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Current Evaluation and Treatment Strategies for Managing

Concussions in the Outpatient Physical Therapy Setting

By: Sheryl Massella, Christine Thompson,

Gregg Kaplan, and Michael Witter DPT

Objectives

Month Day, Year 2

Learning Objectives

#1 Describe and understand the 6 common clinical sub-types following a sports related concussion, recognizing s/s’s associated with each clinical sub-type, and identify treatment/management strategies for each clinical sub-type.

#2 Perform a basic VOM and BPPV screen to rule in or out PCS s/s’s related to BPPV/vestibular dysfunction, and/or VOM dysfunction as well as if there is the need for more skilled intervention by a more qualified vestibular therapist following sports related concussions.

#3 Understand and administer the BCTT for safe gradual progression of exertional activities w/ concussion management in individuals with PCS.

#4 Provide exercise prescriptions based on BCTT results and through clinical reasoning.

#5 To be able to determine if PCS headache s/s’s are due to cervicogenic involvement, post-traumatic migraines, or cognitive fatigue s/s’s following a sports related concussion, and be able to demonstrate manual therapy techniques to address cervicogenic pain and headaches due to a sports related concussion and PCS.

#6 Verbalize basic psychological factors that contribute to PCS, basic communication and education strategies as well as potential referral sources to address factors outside the scope of physical therapy.

#7 Understand the neuro-visual component and the role of neuro-optometric rehabilitation in PCS and the concussed patient.

Purpose of this Course

There are 2 main groups following a concussion:

1) Normal recovery group • 80-90% recover from a concussion w/i 7 to 14 days

• They are able to progress through a RTP (*RTW/RTS*) protocol with minimal to no complications, and can return to normal school, work, and sports related activities as early as 6-7 days after sustaining the concussion

• Normal recovery time can be slower for adolescent and high school athletes (13-18 y/o) as compared to college athletes as well as for females as compared to males

2) Protracted recovery group • 10-20% of individuals can have concussion s/s’s that last for weeks, months, or even years.

• These individuals are said to have Post Concussion Syndrome (PCS)

• There are 6 common clinical sub-types that are used to classify patients into different categories to allow for the appropriate treatment and management of each individual sports related concussion

Month Day, Year 3

Month Day, Year 4


• Most athletes who sustain a concussion, 80-90% of the individuals, are

either able to perform a RTP at there school with the ATC or under the guidance of the school/team MD, or if seen in clinic can only perform stage 2 and 3 of the RTP protocol and usually referred to a vestibular therapist

Or

• The other 10-20% are also usually referred to a therapist who specializes in vestibular therapy even when the patient/athlete either does not present w/ or has very mild vestibular and/or VOM dysfunction sub-type s/s’s

• This group can be classified into 6 different clinical sub-types as well as the physiologic/autonomic dysfunction/exercise intolerance group.

Month Day, Year 5

Typical RTP Protocol

Month Day, Year 6

6 Clinical Sub-Types of Concussions

Month Day, Year 7

6 Clinical Sub-Types of Concussions

• The 6 sub-types can have overlay which can complicate treatment, and make

accurate diagnosis of cause of PCS s/s’s difficult

• Vestibular, Cervicogenic, Ocular/Visual, and cognitive/fatigue sub-types are usually able to be treated in an OP physical therapy setting with a trained physical therapist if diagnosed correctly

• Post-traumatic migraine and anxiety/mood sub-types (as well as any other sub-types) can be managed w/ patient education, but may require referrals to appropriate specialist for further treatment

• New research emerging that rest and waiting for someone to be symptom free before starting to resume normal activity can actually be more detrimental than allowing that individual to start to return to normal activity under the guidance a multi-disciplinary concussion team

Month Day, Year 8

Buffalo Concussion Treadmill Test

• The use of the BCTT in conjunction w/ standard physical therapy treatment for BPPV/Vestibular dysfunction, VOM dysfunction, and Cervicogenic dysfunction is being utilized more and more by sports MD’s/DO’s, DPT’s, and ATC’s as not only a diagnostic tool, but also a way to gradual progress athletes PCS back to normal school and sports related activities

• The BCTT can also be effective in treating the other sub-types (i.e. cognitive/fatigue) as well as exercise intolerance due to physiologic concussion/autonomic dysfunction

Month Day, Year 9

Typical RTP Protocol

Month Day, Year 11


So the purpose of this course is to:

• To help provide those individuals with the most up to date evidenced based screening as well as treatment and management strategies as it pertains to individuals, including athletes, with PCS in the protracted recovery group.

• To provide the basic skills required to treat individuals w/ PCS regardless of whether or not you are primarily an ortho or vestibular physical therapist

Month Day, Year 12

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Treatment of the Concussed Athlete -- BPPV

Presented by

Christine Thompson, PT, MS

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• Otoconia become dislodged from the membrane in the utricle and fall into the semicircular canal

• Otoconia in the tubes of the canal = canalithiasis

• Otoconia adhered to the cupula = cupulolithiasis

Anatomy of vestibular system Anterior

canal Posterior

canal

Horizontal

canal

utricle

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What causes BPPV?

• Age related degeneration of vestibular system

• Mild to severe head injury (concussion)

• Whiplash

• Surgery causing trauma to the ear

• Extensive dental work

• Prolonged inactivity

• Migraine

• Other vestibular abnormalities

BPPV and Concussion

• 8 to 20% post-concussion cases develop BPPV

• 67% will have recurrence in the first year

• Higher instances of bilateral involvement

• Anterior canal has 27.3% occurrence

post-concussion

It is important to rule out BPPV in the concussed patient via Dix Hallpike!

Month Day, Year 16

Symptoms of BPPV Vertigo provoked with changes in head position relative to gravity

- Lying down and getting up from bed

- Rolling in bed

- Bending over (tying shoes, picking up something from floor, gardening)

- Looking up (reaching into cabinet, washing hair in the shower)

Symptoms described as brief room spinning, decreased ability to focus, or falling off the bed

- Complaints of lightheadedness, woozy, constant dizziness/imbalance are likely another vestibular cause

Nausea and vomiting can be associated with BPPV

Positional testing

Dix-Hallpike (can do with or without fixation block) •Pt long sits on table, head

turned 450

•Head and trunk brought back “en bloc” so head is hanging 200 off bed

•Bring pt. to long sitting with head still turned 450

•Do in other direction •Look for nystagmus and pt

c/o vertigo

Positional Testing

Sidelying Test /Modified

Dix-Hallpike (with/without fixation blocked) •Pt sits on bed with head turned

450 to left

•Pt quickly lays on right side with head turned in same position so pt is looking up

•Pt sits with head still turned

•Do on other side

•Look for nystagmus and pt c/o vertigo

Positional Testing

Roll test • Pt lays supine with head in 200 of cervical

flexion

• Turn pts head to right, look for nystagmus beating either towards ground (geotropic = canalithiasis) or beating away from ground (ageotropic = cupulolithiasis) ----indicates horizontal canal BPPV

• Turn pts head to left; the direction will be the same in both head positions

• Pt will likely notice more vertigo on one side

Nystagmus

• Upbeating or downbeating? - If pure up/down beat, likely central

lesion

• Torsional component? - BPPV will have torsion - Name for direction that superior

orbital pole is moving

• Direction name is based on the patient’s right or left, not practitioner’s right or left!!

