Concussion Management:

A Team Approach

Bill Condon, PT, MPT

Maria Davenport, MPT

Jamie L Johnson, MA L/CCC-SLP, BCS-S

Claude Lamoureux, PT, DPT, NCS1

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• https://www.youtube.com/watch?v=Sno_0Jd8GuA

• https://www.youtube.com/watch?v=_55YmblG9YM

Objectives:

• Develop a better understanding of Concussion and Post-Concussion Syndrome

• Develop a better understanding of evidence-based assessment and intervention by Speech Therapy following Concussion

• Develop a better understanding of evidence-based assessment and intervention for Concussion Management/Vestibular Therapy by trained Physical Therapist,

• Further understand impact on balance following a concussion

• Knowing when to refer to other disciplines (SLP, OT, NeuroOptometry, NeuroPsychology)

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Concussion

4

What is a concussion?• CDC 2010

• A type of TBI, caused by a bump, blow, or jolt to the head that can change the way your brain normally works.

• Concussions can also occur from a fall or blow to the body that causes the head and brain to move rapidly back and forth.

• Even what seems to be a mild bump to the head can be serious.

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Concussion symptoms generally last less than 24

hours, and usually recovery is within 2-3 weeks

By 3 months 75% of patients will be

symptom-free (Anderson, et al. .2006)

PCS seek therapy 3-6 months after injury

Children and adolescents are among those at

greatest risk for concussion.

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7

• The potential for a concussion is greatest during

activities where collisions can occur, such as

during physical education (PE) class, playground

time, or school-based sports activities.

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Most concussions occur

WITHOUT

loss of consciousness.

Concussion

Signs and Symptoms

• Confusion

• Dazed or stunned

• Answers questions slowly

• Concentration or memory

problems

• Forgets plays

• Unsure of game, score or

opponent

• Can’t recall events prior to

or following incident

• HA or pressure

• Balance problems or

dizziness

• Light and/or noise sensitivity

• LOC

• Double or blurry vision

• Clumsiness

• Behavior or personality

changes

• Sleep disturbances

9

Adolescent Brain

– Prolonged brain swelling

– Slower recovery

– Greater potential for lingering problems with

LEARNING

MEMORY

JUDGEMENT

SOCIAL BEHAVIORS**KEY!!!!**

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Adult brain connections at 18-

24 years

Disordered patterns become

permanent with long-term

consequences.

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Danger Signs:

• Adults:

– Headache that worsens

– Weakness, numbness or decreased coordination

– Repeated vomiting or nausea

– Slurred speech

– Sleeping and Unable to awaken

– One pupil larger

– Convulsions or seizures

– Can’t recognize people or places

– More confused, restless or agitated

– Unusual behaviors

– LOC12

Danger signs:

• Additional signs in Children:

– Won’t stop crying

– Won’t eat/drink

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Gender

• Girls are twice as likely to sustain a concussion

• More likely to report sleep disturbances and HA

• More likely to have PCS at one, three and six mos

post injury

• Less likely to be in school one year after injury

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Proper Recognition and Response

Prevent further injury Help with recovery

Factors Influencing Risk and Recovery from

Sport-Related Concussion: Reviewing the

Evidence

• Primary Risk Factors:

• Sport Type and Setting -Football, Ice hockey, lacrosse, women’s soccer and Cheerleading.

• Sex –Female

• Age/Level of Competition – College>HS

• Genetics –APOE e4 and G-219T

• History of Concussion -3x more likely

• Equipment

Elgin, et al 2015

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Four primary categories:

• Physical

• Thinking

• Emotional/Mood

• Sleep

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Physical:

•Headache or “pressure” in head

•Nausea or vomiting

•Balance problems or dizziness

•Fatigue or feeling tired

•Blurry or double vision

•Sensitivity to light or noise

•Numbness or tingling

•Does not “feel right”

18

Thinking/Remembering:

• Difficulty thinking clearly

• Difficulty concentrating or remembering

• Feeling more slowed down

• Feeling sluggish, hazy, foggy, or groggy

• Difficulty finding the "right" word; difficulty

expressing words or thoughts; changes in speech.19

Emotional:

• Irritable

• Sad

• More emotional than usual

• Nervous *ANXIETY

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Sleep:

• Drowsy

• Sleeps less than usual

• Sleeps more than usual

• Has trouble falling asleep

21

Signs observed by others:

Appears dazed or stunned

Is confused about events

Answers questions slowly

Repeats questions

Can’t recall events prior to/after the hit, bump, or fall

Loses consciousness (even briefly)

Shows behavior or personality changes

Forgets class schedule or assignments

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Work place presentation…

23

Recovery• Varies

• Look Fine

• Don’t understand symptoms

• Days, weeks or longer

• Slower for older adults,

young children and teens

• IF Previous concussion-

longer to recover

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• Symptomatic students may require active supports

and accommodations in school, which may be

gradually decreased as their functioning improves.

• Inform the student’s teacher(s), the school nurse,

psychologist/counselor, and administrator of the

student’s injury, symptoms, and cognitive deficits.

