Concussion Assessment & Management the UPMC Approach – Flashcards
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UPMC Concussion Evaluation
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- detailed clinical interview • questions that link to 6 clinical trajectories • determine risk factors prior to concussion - vestibular-ocular screen (VOMS) - computerized neurocognitive testing • how do the scores on the various items in IMPACT fit into each trajectory - determine trajectory(s) • primary, secondary, tertiary
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Concussion - General Points
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- energy crisis involving increased extracellular potassium and increased intracellular calcium - athlete may experience any or all of ~21 symptoms - approx 80% of patients will recover in 3 weeks - 20% take over 3 weeks
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Most commonly reported symptoms post concussion
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- headache - feeling slowed - difficulty concentrating - dizziness - fogginess - fatigue - visual blurring/double vision - memory dysfunction - balance problems
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Primary Risk Factors
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existing prior to the injury - history of migraine - dx of learning disability - gender (females - migraines) - age (younger) - history of car sickness/motion sickness and ocular motor dysfunction (nystagmus)
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Secondary Risk Factor
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occurring risk factor - a risk factor that when present will impede recovery, also termed a prognostic risk factor
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Prognostic Risk Factors
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the following may cause slower recovery: - post concussion migraine • migraine is defined as headache with nausea, and photo and/or photosensitivity - immediate post concussion dizziness - sub acute fogginess, difficulty concentrating, vomiting, nausea, headache, imbalance, photosensitivity (comes on within 3-7 days) predict recovery last 14-21 days and even longer
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Detailed Interview
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- some questions will mimic SCAT-3 questions and items such as Maddocks score are good - however, SCAT-3 does not address risk questioning specific to 6 trajectories and does not include any vestibular ocular screening. *SCAT-3 includes modified BESS for vestibular screen
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Vestibular System
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two parts: - vestibulospinal reflex - vestibular ocular reflex
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Vestibular Spinal Reflex
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descending pathway, meaning, its mainly peripheral. - Collin's group sees the BESS is most useful the first week post concussion
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Vestibular Ocular Reflex
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ascending system that involves how we control and coordinate head and eye movement. the ability to stabilize vision while head moves. dysfunction of it must involve CNS - VOMS screening
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Concussion Clinical Trajectories
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- vestibular - ocular - cognitive/fatigue - post traumatic migraine - anxiety/mood - cervical
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The aim of the UMPC Concussion Evaluation
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- ask detailed history questions that should help categorize the concussion into one or more of the trajectories - analyze impact scores - perform VOMS to see if deficiencies are present - provide treatment targeted at the trajectories found
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Vestibular Trajectory Assessment
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- risk factors = car sickness and motion sensitivity - symptoms = foggy, slow/wavy dizziness, "feel like one step behind", nausea, feel overwhelmed in high stimulus environment - impact deficits most likely in visual motor speed
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Vestibular Treatment
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- refer to PT to correct deficits - when athlete returns, implement dynamic exertion protocol - MD may prescribe mood, migraine, or sleep medication if needed - school/home = sit in front of car, limit crowded noisy high stimulus environments, slowly expose to higher stimulus environment
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Anxiety/Mood Assessment
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being in vestibular trajectory can cause anxiety, THIS MUST BE TREATED FIRST! - risk factors = personal/family history of anxiety. type A helicopter parent family, hypochondriac - VOMS screening = if anxiety/mood only, then VOMS should be negative - impact testing = may be clean
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Anxiety/Mood Treatment
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- treat vestibular if involved - supervised exertional rehab - make sure no symptoms return - regulate daily schedule - psychotherapy - counseling - if anxiety only, they should be in school and participating
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Ocular Assessment
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- risk factors = personal or family hx of nystagmus, strabismus - symptoms = frontal headache, fatigue, distractible, difficulty, with visually based classes, pressure behind the eyes, difficulty focusing eyes - impact deficiencies • visual memory, reaction time • difficulties with encoding rather than retrieving - VOMS • pursuits and saccades, and near point of convergence (>5cm)
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Ocular Treatment
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- vestibular therapy with ocular-motor focus - vision therapy - when resolved, proceed with dynamic exertion protocol - school accommodations = less reading, less computer work. may need to limit time in visual intense courses - math and sciences. - consider audio learning
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Cognitive/Fatigue Assessment
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- risk factors = history of learning disability - symptoms = fatigue, general headache, 'end of day' symptoms, may have sleep deficits - VOMS = normal - Impact = global mild deficits across all items
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Cognitive/Fatigue Treatment
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- physical/cognitive breaks throughout the day (no naps) - gradual exertional progression - pharmacological •should be on medication for any learning disability that they were on pre-concussion • may need a sleep aid - cognitive therapy if not resolving
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Post Traumatic Migraine Assessment
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- risk factors = personal or family history of migraine - VOMS = should be normal, unless vestibular trajectory involved - impact = verbal and visual memory deficits present, speed should be ok unless there is also vestibular involvement
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Post Traumatic Migraine Treatment
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- pharmacological antidepressants migraine meds - cardiovascular activity as tolerated - need regulated schedule
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Cervical Trajectory
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group that maintains a headache post concussion. this headache isn't in the migraine family, it is C-spine induced. - headache is dull and throbbing - headache is frontal, temporal, or occipital and can be changed with treatment interventions based on the cervical segments causing the problem
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Vestibular/Ocular Motor Screening
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VOMS uses brief tests & measures in 5 domains - smooth pursuits - horizontal and vertical saccades - near point convergence - horizontal vestibular ocular reflex (VOR) - vertical vestibular ocular reflex (VOR) - visual motion sensitivity at baseline and following each test above patients rate (0-10) for: h/a, dizziness, nausea, fogginess*
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General VOMS Instructions
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- designed for clients 9-40 y/o. used outside this group may skew interpretation - (+) tests or provocation of symptoms should prompt communication with an MD and proper referral. - equipment: tape measure (cm), metronome, target w/ 14 pt. font - start by taking baseline symptoms (0-10) for above symptoms
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Psychometric Properties of VOMS
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- concurrent validity with symptom report - differentiates concussed from controls • symptom score >2 on any test along with NPC distance ≥5cm raises likelihood of concussion 94% - VOR, visual motion sensitivity and NPC are most predictive of concussion status - VOMS was unrelated to BESS score
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What if VOMS abnormal?
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VOMS may guide referral and tx following concussion - may show vestibular or ocular trajectory - (+) VMS and VOR should go to vestibular trained PT - convergence insufficiency may be treatable in PT, may need vision specialist