• Example – upbeating, Right torsional nystagmus = would be Right Posterior semicircular canal BPPV

BPPV • Canalithiasis

- Otoconia are free floating in canal

- Brief duration, short latency, less than 30 seconds typically, will habituate with repetitions

• Cupulolithiasis

- Otoconia adhered to the cupula

- Prolonged duration, no latency, will last more than 30 seconds

• Must have both vertigo complaints and nystagmus to be BPPV diagnosis

Posterior Semicircular Canal •Upbeating, torsional nystagmus

Anterior Semicircular Canal •Downbeating, torsional nystagmus

DIRECTION WILL REVERSE WHEN BROUGHT BACK INTO SITTING Horizontal Semicircular Canal •Horizontal nystagmus either geotropic or ageotropic– stays

the same direction both ears, involved ear is usually the one with the worst symptom complaints

Which Canal?

Nystagmus– Posterior and Anterior Canalithiasis

Posterior Anterior

Horizontal Canal

Geotrophic Nystagmus

(to the ground) = canalithiasis • Head to right, see right beat

• Head to left , see left beat

Ageotrophic Nystagmus (away from ground) = cupulolithiasis • Head to right, see left beat

• Head to left, see right beat

Above is canalithiasis

Treatments for BPPV

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BPPV -- Canalithiasis •Posterior and anterior canals = Canalith Repositioning

Maneuver (CRM), otherwise known as Epley maneuver

•Horizontal canal = - “Barbeque”roll CRM

- Appiani or Gufoni liberatory maneuver

- prolonged lying (lay on involved side x 1 min then sleep on uninvolved side for up to 12 hours

•Brandt-Daroff exercises - Modified for horizontal canal – keep head neutral

Treatments for BPPV

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BPPV -- Cupulolithiasis

•Posterior canal = Liberatory/Semont maneuver

•Anterior canal = modified Liberatory maneuver

•Horizontal canal =

- Gufoni liberatory maneuver

- prolonged lying (lay on uninvolved side x 1 min then sleep on involved side)

Canalith Repositioning Maneuvers for Canalithiasis

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Posterior/Anterior Horizontal

Another Canalith Repositioning Maneuver for Horizontal Canalithiasis

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Go onto uninvolved ear, turn head down 45 deg for 2-3 min

Brandt Daroff HEP

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• Each position held x 30 sec

• Completing exercise on both sides = 1 rep

• Done 5 reps total ; 3x/day while vertigo persists; 1x /day after vertigo resolved

• Should take 10 minutes to complete

Canalith Repositioning Maneuvers for Cupulolithiasis

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• Start on affected side with head turned up for 1 min

• Quickly move opposite side facing down for 1 min

• Return to sitting with head level

• FOR ANTERIOR CANAL • You will start on

affected side face down for 1 min and then lie face up on opposite side for 1 min

Canalith Repositioning Maneuvers for Cupulolithiasis

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Treatment Progression

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BPPV •After CRM or Liberatory, pt should avoid sleeping on affected

ear and sleep on a few pillows that night only.

•Activity following CRM should be modified to avoid excessive head movement and bending for that day.

•Pt should continue Brandt-Daroff exercises for at least 2 days after the vertigo stops

•There is reoccurrence rate for BPPV, so advise pt. to always do Brandt-Daroff exercises once daily

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Case Study • 42 year old female who was on vacation in France and slipped on

steps and hit head. Occipital Fx, Right SDH and left SAH found on CT scan and MRI as well as left frontal superior and anterior contusions and blood over orbital wall.

• Pt reports that she is dizzy when laying down, rolling, & bending over. Pt reports walking and turning corners has been difficult

• Pt is a Northwell ER pediatrician and is unable to work at time of PT

• eval on 7/3/18.

• Right Dix Hallpike = downbeat with some torsion , +vertigo then goes to left beat

• Left Dix Hallpike = downbeat, no vertigo , then right beat

• PT vestibular diagnosis = central vestibular signs during oculomotor exam as well as possible right anterior canalithiasis

• Pt treated 5 visits with right anterior canalith repositioning as well as introducing other vestibular gaze stabilization and balance exercises. Pt had resolution of vertigo and able to do bed mobility and bending without issue. Pt continued PT for balance, vestibular and endurance training at 2x/wk and had returned to work on 8/20/18. Pt was discharged from PT on 9/25/18 with return to all prior activities and premorbid functional status.

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Evaluation and Treatment of Visual Dysfunction Following Concussion

Sheryl Massella, PT Senior Physical Therapist – STARS Vestibular Rehabilitation

Learning Objectives

Identify the most common visual system impairments occurring after mild traumatic brain injury.

Demonstrate screening and assessment techniques for identifying visual system impairment for the physical therapist.

Identify potential intervention for managing visual deficits following concussion

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Literature Review

ENG of 309 whiplash patients show frequent vestibular abnormalities, abnormal calorics in 57%, and abnormal rotational tests in 51%. Toglia, 1976

“Vestibular complaints are the most frequent sequelae of mTBI. Vestibular physical therapy has been established as the most important treatment modality for this group of patients.” Gotshall, 2011

A combination of cervical and vestibular physiotherapy decreased time to medical clearance to return to sport in youth and young adults with persistent symptoms of dizziness, neck pain and/or headaches following a sport-related concussion.” Schneider, 2014

“Vestibular and ocular motor impairments and symptoms have been documented in patients with sport related concussions.” “Sixty one percent of patients reported symptom provocation after at least 1 VOMS item.” Mucha, 2014

Month Day, Year 37

Concussions and Dizziness

Dizziness and/or ocular motor disturbance reported in nearly 50% of concussed athletes

Symptoms vary among athletes that sustain concussions with many of them reporting dizziness (50%), visual disturbances (30%), balance issues (40%), or any combination of these

Dizziness may be related to prolonged recovery

The Vestibular Ocular Motor Screenings (VOMS) developed and published at the University of Pittsburgh has emerged as a clinical assessment tool

Part of the multi-faceted approach necessary in assessing the athlete’s sport-related concussion.

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Commonly Reported Symptoms - High School & College Athletes within 3 days of injury (Lovell et al, 2004, N=215

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Ocular Motor Dysfunction Following mTBI*

*Blast related mTBI, Capo-Aponte et al, Military Medicine 2012

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Visual Symptoms

Similar to Vestibular Symptoms Blurred Vision - shadows

Double Vision – horizontal or vertical

Photophobia – light sensitivity

Photopsia – illusion of flashes of light

Oscillopsia - illusion of movement

Poor eye tracking

Eye fatigue or pain

Vertigo

May see a head tilt in an attempt to align the eyes

Reports of needing to close one eye

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Vestibular Reflexes The Vestibular System

includes the sensory organs of the inner ear, connections to the cerebral cortex, cerebellum, brainstem, ocular system, and postural muscles.

responsible for communicating posture and head movements to maintain visual stability and balance control.

Vestibulo-spinal Reflex senses falling /tipping contracts muscles for postural support

Vestibulo-collic Reflex acts on the neck musculature to stabilize the head if the body moves

Vestibulo-ocular Reflex stabilizes the visual image during head movement causes eyes to move simultaneously in the opposite direction

in equal magnitude to the head movement

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Vestibulo-Ocular System Dysfunction of the vestibulo-ocular component of the vestibular system

presents with dynamic symptoms, such as dizziness and visual instability.