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Returning to Daily

Home/Community Activities

• Increased rest and limited exertion are important to facilitate the patient’s recovery.

• Physicians should be cautious about allowing patients to return to driving, especially if the patient has problems with attention, processing speed, or reaction time.

• Patients should also be advised to get adequate sleep at night and to take daytime naps or rest breaks when significant fatigue is experienced.

• Symptoms typically worsen or re-emerge with exertion.

• Let any return of a patient’s symptoms be the guide to the level of exertion or activity that is safe.

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Post Concussion Syndrome (PCS)

• Symptoms occur in 30-80% of mild brain injury

– May appear immediately or after injury

– May persist 3-6 months

– Subjective problems after test scores return to NL

– Evidence of altered brain metabolism and blood flow > 3 years

– Delayed or persistent symptoms seldom attribute to the injury

Memory problem, behavioral changes too much/little sleep, HA, fatigue

Mistaken for sinus inflammation, allergies, stress, “typical teenager” behaviors

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Identify the Team

Schools:

Teachers

School psychologist and/or school counselor

Speech-Language Pathologists

Monitor/Identify concussed students withdifficulty in the classroom

Services may include: Testing, Classroom strategies or Modifications

School Principal or other school administrator

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Identify the Team

Hospital:

KU Concussion Center

Neurologist

Physical Therapist

Speech-Language Pathologists

Neuro Optometrist/Opthamologist

Neuro-Psychologist

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Anatomy and Physiology –

Vestibular System

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Signs and Symptoms

• Dizziness/lightheadedness

• Blurred vision

• Vision deficits

• Nystagmus

• Tinnitus/hearing loss

• Vertigo

• Balance impairments, especially in the dark

• Falls

• Motion discomfort/motion sensitivity

• Sweating/nausea/vomiting episodes

• Height and busy environment avoidance31

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MotionInput

Intended Movement

VestibularProprioception

Visual

Vestibular NuclearComplex

Eye movement(VOR)

Motor Neurons

Body movement(VSR)

Adapted from Vestibular Rehabilitation, Herdman and Clendaniel33

Cerebellum

Peripheral Vestibular System

Functions:

• Stabilization of visual images on the fovea of the

retina during head movement to allow clear vision

• Maintain postural stability especially during

movement of the head

• Provide information used for spatial orientation

Involves the vestibular apparatus in the inner ear:

• Semicircular canals (SCC)

• Utricle

• Saccule

• CN VIII: Vestibulocochlear nerve 34

Labyrinth

• Bony structure- contains the three semicircular

canals, cochlea and vestibule. The canals are

filled with perilymphatic (similar to cerebrospinal

fluid). This fluid moves freely within the canal in

response to direction head motion.

• Membranous- is contained within the bony

structure and includes the three semicircular canal

as well as the utricle and saccule (otoliths).

Contains endolymphatic fluid surrounding the

structures, which has density slightly higher than

water.35

Anatomy

36

Orientation of Canals

• The three semicircular canals - anterior, horizontal,

and posterior-respond to angular acceleration and are

at right angles in respect to each other

• The horizontal (or lateral) canals form a coplanar pair,

inclined approximately 30 degrees upward from

horizontal plane

• The posterior (inferior) and anterior (superior) canals

are inclined approximately 90 deg from plane; the

posterior and contralateral anterior SCCs form pairs

( i.e. R posterior and L anterior; L posterior and R

anterior with Dix-Hallpike testing)37

Inertial Navigation: Inner Ear

• Semicircular Canals (3) are angular rate sensors--*anterior, horizontal, posterior

• Otoliths (utricle and saccule) are linear accelerometers

• Utricle excitation during horizontal; saccule excites with vertical accelerations 38

How Does This Work?

Each canal enlarges

at one end to form

the AMPULLA-

(shape of a

lightbulb). Within

the ampulla lies a

CUPULA, which

contains many hair

cells. Through head

movements, the

cupula transmits

signals via the

Vestibular Nerve to

the Brain.

The ratio of eye to

head movement

should be 1:1.

Abnormal gain can

cause symptoms of

blurry vision/vertigo

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Central Vestibular System

– Vestibular reflexes are controlled by processes

primarily in the brainstem

– Connections between the vestibular nuclei,

reticular formation, thalamus & cerebellum are

seen

– SCC (angular) & otolith (linear) input is sent to

the vestibular nuclei

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Central Vestibular System(cont.)

