and burns
12
Q
Direct Impact Injury mechanism =
A
Occurs when an external object strikes the head, causing the brain to collide with the inner skull.
This can result in localized damage at the site of impact (coup injury) and potentially on the opposite side (contrecoup injury) due to the brain’s movement within the skull
13
Q
Acceleration-Deceleration Injury mechanism =
A
Involves rapid movement of the head, causing the brain to move within the skull.
This movement can lead to shearing forces that damage brain tissues, particularly axons
14
Q
Blast Injury mechanism =
A
Results from exposure to explosive forces.
The blast wave can cause complex injuries through overpressure, shrapnel, and the body’s displacemen
15
Q
Approximately ___ of U.S. high school students reported experiencing at least one concussion related to sports or physical activity in the previous 12 months
A
15%
16
Q
___ settings are a major contributor (nearly ____).
A
School
1 in 6
17
Q
Over half are from “Other” settings — suggesting:
A
a wide range of causes including non-categorized incidents or underreported sources
18
Q
___ leads the way among sport-related concussions in this dataset (___%).
A
Soccer
13
19
Q
____ is still a major contributor (__%), but not as dominant here — likely depends on sample demographics (e.g., gender balance).
A
Football
10
20
Q
____ also contribute meaningfully (4%).
A
Non-contact sports like cheerleading
21
Q
Don’t assume football is always #1 — soccer often ranks higher due to:
A
heading, collisions, and higher participation rates across genders
22
Q
____ are often underestimated — high concussion potential due to flips/falls and head trauma.
A
Cheerleading and combat sports
23
Q
____ are major sites of injury — concussion isn’t just a “sports thing.”
A
School and recreational settings
24
Q
SCAT6 (Sport Concussion Assessment Tool 6)
A
validated for athletes ≥13 years in acute, sideline settings
Includes:
Symptom checklist
Maddocks questions (orientation)
Memory recall
Neurologic screen
Balance testing (BESS)
Coordination test
NOT used for return-to-play clearance but is ideal for initial assessment
25
You’re now moving from acute sideline screening → to clinical assessment and subtyping, followed by developing a PT management plan.
What now (Post-game, 2 days later, in-clinic evaluation)?
Confirm the concussion subtype(s):
Because she had disequilibrium, you should suspect: Vestibular subtype = Dizziness, balance problems, motion sensitivity
Also screen for:
> Cervical dysfunction (especially in rugby players)
> Oculomotor problems (blurred vision, convergence issues)
> Cognitive/fatigue if she reports difficulty focusing or increased exertional symptoms
26
Use targeted assessment tools:
Vestibular/Ocular:
Balance/Posture:
Symptom severity:
Perception:
Cervical spine: AROM,
Vestibular/Ocular: VOMS, Dynamic Visual Acuity Test
Balance/Posture: BESS, FGA, mCTSIB
Symptom severity: Post-Concussion Symptom Scale
Perception: Dizziness Handicap Inventory (DHI), ABC
Cervical spine: AROM, joint mobility, provocation tests
27
Use ___ to help guide aerobic progression
Buffalo Concussion Treadmill Test (BCTT)
28
Advance return-to-learn and return-to-play protocol based on ___
symptom resolution and tolerance
29
Concussion -
a traumatically induced transient disturbance of brain function
involves a complex pathophysiological process
is generally self-limited and at the less-severe end of the brain injury spectrum
30
Concussion is a subset of ____
mild traumatic brain injury (mTBI)
31
Concussion produces an onset of ____
non-specific s/s and/or changes in mental function
32
not all ___ are ___, but all ___ are ___
mTBIs
concussions
concussions
mTBIs
33
Traumatically induced =
caused by a direct or indirect biomechanical force
34
Transient =
short-term (though symptoms may persist)
35
Functional disturbance =
not typically seen on neuroimaging
36
Neurochemical/metabolic disruption
not structural brain damage
37
Concussion: Molecular Pathophysiology
Series of complex, overlapping, disruptive brain events
RESULT: neuronal crisis that requires a variable and unknown amount of time for physiological recovery
38
Symptoms/dysfunction associated with the mechanism of neuronal injury:
ionic shifts- potassium outflow, sodium and calcium in-flow = energy crisis
damaged neuronal architecture- microstructures (e.g. axons, microtubules) collapse; axons swell
higher concentrations of inflammatory chemicals
increased excitatory neurotransmitter release- possible connection between damage-associated molecular patterns (DAMPs) and neuro-inflammation following concussion
cerebral blood flow disruption
39
Molecular Cascade After Concussion:
Ionic shift (K+ out, Ca2+ in) = Neuronal depolarization
Glutamate release = Excitotoxicity
↓ Cerebral blood flow = Energy crisis → fatigue, HA, fogginess
Axonal stretching = White matter dysfunction
Inflammation (microglia) = Prolonged symptoms
40
Step 1: Mechanical Injury Triggers Ionic Imbalance
External force causes neuronal stretching/shearing
Disrupts cell membranes → ions shift:
K+ rushes out
Ca2+ and Na+ rush in
This causes widespread neuronal depolarization
✅ Think of it as a brain-wide electrical storm
41
Step 2: Glutamate Release + Excitotoxicity
Massive release of glutamate (excitatory neurotransmitter)
Overstimulates NMDA receptors → more Ca2+ influx
Leads to neuronal dysfunction and risk of cell death
42
Step 3: Energy Crisis
Na+/K+ pumps try to restore balance → requires ATP
BUT: Cerebral blood flow drops post-injury (up to 50%↓)
Result = energy mismatch
↑ Demand + ↓ Supply = metabolic crisis
Clinically → this causes:
Fatigue
Exercise intolerance
Headache with exertion
Slowed thinking
43
Step 4: Axonal Disruption
Axons are stretched → cytoskeletal damage
Microtubules break, impairing transport of nutrients/neurotransmitters
This contributes to diffuse symptoms and delayed recovery
✅ Associated with diffuse axonal injury (DAI) — often not visible on imaging
44
Step 5: Neuroinflammation
Injury triggers release of DAMPs (damage-associated molecular patterns)
Microglial activation leads to:
Cytokine release
Swelling
Longer-lasting symptoms (especially with repeated injuries)
✅ Seen in post-concussion syndrome and prolonged recovery
45
___ tolerance is impaired early on due to this energy crisis → start low, go slow
Aerobic exercise
46
Microglia =
“immune cells” of the central nervous system
47
Microglia appear as early as ___ following concussion
with noticeable morphological changes within ___ after injury
6 hours
72 hours
48
The release of ___ and ___ occur rapidly in extracellular space post-injury
DAMPs
microglia activation
= associated with poor outcomes post-trauma
49
mTBI vs concussion:
mTBI = Traumatic brain injury classified by GCS 13–15, brief LOC or confusion, possible amnesia
concussion = A subset of mTBI characterized by a functional disturbance and typically normal imaging
50
Concussion is often used in ___ settings, mTBI more in ___ contexts.