Balance difficulties are more indicative of dysfunction of vestibulo-spinal component

assessed with static tests, such as the Balance Error Scoring System (BESS).

static assessments do not address the symptoms related to dynamic aspects of the vestibular system

May experience other symptoms including

fogginess anxiety de-realization (feeling as if surroundings are not real) nausea motion sickness difficulty in the classroom intolerance for busy environments

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Why is vision affected after concussion?

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50% of the cranial nerves impact vision either directly or indirectly

Primary and associated neurons transverse all four cortical lobes (not just occipital lobe)

Team Effort Saccades conjugate rapid movements of the eye between two fixation points

Smooth Pursuits conjugate eye movements tracking a moving target

Fixation maintaining gaze on a single target to maintain the image on the

fovea

Vergence moves eyes in opposite directions to align both fovea on an object

Accommodation keeps the image clear on the retina when looking near to far and

vice versa

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VESTIBULAR OCULAR MOTOR SCREENING (VOMS)

Ocular Function:

Smooth Pursuits Horizontal and Vertical Saccades Near Point Convergence (NPC)

Vestibular Function

Horizontal VOR Vertical VOR Visual Motion Sensitivity (VMS)

Rate on a scale of 0 (none) to 10 (severe) changes in:

Headache, Dizziness, Nausea and Fogginess symptoms Convergence is assessed by both symptom provocation and NPC distance Average of three trials Normal= <5cm

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Vestibular Ocular Motor Screening Tool

This test is designed for use with subjects ages 9-40. When used with patients outside this age range, interpretation may vary.

Equipment: Tape measure (cm); Metronome; Target with 14 point font print.

Baseline Symptoms: Record: Headache, Dizziness, Nausea & Fogginess on 0-10 scale prior to beginning screening

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Smooth Pursuits Tests the ability to follow a slowly moving target.

The examiner holds a fingertip at a distance of 3 ft. from the patient.

The patient is instructed to maintain focus on the target as the examiner moves the target smoothly in the horizontal direction 1.5 ft. to the right and 1.5 ft. to the left of midline.

One repetition is complete when the target moves back and forth to the starting position, and 2 repetitions are performed.

The target should be moved at a rate requiring approximately 2 seconds to go fully from left to right and 2 seconds to go fully from right to left.

The test is repeated with the examiner moving the target smoothly and slowly in the vertical direction 1.5 ft. above and 1.5 ft. below midline for 2 complete repetitions up and down.

The target should be moved at a rate requiring approximately 2 seconds to move the eyes fully upward and 2 seconds to move fully downward.

Record: Headache, Dizziness, Nausea & Fogginess ratings after the test. (Figure 1)

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Smooth Pursuits

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Saccades Tests the ability of the eyes to move quickly between targets.

Horizontal Saccades:

The examiner holds two single points (fingertips) horizontally at a distance of 3 ft. from the patient, and 1.5 ft. to the right and 1.5 ft. to the left of midline so that the patient must gaze 30 degrees to left and 30 degrees to the right.

Instruct the patient to move their eyes as quickly as possible from point to point. One repetition is complete when the eyes move back and forth to the starting position, and 10 repetitions are performed.


Vertical Saccades:

Repeat the test with 2 points held vertically at a distance of 3 ft. from the patient, and 1.5 feet above and 1.5 feet below midline so that the patient must gaze 30 degrees upward and 30 degrees downward.

Instruct the patient to move their eyes as quickly as possible from point to point. One repetition is complete when the eyes move up and down to the starting position, and 10 repetitions are performed.


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Saccades

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Convergence

Measures the ability to view a near target without double vision.

The patient is seated and wearing corrective lenses (if needed).

The patient focuses on a small target (approximately 14 point font size) at arm’s length and slowly brings it toward the tip of their nose.

The patient is instructed to stop moving the target when they see two distinct images or when the examiner observes an outward deviation of one eye.

Blurring of the image is ignored.

The distance in cm. between target and the tip of nose is measured and recorded.

This is repeated a total of 3 times with measures recorded each time.

Record: Headache, Dizziness, Nausea & Fogginess ratings after the test.

Abnormal: Near Point of convergence ≥ 6 cm from the tip of the nose. (Figure 4)

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Convergence

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Vestibular-Ocular Reflex (VOR) Assesses the ability to stabilize vision as the head moves.

The patient is seated and the examiner holds a target of approximately 14 point font size in front of the patient in midline at a distance of 3 ft.

Horizontal VOR Test:

The patient is asked to rotate their head horizontally while maintaining focus on the target.

The head is moved at an amplitude of 20 degrees to each side and a metronome is used to ensure the speed of rotation is maintained at 180 beats/minute (one beat in each direction).

One repetition is complete when the head moves back and forth to the starting position, and 10 repetitions are performed.

Record: Headache, Dizziness, Nausea and Fogginess ratings 10 sec after the test is completed. (Figure 5)

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Vestibular-Ocular Reflex (VOR)

Vertical VOR Test:

The test is repeated with the patient moving their head vertically.

The head is moved in an amplitude of 20 degrees up and 20 degrees down and a metronome is used to ensure the speed of movement is maintained at 180 beats/minute (one beat in each direction).

One repetition is complete when the head moves up and down to the starting position, and 10 repetitions are performed.

Record: Headache, Dizziness, Nausea and Fogginess ratings after the test. (Figure 6)

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Vestibular-Ocular Reflex (VOR)

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Visual Motion Sensitivity Test (VMS) Tests visual motion sensitivity and the ability to inhibit vestibular-induced eye movements using vision.

The patient stands with feet shoulder width apart, facing a busy area of the clinic. The examiner stands next to and slightly behind the patient, so that the patient is guarded but the movement can be performed freely.

The patient holds arm outstretched and focuses on their thumb.

Maintaining focus on their thumb, the patient rotates, together as a unit, their head, eyes and trunk at an amplitude of 80 degrees to the right and 80 degrees to the left.

A metronome is used to ensure the speed of rotation is maintained at 50 beats/min (one beat in each direction).

One repetition is complete when the trunk rotates back and forth to the starting position, and 5 repetitions are performed.


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Visual Motion Sensitivity Test (VMS)

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Interpreting the VOMS

No controls in the study reported a total symptom score of >2 following any VOMS individual item

Controls have normal NPC distances (< 5 cm)

VOMS symptom scores >2 and NPC distance >5cm represent clinically useful cut-offs.

3 VOMS items (VOR, VMS, NPC distance) resulted in 89% accuracy for identifying patients with concussion

The VOMS measures distinct constructs than traditional concussion tools and compliments neurocognitive testing, balance assessment and symptom reports

Initial research provides preliminary support for the utility of the VOMS as a brief vestibular/ocular motor screen following SRC.

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Ocular Motor Symptoms Following Concussion Using VOMS (N=85) Mucha et al: AJSM 2014

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Ocular Motor and Vestibular Findings (N=85)

Mucha et al 2014

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What if the VOMS is abnormal?

