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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.