sports
military or medical/trauma
51
Some experts label concussion as uncomplicated mTBI:
No trauma-related intracranial abnormalities are seen on structural neuroimaging due to microscopic cellular injury
52
mTBI has specific diagnostic criteria based on the ___
GCS
Some mTBIs involve structural injuries (e.g., small bleeds, contusions) → these would not be called a concussion.
53
The ___ uses concussion and mTBI interchangeably.
DOD
54
Mild TBI = Concussion
You are dealing with a concussion if the patient fits ALL of the following:
Structural Imaging: Normal
Loss of Consciousness (LOC): 0–30 minutes
Altered Mental State: Momentary to ≤24 hrs
Post-Traumatic Amnesia (PTA): 0–1 day
GCS Score: 13–15
55
A concussion is NOT present if the injury meets any of the following moderate/severe criteria:
LOC > 30 minutes
PTA > 1 day
GCS < 13
Altered mental state > 24 hours
Structural abnormalities (e.g., hemorrhage) seen on imaging
56
It IS a concussion if…
GCS 13–15
LOC < 30 min
PTA ≤ 1 day
Normal structural imaging
Mental status altered < 24 hrs
57
It is NOT a concussion if…
GCS < 13
LOC > 30 min
PTA > 1 day
Visible hemorrhage, contusion, or skull fx
AMS > 24 hrs
58
Glasgow Coma Scale (GCS) –
scored from 3 to 15
evaluates 3 behavioral responses:
- eyes opening
- verbal
- motor
59
Eye Opening Response (E) – Max 4 points
4 - Opens eyes spontaneously
3 - Opens eyes to speech
2 - Opens eyes to pain
1 - No eye opening
60
Verbal Response (V) – Max 5 points
5- Oriented to time, person, and place
4 - Confused conversation
3 - Inappropriate words
2 - Incomprehensible sounds
1 - No verbal response
61
Motor Response (M) – Max 6 points
6 - Obeys commands
5 - Localizes pain
4 - Withdraws from pain
3 - Abnormal flexion (decorticate)
2 - Abnormal extension (decerebrate)
1 - No movement
62
TBI Severity Classification by GCS
13–15: Mild ✅ Includes Concussion
9–12: Moderate ❌ Not concussion
< 9: Severe ❌ Not concussion
63
GCS 13–15 + brief LOC/AMS = likely ____
concussion/mTBI
64
If a patient’s GCS drops below 13:
you are outside the realm of concussion
That would be a moderate or severe TBI, requiring immediate medical attention and likely imaging.
65
Common Symptoms of Concussion/mTBI
physical: most commonly reported and typically show up first
Headache
Nausea
Vomiting
Blurred/double vision
Seeing stars or lights
Balance problems
Dizziness
Sensitivity to light/noise
Tinnitus
Vertigo
66
Common Symptoms of Concussion/mTBI
behavioral/emotional: often develop or worsen over time, especially with prolonged recovery
Symptoms
Drowsiness
Fatigue/lethargy
Irritability
Depression
Anxiety
Sleeping more than usual
Difficulty falling asleep
67
Common Symptoms of Concussion/mTBI
cognitive: mpact attention, executive function, and memory
Feeling “slowed down”
Feeling “in a fog” or “dazed”
Difficulty concentrating
Difficulty remembering
68
If dizziness, balance issues, or vertigo are present →
screen vestibular + ocular motor systems (VOMS, mCTSIB, DGI, BESS)
69
Fatigue + irritability + poor sleep = signs of ____
post-concussive syndrome
** Educate on sleep hygiene, stress management, and gradual pacing
70
Concussion Assessment: Key Takeaways
Concussion = a clinical diagnosis, based on a cluster of signs and symptoms across multiple systems.
*There is no single gold standard concussion assessment
multi-modal and symptom-driven
71
CRT6 =
Concussion Recognition Tool 6 — designed to recognize suspected concussion immediately after injury
For use by:
> Non-medical personnel (coaches, trainers, bystanders)
> First responders
> Sideline staff
Not a diagnostic tool — it's a triage tool to help identify and refer suspected cases.
