1 Concussion Introduction and Assessment Domains Bara Alsalaheen, MS,PT University Of Pittsburgh UPMC Sport concussion Team • Cara Camiolo Reddy, MD • Michael Collins, Ph.D • Joseph Furman, Ph.D • Anthony Kontos, Ph.D • Mark Lovell, Ph.D, MD • Anne Mucha, PT, NCS • Patrick Sparto, Ph.D,PT • Susan Whitney, PT, DPT, PhD, NCS, ATC, FAPTA • Bara Alsalaheen, MS,PT Concussion Incidence • Most TBI injuries are mild TBI(i.e. concussion) • The annual rate of mTBI is 130-546 per 100,000 persons • Approximately 300,000 sports-related concussions occur in the United States every year Concussion & Public Health • The estimated annual cost (direct and indirect) in U.S ranges between $12 -17 billion • Concussion has a negative effect on psychological well being and health related quality of life (HRQOL) • Concussion is linked to higher family burden and emotional distress Concussion Terminology • Minor head injury • Mild closed head injury – The American Academy of Pediatrics • Mild traumatic brain injury - (WHO) and ACRM • Concussion and Sports- concussion – the American Academy of Neurology and Concussion in sport group, respectively Concussion definition • Until the CDC definition, no consensus on a definition • Lack of consensus is problematic when reporting incidence and prevalence of symptoms • Lack of consensus becomes problematic during process of care
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Concussion UPMC Sport concussion Team Introduction and ......testing and comprehensive symptom evaluation Slide courtesy of Cara Camiolo Reddy, MD Concussion Assessment Domains •
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Concussion
Introduction and Assessment
Domains
Bara Alsalaheen, MS,PT
University Of Pittsburgh
UPMC Sport concussion Team
• Cara Camiolo Reddy, MD
• Michael Collins, Ph.D
• Joseph Furman, Ph.D
• Anthony Kontos, Ph.D
• Mark Lovell, Ph.D, MD
• Anne Mucha, PT, NCS
• Patrick Sparto, Ph.D,PT
• Susan Whitney, PT, DPT, PhD, NCS, ATC, FAPTA
• Bara Alsalaheen, MS,PT
Concussion Incidence
• Most TBI injuries are mild TBI(i.e.
concussion)
• The annual rate of mTBI is 130-546 per
100,000 persons
• Approximately 300,000 sports-related
concussions occur in the United States
every year
Concussion & Public Health
• The estimated annual cost (direct and indirect)
in U.S ranges between $12 -17 billion
• Concussion has a negative effect on
psychological well being and health related
quality of life (HRQOL)
• Concussion is linked to higher family burden and
emotional distress
Concussion Terminology
• Minor head injury
• Mild closed head injury – The American Academy of Pediatrics
• Mild traumatic brain injury - (WHO) and ACRM
• Concussion and Sports- concussion – the American Academy of Neurology and Concussion in sport group, respectively
Concussion definition
• Until the CDC definition, no consensus on
a definition
• Lack of consensus is problematic when
reporting incidence and prevalence of
symptoms
• Lack of consensus becomes problematic
during process of care
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• A complex pathophysiologic process affecting the brain,
induced by traumatic biomechanical forces secondary to
direct or indirect forces to the head.
• Caused by a jolt to the head or body that disrupts the
function of the brain.
• Typically associated with normal structural neuroimaging
findings (ie CT scan, MRI).
• Results in a constellation of physical, cognitive,
emotional or sleep-related symptoms that may or may
not involve a loss of consciousness (LOC).
• Duration of symptoms is highly variable and may last
from several minutes to days, weeks, months, or longer
in some cases.
