CONCUSSION AND HEAD TRAUMA PROGRAM - PowerPoint Presentation

1. CONCUSSION AND HEAD TRAUMA PROGRAM

2. The Impact of ConcussionDaniele Shollenberger, CRNP, CICCoordinator of the Concussion and Head Trauma Program

3. MythsYou must lose consciousness to have a concussionConcussions only happen in sportsThe next concussion is always worse than the lastConcussion symptoms are obvious as soon as the concussion occurs

4. A concussion is a brain injury and is defined as:(Fourth International Conference on Concussion, McCrory, 2013).a complex pathophysiological process affecting the brain, induced by biomechanical forces.What is it?

5. Concussion is an Image NEGATIVEDiagnosisIt is a functional disturbance rather than a structural disturbanceDiagnosis

6. With a Concussion there is no structural finding like brain hemorrhage. Instead there is dysfunction at the cellular level that results in signs and symptoms.

7. A Concussion can be caused either by a direct blow to the head, face, neckWhat causes it?

8. or a blow elsewhere on the body with an impulsive force transmitted to the head.

9. External forces create accelerations and decelerations of the brain within the skull.These forces create coup-contrecoup injury.

10. The types of forces or accelerations are either linear or rotational

11. Linear Force

12. Rotational Force

13. Concussion results in the rapid onset of temporary impairment of neurologic function.What happens?

14. Concussion Cascade

15. Metabolic ChangesCells communicate in a disorderly mannerPotassium which is normally in the cell floods outCalcium which is normally on the outside of the cell rushes inThese imbalances diminish the brain’s normal energy levelReduced blood flow to the brain

16. Loss of Consciousness90% of the time a person suffering a concussion hasNO LOC

17. Causes of Concussion:Motor vehicle collisionsFallsAssaults/abuseHousehold accidentsRecreational activitiesSportsWorkplace injuries

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19. Diagnosing is often difficult even with all the right people at the right time.If the injury is not observed we do not have specifics. There are not always immediate symptoms/signs.Diagnosing concussion

20. Depends on the biomechanical forcesWhat areas of brain are involvedHistory of previous injury-concussionsInitial evaluation is often variable

21. Clinical EvaluationSince there is no diagnostic or blood test for concussion -we rely on the presence of signs and symptoms after an individual has experienced a hit to the head.Every concussion is different and has it’s own recovery arc.

22. Risk FactorsConcussion historyAgeFemaleLearning disabilityMotion sensitivityMigraine history

23. Signs and SymptomsDo NOT always show up immediately after injury

24. The Signs and Symptoms of Concussion Fall into 4 Categories

25. Physical SymptomsHeadacheNauseaVomitingBalance problemDizzinessVisual changesFatigueSensitivity to lightSensitivity to noiseNumbness/tinglingPain other than headache

26. CognitiveCognitive/ThinkingFeeling mentally foggyFeeling slowed downDifficulty concentratingDifficulty remembering

27. SleepSleepDrowsinessSleeping less than usualSleeping more than usualTrouble falling asleep

28. EmotionalEmotionalIrritabilitySadnessNervousnessFeeling more emotional

29. REMEMBER:There may be ONE symptom or sign or many symptoms

30. Post concussion symptomsCommon symptomsHeadachesFeeling slowed downDifficulty concentratingDizziness Blurred visionLight sensitivityIncidence of symptoms71%58%57%55%49%47%

31. Dizziness is the best predictor of protracted recovery6.4 times more likely to take one month or more to recover

32. Dizziness and ConcussionRepresents an underlying impairment of the vestibular and/or ocular motor systems. It is associated with predicting prolonged recovery.

33. Significance of DizzinessThe frequency of reported dizziness and visual problems after concussion indicates that we need to evaluate for vestibular and ocular motor impairment/symptoms. Identifying vestibular and ocular related impairments requires a comprehensive assessment process to add to our current approaches to concussion management.

34. Beyond Balance Measuring Balance alone is limited because objective clinical balance impairments recover in about 3 days. Historically we have used the Balance Error Scoring System (BESS).The new thinking is to include vestibulo-ocular and ocular motor assessment.

35. The vestibular and ocular motor systems are responsible for integrating balance, vision and movement.

36. The Vestibular SystemA complex network including the sensory organs of the inner ear-the utricle, saccule and semicircular canals with connections to the brainstem, the cerebellum, cerebral cortex, ocular system and postural muscles.

37. The Vestibular SystemIs organized into 2 functional units: The vestibulo-ocular system and The vestibulo-spinal system.

38. Vestibulo-ocular SystemThe vestibulo-ocular system maintains visual stability during head movements.

39. With impairment in the vestibulo-ocular system there will be Dizziness and Visual Instability

40. Vestibulo-spinal SystemThe vestibulo-spinal system is responsible for postural control.

41. With impairment in the vestibulo-spinal system there will be IMBALANCE

42. Vestibulo-spinal systemVestibulo-spinal impairments are common for a few days after concussion This is reported as imbalance.

43. Vestibulo-ocular systemResponsible for integrating vision, eye tracking and movementDizziness, fogginess and vision issues are associated with a prolonged recovery

44. Definition of VisionThe concept of identifying what is seen, processing or interpreting that information and responding appropriately. Vision “happens” in the brain.

45. Vision and Concussion30 areas of the brain and 7 of the 12 cranial nerves deal with vision

46. Vision is the most important of the senses taking into the brain more information than any other sensory system.

47. Clinical TrajectoriesVestibularCognitiveCervical Ocular MotorPost-Traumatic MigraineAnxiety/Mood

48. The Vestibular trajectoryCharacterized by symptoms of fogginess, nausea, feeling detached, feeling nervous/anxious and easily overstimulated.Rapid head or body movements exacerbate symptoms. Symptoms worsen in busy environments like grocery stores Simple triggers may include riding in a car, being in an elevator, trying to jog, exercise.

