CONCUSSIONS. What really happens? Physical therapy can help treat this? By: Tressa Thomas, DPT

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1 CONCUSSIONS What really happens? Physical therapy can help treat this? By: Tressa Thomas, DPT Select Physical Therapy 3025 Market Street Camp Hill, PA 17011

2 What is a concussion? Concussion is a complex pathophysiologic process induced by traumatic forces secondary to direct or indirect forces to the head that disrupts the function of the brain. According to the Centers for Disease Control and Prevention, concussion is synonymous with the term mild TBI (traumatic brain injury).

3 Common Concussion Signs and Symptoms Physical: headache, balance problems, light/noise sensitivity, dizziness, fatigue Cognitive: mentally foggy, difficulty concentrating, confusion Emotional: irritability, sadness, nervousness, anxiety Sleep: drowsy, altered sleep patterns

4 Concussion: A traumatic brain injury that changes the way your brain functions. This can lead to bruising and swelling of the brain, tearing of blood vessels and injury to nerves, causing the concussion The brain is made up of soft tissue and is protected by blood and spinal fluid. When the skull is jolted too fast or is impacted by something, the brain shifts and hits against the skull. Some concussions do resolve with rest and medical management. Some need further skilled care like vestibular rehabilitation.

5 Neuron Anatomy

6 Physical Therapy Evaluation Medical History Screen Yellow Flags Ataxia Nausea Medication use Anxiety or other mental disorders Red Flags= DO NOT TREAT, immediate MD referral Persistent dizziness in quiet sitting Drop attacks Diplopia, dysarthria, dysphagia Distal paresthesia

7 DHI Functional Outcome Tools

8 Functional Outcome Tools

9 Musculoskeletal Screen Cervical AROM/PROM Flexibility Palpation MMT Joint Mobility DTRs Ligamentous Stability

10 Upper Cervical Ligamentous Laxity Tests

Ligamentous Laxity: Sharp Purser 1. Assess laxity of Transverse Ligament 2. Forward flex head, support forehead with hand, opposite hand on SP of C2 3.

11 Ligamentous Laxity: Sharp Purser 1. Assess laxity of Transverse Ligament 2. Forward flex head, support forehead with hand, opposite hand on SP of C2 3. Deliver posterior force through pt s forehead while stabilizing C2 3. Positive test = head sliding posteriorly relative to C2, audible clunk, and/or reduction of neurological symptoms 4. Positive test is an immediate ER referral!

12 Alar Ligament The function of the alar ligament is to limit the amount of head rotation and side bending.

13 Ligamentous Laxity: Alar Ligament Test 1. Palpate the C2 SP 2. Passively side bend the upper C/S 3. Passively rotate the upper C/S 4. Should be a hard end feel 5. Soft end feel or increased pain and/or spasm is a positive test

14 Vertebral Artery

dizziness or nystagmus Red flags: -Diaphoresis

15 Vertebral Artery Test Keep arms extended and watch for dropping of one arm or increased parasthesia, dizziness or nystagmus Red flags: -Diaphoresis -Dysphagia -Dysarthria -Drop Attacks -Diplopia ->10/10 pain -Confusion

16 Ocular Motor Screening 1) Smooth Pursuit 1. Have the patient follow target while head is kept steady 2. Keep target within 2-3 ft of head 3. Check horizontal and vertical 4. Movement should be smooth and keep up with speed of object 5. Positive test is saccadic tracking

17 Ocular Motor Screening 2) Saccades 1. Patient looks back and forth between targets held aprox. 12 apart -Horizontal -Vertical -Diagonal 2. Look for accuracy and speed 3. Abnormal saccades may only show after fatigue

18 Ocular Motor Screening 3) Convergence/Divergence Move target slowly towards patient s nose and then out again. Can use pen point or word on the pen Ask when pt sees 2 pens or word becomes blurry Convergence should be sustainable to within 5-8 cm from brow and both pupils should constrict

19 Ocular Motor Screening 4) Head Thrust Patient focuses on examiner s nose The head is rapidly thrust from midline to one side aprox. 10 deg. Observe for corrective saccade back to target after thrust

20 Balance Testing Modified CTSIB Stand in four positions 1. Eyes Open Firm Surface 2. Eyes Closed Firm Surface 3. Eyes Open Foam Surface 4. Eyes Closed Foam Surface Hold Each position for 30 sec Rate quality of balance 1. Normal/Minimal Sway 2. Mild Sway 3. Moderate Sway 4. Loss of Balance 5. Unable to perform

21 Release Test: Balance Testing Stand behind patient with hands between shoulder blades Patient leans back into hands Remove hand from patient, observe # of steps to regain balance

22 Balance Testing Release test scoring: 0- No observable attempt to step (max assist) 1- Takes >2 steps and requires some assistance 2- Takes >2 steps, but is able to restore balance independently 3- Takes 2 steps, but is able to restore balance independently 4- Able to restore balance independently with only one step

23 Gait Assessment FGA: Functional Gait Assessment <22 indicates increased fall risk DGI: Dynamic Gait Index <19 indicates increased fall risk Balke Treadmill Test Determines threshold for aerobic activities Intensity increases as patient s tolerance increases Identifies possible post-concussion blood flow problem

