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Anthony “Toby” Kinney DPT, OCS, FAAOMPT, MBA University of Montana
School of Physical Therapy & Rehabilitation Science Missoula, MT
Amy Garrigues, DPT, OCS, FAAOMPT Hennepin County Medical Center
Minneapolis, MN
DISCLOSURES
The authors have nothing to disclose.
SESSION DESCRIPTION • This educational presentation will incorporate the best available evidence
in the management of patients following a concussion. Lecture and case presentation will provide participants with an evidence-based approach in the evaluation and treatment of patients post-concussion.
• Please note: This is NOT a comprehensive course in concussion management.
• Pre-requisite knowledge: Assumes basic knowledge of concussion signs and
symptoms • The presenters recommend that participants familiarize themselves with basic
knowledge of concussion using the following: • http://www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html
SESSION OBJECTIVES • Objectives:
(1) Briefly discuss the classification, epidemiology and background of concussion and post-concussion syndrome. (2) Discuss and distinguish the signs and symptoms of post-concussion syndrome with a focus on cervicogenic headache, dizziness, vestibular impairment, and autonomic dysfunction. (3) Using the best available evidence and clinical reasoning discuss the evaluation and management of patients who present to physical therapy following a concussion (4) Discuss manual therapy techniques used to treat impairments commonly seen in patients post-concussion. (5) Discuss balance, vestibular, and oculomotor retraining and a graded exercise approach in patients post-concussion.
WHAT IS A “CONCUSSION?” • A concussion is a subcategory of traumatic brain injury (TBI) • Consensus Statement on Concussion in Sport, 2012 (McCrory,
Meeuwisse, Aubry et al, 2013) • Direct blow!”impulsive” force to head • Resultant short-lived neurological impairments that resolve • Acute clinical symptoms are reflective of a ‘functional
disturbance’ of the brain, not a structural abnormality • May involved loss of consciousness (LOC).
• Resolution of symptoms my be sequential. • Some patients may have prolonged recovery
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SIGNS/SYMPTOMS
• Headache • Nausea • Vomiting • Balance Problems • Dizziness • Fatigue • Trouble falling asleep • Excessive sleep • Loss of sleep • Drowsiness • Light Sensitivity
• Noise Sensitivity • Irritability • Sadness • Nervousness • More emotional • Numbness • Feeling "slow" • Feeling "foggy" • Difficulty concentrating • Difficulty remembering • Visual problems
ACUTE PHASE
SUBACUTE PHASE
CHRONIC PHASE
0-3 months in non-athletes 3-6 weeks for adult athletes
4-6 weeks for child and adolescent athletes
CONCUSSION: EPIDEMIOLOGY
• CDC reports that 1.7 million individuals in the U.S. sustain a TBI annually.
• 75% of TBIs are concussions or mTBI
• Leading Causes of TBI • Falls:35.2%
• MVA or Traffic accident: 17.3%
• Struck by or against: 16.5%
• Assaults: 10% http://www.cdc.gov/traumaticbraininjury/causes.html accessed on 2/23/2013.
TBI-RELATED HOSPITALIZATION BY �MECHANISMS OF INJURY AND AGE
Modified from National Hospital Discharge Survey presented http://www.cdc.gov/traumaticbraininjury/data/dist_hosp.html
ACUTE PHASE
SUBACUTE PHASE
CHRONIC PHASE
1-6 weeks in athletes 1-3 months in non-athletes
Hea
dach
e/N
eck
Pain
• MSK • Migraine • Visual • Physiological
Diz
zine
ss/U
nste
adin
ess
• MSK • Migraine • Visual • Physiological • Vestibular • Psychological
Dec
ondi
tioni
ng/F
atig
ue
• Cardiovascular • Physiological • Psychological
SUBACUTE CONCUSSION MANAGEMENT
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HEADACHE / NECK PAIN
Musculoskeletal
Impaired ROM and strength
Impaired Joint Mobility
Impaired CJPE
Migraine
History of migraine
Associated with dizziness
Non MSK triggers
Visual
Impaired Oculomotor function
Autonomic/Autoregulatory
Related to activity intensity
DIZZINESS / UNSTEADINESS
Musculoskeletal Impaired CJPS
Migraine Related to headache
intensity
History of migraine
Visual Impaired gaze stability
Impaired convergence
Autonomic/Autoregulatory Increases with exercise
intensity
Orthostatic hypotension
Increases with changes in head position
Vestibular BPPV
Central Signs
Oculomotor dysfunction
Psychological #1 cause of dizziness in
adults
FATIGUE / DECONDITIONING
Cardiovascular
Increased HR at rest, linear response to exercise
Autonomic/Autoregulatory
Increased HR at rest, non-linear response to exercise
Increased symptoms with exertion
Psychological
Concomitant depression
Rest & Education
Sx > 3 wks
Treadmill Test
Pass
Alternate Dx
RTA after Tx for Specific
Problem
Fail
Controlled Aerobic Exercise
RTA if Asymptomatic During
Peak Exertion
Sx resolve
Treadmill Test + NP
Test
Pass Fail
RTA
More Recovery
Time needed
Fail TM Test OR
Abnormal NP Test
Pass TM Test and Normal NP Test
RTA
RETURN TO ACTIVITY
Modified from Leddy et al 2012
CLINICAL REASONING
Context Goals
Strategies
Clinician
Patient Patient preferences Patient support network
Knowledge & Judgment
Higgs & Jones, 2000; Jones & Rivett, 2004
CLINICAL REASONING
PATIENT MANAGEMENT
Application of
procedures
Reasoning strategies
Knowledge base
Jones & Rivett, 2004
H0 Testing
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CLINICAL REASONING USING� A CASE BASED APPROACH
• Format: • Case Background provided
• Pertinent findings addressed in the case summary
• Presenters will address the following during each case • Evidence informed practice strategies • Clinical reasoning process CASE STUDY 1
CASE STUDY 1: DESCRIPTION • A 16 year-old female presented to physical therapy under direct
access. She reported having recent onset of headaches and neck pain following an injury while playing soccer. She had an unremarkable past medical history except for intermittent headaches attributed to dietary factors.