The VOMS may guide referral and treatment following concussion

In conjunction with other measures, helps to identify presence of concussion

May indicate a vestibular and/or oculomotor issue. Further evaluation and treatment indicated when issues persist beyond acute stage (2 - 4 weeks)

Refer for Neuro-Visual Optometrist Exam if symptoms > 4 weeks

Neuro-Visual Center of New York 516-244-4888 www.nvcofny.com

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Vision Exam Beyond the VOMS

Ocular Alignment – Pre-existing ocular conditions worsen as a result of decompensation

- Strabismus, 4th or 6th nerve palsies, phorias (ocular deviations)

- Always refer a vertical misalignment for a neuro-visual exam

Gaze Holding

Cover/Uncover and Alternate Cross Cover Test

Look for jumping of eye that is covered and uncovered

Head Thrust (Head Impulse Test or HIT)

Have patient look at your nose Quickly thrust 30-45 degrees to right Patient should be able to maintain gaze Repeat to left Peripheral hypofunction to the side of the thrust

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Convergence In order to be functional Should be automatic

Should be stable with both eyes working together, with head movement and with different body positions

Should be able to switch near and far

Should remain symptom free with

- varying degree of balance changes

- during functional mobility

- in complex stimulating environments

Treatment Ideas

Pencil Push-ups

Brock String

Two Thumbs

Golf Tee in Straw

3 dot paper

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Smooth Pursuit Cerebellar function

can be age related corrective or catch-up saccades red flag for central pathology Look for smooth, precise movement vs jerky, broken movement Both directions (left/right), vertical and horizontal

In order to be functional

Should be able to track a moving target at varying speeds

Should be able to disassociate head and eye movement

Should be symptom free for tolerance to visual motion

Should be smooth in all directions

Should remain smooth and symptom free with

- varying degree of balance changes

- during functional mobility

- in complex stimulating environments

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Smooth Pursuit

Treatment Ideas Push / pull moving target

Follow the laser

gaze tracking

Pass ball back and forth

Pair with proprioceptive input

Start with large objects move to smaller objects

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Saccade Testing

Indicates neurological involvement Can be age related Delayed or slow movement Disconjugate movement of the 2 eyes Inaccuracy in re-fixation undershoot or overshoot Unilateral vs bilateral More than 3 saccades to get to target, Slow speed abnormal findings = central

problem

In order to be functional Should be able to disassociate head and eye movement and body movement Should be accurate for reading Should remain smooth and symptom free with - varying degree of balance changes - during functional mobility - in complex stimulating environments

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Saccades

Treatment Ideas Looking between targets

Laser light to point to various targets

Sorting letter blocks or tiles

Word Search

Hart Chart

Throwing ball at target on wall

9 point pattern

Add postural engagement

Add metronome

Eyecanlearn.com

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HART CHART Use for saccades and accommodation Large chart on wall and small font hand held or on table or floor Add proprioception, rocking, quadruped

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VOR Cancellation

Move patients head from side to side while you move Ask patient to keep their gaze on your nose Does the patient maintain fixation with head movement

“over-riding” of VOR

This can be used to assess visual motion sensitivity

Increased awareness of normal visual motion

Symptom provocation created by moving crowds, busy environments

Ex: supermarket, school hallway, hockey game

Treatment ideas: Ball toss, Lunges with medicine ball tracking, gaze tracking

Dynamic Visual Acuity

Static: Sitting 4 feet away – smallest letter they can read

Dynamic: 240bpm (2Hz) - smallest full line they can read correctly

Dynamic - Static = <3 lines (normal)

Treatment Program:

Sitting for safety at home

Single letter target from line above smallest they can read

Plain background

Start 120 bpm (physiological VOR) with metronome

Increase speed as tolerated

Progress to standing

Printable pdf ETDRS charts (3 versions) http://i-see.org/eyecharts.html

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http://i-see.org/eyecharts.html



Gaze Stabilization: x1 Viewing Duration: 60seconds 120 seconds

Speed: Slow 120bpm (1Hz) fast 240bpm (2Hz)

Background: Non-conflicting (plain) Conflicting (patterns)

Position: Static: Seated Standing Vary surface, Vary BOS Dynamic: Ambulating, Treadmill, Forward/Back

Distance: Far Near Varied

Target Size: Large Small

Frequency: UVH: 3x /day for total of 12-20 min/day

(60s x3 / 3xday)

Avoid Overstimulation: Less is More Symptoms should subside 10-15min after stopping Need to induce some discomfort to get change Progress to x 2 Viewing Eyes and head move in opposite directions

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Habituation Exercises for Treatment of Motion Sensitivity Motion provoked Dizziness is common in patients with Cerebellar/brainstem lesions TBI/Concussions Vestibular Migraines Anxiety / 3PD (Persistent Postural Perceptual Dizziness) Vestibular Hypofunction in combination with any of the above, BVH Abnormal saccades, smooth pursuit, DVA like looking at the world through a

Go-Pro without image stabilization

VRT can help decrease the symptoms Habituation Exercises reduce the response of the noxious stimuli by repeated exposure of the provocative environment or movement Repeated movements that provoke the symptoms Finding letters in busy backgrounds Walking with head turns , body turns, throwing and catching while walking Videos – optokinetic stimulation (walking through supermarket, driving in

Manhattan, skiing down a mountain)

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Eye Fatigue and Headache

Palming

Electronics – Blue Light Filter

Blue Tint Transparency

Noise Cancelling Headphones or earplugs (“Eargasm” ear plugs)

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REFERENCES 1. Collins MW, Kontos AP, Reynolds E, et al. A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion. Knee Surg Sports Traumatol Arthrosc. 2014;22:235-246. 2. Khan S, Chang R. Anatomy of the vestibular system: a review. NeuroRehabilitation. 2013;32;437- 443. 3. Kontos AP, Sufrinko A, Elbin RJ, Puskar A, Collins MW. Reliability and associated risk factors for performance on the vestibular/ocular motor screening (VOMS) tool in healthy collegiate athletes. Am J Sports Med. 2016:44:1400-1406. 4. Mucha A, Collins MW, et al. A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions: preliminary findings. Am J Sports Med. 2014;42:2479-2486.

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Cervical and Physiological Post Concussion Syndrome Sub-Types:

Evaluation and Treatment Strategies

Michael Witter PT, DPT

f

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Objectives

• Recognize importance of considering the c-spine as it relates to PCS evaluation and treatment/management.

• Describe key components of cervical examination.

• Describe what impairments should be considered when examining a patient with cervicogenic symptoms s/p concussion, and how to provide appropriate interventions to address these impairments including manual therapy techniques.

• Be able to perform exercise tolerance testing (BCTT) to help differentiate b/w cervical spine involvement vs. autonomic dysfunction/exercise intolerance.

• Be able to provide exercise prescription for safe gradual progression of exercise tolerance in individuals w/ physiological intolerance to exercise w/ use of BCTT.

Month Day, Year 79

Cervical Role in Post-Concussion Syndrome

• According to a study by Ellis et al. on cervical spine dysfunction followed pediatric sports related injury found that:

• Of 246 individuals (ages 6-19) who were diagnosed w/ sports related concussion, 32.5% were found

to have subjective and objective evidence of cervical spine dysfunction.

• Those with cervical spine dysfunction were 3.95 times more likely to have a delayed recovery time (>4 weeks).