72
CRT6 Sections Include:
Red flags: Signs of serious injury (e.g., seizure, deteriorating consciousness) — requires immediate medical referral
Observable signs: E.g., balance issues, vacant stare, slow to get up
Memory assessment (Maddocks Questions): Quick screen for orientation in sport context
Symptoms: Self-reported symptoms (e.g., HA, fogginess, nausea)
Signs: Noted by others (e.g., slurred speech, confusion)
73
CRT: Red Flags: CALL AN AMBULANCE
Neck pain or tenderness Repeated vomiting
Seizure, fits, or convulsion
Severe or increasing headache
Loss of vision or double vision Increasingly restless, agitated, or combative
Loss of consciousness
Visible skull deformity
Confusion/drowsiness, deteriorating mental state
Weakness/numbness/tingling in more than one limb
74
If any red flags are present, the athlete must be:
Removed from play
Not returned that day
Referred for emergency medical care
75
If no red flags, you continue with:
Symptom screening (e.g., CRT6 symptoms list)
Brief cognitive questions (e.g., Maddocks)
Monitor for delayed symptom onset
76
What CRT6 Is:
A field-side recognition tool
For use by non-medical staff
Flags emergency red signs
77
What CRT6 Is NOT:
A diagnostic or clearance tool
Not used for return-to-play
Doesn’t assess all domains of concussion
78
Visible Clues of Suspected Concussion
observational signs — what a coach, trainer, or clinician might see after the injury:
Loss of consciousness or responsiveness
Lying motionless on the playing surface
Falling unprotected to the ground
Confusion, staring, or lack of appropriate responses
Dazed or blank/vacant expression
Seizure or convulsion
Delayed to get up after impact
Unsteadiness, poor balance, wobbliness
Facial injury (esp. with head impact)
79
Symptoms of Suspected Concussion
This is where you ask the athlete or patient what they’re experiencing:
Headache
“Pressure in head”
Balance problems
Nausea or vomiting
Drowsiness
Dizziness
Blurred vision
Light/noise sensitivity
Fatigue or low energy
“Don’t feel right”
Neck pain
79
Changes in Thinking:
Difficulty concentrating
Difficulty remembering
Feeling slowed down
Feeling like “in a fog
79
Changes in Emotion:
More emotional
Irritable
Sad
Anxious
80
CRT takeaways:
CRT6 = recognition tool only, not diagnostic.
Visible clues + symptoms → warrant removal from play and further clinical evaluation.
You may later use SCAT6, VOMS, BESS, etc. as part of your PT assessment.
81
“Symptoms may develop over minutes or hours.” =
That’s why re-assessment and serial observation matter (especially in the first 24–48 hours).
82
Awareness = Sideline Orientation Screening
If the athlete can't answer these correctly → suspect concussion
Examples:
“Where are we today?”
“What event were you doing?”
“Who scored last in this game?”
“What team did you play last week/game?”
“Did your team win the last game?”
These assess:
> Short-term memory
> Contextual awareness
> Sport-specific recall
83
Any athlete with a suspected concussion should be IMMEDIATELY REMOVED from practice or play and not return until medically cleared — even if symptoms go away
NO Return to Play
No same-day return-to-play
Clearance must come from a healthcare professional
Even a brief symptom (e.g., dazed look, fogginess) requires this protocol
84
These are non-negotiable precautions for the first few hours after injury:
These rules apply even if symptoms are mild or resolve quickly
Do NOT:
Leave athlete alone for at least the first 3 hours
Send them home alone — must be with a responsible adult
Allow them to drink alcohol or use unprescribed drugs
Let them drive until cleared by an HCP
85
SCAT6
Sport Concussion Assessment Tool – 6th Edition
Designed for licensed healthcare professionals only.
Used after injury, not for return-to-play clearance.
86
Who Can Get SCAT6?
NO red flags
GCS is 15
No spinal or neurological emergency
Athlete is stable for sideline screening
13+ yrs old
87
If any of these are present: DO NOT use SCAT6 — refer to ER.
Neck pain/tenderness
Seizure or convulsion
Double vision
LOC
Weakness/tingling/burning in limbs
Deteriorating consciousness
Vomiting
Severe or increasing headache
Restlessness/agitation
GCS <15
Skull deformity
88
The SCAT6 is part of ____, NOT ____
initial evaluation
a return-to-play clearance tool
88
GCS Score ____ = REFER OUT
≥15
89
Diagnostic Interview for mTBI:
Step 1: Establish Plausible Injury Mechanism
Step 2: Query Signs & Symptoms (Immediately After the Injury)
Step 3: Rule Out Confounding Factors
90
Step 1: Establish Plausible Injury Mechanism
Ask the patient:
What exactly happened before, during, and after the impact?
Did your head move rapidly (e.g., whiplash)?
Was there a fall, collision, or jolt?
How intense was it?
Can you separate what you remember from what others told you?
🧠 Goal: Confirm that the mechanism is consistent with a concussion (e.g., rapid acceleration-deceleration, direct blow to the head, etc.)
91
Step 2: Query Signs & Symptoms (Immediately After the Injury)
Ask about:
- Memory gaps
- Mental confusion or fogginess
- Trouble answering/following instructions
- Unusual behavior or speech issues
Examples:
“Did you seem confused right after it happened?”
“Were you unresponsive at any point?”
