pcs –o care & considerations · 2020-04-17 · ongoing care •constant education and...

4/17/20

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PCS – ONGOING CARE & CONSIDERATIONSEvidence-Based Concussion Care

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Complete Concussion Management Inc. © 2019. All rights reserved

PCS Management Algorithm

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Ongoing Care• Constant education and reassurance! • Re-test treadmill each week or two (until passed)• Re-test VOMS periodically – encourage adherence and

progression of visual/vestibular exercises• Provide Manual treatment to cervical spine as needed• Provide in-house rehabilitation as needed – progressive!• Refer as necessary

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Key to treatment• Integration of multiple subsystems– Ingriselli et al., 2013 – dual task rehab provides additional rehab

benefits over single task (ex Balance and Cognitive)– Static to dynamic balance progression (don’t forget core and

hip stability) while incorporating other dysfunctional areas• Visual tracking• Vestibular function• Neck movement• Throwing and catching balls while counting backwards from 100 by 7’s

– Figure out areas of their life that they are having trouble with and go after it…Be creative and share your ideas!

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Other Considerations• Ongoing Dizziness• When to refer?• Detecting Migraines• Sleep Issues• Hyperacusis• Light Sensitivity & Screens• Cognitive Rehabilitation• Anxiety/Depression• Hormone Imbalances• When to end a season, when to end an athletic career

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Ongoing Dizziness• If able to pass VOMS and cervical spine treatment is

not reducing dizziness substantially after 1-2 treatments, look to habituation/adaptation-type exercises – Habituation/Adaptation = What activities/motions cause their

dizziness?• Target these areas to get the patient accommodated to these things

• If still having dizziness and/or visual issues after 4-6 weeks of treatment, refer for co-management to specialized vestibular physiotherapist (or neurologist) and/or vision therapist (neuroptomotrist)

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Habituation/Adaptation• Figure 8 walking

– Place 2 objects on floor 4 feet apart and walk in a figure 8 pattern – 5x, 2x/day for 2 weeks

• Forward Bending to pick up object– Seated then standing– Bend down pick up object, come back up to neutral until dizziness

subsides then bend back over and put it down – work up to 15x, 2x/day• Ball Throwing

– Throw ball from one hand to another over your head and track it with your eyes and head

• Standing on pillow with rotations– Stand on pillow and rotate all the way around to right to look at a spot on

the floor behind your right heel – then go to left– Repeat 10x in each direction 2x/day

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Persistent Postural-Perceptual Dizziness (PPPD)What is PPPD? • PPPD is a newly defined diagnostic syndrome that describes a common chronic dysfunction of the vestibular

system and brain that produces persistent dizziness, non-spinning vertigo and/or unsteadiness. It constitutes a long-term maladaption to neuro-otological, medical or psychological event that triggered vestibular symptoms

How is diagnosed? • Diagnostic criteria for PPPD consensus document (Staab et al., 2017), defined by all 5 of the following criteriaA. One or more symptom of dizziness, unsteadiness, non-spinning vertigo on most days for 3 months or more

1. Symptoms last for prolonged period but wax and wane in severity 2. Symptoms need not be present continuously throughout the day

B. Persistent symptoms occur without specific provocation by exacerbated by:1. Upright posture2. Active or passive motion without regard for direction 3. Exposure to moving stimuli or complex visual patterns

C. Disorder is precipitated by conditions that cause vertigo, unsteadiness, dizziness, or problems with balance, other neurological or medical illness, or psychological distress– Concussion or whiplash injury account for 10-15% of precipitating factors

D. Symptoms cause significant distress or functional impairmentE. Symptoms are not better accounted for by another disease or disorder

What is the treatment? • Various treatments are thought to help including vestibular rehab therapy, cognitive

Behavioral therapy and medication to address underlying mood disorder.

Staab et al., 2017

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Vestibular rehabilitation therapy outcomes in patients with persistent postural-perceptual dizziness (PPPD)• The purpose of the study was to determine the effectiveness of Vestibular rehab therapy

(VRT) on patients with PPPD• 60 adult patients were diagnosed with PPPD according to Staab et al., 2017 diagnostic

criteria. • Clinical assessment included the following:

– Hx– Dizziness Handicap Inventory (main outcome measure)– Vestibular assessment, VNG testing, VEMP test.