– Information travels to the ocular motor nuclei

(III, IV , VI) for mediation of the VOR

– Information travels further to the thalamus &

cortex for arousal & conscious awareness of

the head & body in space

– Maintenance of postural control – peripheral

vestibular input is sent distally as the medial &

lateral vestibulospinal tracts

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Motor Outputs

• VOR (Vestibular Ocular Reflex): generates eye

movements, which enables clear vision while head

is in motion

• VSR (Vestibular Spinal Reflex): generates

compensatory body movement in order to maintain

head and postural stability, thereby preventing falls

• VCR (Vestibular Collic Reflex): stabilizes the

head in space

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Vestibular Ocular Reflex

• Stabilizes eye in space

• Necessary to see while head is in motion

• Has 2 components, angular and linear VOR

• VOR is primarily responsible for gaze stabilization

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Vestibular Spinal Reflex

• Stabilizes body

• Helps maintain desired orientation to environment

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Function of Vestibular System

Vestibular Ocular Reflex (VOR) Vestibular Spinal Reflex (VSR)

Stabilizes Vision When

Head Moves

Balance Control

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Anatomy and Physiology –

Vision Overview

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Oculomotor System

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Oculomotor System• Purpose: to produce eye movements to direct the fovea

toward the target of interest

• 6 extraocular muscles rotate the eye

– Divided into 3 pairs with complementary actions

• 3 cranial nerves control the eye movement

– CNIII (oculomotor): Medial rectus,

superior rectus, inferior rectus and

inferior oblique

– CN IV (Trochlear): Superior oblique

– CN VI (Abducens): Lateral rectus

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Physical Therapy Management of

Concussion

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Evaluation

• Balance

• Outcome Measures

• Oculomotor

• Cervical

• Exertion

• Reaction time and Divided attention52

Balance

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Balance

• There is two “type” of balance: static and dynamic

• Balance is composed of three main systems:

– Visual

– Proprioception

– Vestibular

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Balance

• mCTSIB

– Traditional versus computerized

• Bertec Cobalt

– Assessment of balance with Head Shaking and Visual

Motion Sensitivity

• Performed on a force plate which measures sway with

and without compliant surface

• Functional Gait Assessment

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Balance

• BESS test

• Sharpened Romberg

– Eyes open and eyes closed

• Single leg stance

– Eyes open and eyes closed

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Outcome Measures

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Outcome Measures

• Dizziness – Dizziness Handicap Inventory (DHI)

• Adult

• Youth

• Pediatric

• Patients answer 25 questions, subgrouped into functional, emotional, and physical components

• Headache– HIT-6

– Headache Disability Index (HDI)

• Cervical– Neck Disability Index (NDI)

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Outcome Measures

• Anxiety

– Hospital Anxiety and Depression Scale (HADS)

– Generalized Anxiety Disorder 7(GAD-7) Scale

• Vision

– Developmental Eye Movement ( Adult –ADEM)

– King Devick

• Migraine

– Migraine Disability Assessment (MIDAS)

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Oculomotor

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Major Oculomotor Gaze Systems

• Eye movement controlled by 4 major system

– Saccadic eye movement: for rapid eye movements to bring new objects being viewed on to the fovea

– Smooth Pursuit: for eye movements to keep a moving image centered on fovea

• CN III. Oculomotor: eye movement (dilation of pupils, follow target)

• CN IV. Trochlear: eye movement (look down)

• VI. Abducens: eye movement (look lateral)

– Vestibulo-ocular reflex: keeps image steady on fovea during head movements

– Vergence: keeps image on fovea predominately when the viewed object is moved closer

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Spontaneous/ Fixed Nystagmus

• Spontaneous

– Simple test! Patient holds head still while looking

at you. Will not see unless acute event has

occurred!

– Observe for nystagmus

• Fixed Gaze Nystagmus

– Hold patient’s head stationary

– Use your finger or pen and take patient to 30

degrees left, right, up and down from center and

hold gaze

– Observe for any nystagmus at 30 degrees angle

– DO NOT TAKE TO END RANGE!!! 62

Smooth Pursuits

• Holds images of a moving target on the retina

• Keep target between 18” from patient

• 60 degree total arc to avoid end range nystagmus

• Do not move pen/finger too fast

• Positive findings: Saccadic intrusion

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Smooth Pursuit

• practice

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Saccades

• Rapid conjugate movements of the eyes to place the object of interest on the fovea

• Have patient look between 2 targets approximately 15 degrees apart

• Nose, pen, nose, pen in left right and up and down

• Looking for the eyes to reach each target in one smooth movement

• Positive findings: hypometric and hypermetric (cerebellar) or inability to increase speed

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Saccades

• Practice

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VOR

• Tilt patient’s head down 30 degrees

• Start slowly moving head side to side while they

focus on your nose, gradually increasing speed

• Repeat in vertical plane

• Pace:120 bpm

• Positive finding: Patient unable to stabilize

gaze on nose71

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VOR

• practice

73

VOR Cancellation

• Hold patient’s head and tilt forward 30 degrees

(HC is in horizontal plane)

• Have patient look at your nose while you and the

patient move side to side

• Repeat in vertical plane

• Pace: 60 bpm

• Positive findings: saccadic intrusion

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VOR Cancellation

• Practice

76

Convergence

• Hold patient’s head stable with pen or optotype 2 feet away from their nose

• Ask patient to focus on pen or optotype while you move it towards their nose

• You should be able to observe convergence of the eyes

• Ask patient when they see double. If patient sees blurry before double, they may need reader glasses to facilitate testing.