“Did you feel like your thoughts weren’t making sense?”
🧠 These reflect acute cognitive changes that support a concussion diagnosis.
92
Step 3: Rule Out Confounding Factors
You’re checking whether something else could have caused the symptoms:
Ask about:
Alcohol or drug use
Panic or extreme fear
Severe pain elsewhere (e.g., broken bones)
Anticipation of impact (did they see it coming?)
🧠 If yes to any of these → symptoms might be non-neurological in origin
93
Maddocks Questions – Sideline Orientation Screening
These are short-term memory and awareness checks. They're part of:
- CRT6
- SCAT6
- On-field acute concussion screening
94
Maddocks Question For Athletes ≥13 Years Old:
“What venue are we at?”
“What team are you playing?”
“What half is it?”
“Who scored last?”
“Who did you play last week?”
“Did your team win the last game?”
95
UPMC VOMS (Vestibular/Ocular Motor Screening)
Screen for vestibular and oculomotor deficits in patients with suspected concussion or persistent post-concussive symptoms (PPCS).
⏱️ Takes ~5 minutes
🚫 Not diagnostic alone — used in combination with symptom rating and functional testing.
1) horizontal & vertical pursuits
2) horizontal & vertical saccades
3) horizontal & vertical VOR
4) near point convergence
5) visual motion sensitivity
96
Horizontal & Vertical Pursuits =
What it tests:
- Smooth pursuit eye movements
- Ability to track a slow-moving target smoothly without jerking
PT Instructions:
- Move your finger ~18 inches away at a speed of 2 seconds per direction
- Patient follows with eyes only (no head movement)
Positive sign:
Symptom provocation (↑ headache, dizziness, nausea, fogginess ≥2/10)
97
Horizontal & Vertical Saccades =
What it tests:
- Rapid eye movement from one target to another
PT Instructions:
- Hold two fingers ~12 inches apart, patient rapidly switches gaze back and forth (10 reps each direction)
Positive sign:
Overshooting, fatigue, symptom increase
98
Near Point Convergence (NPC) =
What it tests:
- Ability to converge both eyes on a near object (e.g., a pen)
PT Instructions:
- Slowly move target toward nose
- Ask patient to report when the object becomes double or they feel symptoms
- Measure distance (normal = ≤5 cm)
Positive sign:
NPC >5 cm or provokes symptoms
99
VOR (Vestibulo-Ocular Reflex) – Horizontal & Vertical =
What it tests:
- Eye stability with head movement (gaze stabilization)
PT Instructions:
- Patient holds target at eye level
- Turns head at ~180 bpm while maintaining focus (20 reps)
Positive sign:
Blurred vision, dizziness, headache
100
Visual Motion Sensitivity (VMS) =
What it tests:
Central integration of visual + vestibular input
PT Instructions:
- Patient holds thumbs out, focuses on them
- Rotates trunk/shoulders/head together ~80° side-to-side (50 bpm, 5 reps)
Positive sign:
Dizziness or symptom increase
101
When to Use VOMS:
Patient has dizziness, blurred vision, motion sensitivity, balance complaints
Post-concussion symptom screen is positive
As part of a comprehensive PT concussion eval
102
Horizontal Smooth Pursuit
Normal Tracking
- Smooth, sinusoidal movement
- Eye trace closely follows the stimulus
- Few or no red marks (catch-up saccades)
✅ Suggests intact smooth pursuit
Mild Deficit
- Still tracking the sinusoidal pattern
- More visible corrective saccades
- Slight phase lag or drift from the target line
⚠️ Suggests mild oculomotor dysfunction — commonly seen post-concussion
Moderate to Severe Deficit
- Poor tracking
- Many red saccades = catch-up attempts
- Eye trace significantly deviates from target line
- Disorganized movement pattern
❌ Suggests significant oculomotor or central integration issue — often found in patients with:
Concussion/mTBI
Vestibular dysfunction
Neurologic conditions affecting gaze control
103
PT Role After Abnormal Smooth Pursuit:
Begin oculomotor training: slow eye tracking → faster speeds
Incorporate VOR and convergence exercises
Screen for symptom provocation
Use objective tools (e.g., VOMS, symptom scales) to guide progression
104
Previously, concussions were treated passively:
Remove from activity
Rest in a dark room
Wait for symptoms to go away
❌ But this approach often leads to delayed recovery, deconditioning, and increased anxiety
105
Updated Model: Active, Patient-Centered Management
Rule Out Emergencies First
Brain imaging not routinely needed for healthy patients under 65 unless red flags are present.
CT/MRI indicated only if:
- LOC >30 min
- Focal neurological deficits
- Skull fracture suspected
- GCS <15
106
Patient & Family Education = First-Line Intervention
Many post-concussion symptoms are worsened by fear, confusion, or misinformation
Studies show that education leads to:
Less anxiety and stress
Fewer sleep disturbances
Faster return to baseline
107
Management of Concussion-mTBI
What to educate on:
mTBI = functional, not structural injury
Recovery is expected (most recover within 2–4 weeks)
Symptoms may wax and wane
Gradual return to activity is safe and beneficial
Avoid alcohol, heavy screen time, overexertion early on
108
Current Best Practice:
Brief rest (24–48 hrs) → gradual return
Active symptom-based rehab
Provide thorough education & reassurance
Refer to PT/OT early if symptoms persist
109
___ of patients recover fully and symptoms are ___.
~90%
transient
110
Typical Symptom Duration:
Children: 10–14 days
Adults: 10–14 days
But: some may experience persistent symptoms lasting weeks to months (Post-Concussion Syndrome)
111
Patients should only return to play or usual activity once:
symptom-free at rest
112
Children return to school after a median of ____
2-4 days
113
Adults return to work after a median of ___
1-2 weeks
114
Increased symptoms shortly after mTBI =
more symptoms weeks and months later
115
PT Concussion Exam & Evaluation: Structured Breakdown
1. Subjective history
2. Cervical spine exam
3. Cranial Nerves
4. Vestibulo-ocular Exam
> Extraocular eye movements
> VOR
5. Posttraumatic vertigo? BPPV?
6. Coordination and balance
7. Cognitive (e.g. Maddocks score-acute)
116
1. Subjective History
Mechanism of injury (direct blow, whiplash, fall?)