49. The Ocular motor trajectoryCharacterized by localized frontal headaches, fatigue, pressure behind the eyes, trouble focusing, and being easily distracted. Other symptoms may include blurred vision, double vision, eye pain, difficulty tracking or moving eyes from one object to anotherThere are worse symptoms with electronics, reading and working for full days.

50. Targeted treatmentThe gold standard for the vestibular trajectory is a vestibular therapy program. The therapist must be trained specifically in neuro-rehab in order to design a specific plan of treatment.

51. Targeted treatment for ocular motor trajectoryA vestibular therapist can evaluate and begin treatment for this trajectory.Exercises and maneuvers in vestibular programs will address convergence changes.

52. However…Beyond Vestibular Therapy there are specially trained neuro-optometrists.

53. Neuro-optometryOptometrists trained in behavioral optometry and vision therapy. The certifying organization is the College of Optometrists in Vision Development.

54. Vision TherapyA sequence of activities individually prescribed and monitored by a doctor of optometry to develop efficient visual skills and processing.

55. Evidence Based DataAt UPMC researchers found that visual symptoms, mental fogginess, and dizziness were symptoms associated with prolonged recovery. The goal was to create an evidence-based examination to isolate and assess these areas specifically. The result was VOMS.

56. Vestibular Ocular Motor ScreeningVOMSAssesses 5 areas of the vestibular and ocular systemsSmooth pursuitsSaccadesVestibular ocular reflexNear Point ConvergenceVisual motor sensitivity

57. Research has demonstrated the VOMS to be 90% accurate in identifying patients with concussion.

58. Symptoms and /or signs indicating vestibular and ocular deficits indicate that the brain is not fully healed.

59. Evaluation and Treatment

60. The Clinical Evaluation Includes:Symptom checklistSymptom scaleInterview and review of symptoms, past medical history, and exact details of injuryBalance testingEvaluation for dizzinessPhysical examinationNeurologic examination

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62. Vestibular Findings with ConcussionVestibular Signs include a change in baseline balance, having a change in gait, a spinning sensation with movements, tripping/falling and increase in imbalance when eyes are closed. Head and body movements exacerbate symptoms.

63. Ocular Motor Findings and ConcussionSigns of ocular motor impairment include altered eye movements, dizziness, headache, ocular pain, inability to focus/concentrate all when using eyes for testing.

64. Cognitive Findings and ConcussionCognitive deficits will be assessed by reports of difficulty remembering information with ADLs, changes in short term memory, difficulty completing tasks that include steps. Signs of cognitive deficits may include an altered speech pattern, confusion and slowed thought processing.

65. Cervical Findings and ConcussionTenderness and/or pain to palpation at the traps or at the paraspinals.Decreased Range of Motion

66. We bring certain traits to the injury:h/o motion sensitivity-more vestibular changesh/o strabismus-more ocular deficitsh/o migraine-more headachesh/o learning disabilities-more cognitive changes

67. ConcussionConcussion Management needs to be individualized and not “ONE SIZE FITS ALL”Variables include the clinical presentation, signs and symptoms, and recovery arcs or trajectories.

68. Current Discussion A mandatory/prolonged prescribed physical and cognitive rest is not indicated for all patients.Complete brain rest is no longer required. Recovery will vary depending on injury severity, available treatments.Active Rehab involving a multidisciplinary team is the recommended approach.

69. A mandatory/prolonged prescribed physical and cognitive rest period is not indicated for all patients.

70. Complete brain rest is no longer required.

71. Recovery will vary depending on injury severity, available treatments.

72. Active Rehab involving a multidisciplinary team is the recommended approach.

73. After a ConcussionBrain and Body rest for 3 days post injury.Return to work with modifications.If symptoms and signs persist past 2 weeks refer for assessments.

74. Treatment Goalsfor concussionDetermine clinical trajectoryPrescribe therapy programs for evaluationAfter the diagnosis is made

75. Concussion Clinical TrajectoriesVestibularCognitiveCervicalOcular motorAnxiety/MoodPost traumatic migraine

76. Referrals for TherapyVestibular evaluation(PT)Cognitive evaluation (OT) /Speech Cervical evaluation Neuro-optometry evaluation

77. Other modalitiesNeuropsychological testing CounselingNeurology

78. Modify restrictions to address symptoms If vestibular (balance symptoms) keep out of busy environments and heights If ocular symptoms keep off electronics May need to limit/modify work duties depending on symptom severityIf physical symptoms may need meds

79. MedicationsExcedrin TensionIbuprofen productsTylenolMelatoninAmitriptyline or Nortriptyline

80. Concussion endpointSymptom free at restSymptom free with physical exertionSymptom free with an examNormal neurocognitive dataNormal balance/VOMS

81. On the Horizon…. An MRI-like diagnostic study to evaluate for injury caused by concussionBlood test (Biomarker/indicator)that measures the level of a protein in the blood when a concussion occurs (JAMA Neurology March 2014)

82. Concussion FactsYou do not need to be hit in the head to have a concussionYou do not need to have a loss of consciousness to have a concussionConcussion symptoms are not always obvious as soon as a concussion occurs

83. Concussion Facts (cont’d)Concussions occur from MVC, falls, assaults/abuse, household or workplace injuries, and in every sport.Each concussion has its own healing arc-the next one is not always worse than the previous one.

84. Thank You

85. Contact Information:Daniele ShollenbergerNeurosurgical Associates of LVPGDaniele.Shollenberge@LVHN.org