24 Administering Balke TM Test: Determine BP, HR, BORG Scale exertion Treadmill set at 3.3 mph for men & 3.0 mph for women, 0% incline For men Increase grade to 2% after 1 st minute and add 1% every minute thereafter For women Increase the grade 2.5% every 3 minutes Provocative exercise testing should only be performed, however, in patients whose rest symptoms have resolved and for whom a determination is being made as to fitness to return to sport or activity 24

25 Balke TM Test is complete if A. 15 min HR and RPE is documented B. Pt reaches max HR (220-age) HR and RPE is documented C. First sign of symptom exacerbation HR and RPE is documented D. Pt reports exhaustion based on RPE HR and RPE is documented

26 BPPV Screen Dix-Hallpike Test: gold standard If positive, perform Epley Manuver Ex: Dix-Hallpike Test (R side)

27 Vestibular Exercises What are those??

28 Vestibular Exercises Refer back to PT evaluation: 1. HA Management 2. Ocular Motor Re-education 3. Balance Retraining 4. Aerobic Endurance 5. Strengthening

1. Headache Management Stretching Chin tucks Headache SNAGS Massage Suboccipital Release/Traction Modalities Ergonomic modifications Computer height

29 1. Headache Management Stretching Chin tucks Headache SNAGS Massage Suboccipital Release/Traction Modalities Ergonomic modifications Computer height Reading positions Lighting Length of tasks Complexity of tasks Ex: Self Headache SNAG-extension Towel in sub-occipital region Pull towards eyes as the neck extends

30 1. Headache Management OA Release (Manual Therapy Technique): -Gentle to firm pressure on suboccipital region -Can add distraction

31 2. Ocular Motor Exercises A) Smooth Pursuit: keep head still and track moving target with eyes Left/Right, Up/Down, Diagonals Start sitting, then advance to standing

32 2. Ocular Motor Exercises B) Saccades: use 2 targets, keep head still and move eyes

33 2. Ocular Motor Exercises C) Habituation: reduce symptoms from repetition/exposure to various stimuli Track various targets: 1. Add upper extremity movements 2. Use firm and foam surfaces 3. Busy backgrounds

34 Habituation Track target while moving Standing toss and catch Walking toss and catch Pivoting toss and catch Juggling Squat

35 2. Ocular Motor Exercises D) Convergence/Divergence Pencil Push-Ups Brock String Ex: Brock String

36 Convergence: Magic Eye

37 Convergence: Where s Waldo

38 2. Ocular Motor Exercises E) VOR X1: keep target still, move head X2: move head/target in opposite directions Added resistance bands for c/s strengthening and stability

39 Added tandem stance Use of background Distance from a target

40 Advancements For All Ocular Motor Exercises: 1. Sit, stand, walk -Tandem walking, walking backwards, stepping up and down, obstacle course 2. Change duration, speed, direction, surface and distance from target 3. Use background

41 3. Balance Eyes open/closed, standing on firm/foam surface Feet together/tandem/single leg

42 3. Balance Balance and memory game Remember location of cones Start with 2-3 color sequences Increase speed and complexity of patterns as they progress Add EO/EC Add foam surface Single leg stance

43 4. Aerobic Endurance Treadmill, bike, elliptical, UBE Gradual increase in frequency and intensity Duration determined by symptom-free time Eventual progression to agility and plyometric training

44 5. Strengthening Supine Chin tuck and head lifts Arm movements with head off table Supine to sit with head neutral Prone/Quadraped Planks Alt UE/LE lifts Pushups Walk-outs on ball Side Lateral Planks

45 5. Strengthening Forehead on ball One arm raise Forehead on ball B/L arm raise

46 5. Strengthening Two Ball Chin Tucks One behind head One between shoulders Chin Tuck and hold Add nodding 10 deg Add c/s rotation 10 deg Add X 1/X2 viewing

47 5. Strengthening Prone WIYT exercise With or without # Posture and Scapular Stability Prone planks on ball With chin Tucks With leg or arm raise

48 5. Strengthening Standing forehead on ball with UE movements Unstable Dips

49 Concussion Treatment Guidelines Rest period for 1-2 weeks 1-4 weeks s/p injury -patients need to be symptom free at rest Week 1 -light cardio min (bike) -ocular motor re-education -static balance -habituation with EO *all exercise is symptom free *when symptoms are provoked, rest until symptoms return to baseline

50 Concussion Treatment Guidelines Week 2-3 (if completely symptom free during all activity in previous step) Continue aerobic exercises (15-30 min, TM) Continue ocular motor re-education PRN Dynamic balance and EC Habituation with EC Add upper body/cervical strengthening High reps, low weight

51 Concussion Treatment Guidelines Week 4-5 (if completely symptom free during all activity in previous step) Advance aerobic activity (30-45 min, TM jog) Continue with strengthening and dynamic balance Habituation: EC during activities Light agility and plyometric drills

52 Concussion Treatment Guidelines Week 6-8 (if completely symptom free during all activity in previous step) Sport specific drills or return to work tasks * If patient can complete all exercises symptom free, refer back to MD for final Return to Sport/Work Clearance

53 Thank You!

Concussion Rehabilitation Specialist

Concussion Rehabilitation Specialist Complex pathophysiological process affecting the brain, induced by biomechanical forces Common Features Direct or transmitted blow the the head/neck Rapid onset, short-lived