Immediate and delayed symptoms (foggy, dizzy, vision issues?)
Current functional limitations (balance, reading, exertion)
Past concussion history or migraine, ADHD, vestibular conditions
Symptom scales: PCSS, DHI, ABC
117
2. Cervical Spine Exam
Concussion frequently includes cervicogenic involvement, especially after whiplash-type trauma.
Check for:
AROM/PROM
Palpation (upper cervical tenderness)
Joint mobility
Alar/Sharp-Purser tests (instability if trauma suspected)
Cervical proprioception (joint position error testing)
118
3. Cranial Nerve Screen
CN II – visual fields
CN III, IV, VI – extraocular eye movement (EOM)
CN V – facial sensation
CN VII – facial symmetry
CN VIII – hearing, balance
CN IX/X – voice, swallow
CN XI – shoulder shrug
CN XII – tongue movement
119
4. Vestibulo-Ocular Motor Exam
Smooth Pursuits - Oculomotor coordination
Saccades - Rapid target switching
VOR (x1) - Gaze stability with head motion
Near Point Convergence - Binocular control
Visual Motion Sensitivity - Central vestibular integration
120
5. Posttraumatic Vertigo / BPPV Screening
If dizziness is provoked:
Dix-Hallpike → test for posterior canal BPPV
Roll Test → test lateral canal
Assess for:
Positional nystagmus
Duration of vertigo
Reproducibility of symptoms
✅ Treat with Epley/Semont/BBQ maneuvers if appropriate.
121
6. Coordination & Balance
mCTSIB – static balance
DGI/FGA – dynamic gait & vestibular loading
BESS – sideline testing
Tandem, single leg, Romberg
Coordination (finger-to-nose, heel-to-shin)
Look for: instability, sway, dizziness, sensory conflict
122
7. Cognitive Assessment (Acute)
Use:
Maddocks Questions for orientation
SCAT6 cognitive section: memory, recall, concentration
Computer-based tests (e.g., ImPACT) in outpatient
Note any:
Word-finding issues
Processing delays
Short-term memory deficits
123
Return to School After a Concussion –
General Rules Across All Stages:
Each stage lasts at least 24 hours
Only progress if no new or worsening symptoms
If symptoms reappear → drop back a stage and rest 24 hours
If no improvement → contact physician
124
Return to School Stage 0:
Cognitive & Physical Rest (24–48 hours)
Goal: Recovery begins with rest
✅ OK: Short board games, phone calls, crafts, camera photography
❌ NOT OK: School, physical exertion/stair climbing, organized sports
if tolerated, limited amounts: TV, cell phone/computer use, reading
▶️ Progress to next stage: when symptoms start to improve OR after max 48 hours of rest.
125
At Home Stages
Return to School Stage 1:
Light Cognitive Activity
✅ OK: Easy reading, drawing, LEGO, limited TV, some peer contact
❌ NOT OK: School, work, physical exertion, organized sports
▶️ Limit screen time if tolerated
▶️ Progress to next stage: if tolerates 30 mins of cognitive activity at home
126
At Home Stages
Return to School Stage 2:
School-Type Work/Light Physical Activity
✅ OK: School-style work at home, light movement, some peer contact
❌ NOT OK: School attendance, work, physical exertion, organized sports
▶️ Progress to next stage if: tolerates up to 60 mins in chunks = ready to move to school re-entry
127
At School Stages
Return to School Stage 3a:
Part-Time School, Light Load
✅ OK: Up to 2 hours cognitive activity in chunks, half-days at school 1-2x week, some light PA
❌ NOT OK: Music/phys ed. class, tests, heavy workloads, organized sports
▶️ Progress to next stage if tolerates: up to 120 mins/day for 1–2 days/week
128
At School Stages
Return to School Stage 3b:
Part-Time School, Moderate Load
✅ OK: limited testing. 4–5 hrs school/day in chunks, basic homework up to 30 min., decreased learning accommodations, 3-5 days of school/week
❌ NOT OK: Tests, full-day attendance, physical exertion, organized sports
▶️ Progress to next stage if tolerates: 4–5 hrs/day in chunks for 2-4 days/week
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At School Stages
Return to School Stage 4a:
Nearly Normal Workload
✅ OK: nearly normal cognitive activities, routine school work as tolerated, homework up to 60 min/day, minimal learning accomodations
❌ NOT OK: Phys. Ed, tests, full return to sports
▶️ Progress to next stage if tolerates: Full academic load without symptoms = progress
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At School Stages
Return to School Stage 4b:
Full Return to School
✅ OK: Full days (normal cognitive activities, routine school work, full currriculum load), regular classes, no accommodations
❌ NOT OK: Return to contact sports without clearance
▶️ Progress to next stage if tolerates: stages 5-6 of return-to-sport strategy
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Return-to-Learn and Return-to-Play Are Parallel but Separate =
An athlete must complete Stage 4b of return to school before full clearance to Stage 6 of return-to-sport
132
Return-to-School stages 0-2 =
setting: Home
goal: Rest ➝ tolerating light activity
133
Return-to-School stages 3a-3b =
setting: Partial school
goal: Reintroduce school in chunks
134
Return-to-School stages 4a-4b =
setting: Full school
goal: Return to full workload with no symptoms
135
Return-to-Sport (RTS) Progression
Often used in conjunction with the Return-to-Learn protocol
t's structured as a 6-stage model and closely aligns with the Berlin Consensus Statement on Concussion in Sport