• Another study from 2006 on the relationship b/w whiplash associated disorder (WAD) and concussion in hockey found that:

• 100% of individuals had s/s’s of both WAD and concussion

Month Day, Year 80

Cervical Role in Post-Concussion Syndrome: Why?

• The cervical spine, especially the upper cervical spine, is the most mobile part of the vertebral column

• Mobility happens at the expense of mechanical stability

• The proprioceptive system provides neuromuscular control to the mobile cervical spine and has unique connections to the vestibular, visual and central nervous systems

• This explains why the c-spine can be a source of a variety of symptoms that do not arise from any other musculoskeletal region of the body

Month Day, Year 81

Cervical Role in Post-Concussion Syndrome: Why?

• Can be difficult to differentiate cervical dysfunction from physiologic concussion due to:

1. Similar MOI

2. Symptoms are nearly identical

3. Absence of clinical tests w/ good diagnostic utility

Month Day, Year 82

Cervical Role in Post-Concussion Syndrome: Brain vs Strain

Month Day, Year 83

Cervical Role in Post-Concussion Syndrome

• Conclusion:

• Symptoms alone do not distinguish physiologic concussion from cervical/vestibular injury

• Differentiating the symptoms of concussion and cervical injury is a vital part of concussion screening to ensure appropriate diagnosis, management, and treatment to optimize outcomes and reduce recovery time.

• Conventional musculoskeletal examination and intervention may not be sufficient for this population

• i.e. BCTT

• Clinical tests are invaluable for differentiating among damaged structures and providing methods to measure improvements after treatment intervention.

Month Day, Year 84

Cervical Role in Post-Concussion Syndrome : Examination

• Symptom inventory w/ Post Concussion Symptom Scale • The PCSS is a 21-item self-report measure that records symptom severity using a 7-point Likert scale of

severity.

• Given pre- and post-session to assess response to treatment/activity

• Additional Patient Reported Outcomes • Neck Disability Index (NDI)

• Fear Avoidance Belief Questionnaire

• Patient interview • MOI

• Relationship b/w neck pain and other symptoms (i.e dizziness, headache, imbalance, etc…)

• Aggravating/relieving factors

• Frequency/intensity/duration of symptoms

Month Day, Year 85

Cervical Role in Post-Concussion Syndrome : Examination- Red Flags

Month Day, Year 86

Spine Fractures

Upper Cervical Ligamentous

Instability

Cervical Myelopathy

Cervical Artery Dysfunction

Neoplastic Conditions

Systemic disease

Cervical Role in Post-Concussion Syndrome : Examination

• Key Components of C/S Exam Include Assessing for:

1. Impaired Cervical Mobility

2. Impaired Cervical Muscle Function

3. Impaired Cervical Kinesthetic Ability

4. Impaired Oculomotor Function

5. Impaired Postural Control

Month Day, Year 87

Cervical Role in Post-Concussion Syndrome : Impaired Cervical Mobility

• PROM and AROM assessment

• Flexion, Extension, Rotation, Sidebending.

• Quantity/Quality/Questions

• Upper vs mid/lower cervical

• OA (C0/C1)- Flex/Ext/Lateral Flexion

• AA (C1/C2)- Rotation

Month Day, Year 88

Cervical Role in Post-Concussion Syndrome : Impaired Cervical Mobility- Cervicogenic HA

• Cervical Flexion Rotation Test

• Diagnostic test for Cervicogenic HA

• Primary motion at AA joint is rotation

• Full passive flexion of head and neck

• Passively rotate neck right and left

• Positive if firm end feel with >10° ROM limitation

• Sensitivity 70-91.3% /Specificity 70-92%

• Diagnostic Accuracy 85-91%

Month Day, Year 89

Cervical Role in Post-Concussion Syndrome : Impaired Cervical Mobility-Treatment

• PAVIM- Passive Accessory Intervetebral Motion • AA joint- Central and unilateral

• Can be used diagnostically as well as treatment to help improve segmental mobility

• Sub-occipital release

• Cervical mobs and manual stretching to improve upper cervical flexion and lower cervical extension

• Prone

• Supine

• Sitting

• PROM/AAROM to improve motor control

• Self stretching/mobilization/McKenzie techniques

Month Day, Year 90

Cervical Role in Post-Concussion Syndrome : Impaired Cervical Muscle Function

• Neuromuscular control

- Assessed w/ Cranio-Cervical flexion test

• Muscle Endurance

- Assessed w/ Neck flexor muscle endurance test

Month Day, Year 91


• Neuromuscular control

• Cranio-Cervical Flexion Test

• Used to assess neuromuscular control of deep neck flexors

Month Day, Year 92


• Muscle Endurance

• Neck Flexor Muscle Endurance Test

• Normative values: 38.9” Males/29.4” Females/24.1” individuals w/ neck pain

Month Day, Year 93

Cervical Role in Post-Concussion Syndrome : Impaired Cervical Muscle Function- Treatment

• Chin tuck head lift • Avoid substitutions

• Sustained holds against gravity • Supine/Sidelying/Prone

• AKA “Neck Planks”

• Cervical Isometrics • Start out at sub-max holds 5 x 5” sec into flex/ext/sidebending

• Can perform on unstable surface such as sitting on physioball

Month Day, Year 94

Cervical Role in Post-Concussion Syndrome : Cervical Kinesthetic Ability

• Assessed w/ Cervical Relocation Test

• Laser mounted to head

• Patient sits 90 cm from wall

• With EC patient actively moves head and attempts to return to resting position

• Difference between final and starting position in cm.

• The error needs to be transformed from distance to degrees.

• Normal values for healthy individuals is <4.5 deg

• Repeated at least 3x’s

• Also used as treatment

Month Day, Year 95

Cervical Role in Post-Concussion Syndrome : Cervical Kinesthetic Ability

Month Day, Year 96

Cervical Role in Post-Concussion Syndrome : Impaired Oculomotor Function

• Smoot Pursuit Neck Torsion Test (SPNTT)

• A smooth pursuit test

• Gain is measured (target vs. eye speed) with the neck in neutral and in 45° of right/left.

• Patients with WAD demonstrate saccadic eye movements with trunk rotated 45° as opposed to neutral position

• In WAD patients with dizziness: Specificity 91% Sensitivity 90%

Month Day, Year 97

Cervical Role in Post-Concussion Syndrome : Cervicogenic Dizziness

• Head Neck Differentiation Test

• The patient starts seated on a swivel chair.

• The head is held still while the trunk rotates right and left.

• The patient reports any provocation of dizziness.

• The chair is then rotated without stabilizing the head (en bloc rotation).

• Dizziness with trunk rotation and stable head implies cervical spine while dizziness en bloc indicates a vestibular issue.

Month Day, Year 98

Cervical Role in Post-Concussion Syndrome : Impaired Postural Control- Postural Sway

Month Day, Year 99

Cervical Role in Post-Concussion Syndrome : Impaired Postural Control- Gait

• Functional Gait Assessment • Assesses postural stability when walking

• 10 item assessment test • 7 items from DGI in addition to:

• Gait with narrow base of support

• Gait with eyes closed

• Ambulating backwards

• Maximum score of 30 (higher is better)

Month Day, Year 100


Month Day, Year 101

Buffalo Concussion Treadmill Test: Autonomic Dysfunction/Exercise Intolerance

• The BCTT (Leddy et al. 2018) has been shown to diagnose physiologic

dysfunction in concussion safely and reliably, differentiate it from other diagnoses (e.g., cervical injury), and quantify the clinical severity and exercise capacity of concussed patients.