• Patients were randomized into two groups 1. Group 1 (n=30) – customized self-guided vestibular rehab2. Group 2 (n=30) – customized VRT plus placebo (vitamins and were told they decreased dizziness)

• Customized VRT consisted of self-guided program, performed 2x/day , tailored to the patients complaints and progressed in difficulty over 6 weeks with exercises performed 5x/day by the end of the program. – Two sets of exercise utilizing gaze and gait stabilization

• Patients followed-up in clinic every 2 weeks to assess for progression of exercises and daily check in with patients using Whats-App.

• After 6-weeks patients were re-evaluated using dizziness handicap inventory

Nada et al., 2018

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Example gaze and gait stabilization exercises used in the study

adapted from Huesel-Gilling et al, 2014

Results There was significant improvement in Dizziness Handicap Inventory (DHI) Scores in both groups following VRT.

ConclusionCustomized vestibular rehabilitation exercises in a home-based program suited to the patient’s aggravating factors provided a suitable solution to reduce dizziness.

Nada et al., 2018

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Exercises for Persistent Dizziness

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Habituation Exercises• Brandt-Daroff (mostly for BPPV)– Seated in middle of bed– Turn head 45 degrees to right and lay down on left side

until dizziness subsides plus 30 sec– Sit up until dizziness subsides plus 30 sec– Turn head 45 degrees to left and lie down on right side

until dizziness subsides plus 30 sec– Complete sequence 5 times, 2x/day for 2 weeks

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Other Things to Keep in Mind…

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Detecting Migraine• This study examined mTBI patients with and without

migraines on several self-administered questionnaires – looking for most valid measures for detecting migraines

• The best tool was the Headache Disorders, 2nd Edition (ICHD-II): Nine-Item Screener– This consists of nine yes or no questions that serve to identify

potential migraine (see next slide)– The mean number of symptoms (“yes” responses in the

migraine group was 7.6+1.6 with a median score of 5– The group without migraine had a mean of 4.2+3.1 with a

median of 8 so there is some overlap here (proceed with caution)

– Total sensitivity was 90% and total sensitivity was 70%

Anderson et al., 2015

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• Nine Item Screener Questions (yes or no responses to each):1. Pain is worse on just one side (can be cervicogenic as well)2. Pain is pulsing, pounding, or throbbing3. Pain is moderate or severe4. Pain is made worse by activities such as walking or climbing

stairs5. You feel nauseated or sick to your stomach6. You see spots, stars, zigzag lines, or gray area for several minutes

or more before or during your headaches7. Light bothers you (a lot more than when you do not have

headaches)8. Sound bothers you (a lot more than when you do not have

headaches)9. Functional impairment due to headache in the last 3 months-Prophylactic medication may work

Anderson et al., 2015

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Other Potential HA treatments• TMJ therapy/rehab– Malocclusion, bruxism– Look to temporalis, masseter, pterygoids (vibration works well here)– Mobilizations

• Trigger Point Injections• Botox– Preliminary study – Yerry et al., 2015 – decent results but quite a few

side-effects– Be wary!

• Pharmaceuticals – Opioids should be avoided– Preliminary evidence for medical cannabis for concussion-related

chronic pain – McVige et al., 2018 - 70% of patients experienced improvement in sleep, headache, and mood

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Sleep

• Prevalence of sleep disorders is between 42 – 70% following TBI

• Sleep disruption on it’s own has been shown to result in cognitive problems

• Sleep hygiene (handout), CBT, referral to sleep clinic, short term medication use

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Sleep Review• Altered sleep patterns following mTBI:– Decreased REM– Increased non-REM (stages 1 and 2)

• Pre-injury sleep deprivation is a potential risk factor for developing chronic symptoms– Adolescents frequently have poor sleep habits and are

also the most likely to suffer concussions• The neurometabolic cascade of the concussion

injury itself and high glutamate release can affect the sleep-wake cycle

Jaffee et al., 2015

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Sleep Review• M/C complaints within the TBI population

– Excessive daytime sleeping (50%)– Insomnia at night (~33%)