Concussion: CDC Definition
Centers for Disease Control, 2007
Concussion severity
• At least 17 grading scales
– None of them is evidence- based
– Heavily based on LOC and other markers of
severity
– Assumed universal effects of concussion for
all age and gender groups
Concussion Management STANDARDIZED CONCUSSION
GRADING SCALES
INDIVIDUALIZED CONCUSSION
MANAGEMENT
Neurocognitive
testing and
comprehensive
symptom
evaluation
Slide courtesy of Cara Camiolo Reddy, MD
Concussion Assessment
Domains
• Neuropsychological testing
– Paper & Pencil testing
– Computerized testing
• Self report symptoms
– Instrumented (i.e. checklists)
– Non instrumented (e.g. interview)
• Balance and postural stability
– Clinical testing
– Laboratory testing (e.g. posturography)
Neuropsychological
Assessment
Most significant advancement in the field
of sports concussion
– Allows for reliable and valid approach to
quantify major manifestations
• Processing speed, reaction time, visual/verbal
memory
– Tracks recovery
– Provides dependent variable to research
individual factors in recovery
Slide courtesy of Cara Camiolo Reddy, MD
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Neuropsychological
Assessment
• Now the cornerstone of proper concussion
management
– Baseline testing (preseason/preinjury)
– Repeated post injury evaluations
– Computer-based models currently used:
• ImPACT
• Cog Sport
• Headminders
ImPACT
• Self administered software
• Use a number of tests to generate 4
composite scores for different areas of
cerebral functioning
– Visual memory
– Verbal memory
– Reaction time
– Processing speed
Neuropsychological
Assessment
This is not a stand-alone instrument
– Must be used in conjunction with
• clinical interview
• overall symptom presentation
• medical/concussion history
• results of other diagnostic studies
Slide courtesy of Cara Camiolo Reddy, MD
Recovery
• 80% of athletes recover spontaneously within three weeks of trauma
• Who does worse?
– Preexisting learning disability
– Younger age
– Prior concussive injury
– Amnesia
– Migrainous symptoms
– Over-exerters
Collins et al, 2006; Yang et al, 2007; Collins et al, 1999; Iverson et al, 2004.
Slide courtesy of Cara Camiolo Reddy, MD
Predictors of Outcome:
Age
– Research with severe TBI suggest that
children undergo more prolonged and diffuse
cerebral swelling after TBI
• Increased risk for secondary injury
• More sensitive to glutamate
• These factors may lead to a longer recovery period
and could increase the likelihood of permanent or
severe neurologic deficit
Field et al, 2003
Recovery Rates Vary by Age/Dependent Measure Authors Sample
All measures are statistically significant, P <.05
Results (Age effect)
Outcome measures Children Adults
DHI 36 + 6 46 + 20
FGA 25 + 2 23 + 3
5TSTS 9.5 + 2.6 s 13.8 + 5.8 s
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Conclusion
• Significant treatment effect for vestibular
rehabilitation
• Age effect for some balance measures
• Interaction effect for dizziness severity
only
• Meaning vestibular rehab can be used for
both population(i.e. adults and children)
Vestibular Rehab & Whiplash
In a review, it was found that vestibular
rehab reduces handicap and improves
postural control
Goals of VR After Concussion
• Reduce dizziness, imbalance, headache
and other symptoms
• Improve balance performance
• Improve gaze stability and eye-head
coordination
• Offer entry point to exertion program for
athletes
Concussion Evaluation
• Three domains:
Neuropsychological performance
Balance performance
Self report symptoms (Somatic, mood, sleep,
and cognitive)
Concussion Evaluation
• History of concussion
Mechanism of injury
Date of Injury
On field symptoms
• Present symptoms and dysfunctions
Somatic symptoms (Keep in mind other
clusters: mood, sleep, and cognition)
Duration & severity of symptoms
Exacerbating and relieving factors
Post concussion symptom
checklist (PCS)
• 22 symptom severity
• 7- point likert scale
• 0 (no symptom) - 6 (severe)
• Add up the scores
• Used by athletic trainers and
neuropsychologists
• Acute phase
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Vestibular Evaluation for
concussion
• Assessment of symptoms (dizziness,
headache)
• Assessment of Eye-Head coordination
• Balance assessment
Assessment of dizziness/
vertigo
• Spontaneous or provoked
– If provoked, precipitating factor?
– All directions or Dix-Hallpike
• Characteristics
• Onset, duration, effect of repeated head
movement
• Presence/ type of nystagmus
Provoked dizziness
• Are you dizzy when?
