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


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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


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.


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

Size Population Tests

Utilized Total Days Cognitive

Resolution

Total Days Symptom Resolution

Lovell et al.

2005

95

Pro (NFL) Paper and

Pencil

1 day 1 day

Echemendia

2001

29

College Paper and

Pencil

2 days 2 days

McCrea et al.

2003

94

College Paper and

Pencil

5-7 days

7 days

Guskiewicz

2003

94 College Balance

BESS

3-5 Days 7 Days

Bleiberg et al.

2005

64

College Computer

ANAM

3-7 days

Did Not

Evaluate

Iverson et al.

2006

30 High School Computer

ImPACT

10 days 7 Days

McClincy

2006

104 High School Computer

ImPACT

14 days 7 Days

Slide courtesy of Micky Collins, PhD

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Signs and Symptoms of

Sports Concussion

Signs observed by staff

• Appears to be dazed or stunned

• Is confused about assignment

• Forgets plays

• Is unsure of game, score, or

opponent

• Moves clumsily

• Answers questions slowly

• Loses consciousness

• Shows behavior or personality

change

• Forgets events before play

(retrograde)

• Forgets events after hit

(posttraumatic/anterograde)

Sx reported by athlete

• Headache

• Nausea

• Balance problems or dizziness

• Double or blurry vision

• Sensitivity to light or noise

• Feeling sluggish or slowed down

• Feeling “foggy” or groggy

• Concentration or memory

problems

• Change in sleep patterns


Cognitive Symptoms

• “Fogginess”

• Difficulty concentrating

• Memory deficits

• Cognitive Fatigue

Somatic Symptoms

• Headaches

• Dizziness

• Nausea

• Light/Sound Sensitivity

Mood Disruption

• Irritability

• Feeling sad

• Anxiety

Sleep Alterations

• Difficulty falling asleep

• Fragmented sleep

• Too much/too little sleep


Symptom Evaluation

• Can be evaluated by instrumented and non

instrumented methods

• Different checklists have been

implemented

• Used to quantify highly subjective

complaints, and to track recovery

• Commonly used by athletic trainers

Post Concussion Symptom

(PCS) Checklist – Most commonly used checklist

– Used to track recovery in symptom resolution

– Patients are asked to rate their symptoms on

a scale from 0 (no symptoms) to 6 (severe)

– The scale consists of 22 symptoms

– Total score is calculated by adding all the

individual symptom’s scores

– Higher scores are worse

The Rivermead Post-Concussion Symptom

Questionnaire

• 0 = Not experienced at all

• 1 = No more of a problem

• 2 = A mild problem

• 3 = A moderate problem

• 4 = A severe problem

Somatic Symptoms • Headaches

• Dizziness

• Nausea


Somatic Symptoms:

Treatment

• Dizziness /Balance Disorders – Vestibular Therapy

• Headaches – Musculoskeletal (manual

therapy)

– Vascular

– Biochemical

– “Cognitive Fatigue”


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Balance and Posture Evaluation

• Balance deficit up to 3 days after

concussion using the Clinical Test for

Sensory Interaction of Balance ( CTSIB) (Guskiewicz,1996)

• Increased sway, and decreased balance

up to 10 days after concussion via the

Sensory Organization Test (SOT)

• Balance Error Scoring System (BESS) and

force plate testing found not to be sensitive

to detect the balance deficit after

concussion (Guskiewicz,2004)

Summary

• Concussion is a major public health

concern

• 3 domains of assessment are used, none

of them is stand alone

• Individualized treatment approach is

recommended rather than using one based

solely on concussion grading scales

• Closer look is needed when interpreting the

evidence

• PT’s Role? Are we doing enough?

Concussion & Vestibular

Rehabilitation

Concussion & Vestibular

Rehabilitation

• Patients usually referred to PT if they did

not recover within the normal window of

recovery

• Patients with dizziness show worse

recovery in neuropsychological

assessment and different self report

symptoms (Chamelian et al, 2004)

Cognitive Symptoms

• “Fogginess”