• Patient should be able to converge from 6 to 10 cm measured from the forehead

• Positive findings: Greater than 10 cm

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Convergence

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Convergence

• Practice

81

Accommodation

• A reflex action of the eye, response of focusing on

a near object, then looking at a distant object

• Ask the patient to close one eye to check for

accommodation monocular vision

• Start close to the eye then patient move the target

out until just able to read and measure the

distance from target to cheek in inches

• The reflex is dependent on CN II (optic) and CN III

for changes in the shape of the lens; assisting with

focus on vision

• Positive findings: Age group normative data82

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Visual Acuity

• Visual acuity (VA) is acuteness or clearness of

vision, which is dependent on the sharpness of the

retinal focus within the eye and the sensitivity of

the interpretative faculty of the brain.

84

Dynamic Visual Acuity

• Using a ETDRS eye chart asked the patient to

read the chart until the lowest line or until the

lowest line is recognizable or until they are unable

to identify all the letters on a given line

• Hold patient’s head and tilt at 20 degrees of flexion

• Rotate their head yaw at 120 bpm

• While maintaining the rotation, ask the patient to

read the eye chart as described above

• Note how many lines above the baseline they are

able to read

• Repeat in the pitch plane

85

Dynamic Visual Acuity

• Positive findings: Greater then 2 lines

difference both vertically and horizontally

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Optokinetic Reflex

• Optokinetic reflex (response) allows the eyes to

follow objects in motion while the head is

stationary. It is a combination of slow-phase and

fast-phase eye movements

• Patient is sitting looking at a ribbon with a

repeating vertical pattern at eye level

• While the patient keeps on looking at the ribbon

the examining therapist quickly moves the ribbon

horizontally to the right for 5 repetitions. Repeat to

the left, up and down

• Positive findings: Decreased “nystagmus"88

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Visual Motion Sensitivity

• Clinical technique to measure motion-provoked

dizziness in patients with vestibular disturbances

• In standing , patient turns head, eyes, and trunk 80

degrees to the right and left at 50 bpm- 5

repetitions

• Positive findings: Reproduction of symptoms

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Vestibular/Ocular-Motor Screening

(VOMS)

• The VOMS was developed to assess vestibular

and ocular motor impairments

• Evaluates 5 domains:

– Smooth pursuit

– Horizontal and vertical saccades

– Near point convergence

– Horizontal and Vertical VOR

– Visual and Motion Sensitivity

93

VOMS

• Patients rate and compare their levels with their

pre-assessments levels

– Headache

– Dizziness

– Nausea

– Fogginess

• It has demonstrated a high sensitivity in

identifying athletes who experienced a sport

related concussion

• Provides information to guide clinical management94

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Yorke et al (2017) Sports Health

Cervical Spine

96

Cervical Spine –

Anatomy and Physiology

97

Why do we look at the Cervical Spine?

• For whiplash patients, did the patient also sustain

a concussion during the injury?

• For concussion patients, did the patient also

sustain a whiplash affecting the cervical region?

• Forces to cause mild traumatic injuries

(concussions) are between 60 to 160 g on the

other hand as little as 4.5 g, can cause mild strain

injury to the tissues of the cervical spine

98

Signs and Symptoms

• Unilateral headaches, often developing at the

occiput and extending around the temporal region

to the forehead (“ram’s horn”)

• Localized pain to occipital region, cervical

paraspinals, upper trapezius

• Stiffness with movement

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Signs and Symptoms

• Reduced cervical motion

• “Bobble head motion” – feeling unstable

• Numbness or tingling in arm or hand

100

Signs and Symptoms

ConcussionHeadache

Pressure in head

Neck pain

Nausea/vomiting

Dizziness

Blurred vision

Balance problems

Sensitivity to light

Sensitivity to noise

Feeling slowed down

Feeling like in a “fog”

“Don’t feel right”

Difficulty concentrating

Difficulty remembering

Fatigue or low energy

Confusion

Drowsiness

Trouble falling asleep

More emotional

Irritable

Sadness

Nervous or anxious

Whiplash Associated Disorder

Neck/shoulder pain

Reduced/painful neck movement

Headache

Reduced/painful jaw movements

Numbness, tingling arm and hand

Numbness, tingling leg and foot

Dizziness/unsteadiness

Nausea/vomiting

Difficulty swallowing

Ringing in ears

Memory problems

Problems concentrating

Vision problems

Lower back pain

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Structural Anatomy

102

Cervical Ligaments

103

Blood Supply- Cervical Spine

• Vertebral Artery:– Branch of the first part of

subclavian artery

– Passes through foramen

transverse of the upper six

cervical

– Enters skull through

foramen magnum

– At the lower border of the

pons, it joins the vessel of

the opposite side to form

the basilar artery

104

Supporting Musculature - Posterior

105

Supporting Musculature

106

Deep Cervical Flexor Muscles

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Physiology of the cervical Spine

• Sensorimotor process

• Proprioception

• Sensory

108

Proprioception

• Proprioception is important to maintain the stability

and control of head movement

• Proprioceptors of the cervical spine have

anatomical connections with the vestibular and the

visual system

109

Proprioception Deficits

• Deficits in the cervical proprioception may results

in:

• Cervicogenic dizziness

• Oculomotor deficits

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Sensory

• Sensory- afferents from ganglion root C2-C3 end

on the same nerve roots as the trigeminal nerve.

