SRC (Final)
What is the rule of using OMT in first 24 hrs after a concussion?
As a general principle, do not use any OMT procedure at the game/event, or within the first 24 hours Treatment may be performed within the first 24 hours if symptoms are (1) improving, (2) rated as mild, or (3) only one reported symptom (such as headache)
When should you avoid HVLA post-concussion?
Avoid HVLA of cervical spine if unstable, symptomatic problems exist
What are some problematic areas that most likely need OMT after a concussion?
Decrease muscle tension in cervical and upper thoracic regions
What do we know about incidence and prevalence of CTE?
Incidence and prevalence in all populations of are UNKNOWN
What is a common problem with PPCS and concussions?
It is not unusual for common symptoms to be inappropriately or mistakenly attributed to concussion It is critical to understand pre-existing or coexisting symptoms and conditions in the evaluation of PPCS
Describe the use of acceleration data in predicting concussions
Measured linear and rotational acceleration data alone DO NOT accurately predict. NO direct relationship between impact biomechanics and symptoms or cognitive performance change scores has been identified
What is the relationship between CTE and behavioral changes?
No cause/effect relationship between postmortem CTE changes and antemortem behavioral manifestations has NOT been demonstrated
Describe the King-Devick (KD) Test and how it can be used in the evaluation of a concussion.
Proprietary, timed saccadic eye movement test requiring individuals to quickly read numbers aloud Requires a baseline test as well as an understanding of potential learning and practice effects to be useful
What is standardized test for the sideline assessment?
SCAT5 and Child SCAT5 --> Standardized approach which incorporates multiple domains of function and are widely available at no cost
How are concussions managed?
SRC clinical symptoms typically resolve spontaneously, with 80%-90% of concussed older adolescents and adults returning to pre-injury levels of clinical function within 2 weeks. In younger athletes, clinical recovery may take longer, with return to preinjury levels of function within 4 weeks
When using assessments like the SCAT5, how should decision be made?
Scoring should not be used as a stand-alone method to diagnose concussion, measure recovery or make decision about an athlete's readiness to return to competition after concussion
Where should sideline assessment performed?
Should be performed in a distraction-free environment with adequate time
What are are the short term risks of returning to sports after sports-related concussion despite following standard protocols?
Some research has demonstrated that athletes who return to sport after SRC following standard return to sport protocols had an increased rate of musculoskeletal injury
What is chronic traumatic encephalopathy (CTE)?
described in former athletes with a history of concussion or repetitive head impact exposure, typically accompanied by behavioral change
What are the short-term risks of continuing to play immediately following a concussion?
uContinuing to play immediately following a concussion is a risk for (1) increased symptom burden, (2) worsening of the injury and (3) prolonged recovery
How are some players diagnosed with CTE?
Asymptomatic players have had confirmed CTE pathology at autopsy.
What are the short-term risks of returning to sports prior to full recovery?
Athletes who return to sport prior to full recovery are at increased risk of repeat concussion
How are concussions diagnosed?
Based on clinical assessments - history and physical exam findings as the injury evolves, which can be challenging
What are some school environmental adjustments that may need to be made when returning to learning after a concussion?
Allow use of headphones/ear plugs to reduce noise sensitivity Allow use of sunglasses/hat to reduce light sensitivity Limit use of electronic screen or adjust screen settings, including font size, as needed. Allow student to leave class early to avoid crowded hallways. Avoid busy, crowded or noisy environments - music room, hallways, lunch room, vocational classes, assemblies
What is exercise intolerance?
An objective physiological sign of acute concussion that appears to reflect impaired autonomic function and control of cerebral blood flow
Describe how neurocognitive test apps can be used to evaluate for concussion
App-based measures of reaction time, eye trackers, postural stability, speech pattern, quantitative electroencephalography and various abbreviated neurocognitive tests are being developed
What are some classroom adjustments that may need to be made when returning to learning after a concussion?
Breaks as needed during the school day Reduce in class assignments and homework. Allow increased time for completion of assignments and testing. Delay exams until student is adequately prepared and symptoms do not interfere Allow testing in separate, distraction-free environment Modify due dates or requirements for major projects Provide preprinted notes or allow peer notetaker. Avoid high-risk or strenuous physical activity.
On the SCAT5 sideline assessment, you are assessing neurologic function. What might you be looking for?