136
Return-to-Sport Strategy General Rules:
Each stage lasts at least 24 hours
Advance only if no new or worsening symptoms
If symptoms return ➝ drop back 1 stage & rest for 24 hrs
If symptoms return after clearance ➝ re-assess with MD
137
Return-to-Sport Stage 1:
Symptom-Limiting Activities:
After 24–48 hrs of initial rest
Light cognitive and physical activity
Activities: Light household tasks, easy walking - gradually introduce school and work activities at home
Goal: Resume normal daily activities without symptom flare-up
✅ Entry point after acute rest phase
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Return-to-Sport Stage 2:
Light Aerobic Activity:
Walking, stationary cycling (~10–15 min)
No resistance training
No symptom worsening during or after exercise
✅ Assess for exertion intolerance
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Return-to-Sport Stage 3:
Sport-Specific Exercise (No Contact):
E.g., skating, running, throwing
20–30 minutes
Still no jarring motions/body contact
No resistance training
✅ Reintroduce basic sport motions without impact
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Return-to-Sport Stage 4:
Non-Contact Training Drills:
Add more challenging passing and agility dills
Still NO impact (no heading, no tackling)
Add in progressive resistance training
Start cognitive-motor integration
✅ Simulates more complex sport scenarios
141
Return-to-Sport Stage 5:
Full Contact Practice:
Requires medical clearance
Resume normal training with full contact
✅ Final test before game return
142
Return-to-Sport Stage 6:
Stage 6: Return to Sport:
Full game play or competition
✅ Only after successful progression through all stages
143
Concussion: Return to Sport stages summary:
1 Household activity without symptoms
2 Light cardio without symptom return
3 Basic sport movements (no contact)
4 Full non-contact drills + resistance
5 Full practice after MD clearance
6 Game/competition return
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Step Return to Play Progression – Youth/CDC Version
Advance only if no new/worsening symptoms
Each step = minimum 24 hours
If symptoms return ➝ rest, back up one step
Medical provider oversees clearance and pacing
145
Step Return to Play Progression Stage 1:
Back to Regular Activities (e.g. School):
green-light from MD
starts with few days of rest (2-3 days)
followed by light activity (short walks) and moderate activity (stationary bike) that do not worsen symptoms
146
Step Return to Play Progression Stage 2:
Light Aerobic Activity:
Goal: ↑ heart rate without head movement
~5–10 min of:
Walking
Stationary biking
Light jogging
❌ No lifting, jumping, or exertion with neck/head movement
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Step Return to Play Progression Stage 3:
Moderate Activity:
Goal: Increase HR by reintroducing body and head motion
Examples:
Light running
Moderate biking
Light/moderate weightlifting with reduced time/load
🧠 Monitor for dizziness, visual symptoms, or fatigue
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Step Return to Play Progression Stage 4:
Heavy, Non-Contact Activity:
Add sport-specific drills and intensity:
Sprints, agility drills
Higher-load lifting (non-max)
Non-contact sport movements 3 planes of motion (e.g. cutting, shooting)
❌ Still no impact, no checking, no tackling, etc.
149
Step Return to Play Progression Stage 5:
Full-Contact Practice:
Requires medical clearance
Controlled, full-speed practice in sport setting
🧠 Final test of exertion + cognition + reaction under pressure
150
Step Return to Play Progression Stage 6:
Return to Competition
Game time!
No restrictions
151
Concussion: Return to Work Strategy
Follows the same principles as return-to-play:
Each stage lasts ~24 hours or until symptoms are stable
Progress only if no new or worsening symptoms
Regress a stage if symptoms reappear
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Return to Work Stage 1:
Initial Rest (24–48 hours)
Cognitive and physical rest in a quiet, relaxing environment
✅ OK: Simple passive activities (e.g., soft music)
❌ NO work, screens, or physical exertion
153
Return to Work Stage 2:
Light Cognitive & Physical Activity
Short reading, basic screen time (in intervals)
Light walking
Regular sleep-wake cycle
✅ Take frequent breaks to prevent fatigue
154
Return to Work Stage 3:
Prepare to Return to Work
Not fully symptom-free yet
Begin:
Light errands
Longer screen time intervals
Trial commute to work
Light aerobic activity
🧠 Goal: Build tolerance to daily demands
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Return to Work Stage 4:
Reduced Hours + Accommodations
Return to work part-time (4–6 hours/day)
Accommodations:
Quiet environment
Scheduled breaks
Task simplification
Reduced screen exposure
✅ Monitor for symptom triggers like lights, multitasking, or stress
156
Return to Work Stage 5:
Regular Hours + Minimal Accommodations
Resume full days
Maintain accommodations as needed
Emphasis on:
Energy conservation
Symptom self-monitoring
157
Return to Work Stage 6:
Full Return to Work
Resume normal workload
No accommodations needed
Can handle meetings, multitasking, deadlines
158
Studies show that patients who rest for ____ return to baseline faster — excessive rest delays recovery.