• It is used to establish a safe/sub-threshold aerobic exercise treatment program to help speed recovery and return to activity for individuals w/ exercise intolerance due to autonomic dysfunction.

• The use of a provocative exercise test is consistent with world expert consensus opinion on establishing physiologic recovery from concussion.

Month Day, Year 102


• Key Concepts

• Submaximal symptom-limited threshold = acutely concussed or not recovered. • Threshold is represented by the HR at symptom exacerbation.

• HR used to prescribe sub-threshold exercise.

• Maximum exertion without symptom limit = cardio- and cerebro-vascularly physiologically recovered.

Month Day, Year 104

Buffalo Concussion Treadmill Test: Establishing the Threshold

• Establish a baseline • Take vitals including HR and BP

• PCSS primarily headache and dizziness

• VAS/RPE

• Monitor throughout test closely and terminate if: • Increase in headache or dizziness by 3 points or a new symptom

appears (one point for each)

• RPE 19-20

• Time >20 min at >80% max HR

• Defer test if pt rates headache/dizziness or other symptoms >7/10 on VAS prior to or during testing

Month Day, Year 105

Buffalo Concussion Treadmill Test: Exercise prescription

• Establish the diagnosis by systematic evaluation of exercise tolerance • Symptom-limited threshold on the treadmill or the bike.

• Sub-threshold exercise prescription (“Exercise is Medicine”):

1. 80-90% of achieved HR on BCTT = target HR. • HR monitor is KEY to prevent athlete from over-exertion.

2. 20 min/day minimum at target HR with 5 min warmup and longer cool down.

3. Stop at symptom exacerbation.

4. Bike first, then running. 6-7 d/wk.

5. Increase target HR 5-10 bpm q1-2 weeks (or re-test).

Month Day, Year 106


• ≥ 80% age-predicted max HR x 20 min without symptoms- “Cardiovascular and Cerebrovascular Physiological Recovery”

• May need concomitant Rx for cervical, vestibular and/or ocular dysfunction before RTP.

• Individuals cont to perform aerobic program while receiving treatment for other dysfunctions

• If individual passes BCTT they can start at stage 3 of RTP protocol when other symptoms resolve

• Advice on RTP based on history (e.g. number of prior concussions) and other signs and symptoms.

Month Day, Year 107


• When can you safely start controlled aerobic exercise after concussion?

• Adults: after two weeks (Leddy et al 2010; Leddy et al 2013: Polak et al. 2014; Clausen et al 2016).

• Adolescents: after 3-4 weeks (Gagnon et al 2009, 2016; Kurowski et al 2017).

Month Day, Year 108

Month Day, Year 109

Month Day, Year 110

References 1. Blanpied PR, Gross AR, Elliott JM et al. Neck pain revision 2017: clinical practice guidelines linked to the international classification of functioning, disability and health from

the orthopaedic section of the american physical therapy association. J Orthop Sports Phys Ther. 2017;47(7):A1-A83.

2. Childs J et al. 2003 Lower Cervical Spine. Independent Study Course 13.3. PT for the Cervical Spine. APTA

3. Daly L, Gifford P, Thomas L. Validity of clinical measures of smooth pursuit eye movement control in patients with idiopathic neck pain. Musculoskeletal Science and Practice. 2018;33:18-23.

4. Domenech MA, Sizer PS et al. The deep neck flexor endurance test: normative data scores in healthy adults. Physical Medicine and Rehabilitation. 2011;3:105-110.

5. Ellis MJ, Leddy JJ, Willer B. Multi-disciplinary management of athletes with post-concussion syndrome: an evolving pathophysiological approach. Frontiers in Neurology 2016;7:136.

6. Ellis M, Leddy JJ, Willer B. Physiological, vestibulo-ocular and cervicogenic post-concussion disorders: an evidence-based classification system with directions for treatment. Brain Injury 2015;29:2: 238-248.

7. Hall T, Robinson K. The flexion-rotation test and active cervical mobility-a comparative measurement study in cervicogenic headache. Manual Therapy 2004;9(4):197-202.

8. Hall T, Briffa K et al. Comparative analysis and diagnostic accuracy of the cervical flexion-rotation test. Journal of Headache Pain 2010;11:391-397 Harris KkD, Heer DM et al. Reliability of a measurement of neck flexor muscle endurance. Physical Therapy 2005;85:1349-1355.

9. Jull G, Barrett C et al. Further clinical clarification of the muscle dysfunction in cervical headache. Cephalagia 1999;19:179-185

10. Jull G, O’Leary S, Falla D. Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test. J Manipulative Physiol Therapy. 2008;31(7): 525-533.

11. Kristjansson E, Treleaven J. Sensorimotor function and dizziness in neck pain: implications for assessment and management. Journal of Orthopaedic and Sports Physical Therapy 2009;39(5):364-377.

12. Marshall CM, Vernon H, Leddy JJ, Bradley BA. The role of the cervical spine in post-concussion syndrome. The Physician and Sportsmedicine 2015; 43: 274-284.

13. Matuszak JM, McVige J et al. A practical concussion physical examination toolbox: evidence-based physical examination for concussion. Primary Care 2016;8(3):260-269.

14. Ogince M, Hall T et al. The diagnostic validity of the cervical flexion-rotation test in C1/2 related cervicogenic headache. Manual Therapy 2007;12(3):256-262.

15. Reiley AS, Vickory FM, Funderburg SE et al. How to diagnose cervicogenic dizziness. Archives of Physiotherapy. 2017:1-12.

16. Reneker JC, Moughiman MC, Cook CE. The diagnostic utility of clinical tests for differentiating between cervicogenic and other causes of dizziness after a sports-related concussion: an international delphi study. Journal of Science and Medicine in Sport. 2015:366-372.

17. Revel M. Minguet M, et al. Changes in cervicocephalic kinesthsia after a proprioceptive rehabilitation program in patients with neck pain: a randomized control study. Archives of Physical Medicine and Rehabilitation 1994;75:895-9.

18. Rubio-Ochoa J, Benitez-Martinez J et al. Physical examination tests for screening and diagnosis of cervicogenic headache: a systematic review. Manual Therapy. 2016; 21:35-40.

19. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidenced based medicine: what it is and what it isn’t. BMJ . 1996;312(7023):71-72.

20. Schneider K, Meeuwisse W et al. Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial 2014;48:1294-1298.

21. Tjell C, Rosenhall U. Smooth pursuit neck torsion test: a specific test for cervical dizziness. American Journal of Otology. 1998;19(1):76-81.

22. Treleaven J, Jull G et al. Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error. Journal of Rehabilitation Medicine 2003;35(1):36-43.

23. Treleaven J. Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control. Manual Therapy 2008;13:2-11.

24. Wrisley CM, Marchetti GF, Kuharsky DK, Whitney SL. Reliability, internal consistency, and validity of data obtained with the Functional Gait Assessment. Phys Ther. 2004;84:906-918.