• Difficulty concentrating

• Memory deficits

• Cognitive Fatigue

Somatic Symptoms

• Headaches

• Dizziness

• Nausea

• Vomiting


• Numbness

• Numbness

• Tingling

• Visual problems

• Balance problems

Mood Disruption

• Irritability

• Feeling sad

• Anxiety

Sleep Alterations

• Difficulty falling asleep

• Fragmented sleep

• Too much/too little sleep


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Somatic Symptoms

– Headaches

– Dizziness

– Nausea

– Vomiting

– Light Sensitivity

– Sound Sensitivity

– Numbness

– Numbness

– Tingling

– Visual problems

– Balance problems

Headache

• The most common symptom after concussion

• Prevalence of initial headache between 43% to

86% of patients

• Persistent headache is also reported in a period

up to three months after concussion

Study

(sample size)

Mean age (years) Outcome measure % report initial

headache (mean

severity)

Time of follow up % reporting

headache at follow

up (mean severity)

Blinnman et

al, (116)

14.1

PCS

71.6 (2.7)

2-3 weeks

31.8 (1.8)

Collins et al,

(109)

15.8

PCS

NS

1 week

33.0 (2.7)

Faux et al,

(100)

33.6

RPQ

100

1 month

3 months

30.4 (NR)†

15.4(NR)†

Lannsjo et al

(2523)

31

RPQ

43.2

3months

22 (2.6)

Lovell et al,

(52)

16.8

PCS

88.5

Between 1 &4

weeks

32.7(NR)†

Savola et al,

(37)

33.7

Modified

version of

PRQ

65

4 weeks

38(NR)†

Headache

• Headache at time of admission to the ER is

associated with development of post concussion

symptoms at 1& 6 months after injury

• Individuals with headache have worse

neurocognitive and balance testing, and were

found to report more symptoms than individuals

who do not have headache after concussion

Headache

• Individuals with headache (> 3 hours) have a

prolonged return to play (RTP) compared to

athletes w/o headache (>3 hours) after sport

related concussion.

• Individuals with migraine headache have greater

neurocognitive deficits compared to individuals

with other forms of headache and individuals

with no headache

Dizziness

• Frequent symptom after concussion

• 23 -81% of persons post concussion

report dizziness in the first days

• Of the 61% who reported dizziness in one

study, the severity breakdown is

– 41% mild

– 16% moderate

– 4% severe

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Prevalence of dizziness Study

(n)

Mean

age

(years)

Outcome measure % report initial

dizziness (mean

severity)


dizziness at

follow up (mean

severity)

Blinmann et al,

(116)

14.1 PCS 60.3(2.7) 2-3 weeks 27.0 (1.6)

Broglio et al

(32)

19.7 PCS 28.1(.75) NS NA

Lovell et al,

(52)

16.8 PCS 78.8 Between 1

and 4 weeks

17.3(NR)†

Lannsjo at al,

(2523)

31 PRQ 31 3 months 16 (2.6)

Savola et al,

(37)

33.7 Modified

version of RPQ

49 4 weeks 43(NR)†

Dizziness

• More symptomatic, and have worse

psychosocial functioning 6 months after

injury

• Dizziness at ER is associated with severity

of post concussion symptoms at 1 and 6

months after injury

• linked to psychological distress at 6 months

after injury

• Independent factor for failure to return to

work after mild to moderate head injury

Balance Problems Study

(sample size)

Mean age (years) Outcome measure % report initial

symptoms (mean

severity)


symptom at follow

up (mean

severity)

Blinmann et al,

14.1

PCS

60.3(2.6)

2-3 weeks

25.4(1.5)

Broglio et al,

(32)

19.7

PCS

34.4 (.75)

NS

NA

Lovell et al,1

(52)

16.8

PCS

55.8

Between 1 and 4

weeks

11.5(NR)†

Rationale for vestibular

rehabilitation post- concussion

• Post- traumatic dizziness associated with

impairments in the vestibular system

• Post- Concussive balance disorders may be

attributed to dysfunction in sensory integration

system

• Vestibular rehab dizziness & imbalance

Vestibular/ Balance

Rehabilitation For concussion

• Evidence for vestibular rehab post-

concussion

• Vestibular/ balance evaluation

Evidence for Vestibular

Rehabilitation

Gurr et al, 2001 • Graded exposure to head and body movements

• Anxiety management

• Coping strategies and education

Results: reduced complaints of vertigo and dizziness, and improved

balance of individuals standing on an unstable surface

Hoffer et al, 2004 Somatosensory exercises combined with aerobic activity, vestibulo-

ocular reflex, and cervico–ocular reflex activities

Results: reduced the complaints of dizziness and accelerated return to

work

8

• Subjects

• 114 patients (67 F/47 M)