• 50% of those report increased sleep latency (trouble falling asleep) – these people tend to report more anxiety symptoms

• 50% report frequent waking – these people tend to report more depression-type symptoms

• Brooks et al., 2019 – 62% of adolescents with persistent symptoms (mean = 6 months) were found to have clinically significant insomnia– Higher insomnia associated with higher concussion symptoms, higher anxiety and

depression symptoms– Higher insomnia was also found to be significantly associated with higher rates of failure

on performance validity testing…– “The associateion between worse sleep disruption, worse postconcussion symptoms, and

greater psychological problems is consistent with the existing pediatric literature, and suggests that insomnia could be a key factor in persistent problems after concussion”

– Allan et al., 2016 – mTBI patients had several subjective sleep complaints but relatively few objective changes on sleep studies

• Studies show a reduction in evening melatonin production following TBI of varying severities

Jaffee et al., 2015

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Sleep Review• Sleep disruption on it’s own has been shown to result in

cognitive problems– Makes it difficult to determine whether cognitive deficits are due to

concussion or ongoing sleep dysfunction• Treatment

– Sleep hygiene education (handout)– Cognitive-Behavioural Therapy– Medications – general consensus that pharmacotherapy is only useful

in acute insomnia and should only be used for a max of 7 days!– Melatonin supplementation can help with reduced production

following mTBI and can help with sleep latency– Blue light therapy (BLT)

• Raikes et al., 2019 – RCT found that BLT significantly reduced daytime sleepiness, and somatic/cognitive symptoms vs. those receiving amber light therapy

Jaffee et al., 2015; Zhou et al., 2018

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Potential for development of light therapies in mTBI –review paper

Raikers & Killgore, 2018

To date, two published studies have

specifically examined effects of light

therapy following mTBI. Both examined

the effects of blue-wavelength light

therapy and found less day time sleepiness, reduced sleep disruption

and self-reported lower levels of

depression.

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Hyperacusis

• Hyperacusis – A general term to describes a self-reported discomfort or reduced tolerance to sounds. Where moderate intensity sounds are perceived as loud.

Study• 58 collegiate athletes were enrolled in the study to determine sensitivity to sound

following a concussion. • 28 athletes sustained a concussion during the season (diagnosed by team

physician) and were compared to 30 athlete controls with no hx of concussion. – 14/28 athletes continued to endorsed sound sensitivity at time of testing and 14/28

athletes with no sound sensitivity following injury were further subdivided and compared• All athletes underwent the following tests:

– Hearing threshold and loudness discomfort levels – Hyperacusis questionnaire– Depression/anxiety questionnaire– Loudness growth function – ex. Continuum: Very soft à soft à ok à loud à very loud

(each increase in category is in a factor of 10 decibels (dB)

Assi, et al., 2018

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Sensitivity to sounds in sport-related concussed athletes: a new clinical presentation of hyperacusisResults • There was no difference in hearing threshold between concussed and

control group. However, the concussed group with self-reported sound sensitivity demonstrated a significantly decreased hearing threshold compared to the concussed group with no sound sensitivity.

• The concussed group with sound sensitivity had significantly higher scores for depression/anxiety compared to controls.

• When looking at loudness growth functions, the concussed group with sound sensitivity had a significant difference of negative 10 dB at loud and very loud categories but no difference in soft or very soft tones when compared to the control and concussed group without sound sensitivity. For example, a 100 dB sound is rated as “too loud” by the control group but in the concussion group with sound sensitivity the rating of “too loud” is now reached at 90 dB instead of 100 dB, which lowers their threshold for sound perception and increases their sensitivity to sound.

Assi, et al., 2018

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Discussion• Hyperacusis in concussion demonstrates a unique pathophysiology compared to other

hearing disorders. For instance, tinnitus is believed to be the result of increased sound evoked firing rate leading to peripheral damage to sound receptors. Where as hyperacusis as a result of concussion is directly related to central biochemical, mechanical, and inflammatory brain responses. Particularly acute release of glutamate following injury leads to changes in GABA, which disrupts the excitatory-inhibitory neural balance and increases neural response to sound.

• Hyperacusis is directly and indirectly related to sound loudness. Directly, by lowering neural threshold for sound perception and indirectly as a result of depression related to sensory and social isolation.