Month Day, Year 111

112

Psychological Factors Associated with Prolonged

Recovery in Individuals with

Post Concussion Syndrome


Psychological Factors Associated with PCS

• “The Consensus Statement on Concussion in Sport, the Concussion in Sport Group (CISG) recognized that psychological issues are commonly reported as a consequence of concussion and, therefore, should be considered when managing individuals who have sustained sports-related concussions.”

Month Day, Year 113

Psychological Risk Factors For Prolonged Recovery

• Prior and/or Acquired Psychiatric/Psychological Disorders

• Coping Styles

• Illness Perception

• Self Efficacy

• Litigation/Secondary gain*

Month Day, Year 114

mTBI/Concussion and Depression

• Greater prevalence of psychiatric disorder in the first year following concussion compared to general population (Fann et al., 2004).

• “Following an mTBI, it is estimated that 12–44% of individuals experience some degree of depression within the first 3 months.”

• Traumatic brain injuries are likely to involve frontal and temporal lobes

• The fronto-limbic subcortical structures are implicated in causing depression s/s’s, therefore it is not surprising that depression is a commonly-observed biological consequence of traumatic brain injuries of all severities

• Studies of depression following traumatic brain injury continue to provide support for the cortical-limbic model of depression

• Concussion vs mTBI

Month Day, Year 115

mTBI/Concussion and Anxiety

- Similar to depression, anxiety-related symptomatology is often observed in individuals following a sports-related concussion or mTBI. • Traumatic brain injuries often involve damage to the prefrontal cortex, ventral frontal lobe and anterior

temporal lobe, areas which are heavily implicated in the recognition of emotionally relevant stimuli and regulation of the reactions to those stimuli

- Other General Anxiety factors including: 1. Life Issues (anxiety about returning to work/sport/driving, etc)

2. PTSD

3. Emotional dysregulation

4. Automatic Negative Thoughts (ANTS)

Month Day, Year 116

Psychological Assessment

• Interview (now/before: injury, recovery, psych issues)

• PCSS - Post Concussion Symptom Scale

• BAI - Beck Anxiety Inventory

• BDI – II - Beck Depression Inventory II

• PANAS - Positive & Negative Affect Scale

• MMPI-2-RF - Minnesota Multiphasic Personality Inventory

Month Day, Year 117

Psychological Assessment: When to Refer?

• Significant anxiety/cognitive complaints early in recovery

• Symptoms lasting over 3 months

• Enduring anxiety/cognitive complaints

• Reported previous traumatic events experiences

• Reported previous episodes of anxiety/depression

• Perceived attribution of all problems to the concussion

• Neuropsychology vs CBT

Month Day, Year 118

Psychological Risk Factors For Prolonged Recovery: Coping Styles

• Coping: Thoughts and behaviors used to manage internal and external demands or situations appraised as stressful (Lazurus & Folkman, 1984)

• Problem focused (aka approach coping): Active efforts to alter situation and solve the problem

• Avoidant: Emotional and behavioral efforts to avoid or escape the problem

• Across studies: – Avoidant coping associated with negative outcomes – Problem-focused/Approach coping associated with mixed outcome

• High achievers can have difficulty due to increased pressure and stress they place on themselves which can negatively affect and prolong their outcome

Month Day, Year 119

Psychological Risk Factors For Prolonged Recovery: Illness perception

• Factors associated with poor outcome after 6 months included:

1. Stronger beliefs that symptoms are due to the injury (identity beliefs)

2. Expectations of lasting severe negative consequences

3. Stronger beliefs that the injury has an emotional impact

• Education and challenging outdated beliefs about concussions is key to improving outcomes and decreasing recovery time!!!

Month Day, Year 120

Fear Avoidance Model

Month Day, Year 121

Psychological Risk Factors For Prolonged Recovery: Self Efficacy

• Self-efficacy: Optimistic belief of being able to control and alter one’s environment (Taylor & Stanton, 2007)

• Self-efficacy was positively correlated with active coping and negatively correlated with avoidant and passive coping (Scheenen et al., 2017).

• Passive coping style remained stable across time

• Poor self-efficacy leads to poor outcomes

Month Day, Year 122

Psychological Risk Factors For Prolonged Recovery: What can we do?

• Perform a detailed patient interview to help get a sense of the individual pre-injury to help individualize treatment strategies and improve motivation

• Promote positive coping strategies and make patient aware of and challenge negative thoughts (ANTS)

• Education and challenging outdated beliefs about concussions is key to improving outcomes and decreasing recovery time!!!

• Setting patients up for success and making sure we are providing the right interventions at the right time

• Communicate with other healthcare professionals about findings, and refer out when appropriate

Month Day, Year 123

Month Day, Year 124

References

1. Anderson, J. F. I., Fitzgerald, P. (2018). Associations between coping style, illness perceptions, and self-reported symptoms after mild traumatic brain injury in prospectively studied pre-morbidly healthy individuals. Neuropsychological Rehabilitation,1-14.

2. Fann, J.R., Burington, B., Leonetti, A., Jaffe, K., Katon, W.J., Thompson, R.S. (2004). Psychiatric illness following traumatic brain injury in an adult health maintenance organization population. Arch Gen Psychiatry, 61, 53-61.

3. Hart, T., Driver, S., Sander, A., Pappadis, M., Dams-O’Connor, K., Bocage, C., Hinkens, E., Dahdah, M.N., Cai, X. (2018). Traumatic brain injury education for adult patients and families: a scoping review. Brain Injury, 32(11), 1295-1306.

4. Lazurus, R.S., Folkman, S. (1984). Stress, Appraisal and Coping. New York, NY: Springer.

5. Losai, H. Silverberg, N. D., Waljas, M., Turunen, S., Rosti-Otajarvi, E., Helminen, M., Luoto, T.M., Julkunen, J., Ohman, J., &Iverson, G. L. (2016). Recovery from Mild Traumatic Brain Injury in Previously Healthy Adults. Journal of Neurotrauma, 33,766-776.

6. Maestas, K.L., Sander, A.M., Clark, A.N., von Veldhoven, L.M., Struchen, M.A., Sherer, M., Hannay, H.J. (2014). Preinjury coping, emotionalfunctioning, and quality of life following uncomplicated and complicated mild traumatic brain injury.J Head Trauma Rehabil, 29(5),407-417.

7. McCrea, M., Powell, M.R. (2012). The concussion clinic: a practical, evidence-based model for assessment and management of sport-related concussion. JClinSport Psychol. 6(3), 275-292.

8. Mittenberg, W., Burton, D.B. (1994). A survey of treatments for post-concussion syndrome. Brain Inj. 8(5), 429-437.

9. Rose, J.M. (2005). Continuum of care model for managing mild traumatic brain injury in a workers’ compensation context: A description of the model and its development. Brain inj. 19(1), 29-39.

10. Scheenen, M.E., Van der Horn, H.J.,deKoning, M.E., van derNaalt, J.,Spikman, J. M. (2017). Stability of coping and the role of self-efficacy in the first year following mild traumatic brain injury. Social Science and Medicine, 181,184-190.

11. Snell, D.L., Hay-Smith, J.C., Surgenor, L.J., Siegert, R.J. (2013). Examination of outcome after mild traumatic brain injury: The contribution of injury beliefs and Leventhal’s Common-Sense Model. Neuropsychological Evaluation, 23(3), 333-362.