2 days (instead of 5)
159
PT interventions including ___ and ____ have been found to be beneficial in treating adolescent and young adult athletes post-concussion
aerobic exercise
multimodal approaches
160
Sub-symptom threshold aerobic training (e.g., Buffalo Concussion Treadmill Test protocols) has shown:
Faster symptom resolution
Better mood regulation
Improved cerebral autoregulation
✅ Typically begins within 10 days post-injury, once tolerated
161
Multimodal Approach > Rest Alone
Combining vestibular, oculomotor, cervical, exertional, and cognitive strategies results in:
Faster return to sport
Greater functional gains
Lower risk of developing post-concussion syndrome (PCS)
162
What’s in a Multimodal Program?
Aerobic: Sub-symptom treadmill or bike intervals
Vestibular/Oculomotor: VOMS-based VOR training, saccades, convergence
Cervical: ROM, joint mobs, proprioception, posture
Balance/Gait: mCTSIB, DGI, dynamic gait training
Cognitive/Fatigue: Pacing, graded return-to-learn/work plans
163
Evidence supports ___ over prolonged rest
early, progressive activity
164
Study Example 1: Symptom-Limited Aerobic Exercise
Intervention: 20 minutes of aerobic activity (e.g., treadmill or stationary bike)
Intensity: Continue until symptoms increase ≥2 points on a 10-point VAS
Outcome:
Aerobic group recovery = median 13 days
Control (rest) group = median 17 days
📌 Conclusion: Sub-symptom exercise shortened recovery by ~4 days
165
Study Example 2: Buffalo Concussion Treadmill Test-Based Prescription
Intervention: Aerobic exercise up to 90% of symptom threshold HR
Protocol:
Use Buffalo Concussion Treadmill Test (BCTT) to determine HR threshold
Prescribed 20 min/day at 80–90% of threshold HR
Stop if reaching 90% of max HR or symptoms increase
Outcome:
Aerobic group = median recovery 14 days
Stretching control group = 19 days
📌 Conclusion: Aerobic training outperformed passive interventions like stretching
166
aerobic exercise interventions for patients recovering from concussion
(sub-acute phase (after 48 hours) who are medically cleared and not symptom-exacerbated at rest)
timing: When to start aerobic exercise post-injury — usually 7–10 days (after brief rest)
dosage: How much to prescribe — 20 minutes daily is the standard from most studies
intensity: How hard they should work — based on symptom threshold (e.g., from BCTT)
safety: When to stop — if symptoms worsen by 2+ VAS points or HR exceeds max
outcome: What benefit the research shows — faster symptom recovery and return-to-play
167
___ patients with mTBI-concussion experience symptoms that persist > 1 month
1 in 5
168
Post-concussive syndrome occurs when ___
symptoms persist > 3 months
169
Research has shown that mTBI resulting in persistent post-concussive syndrome has lasting effects on ____
cognition, memory, learning, and executive function
170
___ and ___ are robust predictors of prolonged recovery (adults)
Preinjury mental health issues
postinjury psychological distress (e.g. depression and anxiety)
171
Postconcussive Syndrome:
Persistent symptoms >3 months post-concussion
More common in adults, females, and those with prior concussion or mental health history
Occurs in ~20% (1 in 5) of concussion patients
172
Pre-Injury Risk Factors for PCS:
History of anxiety/depression
Prior concussion(s)
ADHD, migraines, learning disorders
Female sex
173
Post-Injury Risk Factors for PCS:
Psychological distress
Poor symptom management
Lack of support/education
Overexertion or prolonged rest
174
___ are the strongest predictor of delayed recovery
🧠 Pre-existing mental health issues
175
If a second concussion occurs while symptoms from the initial injury are still present, there’s a risk of:
Rapid cerebral edema
Severe disability or death
This is why no return to play or high-risk activity is allowed until fully symptom-free and cleared.