Referred pain from upper cervical structures, C0-

to at least C3, may radiate symptoms to the upper

cranium/ forehead region

111

Reflexes

• Both the cervicocollic and cervico-ocular reflexes

work in tangent with the VOR reflex to stabilize the

head and trunk during head/neck motions and to

assist in gaze stabilization

• Cervicospinal reflex (CSR)- changes in limb

position driven by neck afferent activity. Can

assist or interfere with the Vestibulospinal Reflex

(VSR)

• Disturbances in these reflexes can cause balance

disturbances and oculomotor dysfunction112

Research

• Vuillerme and Pinsault- 16 healthy males

experienced balance disturbances in which

experimental electrical stimulation was placed on

the bilateral trapezius with patients standing on a

force platform (eyes closed). The students were

asked to stand as still as possible on the platform

in two conditions: no pain and pain in the neck

muscles elicited by painful electrical stimulation.

Postural control and performance was assessed.

Results showed that experimental electrical

current significantly impaired standing balance.

113

Research

• Treleaven, et al- 12 post concussion subjects with

post concussion headache were compared to

normal subjects. PCH group presented with

painful upper cervical segmental joints, less

endurance in neck flexor muscles with testing, and

higher incidence of tightness in neck.

114

Cervical Spine

• Assess if

– Unilateral headaches

– Whiplash

– Pain

– Complain of Stiffness

115

Cervical Assessment

• Vertebral Artery

– administer in sitting (cervical spine in extension)

– turn head to the right count backward from 10 to 0 and

repeat on the left

– looking for 5 D’s: drop attack, diplopia, dysphagia,

dizziness, dysarthria; 3 N’s: Nausea, Nystagmus,

Numbness

116

Cervical Assessment

• Sharp Purser (Transverse ligament)

– with head in slight cervical flexion, anterior translation on

C2 and posterior translation with hand on forehead

– Positive if head slides backward, may hear a clunk

117

Cervical Assessment

• Alar Ligament

– Pinch grip on C2 spinous process

– Rotate head to the right, you should feel spinous process

move to the left

– Repeat on the left

– Same test should be done with side bending to the right

and left

– Absence of spinous process moving in the opposite

direction indicates a positive

118

Cervical Assessment

• Cervical Range of motion

• Upper cervical rotation test

– Performed in supine

– Bring the cervical spine in full flexion in an

attempt to isolate movement to C1-C2

– Rotate head to the right and the left

– Normal range of motion should be between 40

to 45 degrees

– Positive finding is a reduction in rotation of

more than 15 degrees

119

Cervical Assessment

• Passive mobilization

– Sitting (Mulligan Concept) and/or prone

(Maitland)

– Assessment of symptoms: headache and/or

dizziness

120

Cervical Assessment

• Deep neck flexor endurance test

– Assess deep cervical flexors endurance

– Test perform in either supine or hook lying

– Patient asked to tuck chin in and lift off the

table approximately 1” avoiding substitution by

SCM or platysma muscle

– Norms : men 38.9 sec, women: 29.4 sec

121

122

Cervicogenic Dizziness

• Assessment

– Head-Neck differentiation test

– Joint position error test

– Smooth Pursuit neck torsion test

123

Head Neck Differentiation Test

• Patient seated on a swivel chair

– The clinician rotates the chair while stabilizing

the patient head (cervical)

– The clinician rotates the chair without

stabilizing the head (vestibular)

• Reproduction of symptoms

124

Joint Position Error Test

• Assess cervicocephalic proprioception and neck

reposition sense

– Patient is seated 90 cm in front of target

– Patient in neutral head position (target adjusted

accordingly) using a laser light

– Patient instructed to perform active head

rotation to one side with eyes closed and return

to starting position- 3 repetitions

– Greater than 4.5 degrees indicates abnormal

cervical proprioception

125

Smooth Pursuit Neck Torsion Test

• Patient seated with cervical spine in neutral

– Perform smooth pursuit test and observe for

saccadic intrusion

• Patient seated with body rotated to one side 45

degrees while head remains in neutral position to

create cervical torsion

– Repeat the smooth pursuit test

– Tested in right and left side

• Positive findings: saccadic intrusion with

cervical torsion

126

Exertion

127

Exertion

• Following a concussion there is:

– Decreased in cerebral autoregulation capacity

– Potential in decreased in cerebral blood flow

• Preliminary evidence supports

– Symptom limited aerobic exercise programs for

individuals with persistent post concussion symptoms

– Protracted recovery associated

• Autonomic instability

• Physical deconditioning

128

Exertion

• Exertion protocol

– The Buffalo Treadmill concussion test

– Bike protocol to decrease motion sensitivity

(work in progress)