Authors conclusions: “sound sensitivity starting at dB levels that most people find barely loud can represent an important disabling symptom in concussed athletes, especially when some depressive symptoms are present. Because symptoms and loss of activity are reported as the worst part of concussions by athletes, it is important to realize that further social isolation and sensory deprivation can lead to increased symptoms. Although there is no universally accepted treatment for hyperacusis, one therapy that has some support is cognitive behavioural therapy, which is helpful for treating those athletes with associated depression due to noise sensitivity.

Sensitivity to sounds in sport-related concussed athletes: a new clinical presentation of hyperacusis

Assi, et al., 2018

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Other Interventions• Medications (poor evidence of effectiveness –mostly symptom-based approach – be aware of side-effects that look like concussion symptoms)

• Hyperbaric O2• Cognitive Problems• Depression/Anxiety• Pituitary Dysfunction

• Transcranial Magnetic Stimulation

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Light Sensitivity/Screens• Avoid unnecessary use of

sunglasses!• Exposure to normal ambient

lighting• Iris technologies screens (Mansur et al., 2018)

• Possibly getting special light filtering glasses

• Cognitive Behavioural Therapy (similar to sound sensitivity)

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Hyperbaric O2

• Conflicting studies – most show no greater than sham or surface air – Effective with severe TBI however not with mTBI

• 1 positive study (Boussi-Gross et al., 2013)– Massive design flaw

• Cross-over design in which 1 group received HBO (40x60 min sessions @ 100% O2 and 1.5 ATA) and the other group got NOTHING! Who do you think got better?

• Multiple negative studies– Cifu et al., 2013 – 3 groups – 40x60 min tx - all were in tube (sham = surface air)

• “results show no evidence of efficacy by 3 months intervention to treat the symptoms, cognitive, or behavioural sequelae after combat-related mTBI”

– Wolf et al., 2012 – double blind, RCT with a sham • No significant difference on symptoms or neurocognitive performance after 30 treatments

at 100% O2 & 2.4 ATA vs. sham– Cifu et al., 2014 – same thing – no difference vs. sham/surface air– Dong et al., 2018 - “HBO has no significant effect on PCS compared with the

sham group”

ONF guidelines for persistent symptoms (2018)

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Cognitive Complaints• Concentration/Memory– Potential psych overlay (DMN interference) – education and

reassurance• Most common treatment technique utilized by neuropsychologists!• 2nd is CBT (Self-help app – TruReach)

• Testing/Assessment:– ImPACT not very helpful - no effort tests built in– Referral to Neuropsych for full battery (make sure they include

effort testing) – expensive– Other option = Referral to OT (BrainFx) – tests more subtle

deficits & provide rehab• Partnership with CCMI

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Cognitive Rehab• Basic:– Education/Reassurance!– Lumosity/FitBrains Trainer, Sudoku, Guitar Hero, Memory

games– Referral for CBT (or recommend Trureach app), OT

(BrainFx Network), neuropsychologist

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Depression/Anxiety• Education & Reassurance• Referral to clinical psychologist/psychiatrist

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Mindfulness in mTBI• Previous research has indicated a positive effect of

mindfulness training on symptoms of chronic mTBI such as cognitive functioning and emotion

• Study:– Examined 14 military vets with mTBI on resting state fMRI (Default

Mode Network, AKA DMN) before and after 2 weeks of mindfulness training

• Results:– After training there was a significant decrease in the strength of

excitatory input from the medial pre-frontal cortex to the posterior cingulate cortex, and a significant increase in the strength of the inhibitory input from the medial pre-frontal cortex to left inferior parietal lobule

• Conclusion:– Brief mindfulness training can alter the activity of the brain as

shown on resting state fMRI – possible intervention

Tang et al., 2015

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Mindfulness as Treatment – Narrative Review

• Minfulness & mTBI – studies– Borgaro et al., 2005 control study – (8 week Kabat Zinn

program) • Significant reduction in mental fatigue vs. control group

– Azulay et al., 2012 – 10 week program (no control group)• Increased perceived quality of life and self-efficacy for managing

their cognitive and emotional symptoms• Increased visual and verbal attentional abilities• Overall symptoms did not decrease

