8/30/2019 CLINICAL SKILLS – QUESTIONS FROM LEVEL 1 YESTERDAY? Sept 19-20, 2019--------Day 2 1 2 Plan for Day 2 • Concussion & Post Concussion Syndrome Concussion & • Return to Activity • Symptom Management Mild • Pacing and Planning • Neuroplasticity Traumatic • Treatment – vision, vestibular, proprioception, balance Brain Injury • Case Studies 3 4 1 8/30/2019 Why the concern with concussions? mTBI vs Concussion (CDC Website) • An estimated 3.8 million sports and recreation related head trauma annually in the United States • US emergency departments treat an estimated Traumatic Brain Injury Continuum 135,000 sports- and recreation-related head trauma annually Mild Moderate Severe • Concussion from falls in the elderly and the Concussion workforce occur at a much higher incidence than in sports-related activities 80 % • It’s estimated that >50% of adolescents athletes will sustain a concussion by the time they All concussions are a mTBI but not all mTBI’s graduate from high school are a concussion 5 6 Concussion Defined (Berlin Consensus Guidelines 2016) Consensus • Sport Related Concussion: is a traumatic Statement on brain injury induced by biomechanical forces. Concussion in Sport • The clincial signs and symptoms cannot be Berlin Oct 2016 explained by drug, alcohol or medication use, Published in: other injuries (such as cervical injuries, British Journal of Sports peripheral vestibular dysfunction, etc) or Medicine 51(11) 2017 other comorbities (eg. Psychological factors or coexisting medical conditions) 7 8 2 8/30/2019 • 1. may be caused either by a direct blow to • 3. it may result in neuropathological changes, but the head, face, neck or elsewhere on the body the acute clinical symptoms largely reflect a with an ‘impulsive’ force transmitted to the functional disturbance rather than structural so head no abnormality is seen on standard structural neuroimaging studies. • 2. typically results in the rapid onset of short- • lived impairment of neurological function that 4. results in a graded set of clinical symptoms that may or may not involve the loss of resolves spontaneously. In some cases, consciousness. Resolution of the symptoms symptoms & signs may evolve over a number typically follows a sequential course. However, in of minutes to hours some cases symptoms may be prolonged. 9 10 Diagnosis: Berlin Guidelines 2016 • Suspected concussion with 1 or more of the following: 1) Symptoms – somatic (eg. headache), cognitive (eg. in a Diagnosis fog), and/or emotional (eg. Lability) 2) Physical signs (eg. LOC, amnesia, neuro deficit) starts with 3) Balance Impairment – (eg. Gait unsteadiness) 4) Behavioural Changes (eg. Irritability) suspicion of 5) Cognitive impairment (eg. Slowed reaction time) injury 6) Sleep disturbance (eg. Somnolence, drowsiness) • Need a detailed concussion history • Clinical Assessment – SCAT5 and Child SCAT5 *Serial monitoring for deterioration over the first few hours is necessary 11 12 3 8/30/2019 Useful immediately post injury in differentiating concussed from non- concussed but utility 1. Pre-Season Education decreases 3-5 days post injury 2. Head Injury Recognition 3. Assessment Symptom checklist is 4. Management clinically useful for tracking recovery 13 14 Symptom Assessment • Since many of the problems post concussion are self reported symptoms need to try to track this over time • Suggested Tools: SCAT5, Rivermead Post Concussion Symptoms Questionnaire (RPQ-3, RPQ-10), Post Concussion Symptom Scale (PCSS), Neurobehavioural Symptom Inventory (NSI) • Other tools: Headache Impact Test (HIT-6), Brain Injury Vision Symptom Survey (BIVSS), Dizziness Handicap Inventory 15 16 4 8/30/2019 King Devick Test King Devick Test (Galetta et al 2011 & 2013, King et al 2012) • Can be administered in 2 minutes • Assesses eye movement, attention, language • > 5 sec difference from baseline is predictive of concussive event • Not useful in ER setting for diagnosis (Silverberg 2014) • Worse scores on K-D test associated with reductions in Immediate Memory portion of SCAT2 • Can be used for post game screening to help identify unrecognized concussions • Research done with K-D test on NHL hockey players, New Zealand rugby players, MMA competitors 17 18 Vestibular Ocular Motor Screen VOMS Scoring (VOMS) (Mucha et al 2014) (pg 7) Vestibular/ Ocular Motor Not Headache Dizziness Nausea Fogginess Comments: Test: Tested 0-10 0-10 0-10 0-10 • Developed as a screening tool by UPMC BASELINE SYMPTOMS • Ages 9-40 Smooth Pursuits Saccades-Horizontal • Equipment: Tape measure, metronome, Saccades-Vertical Convergence Near point in target with 14 pt font (eg letter on a tongue cm: (Near point) Measure 1: depressor/popsicle stick) Measure 2: Measure 3: • Take baseline of: Headache, Dizziness, VOR-Horizontal