CASE STUDY 1: DESCRIPTION
Initial Injury (I0) I4 I11 I18
Initial PT visit
Pt returned to basketball and soccer playing!HA and neck pain
Visit with PCP; told to rest
No LOC; headache and nausea
CLINICAL REASONING STRATEGIES INTERVENTION CLINICAL REASONING
STRATEGIES
CASE STUDY 2
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CASE STUDY 2: DESCRIPTION • A 46 year-old gentleman, former combat veteran presented to physical
therapy under direct access. He reports a remarkable past medical history for multiple concussions. He reports that he concurrently is experiencing headaches, difficulty with concentration and memory task. He reports that his symptoms became more severe over the past year when you re-enrolled in college.
CASE STUDY 2: DESCRIPTION
17 y.o. 22 y.o. 27 y.o.
30 y.o.
Head injury. LOC; neck pain
Combat head injury; No LOC; neck pain
Head injury: No LOC ; Neck pain
No LOC; headache and nausea
46 y.o.
Initial PT visit
CLINICAL REASONING STRATEGIES INTERVENTION CLINICAL REASONING
STRATEGIES
CASE STUDY 3
CASE STUDY 3: DESCRIPTION • 28 year old male, slipped on ice while stepping out of a HumV
limousine hitting his head first on the runner, then on the ground. +LOC, + findings on imaging.
CLINICAL REASONING STRATEGIES INTERVENTION CLINICAL REASONING
STRATEGIES
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• Concussion results in metabolic and physiologic changes to other organ systems due to disturbances in the Autonomic Nervous System and Autoregulatory Control.
• PCS represents a condition whereby the regulatory and autoregulatory mechanisms of the brain do not naturally return to normal.
PATHOPHYSIOLOGY
Leddy, Kozlowski, Fung, Pendergast, and Willer. Neurorehabilitation. Regulatory and autoregulatory physiological dysfunction as a primary characteristic of post concussion syndrome: Implications for treatment. 2007; 22: 199-205.
AUTONOMIC NERVOUS SYSTEM
Catabolic Expends energy
Fight or flight Increased HR
Shunts blood to the heart and muscles
Anabolic Conserves energy
Rest and digest Decreased HR
Promotes digestion and absorption
Parasympathetic
Sympathetic
CEREBRAL AUTOREGULATION
Definition Associated symptoms
Process which aims to maintain adequate and stable cerebral blood flow in the face of changing systemic pressure
• Increased HA with exertion • Dizziness/head pressure
with position changes • Fatigue • Negative Mood
CONCLUDING REMARKS • Appreciate the acceleration of knowledge and the subsequent
scientific literature • Utilize a biopsychosocial model and sound clinical reasoning
when managing individuals post-concussion • Peel off the layers of the “onion” to get to the multiple issues involved.
• If you have seen one patient with a concussion….. YOU HAVE SEEN ONE PATIENT WITH A CONCUSSION
• No two patients with a concussion are the same
• Manual therapy interventions can benefit a sub-set of patients who have had a concussion
RESOURCESS • http://videos.howstuffworks.com/health/concussion-videos-
playlist.htm#video-48527
• http://www.cdc.gov/concussion/headsup/index.html • http://www.cdc.gov/concussion/pdf/TBI_Patient_Instructions-
a.pdf
REFERENCES • Traumatic Brain Injury in the United States: Fact Sheet
http://www.cdc.gov/traumaticbraininjury/causes.html
Page last reviewed: 2/24/2014. Page last update: 6/2/2014. accessed on 9/5/2014.
• Higgs J, Jones M. Clinical Reasoning in the health professions. In: Higgs J, Jones M, eds. Clinical Reasoning in the Health Profession. 2nd ed. Oxford: Butterworth-Heinemann; 2000:129-146.
• Jones M, Rivett D (eds). Clinical Reasoning for Manual Therapists. Edinburg, Elsevier, 2004.
• Leddy JJ, Sandhu JG, Baker JG et al Rehabilitation of concussion and post-concussion syndrome. Sports Health: A Multidisciplinary Approach. 2012;4(2):147-154.
• Leddy JJ, Kozlowski K, Fung M, Pendergast DR, and Willer B. Regulatory and autoregulatory physiological dysfunction as a primary characteristic of post concussion syndrome: implications for treatment. Neurorehabilitation. 2007; 22: 199-205.
• Lovell M, Collins M, Bradley J. Return to play following sports-related concussion. Clin Sports Med. Jul 2004:23(3):421-441,ix.
• McCrory et al 2009. Consensus statement on concussion in sport-The 3rd International Conference on concussion in sport, held in Zurich, November 2008. Clin J Sport Med. May 2009:19(3):185-200.