Link et al., 2016

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Mindfulness as Treatment – Narrative Review

• Conclusion:– Mindfulness-Based Stress Reduction has been widely

researched and shown to increase well-being, attention, memory, executive functioning, and increased ability to tolerate stressful situations

– Though the studies on mTBI are lacking, each of these areas is frequently problematic for concussion patients and it is plausible that MBSR would likely have a positive effect for these patients• More high-quality control studies are necessary to validate this

hypothesis– There has also been demonstration of increased gray matter

of the brain

Link et al., 2016

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Pituitary Dysfunction in Chronic Concussion Patients• Aim: determine the prevalence of pituitary dysfunction in

patients presenting with cognitive/mood complaints and/or fatigability long after a concussion

• n= 38 (25 male), mean age 36, mean to 23 months post-injury (range 9-40)

• Results:– No patients showed any posterior pituitary dysfunction– Anterior pituitary dysfunction requiring substitutive treatment was

found in 60.5%!– Most common: Thyroid Stimulating Hormone (TSH) (18.4%),

Adrenocorticotropic Hormone (ACTH) (23.7%), Severe Growth Hormone (GH) deficiency (23.7%)

• If all other treatments are ineffective for chronic patients with fatigability, cognitive, or mood disorders, refer back to the family doctor for blood work, specifically to examine pituitary function!

Moreau et al., 2015

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A pilot Randomised Double-Blind study of the tolerability and efficacy of repetitive Transcranial Magnetic Stimulation on Persistent Post-Concussion Syndrome

Moussavi et al., 2019

Repetitive Transcranial Magnetic

Stimulation (rTMS) involves the repetitive

application of a quickly changing magnetic

field pulse to the brain. The rapidly

changing magnetic field induces an electric field and causes ions to flow in

brain tissue. This can either depolarize or

hyperpolarize neurons depending on the

frequency (hypothesis is high frequency =

excitability)

Considered to be a non-invasive procedure and usually well tolerated – side-effects can include increased headaches,

seizures, local pain, and toothache. Has mixed results for the treatment of depression. Early pilot studies have found a

significant reduction in post-concussion symptom scores, but this is the first RCT

Limitations – they did not clearly define inclusion/exclusion criteria, paper was in an open source journal which is typically paid publication (recent scrutiny regarding ease of acceptance criteria)

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A pilot Randomised Double-Blind study of the tolerability and efficacy of repetitive Transcranial Magnetic Stimulation on Persistent Post-Concussion Syndrome

This study shows that for patients with Short

Duration PCS, the treatment effect was

significant, however for longer duration PCS

there was no effect.

Moussavi et al., 2019

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When to suggest:

• End of season• End of career

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Season Ending Factors• 2 or more concussions that have prolonged recovery in

same season (>30 days)– I would be cautious with someone who’s had 2 concussions in

a short period of time (within 2 to 3 weeks) – especially in children/adolescents

• Abnormal neurological exam (unless cleared by neurologist)

• Abnormality or CT or MRI (due to trauma) (again, not our call – any abnormality on imaging must be cleared by neurologist/neurosurgeon)

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Career ending factors

• Repeated concussions with less force & taking longer and longer to recover with each one**

• Intracranial hemorrhage (neurologist/neurosurgeon)• 3 or more concussions which have taken more than

30 days to recover (in life)• Structural injury on MRI or CT

(neurologist/neurosurgeon)• Development of CTE symptoms

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Medical retirement from sport after concussions

• Absolute contraindications:– Evidence of structural brain injury indicative of recent or remote TBI– Structural abnormalities not likely due to TBI but associated with

increased risk of subsequent intracranial hemorrhage with future head contact

• Relative contraindications:– Postconcussive signs or symptoms that are ongoing at the time of

evaluation or lasting more than 90 days, or increasing in severity with each successive concussion

– Cognitive impairment on neuropsychological testing (with a neuropsychologist)

– Diminished academic performance or social engagement– Decreased concussion threshold or decreased interval between

concussions.

Davis-Hayes et al., 2018

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When to retire?

Davis-Hayes et al., 2018

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pcs –o care & considerations · 2020-04-17 · ongoing care •constant education and...

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