129

Reaction Time

130

Reaction time

• Computerized

131

Treatment

132

Intervention after Concussion

• From the Consensus statement on concussion in sport -2016

“ The Berlin expert consensus is that the use of the term “persistent symptoms” following sport related concussion should reflect failure of normal clinical recovery- that is, symptoms that persist beyond expected time frames (i.e. > 10-14 days in adults and > 4 weeks in children)”

• Preliminary evidence supporting– Individualized symptom-limited aerobic exercise

– Targeted physical therapy program for cervical or vestibular dysfunction

– Cognitive behavioral therapy for mood and behavioral issues

133

Intervention after Concussion

• There as been a change in the “rest “ formula for

concussion patient, from complete rest to

relative/active rest

• Evidence exist that sub-symptom-threshold and

submaximal exercise have been shown to be safe

and may benefit in facilitating recovery.

134

Intervention after Concussion

• Reneker et al. advocates for early intervention to

shorten recovery in Sport Related Concussion

• Interventions included vestibular therapy, oculomotor,

neuro-motor retraining and manual therapy

• Intervention was as early as 10 days

• Recovery time was shorten. The median time for

medical release was 10.5 shorter than the control

group

135

Treatment! Treatment! Treatment!

•Adaptation –Refers to the ability of the Vestibulo-ocular

Reflex to undergo changes through exercises involving

vision and head motion

•Substitution –other strategies to replace lost/impaired

function (strength, ROM, proprioception, assistive

device, activity modification, visual tracking) Improve

Postural Stability through vision

•Habituation–“based on the concept that repeated

exposure to provocative stimulus will result in a reduction

in the pathological response to that treatment”

(Herdman & Clendaniel, 2014, p.399)

136

Treatment Strategies• Treat positive findings (including symptom reproducing tests)• Frequent symptoms check as an assessment for

progression of therapy • Always try to challenge the vestibular spinal reflex

– Decreased base of support• Feet together • Semi-tandem• Tandem

– Progress onto compliant surface• Close cell foam (airex)• Open cell foam• Rocker board• Bosu ball

– Ambulation• Forward/backward

137

Treatment Strategies

• dual task – include a cognitive task

simultaneously while performing a vestibular

activity

– Examples:

• Playing music

• Naming animals or states

• Numbers

138

Example of treatment progression

• Smooth Pursuit– Tracking target

• Progression :

– Increasing repetition or time

– Increasing speed up to 60 degrees per second

– Changing target

• Plain letter on a card

• Busy background

• Marsden ball

• Target on mirror

– www.eyecanlearn.com

139

Example of treatment progression

• Saccades

– Eye movement

• Eye movement only

• Eye/head movement

– Time and Speed

• Increased the speed and the duration of the exercise

– Complexity

• 4 panel saccade

• Hart chart

– www.eyecanlearn.com

140

Example of treatment progression

• Gaze stability

– Speed

• Progress to 120 bpm for general population

• Progress to up to 150 bpm for athlete/high level

patient

– Target

• Plain

• Increasingly busy background

– Complexity

• Viewing X1

• Viewing X2

141

Example of treatment progression

• VOR cancellation

– Speed

• goal 60 bpm

– Target

• Plain

• Increasingly busy background

142

Example of treatment progression

• Motion sensitivity/Optokinetic– Repeating pattern ribbon

– Motion sensitivity test as a treatment

– Optokinetic video https://www.youtube.com/watch?v=kAPtu1WTHYc

– Disco ball

– YouTube videos

– Riding escalator

143

Convergence Exercises

• Pencil Push Ups

• Brock String

• Dot Card

• Convergence fusion pictures

144

Accommodation

• Binocular/monocular

– Poems

– Hart Chart

– Brock Bead with far target

145

Cervicogenic Dizziness Treatment

• Cervical deep flexor strengthening and motor

control

• Cervical manual therapy

• Cervical joint proprioception

• Scapular and cervical stabilization and postural

retraining

146

Exertion Treatment

• Submaximal symptom exacerbation threshold is

identified

– Aerobic exercise 20 minutes/day

– Intensity of 80% of the threshold heart rate

achieved during testing (90% in elite athletes)

– 5 to 6 day per week using a heat rate monitor

– Terminate exercise at first sign of symptom

exacerbation or 20 minutes whichever comes

first

147

Speech Therapy Management of

Concussion

148

Coming Out of the DarkASHA Leader December 2015

• Kathryn Hardin

– Changes 2009- to present

– Turning point:

2013 Journal of Head Trauma Rehabilitation

• Too much inactivity slows down the total recovery time and can make symptoms more severe.

• After acute period of neurotoxicity has passed the brain must begin functional activity to encourage recovery. 149

Before

SLP Role

150

The Rest Trap

• Brain gets better at what it is asked to do.

• Ongoing Dysfunction “steals” energy that would

enable quick bounce back.

• Sacrifice “fun” activities with negative effects.