176
Postconcussive Syndrome (PCS)
Physical Symptoms:
Dizziness
Headache
Blurred vision
Sensitivity to light/noise
Nausea/vomiting
Unequal pupils
Seeing flashing lights
Fatigue / low energy
Balance problems
177
Postconcussive Syndrome (PCS)
Mental (Cognitive) Symptoms:
Difficulty remembering
Trouble focusing
Mental fogginess
Confusion
Slowed thinking
Difficulty with new learning
178
Postconcussive Syndrome (PCS)
Sleep-Related Symptoms:
Sleeping more or less than usual
Trouble falling asleep
179
Postconcussive Syndrome (PCS)
Emotional Symptoms:
Irritability
Anxiety
Sadness
Tearfulness
Lack of interest
Depression
180
🔍 Pre-injury mood disorders = strong predictor of ___
prolonged recovery
181
Medical Management of Post-Concussive Syndrome (PCS):
Pharmacologic options (managed by physician or neurologist):
Headache meds: NSAIDs, amitriptyline, topiramate (migraine-type)
Sleep aids, SSRIs for mood disturbances
Vestibular suppressants (only short-term)
182
Vestibulo-Oculomotor & Cervical Rehabilitation (PT Role)Post-Concussive Syndrome (PCS):
VOMS-guided exercises: VOR x1/x2, convergence drills, saccades
Balance rehab: mCTSIB, dynamic gait, habituation
Cervical spine: ROM, manual therapy, proprioception
Graded aerobic activity: Guided by Buffalo Concussion Treadmill Test (BCTT)
183
Buffalo Concussion Treadmill Test (BCTT) =
Purpose: Identify exertional threshold and guide sub-symptom aerobic training (achieve target heart rate without experiencing symptoms or early exhaustion)
How it works:
Patient walks on treadmill with increasing incline
Stop when:
Symptoms increase ≥2 points
RPE >17
HR max (age-predicted) reached
📈 Goal = find HR threshold for daily aerobic prescription
184
Once patients can achieve ___ and exercise without symptoms for at least 2___, the patient is deemed physiologically recovered
age-related maximal heart rate
0 minutes for 2-3 consecutive days
185
Physiological Recovery Criteria:
Able to exercise at age-predicted max HR
No symptoms during or after 20 minutes of activity
Tolerated for 2–3 consecutive days
🎯 This does not guarantee return to play, but confirms readiness for full aerobic re-engagement
186
Common Outcome Measures in Concussion Management
Balance Error Scoring System (BESS)
Beck Depression Inventory for Youth (BDI-Y)
Post-Concussion Symptom Inventory (PCSI)
Post-Concussion Symptom Scale (PCSS)
Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)
BORG CR10 Rating of Perceived Exertion
Post-Ride Symptom Change Rating
187
Balance Error Scoring System (BESS)
Purpose: Assesses postural stability, static balance under various conditions
Population: Athletes, all ages
188
Beck Depression Inventory for Youth (BDI-Y)
Population: Children & adolescents (ages 7–18)
Purpose: Screens for depressive symptoms in neuro populations
189
Post-Concussion Symptom Inventory (PCSI)
Population: Ages 5–18 (child and adolescent versions)
Purpose: Tracks symptoms in 4 domains:
Physical
Cognitive
Sleep
Emotional
190
Post-Concussion Symptom Scale (PCSS)
Population: Athletes (commonly high school/college)
Purpose: Tracks concussion-related symptoms
191
Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)
Population: High school/college athletes
Assesses:
Attention
Visual memory
Processing speed
Reaction time
192
BORG CR10 Rating of Perceived Exertion
Purpose: Rates effort level during aerobic testing/training
Use in concussion: Monitor during Buffalo Concussion Treadmill Test (BCTT)
193
Post-Ride Symptom Change Rating
Purpose: Measures symptom response to aerobic activity
How it works:
Patient rates symptom severity before and after activity (e.g. biking)
↑ ≥2 points may indicate intolerance and guide intensity modification
194
Pathophysiological processes after concussion include:
neuronal architecture damage
increased neuroinflammation
altered cerebral blood flow
195
🧠 Concussion = Functional Brain Injury
A concussion doesn’t usually cause structural damage visible on imaging (CT/MRI).
Instead, it leads to metabolic and physiological dysfunction in the brain:
Neurotransmitter disruption
Ion imbalance
Mitochondrial dysfunction
Energy supply-demand mismatch
196
The inability to ___ after a concussion, paired with a ____, results in an energy mismatch
deliver energy to the brain
high demand for energy to restore damaged functions
197
Neuroinflammation and Cerebral Blood Flow Alterations:
Post-concussion, the brain experiences:
↑ inflammatory cytokines
↓ cerebral blood flow (CBF)
Impaired vascular autoregulation
198
Screening:
PTs must screen all patients who experienced a potential concussive event.
Screen for:
Signs/symptoms of concussion
Emergency medical conditions (red flags)
Differential diagnoses (e.g., cervical injury, vestibular stroke)
199
Examination:
Cervical musculoskeletal: ROM, joint mobility, proprioception, cervicogenic HA
Vestibulo-oculomotor: VOR, convergence, saccades, VOMS
Autonomic/exertional: HR response, orthostatic vitals, Buffalo treadmill
Motor function: Balance, gait, coordination (e.g., mCTSIB, DGI, FGA)
200
Intervention:
Educate, treat impairments, restore function, refer as needed
Use symptom-guided aerobic and vestibular protocols for gradual return
201
A sideline assessment for concussion should include which of the following tests?
Buffalo Treadmill Test
Maddocks questions
Sensory Organization Test
Dix-Hallpike Test
Maddocks questions ✅
Maddocks questions are part of sideline tools like CRT6 or SCAT6 and are used for acute concussion screening. They assess orientation and memory specific to the sporting event.
Buffalo Treadmill Test is used later for exertional tolerance.
Sensory Organization Test is a lab-based balance test, not practical for sideline use.
Dix-Hallpike Test is for BPPV, not acute concussion diagnosis.
202
Your patient sustained a concussion 4 days ago. When she progresses to Stage 3 in the Return to Sport protocol, she c/o of a HA and lethargy. What recommendations would you make?
Continue with the current Stage 3 activity plan and reassess in the next PT session
Instruct her to return to Stage 2 for at least 24 hours
Stop Stage 3 and immediately return to Stage 1
Recommend ibuprofen and contact her MD if the HA doesn’t go away by tomorrow
Instruct her to return to Stage 2 for at least 24 hours ✅
The Return-to-Sport protocol requires that if symptoms return, the athlete must go back one stage and remain there for at least 24 hours symptom-free before attempting to progress again.
A) Continuing could worsen symptoms
C) Returning to Stage 1 is excessive for a mild flare
D) Medical referral isn’t needed unless symptoms persist or worsen further