• 84 patients received vestibular

Rehabilitation Therapy

• Median number of visits:4 (2-13)

• Median Duration: 7 days(2-181)

Oculomotor abnormalities

• Cover/uncover 8 subjects

• Convergence 7

• Smooth Pursuit 7

• VOR Cancellation 6

• VOR 4

• Saccades 3

• Dynamic visual acuity 3

Results/Self Report Outcome Measure Pre-treatment Post-treatment

Dizziness Severity 21(22) 12 (18)

ABC 64 (27) 84 (17)

DHI 49 (21) 30 (22)

All measures are statistically significant, P <.05

Results/Performance Outcome Measure Pre-treatment Post-treatment

DGI 20 (3) 23 ( 1)

FGA 22 (5) 28 (3)

Gait Speed 1.02 (.28) 1.28 (.23)

TUG (sec) 9.7 (2.5) 7.8 (1.8)

FTSTS( Sec) 13.1 (6) 9.7 (5)

SOT (Composite) 48 (19) 71 (13)

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

9

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


• 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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• 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?

12

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


VOR x 1


13


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

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

14

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

stationary targets (e.g. reading)

• Impairments Indicate brain problem

BPPV

• Dix-Hallpike test?

– Positive findings

– -Negative findings

• Head Thrust test?

Balance Assessment

• Gait assessment

• Balance Error Scoring System

• Objective findings vs. symptoms

provocation?

Clinical outcome measures

• Self Report measures: Activities –Specific Balance Confidence Scale(ABC).

Dizziness Handicap Inventory(DHI)

Dizziness Rating (0-100)

Self report symptoms checklist

Performance measures: Dynamic Gait Index (DGI)

Functional Gait Assessment (FGA)

Five Times Sit to Stand (FTSTS)

Timed “UP &GO” (TUG)

Gait Speed

Sensory Organization Test (Posturography)

Activities –Specific Balance

Confidence Scale (ABC)

16 questions

0 -100 scale

0 No confidence

100 Full confidence

e.g.

Walk around the house?

Walk across the parking lot to a mall?

Walk in a crowed mall where people rapidly

walk past you?

Dizziness Handicap Inventory (DHI)

• Individual’s handicap due to their dizziness

• 25 items

• 3 components: physical, emotional, and

functional domains

• Maximum score 100

• Higher score = Worse performance

15

Dizziness Rating & Descriptions

• Verbal scale (0-100)

Higher score = more severe

Dizziness descriptions:

Spinning

Lightheadedness

Off balance

Nausea

Sensation of motion

Others.

Performance Measures

Dynamic Gait Index (DGI)


Five Times sit to Stand (FTSTS)

Timed “UP &GO” (TUG)

Gait Speed

Sensory Organization Test

(Posturography)

Dynamic Gait Index (DGI)

• DGI:

8 items

Questions are rated on 0-3 scale 0 = severe impairments

3 = Normal

Maximum score 24 ( higher score is better)


• 10 items test

• 7 items from DGI in addition to: Gait With Narrow Base Of Support

Gait With Eyes Closed

Ambulating Backwards

• Maximum score 30 ( higher score is better)

TUG & FTSTS

• TUG (Sec)

Subject stands from a chair, walks three

meters at their normal walking speed, and

returns to the chair

• FTSTS (Sec)

Subject stands-up and sits down from a

standard height chair five times as quickly

as possible.

Dynamic Computerized Posturography

(SOT)

• Tests sensory integration between the

visual, somatosensory, and vestibular

systems

• 1) eyes open, fixed support

• 2)eyes closed, fixed support

• 3)sway-referenced vision, fixed support

• 4) eyes open, sway-referenced support

• 5) eyes closed, sway-referenced support

• 6) sway-referenced vision and support surface

16

SOT SOT

Evaluation Guidelines

• Perform the least number of tests

possible ( testing intolerance)

• Evaluation may take more than one visit

• Rule out/ Treat BPPV first Pure BPPV V.S not pure?

• Re-eval oculomotor testing every few visits

Selection of appropriate

measures

• Self report vs. performance

• Expected ceiling effect in young adults

• Validity and test retest reliability in young

adults

• Normative reference values, and Minimal

clinical important difference(MCID)

Documents

Concussion UPMC Sport concussion Team Introduction and ......testing and comprehensive symptom evaluation Slide courtesy of Cara Camiolo Reddy, MD Concussion Assessment Domains •