Looking up
Walking in supermarket aisle
Reading
Turning over in bed
Bending over
Lying down
Getting out of bed
Cervicogenic Dizziness
• A non-specific sensation of altered orientation in space, and dysequilibrium originating from abnormal afferent activity from the neck (Furman and Cass, 1996)
• Associated with cervical flexion/extension (whiplash) injuries and head trauma
• Symptoms • Ataxia
• Unsteadiness of gait
• Postural instability
• Associated with neck pain, limited neck ROM or headache
• Illusionary sense of motion
Cervicogenic Dizziness
• Diagnostic Criteria – Complaints of ataxia, unsteadiness of gait, postural
imbalance, and illusory sensation of movement
– Close temporal relationship between neck pain or headache and symptoms of dizziness
– Previous neck pain or pathology
– Elimination of other causes of dizziness
– Onset of symptoms may be sudden or gradual and occur days to weeks following the injury
– Symptoms are usually episodic and last minutes to hours
Slide courtesy of Susan L. Whitney PT, DPT, PhD, NCS, ATC, FAPTA
Canalith
repositioning
Maneuver
Chief Complaint
Dizziness or Vertigo
Neck pain associated
with dizziness
yes
Dix-Hallpike
Positive test
Posterior canal
BPPV
yes
Cervicogenic
dizziness likely
no
no
Co-treat
or refer to VR-PT
History of neck pain,
injury or pathology
Cervicogenic
dizziness unlikely
Treat neck appropriately
and refer to MD for
dizziness
BPPV, vestibular disorder,
and/or cervicogenic dizziness
Vestibular disorder, and/or
cervicogenic dizziness
Treat neck appropriately
and refer to MD for
vestibular testing
Co-treat or
refer to VR-PT
Vestibular
disorder
abnormal results normal results
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Cervicogenic Dizziness
• Suggested Treatment in Literature
– Cervical collar Cope and Ryan, 1959
– Cervical traction Mayoux et al, 1951; Jongkees, 1969
– Neck manipulation Stoddard, 1952; Ledru, 1955
– Cold spray and local anesthetic Weeks and
Travell, 1955
– Local anesthetic injection and massage Gray, 1956
• May also benefit from vestibular rehabilitation for residual space and motion discomfort or balance impairments
Assessment of Eye–Head Coordination
• Eye–Head (E-H) coordination plays a role
in gaze stabilization and balance
• Dysfunction in E-H coordination can lead
to dizziness and /or imbalance
• By improving E-H coordination, post
concussion dizziness/ imbalance can be
improved
Perception of Eye-Head
movement
• Signals from labyrinth give info about head
movement in space
• Info is integrated with somatosensory and
visual input
• Whenever asymmetry in vestibular function
occurs, brain interprets it as continuous
movement of head
• May cause spinning even when head is not
moving
Vestibulo-Ocular Reflex (VOR)
• Stabilize visual image on retina during head
movement
• Produces an eye movement of equal
velocity but in opposite direction to the
head movement
• VOR Gain = Eye velocity/ head velocity = 1
Normal VOR
• When head moves to right
• Excites Rt horizontal SCC
• Inhibit Lt horizontal SCC
• Drives eyes to left at same velocity of
head movement
Impaired VOR
• With Rt Unilateral peripheral vestibular
hypofunction
• Head stationary
• No discharge of horizontal SCC
• Normal resting discharge of Lt horizontal
SSC
• Difference indicates head movement (to lt in
this example)
• Nystagmus?
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Impaired VOR (con’t)
• When “false” Lt head movement is
indicated
• Eye will move slowly to Rt (slow phase)
• When eyes get to end range, they will
move back quickly to Lt (fast phase)
• Left beating nystagmus
VORx1 Evaluation
• Negative findings:
– Gross abnormalities
– Symptom provocation
VOR x 1
Slide courtesy of Susan L. Whitney PT, DPT, PhD, NCS, ATC, FAPTA Slide courtesy of Susan L. Whitney PT, DPT, PhD, NCS, ATC, FAPTA
Slide courtesy of Susan L. Whitney PT, DPT, PhD, NCS, ATC, FAPTA
VOR x 1
Slide courtesy of Susan L. Whitney PT, DPT, PhD, NCS, ATC, FAPTA
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Slide courtesy of Susan L. Whitney PT, DPT, PhD, NCS, ATC, FAPTA
VOR X 2
Slide courtesy of Susan L. Whitney PT, DPT, PhD, NCS, ATC, FAPTA
Slide courtesy of Susan L. Whitney PT, DPT, PhD, NCS, ATC, FAPTA Slide courtesy of Susan L. Whitney PT, DPT, PhD, NCS, ATC, FAPTA
VOR cancellation
• If we want to move eye in same direction
with head, VOR must be suppressed.
• Eyes moves in the same direction as the
moving object
Convergence testing
• Convergence spasm
• Convergence insufficiency
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Smooth Pursuit & Saccade
• Smooth pursuit:
Visually pursue a slow moving object without
moving head
Maintain gaze on moving target
• Saccade: Rapid eye movement to allow refoveation of