Nausea, Fogginess – scale of 0-10 VOR- Vertical Visual Motion Sensitivity Test (VOR Cancellation) 19 20 5 8/30/2019 VOMS (Mucha et al 2014) • 60% of patients report at least 1 provoked sx • Concussed patients score higher on all VOMS items than controls (n=85) • Symptom score >2 & NPC distance > 5cm increased diagnostic accuracy 34% & 46% respectively • Females report more symptoms & higher NPC • VOR, VMS & NPC distance items on the VOMS resulted in a 90% +ve prediction rate for mTBI • Related to symptoms scores on PCSS • Independent of balance testing on BESS 21 22 Role of Imaging in mTBI Task based fMRI Summary (Yue 2014) • (1) increased activation in task- related areas • CT and MRI imaging usually normal therefore of the brain without significantly worse not indicated acutely performance, suggesting that some mTBI • More evidence of structural neurological patients need to “work harder” to perform a disruption on newer imaging technology: simple task at a satisfactory level – Functional MRI, Diffuse Tensor Imaging, Qualitative EEG (QEEG), Magnetic Resonance • (2) abnormalities in frontal lobe function, with Spectroscopy (MRS) magnetoencephalography a few studies reporting alterations specifically (MEG) within the middle frontal gyrus – Better for group differences than individual diagnosis 23 24 6 8/30/2019 mTBI & Mental Subtraction mTBI & Rt finger sequencing task http://www.ccs.fau.edu/section_links/HBBLv2/Research/MTBI.html http://www.ccs.fau.edu/section_links/HBBLv2/Research/MTBI.html 25 26 Rest? Early Management • Evolving recommendations • Indicated for 48 hours • Cognitive, physical and environmental as needed • Then need to start activity as tolerated • Treat individually 27 28 7 8/30/2019 How do you get out of rest? • Graduated return to cognitive and physical activity • Don’t leave your patients in REST • Need to educate about how and when to introduce activity and monitor symptoms • Otherwise – depression and non-compliance • Remember! They are brain injured therefore their judgment and decision making is impaired FIGURE 1 . Time course of the neurometabolic cascade of concussion. Copyright © by the Congress of Neurological Surgeons. Published by Lippincott Williams & Wilkins, Inc. 2 29 30 What should you recommend for Rest Recommendations Restful Activities? • Educate patient and family: • Listening tasks – – Limit: TV, computer, reading, cell phone, physical audiobooks, quiet music, activity, school, sports, socializing radio/podcasts – Allow: increased sleep, hydrate and eat well • Meditation or relaxation • Activities should be symptom limited activities • Alternate between types of activity – • Anything leisure that cognitive/physical ‘relaxes’ (i.e. knitting**); • Give examples and guidelines for what to do and but ensure use of a timer what not to do • Colouring • Use caution giving timelines for recovery • Light household tasks • Short walk indoors or out 31 32 8 8/30/2019 Domains of Activity • Need to gradual increase activity in different areas Early Target Activity Pattern (1-4 Weeks post injury) Cardiovascular/ Environmental Cognitive Rest Ideas Physical -Increased heart -Light exposure -Reading tasks -Mindfulness SYMPTOMS rate – walking, -Noise Exposure -Computer tasks -Podcasts cycling, jogging -Social interaction -Memory tasks -Audiobooks Symptom Onset -Walking/running -Busier envts -Problem solving -Listening to music while talking -Fluorescent activities -Bath Intensity -Household lighting -Planning activities -Colouring SYMPTOM FREE OR management tasks -Talking in a small -Cooking -Cuddling pets – cleaning group -Meal planning CONTROLLED Activity - Beginner/gentle -Add yoga or tai chi noise/distraction Time *Work on increasing stamina and complexity of activities while Developed by Parkwood Hospital Outpatient ABI Team monitoring symptoms 33 34 Berlin 2016 – Graduated Return to Clearance for Return to Learn/ Sport Work/Play 1. Symptom • Daily activities that do not provoke symptoms Limited Activity • Goal: Gradual reintroduction of work/school activities Role of Exertion • Walking or stationary cycling at slow to medium pace. No 2. Light Aerobic resistance training Exercise • Vision & vestibular tasks in space with hand/eye • Goal: Increase Heart Rate coordination 3. Sport Specific • Running or skating drills. No head impact activities • Sport specific visual tasks – need to be fast & Exercise • Goal: Add movement multidirectional 4. Non-Contact • Harder training drills. May start progressive resistance training • Should include multiple systems: balance, vestibular, training drills • Goal: Exercise, coordination & increased thinking cognitive & vision 5. Full contact • Following medical clearance, participate in normal training activities • Need to get heart rate up while doing tasks