Month Day, Year 125

Cognitive Fatigue and Post-Traumatic Migraine Sub-Types:

Treatment & Management Strategies


126

Diagnosis: Cognitive/Fatigue Sub-Type

Commonly found early on in concussion recovery

Symptoms include:

• Fatigue

• Feels best in the A.M. and worse at the end of the day

• HA w/ cognitive activities (i.e. screen time on phone/computer!)

• May have sleep deficits

• Normal VOM testing, and no s/s’s of BPPV

• Mild global deficits and difficulty w/ retrieving rather than encoding w/ neurocognitive testing

Questions to ask include:

• “Do you have a generalized headache as the day progresses?”

• “Do you feel more fatigued than normal by the end of the day?”

• “Do you feel more distractible in school/work than normal?”

Month Day, Year 127

Treatment: Cognitive/Fatigue Sub-Type

• Patient education

• Physical/Cognitive breaks throughout the day (no naps)

• Pharmacological interventions including neurostimulants and/or sleep aide

• Cognitive behavioral therapy

• Monitored exertion progression such as w/ BCTT

Month Day, Year 128

Diagnosis: Post-Traumatic Migraine Sub-Type

Symptoms include:

• Variable headache and intermittently severe

• Often wakes w/ headache (as opposed to cognitive fatigue which is later in the day)

• Nausea, photo and/or phonophobia

• Stress, anxiety, lack of exercise

• Sleep dysregulation

• May also present w/ vestibular migraine (vertigo w/o BPPV)

Risk factors include:

• Personal or family hx of migraines

• Hx of motion sensitivity

• Hx of “ice cream” HA

• Hx of vestibular disorder

• Anxiety

Month Day, Year 129

Diagnosis: Post-Traumatic Migraine Sub-Type

VOM Screen • Normal unless vestibular component present

Neurocognitive testing • Verbal and visual memory deficits

• If vestibular component present then speed deficits as well

Key questions • Did you get migraines before your injury?

• Do headaches occur in the morning after poor sleep?

• Is your sleep dysregulated?

• Do you get visual changes before or during a headaches?

• Do you become highly sensitive to normal room noise or light when you have a headache?

Key Takeaway

• You can have a migraine aura w/o headache

Month Day, Year 130

Treatment: Post-Traumatic Migraine Sub-Type

• Education and control of triggers including sleep, caffeine intake, stress reduction, dietary trigger (migraine diet)

• OTC abortive medications including ibuprofen, Tylenol, Excedrin, etc

• Prescription abortive medication including triptans

• Prescription preventative medication including anti-depressants, anti-convulsants, beta blockers, and calcium channel blockers

• Supplements including magnesium oxide, vitamin b2 riboflavin, fish oil, Co-Q 10, Alpha lipoic acid (ALA), green tea, resveratrol, turmeric, vit D, and butterbur extract

• Alternative treatments for stress reduction including float tank/meditation-breathing/mindfulness training (progressive muscle relaxation)

Month Day, Year 131

Treatment: Post-Traumatic Migraine Sub-Type

• Manual Therapy for cervical spine can be effective in the management of

post-traumatic migraines as well!!!

• Neuro-Optometry

Month Day, Year 132

Sleep Dysregulation

Sleep dysregulation is a common symptom following a sports related concussion

Sleep alterations include

• Difficulty falling asleep

• Fragmented sleep

• Too little/too much sleep

Poor sleep quality can negatively impact and prolong PCS s/s’s such as migraine headaches, fatigue, mood, and cognitive difficulties; and so to optimize recovery w/ need to address sleep dysregulation issues

Month Day, Year 133

Treatment: Sleep Dysregulation

Behavioral Management including:

• Avoiding daytime naps

• Regulate wake time and bed time (keep consistent), and shoot for 7-9 hours

• Relaxation exercises

• Caffeine restriction in the afternoon

• Avoid technology near bedtime including no blue light (i.e. phone/ipad)

• Cool room

Pharmacologic Management including:

• Melatonin

• Anti-depressants (i.e. amitriptyline, trazadone)

• Non-Benzodiazepine hypnotics (i.e. ambien, Lunesta)

• Anti-histamines (i.e. Benadryl)

Month Day, Year 134

Putting It All Together

Month Day, Year 135

Month Day, Year 136

Summary

• Typical RTP protocol is only one aspect of sports related concussion treatment and management

• The literature on concussion management is changing, and new screening tools are treatment/management strategies are being utilized that we need to be aware of

• During our evaluations we need to consider the 6 sub-types to help us classify out patients/athletes to allow for the correct treatment to avoid delayed return to normal activity

• Use of BCTT as diagnostic tool as well as tx approach for gradual return to exertional activity in individuals w/ physiologic concussions.

• We need to utilize a multi-disciplinary approach with open communication b/w the various members of the concussion team including medical team that includes sports MD/DO, ATC’s, Neuropsychiatrists/CBT’s; school team that includes teachers, counselors, AD; and of course the family team including parents and sibling.

Month Day, Year 137

Questions

Month Day, Year 138

References

MedBridge Concussion: Physical Therapy and Medical Management

Anne Mucha DPT, MS, NCS

Susan Whitney DPT,PhD, NCS, ATC,FAPTA

1. Alsalaheen BA, Mucha A, Morris LO, et al. Vestibular Rehabilitation for Dizziness and Balance Disorders After Concussion. Journal of Neurologic Physical Therapy. 2010; 34:87- 93.

2. Barkhoudarian G, Hovda DA, Giza CC. The molecular pathophysiology of concussive brain injury. Clin Sports Med. Jan 2011; 30(1):33-48, vii-iii.

3. Collins MW, Kontos AP, Reynolds E, Murawski CD, Fu FH. A comprehensive, targeted approach to the clinical care of athletes following sport-related concussion. Knee Surg Sports Traumatol Arthrosc. Feb 2014; 22(2):235-246.

4. Griesbach GS, Tio DL, Vincelli J, McArthur DL, Taylor AN. Differential effects of voluntary and forced exercise on stress responses after traumatic brain injury. J Neurotrauma. May 1 2012; 29(7):1426-1433.

5. McGrath N. Supporting the student-athlete's return to the classroom after a sport-related concussion. J Athl Train. Sep-Oct 2010; 45(5):492-498.

6. McGrath N. Supporting the student-athlete's return to the classroom after a sport-related concussion. J Athl Train. Sep-Oct 2010;45(5):492-498

7. Moser RS, Glatts C, Schatz P. Efficacy of immediate and delayed cognitive and physical rest for treatment of sports-related concussion. J Pediatr. Nov 2012;161(5):922-926.

8. Mucha A, Collins MW, Elbin RJ, et al. A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions: Preliminary Findings. Am J Sports Med. Aug 8 2014.

9. Ponsford J, Cameron P, Fitzgerald M, Grant M, Mikocka-Walus A, Schonberger M. Predictors of postconcussive symptoms 3 months after mild traumatic brain injury. Neuropsychology. May 2012; 26(3):304-313.

10. Reddy CC, Collins M, Lovell M, Kontos AP. Efficacy of Amantadine Treatment on Symptoms and Neurocognitive Performance Among Adolescents Following Sports-Related Concussion. J Head Trauma Rehabil. May 18 2012.

Month Day, Year 139

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