• Tech restriction-social outlet

• Physical rest and Cognitive rest similar effects-

energy outlet

• Students who most need academic rigor may

prolong the break from it- head off “convenience”

151

Current

SLP Role

152

Evidence-based Practice

• 2 Days Cognitive and physical rest following

concussion

• Some more prone to concussion:

– History of previous TBI, LD, ADHS,

Neuro/psycho-emotional diagnosis

– Person or family history of HA

– Gender-Females

• Neck circumference

• Hormonal fluctuations153

Recovery:

• Cellular level changes even in those with functional recovery

• SLP support is crucial

• Visual-vestibular evaluation-reading

• Mechanism of Injury: TBI Trauma vs. Sports

• Education Setting: Parent, Student and Staff education

• *Work setting: Boss/ manager, Co-Workers

154

EVALUATION

155

EVALUATION

• Symptom Checklist

156

Evaluation-Adults

• Montreal Cognitive Assessment –MoCA

screening

• Wechsler Memory Scale III -Auditory, Working

and Verbal Memory

• Attention Processing Test -Attention

• Cognitive Linguistic Quick Test

• RIPA-2/RIPA G-2

• Assessment of Language-Related Functional

Activities (ALFA) -Functional ADLs

157

Quest for Cognitive Treatment Coverage

• Elaine Ledwon-Robinson, MS, CCC-SLP

• The ASHA Leader, June 2016, Vol 21, 20-

21.doi:101044/leader.GR.21062016.20

• The ASHA Leader, June 2016

158

Memory

159

Working Memory Facts

• May be referred to as Short-term Memory

• Core executive function that closely correlates to both IQ and attention stamina.

• Working memory can impact long-term learning outcomes

• Working memory is essential for comprehension, learning and reasoning that draws from several parts of the brain

– Frontal cortex

– Parietal cortex

160

Working Memory Facts

• Gender balance fairly even with slightly greater

proportion of males than females

• Fluctuates throughout the day and from day to day

• Slow to learn in the areas of reading math and

science

• Unable to meet memory demands of structured

learning activities

• Information is lost through overload or distraction

161

• Need to re-read text

• Difficulty following multi-step directions

• Difficulty attending during class

• Test anxiety

• Need for more time and repetition

• Inconsistent performance

• Lack of focus and attention deficits disorders

• Unable to hold material in mind and manipulate

the material

• Limited in capacity

162

Working Memory deficit checklist:

Struggle to Learn

• Learning is a step-by-step process

• Fail in classroom as working memory loads are too

demanding

• Working memory failure leads to inattentive

behaviors-forget what they are doing!

163

Evaluation

• Standardized Tests include two measures of working memory:

– Forward and backward digit span

436

371

2876

3987

32097

67482

Also consider…..

Auditory Memory

Visual Memory164

ATTENTION

165

Attention

166

Types of Attention

167

• Sustained Attention

• Focus on ONE specific task for a continuous

amount of time without distraction

Types of Attention

168

• Selective Attention

• Ability to select from many factors or stimuli and

focus on only the one you want while filtering out

other distractions

Types of Attention

169

• Alternating Attention

• Ability to switch your focus back and forth between

tasks that require different cognitive demands

Types of Attention

170

• Divided Attention

• Ability to process two or more responses or react

to two more different demands simultaneously.

• Multi-tasking!

TREATMENT

171

172

Classroom/Workplace/Home

Support

• Ways to avoid working memory overload in classroom

– Recognize working memory failures

– Monitor child

– Evaluate working memory load and reduce

– Simplify the load-chunk

– Use of memory guides such as wall charts, posters, memory cards

– Develop personal strategies such as note taking, place-keeping and organizational strategies.

173

Strategies for Cognitive Deficits

Concentrate first on general cognitive skills, such as flexible thinking and organization, rather than academic content.

Focus on what the student does well and expand the curriculum to more challenging content as concussion symptoms subside.

Adjust the schedule as needed to avoid fatigue: shorten day, time most challenging classes with time when student is most alert, allow for rest breaks, reduced course load.

Adjust the learning environment to reduce identified distractions or protect the student from irritations such as too-bright light or loud noises.

Use self-paced, computer-assisted, or audio learning systems for the student having reading comprehension problem

174

GAMES

Memory

Crazy 8

Magazines to circle

words, cut out

pictures

License plates

Card sort

Blink!

175

• Encourage active reading

– Take notes

– Use a highlighter

– Talk about it out loud and ask questions

176

• Chunk information into smaller bites

– Ex. Phone numbers, SS#

– Write down instructions step by step

177

• Make it multi-sensory

– Write down tasks

– Say them out loud

– Say them while completing a task

178

Walk and Talk

179

180

Additional Suggestions• One thing at a time

• To Do List

• One monitor

• Proof read email

• Lighting

• Set a timer for breaks

• Shopping off hours

181

Summary

182

183

Contact Numbers

• Bill Condon, PT, MPT

– wcondon@kumc.edu

• Maria Davenport, MPT

– mdavenport@kumc.edu

• Jamie L Johnson, MA L/CCC-SLP BCS-S

– jjohnson2@kumc.edu

• Claude Lamoureux, PT, DPT, NCS

– clamoureux@kumc.edu184

Reference

• Broglio, S.P., Collins, M.W., Williams, R.M., Mucha, A., Kontos, A. (2015). Current and emerging rehabilitation for concussion: A review of the evidence. Clinical Sports Medicine, 34(2): 213-231.

• Choe M.C. (2016). The pathophysiology of concussion. Current Pain Headache Reports. DOI 10.1007/s11916-016-0573-9

• Cameron M. Marshall, Howard Vernon, John J. Leddy & Bradley A. Baldwin (2015) The role of the cervical spine in post-concussion syndrome, The Physician and Sportsmedicine, 43:3, 274-284.

• Domenech, M.A. et al. (2011). The deep neck flexor endurance test: normative data scores in healthy adults.PM&R 3(2): 105-10

• Hain T. Dizziness and Balance.com. 2015. http://www.dizziness-and-balance.com

• Herdman, S.J., Clendaniel, R.A. (2014). Vestibular rehabilitation. Philadelphia, PA: F.A. Davis Company.

• Kristjansson, E. Treleaven J., 92009). Sensorimotor function and dizziness in neck pain: Implications for Assessment and management. Journal of orthopaedic and sports physical therapy. 39(5): 364-377.

185

Reference

• Leddy, J.J. and Willer, B. (2013) . Use of graded exercise testing in concussion and return to activity management. Current Sports Medicine Reports. 12(6): 370-6.

• Leddy, J.J., Kozlowski, K., Donnelly, J.P., Pendergast, D.R., Epstein, L.H., Willer, B. (2010). A preliminary study of subsymptomthreshold exercise training for refractory post-concussion syndrome. Clinical Journal Sport Medicine, 20(1): 21-7.

• Leddy j.J, Baker J.G., Willer B. (2016). Active Rehabilitation of concussion and post-concussion syndrome. Physical Medicine and Rehabilitation Clinics of North America. 27: 437-454.

• McCrory, P. et al. (2017). Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal Sports Medicine, 0:1-10

• Mucha, A., Collins, M.,Elbin, R.G., Furman, J., et al. (2014) A brief vestibular/ocular motor screening(VOMS) assessment to evaluate concussion. American Journal of Sports Medicine. 42(10):2479-2486.

• Neil, J.A., Adams, M.A., Dolan, P.(2015). Sensorimotor function of the cervical spine in healthy volunteers. Clinical Biomechanics, 30(3): 260-268.

186

Reference

• Ogince, M. et al. (2007). The diagnostic validity of the cervicalflexion-rotation test in c1/2-related cervicogenic headache. Manual Therapy, 12(3): 256-62.

• Reneker, J.C., Hassen, A., Phillips, R.S., Moughiman, M.C., Donaldson, M., Moughiman, J. (2017). Feasibility of early physical therapy for dizziness after a sports-related concussion: A randomized clinical trial. Scandinavian Journal of Medicine and Science in Sports, 1-10. doi: 10.1111/sms.12827.

• Sullivan S. Physical Rehabilitation. Vol 6th Ed. Philadelphia: F.A. Davis Company; 2014.

• Strelzik, J., Langdon, R. (2017). The role of active recovery and ‘rest” after concussion. Pediatric Annals 46(4): 139-144.

• Treleaven, J. (2017). Dizziness, unsteadiness, visual disturbances, and sensorimotor control in traumatic neck pain. Journal of orthopaedic and sports physical therapy. 47(7): 492-502.

• Treleaven J, Jull G, Atkinson L.(1994). Cervical musculoskeletal dysfunction in post-concussional headache. Cephalalgia;14:273–57.

• Vuillerme N, Pinsault N. Experimental neck muscle pain impairs standing balance in humans. Exp Brain Res 2008;192:723–9.

• Yorke, A.M., Smith, L., Babcock, M., lsalaheen, B. (2017). Validity and reliability of the vestibular/ocular motor screening and associations with common concussion screening tools. Sports Health, 9(2): 174-180.

187

Speech Pathology References:

Anderson T, Heitger M, Macleod A D. Concussion and

Mild head injury. Practical Neurology 2006; 6:342-357m

Brain Injury in Children and Youth: A Manual for

Educators Colorado Department of Education

cdc.gov/concussion

Canlearnsociety.ca

Elbin, R.J. et al. Factors Influencing Risk and Recovery

from Sport-Related Concussion: Reviewing the Evidence.

Perspectives on Neurophysiology and Neurogenic

Speech and Language Disorders. Vol 25, January 2015.

Hardin, K. The ASHA Leader, December 2015. Vol 20,

18-44 . Doi:10.1044/leader.FTR1.20122015.38.

Understood.org188

• Krug, H., Turkstra, L. Assessment of Cognitive-

Communication Disorders in Adults with Mild

Traumatic Brain Injury. Perspective on

Neurophysiology and Neurogenic Speech and

Language Disorders. Vol 25, January 2015.

ASHA.

• Ledwon-Robinson, Elaine. The ASHA Leader,

June 2016, Vol 21, 20-21. doi:

101044/leader.GR.21062016.20

189