Can the patient read aloud and follow instructions without difficulty? Does the patient have a full range of pain-free PASSIVE cervical spine movement? Without moving their head or neck, can the patient look side-to-side or up-and-down without double vision? Can the patient perform the finger nose coordination test normally? Can the patient perform tandem gait normally?
What is the effect of stress applied to the neuron during a concussion?
Causes changes in intracellular ion concentrations, indiscriminate release of neurotransmitters, mitochondrial dysfunction --> leading to the production of reactive oxygen species, and increased utilization of glucose to restore sodium and potassium balance
What is an office/subacute assessment after a concussion?
Comprehensive history and neurological examination including details of injury mechanism, symptom trajectory (symptom checklists), neurocognitive functioning, sleep/wake disturbance, ocular and vestibular function, gait/balance, & cervical spine exam Sideline neurocognitive and balance assessments to identify concussion decreases as early as 3 days after injury If computerized neurocognitive tests were performed prior in injury, often repeated during this assessment period
What are the least traumatic techniques for concussion treatment with OMT?
Counterstrain, cranial, and indirect techniques are least traumatic ME is appropriate if done without pain
Describe the return to driving after a concussion.
Driving is a complex process involving coordination of cognitive, visual and motor skills, as well as concentration, attention, visual perception, insight and memory, which can all be affected by SRC. Little is known about the risk of driving after a concussion. Preliminary data suggest some impairment exists when patients with concussion report they are asymptomatic. Currently, NO widely accepted return to driving protocols exist.
What is the role glucose in concussion?
Increased glucose utilization combined with the injury-related decrease in resting cerebral blood flow creates an energy mismatch
While treating a concussion patient with OMT, you notice increased muscle spasm... what does this mean?
Increased muscle spasm during OMT indicates that the patient's tolerance has been exceeded
On the SCAT5 sideline assessment, you are assessing for symptoms. What might be some symptoms the patient experiences?
Indicate baseline or post-injury Indicate if symptoms worsen with physical or mental activity Headache, pressure in head, neck pain, N/V, dizziness, blurred vision, balance problems, sensitivity to light/noise, feeling slowed down, feeling like "in a fog", doesn't feel right, difficulty concentrating/remembering, fatigue or low energy, confusion/drowsiness, more emotional, irritability, sadness, nervous/anxious, & trouble falling asleep
On the SCAT5 sideline assessment, you are assessing for balance. What might you be looking for?
Indicate foot tested, testing surface, footware Condition - double leg stance, single leg stance on non-dominant foot, tandem stance with non-dominant foot at the back Types of errors in balance testing: 1. Hands lifted off iliac crest 2. Opening eyes 3. Step, stumble or fall 4. Moving hip into > 30º abduction 5. Lifting forefoot or heel 6. Remaining out of test position > 5 sec
What are some changes that may be present in stages of concussion?
Inflammatory cell activation, axonal degeneration and altered plasticity may occur in the subacute and chronic stages of concussion
Describe the biomechanics of sport-related concussion.
Occurs as a result of linear and/or rotational accelerations to the brain and can occur from either direct impact to the head or from transmitted (indirect) forces from the body to the head
On the SCAT5 sideline assessment, you are assessing for cognitive function. How is it done?
Orientation --> month, date, day of the week, year, time Immediate memory --> List words and have patient repeat a little later List month in reverse order - *Note some patients may not know the months in the correct order, so may need to practice for baseline* Concentration --> Digits backwards and have patient repeat them
On the SCAT5 sideline assessment, you are assessing the cervical spine. What are you looking for?
Pain or not at rest If no pain, full ROM Normality of limb strength and strength In a patient who is not lucid or fully conscious, a cervical spine injury should be assumed until proven otherwise
What the long-term risks of concussion?
Persistent Post-Concussive Symptoms (PPCS) Mental health problems and depression Chronic Traumatic Encephalopathy (CTE) & neurodegenerative diseases
What are rest recommendation regarding concussions?
Prescribed cognitive and physical rest has been the mainstay of treatment for the last several decades despite insufficient evidence to support this approach. In human studies, strict rest after SRC slowed recovery and led to an increased chance of prolonged symptoms 'The dark room' or 'cocoon therapy', may have detrimental effects similar to social isolation effects seen in animal studies and is no longer recommended Consensus guidelines endorse 24-48hours of symptom-limited cognitive and physical rest followed by a gradual increase in activity, staying below symptom-exacerbation thresholds
What is the pathophysiology of concussions based upon?
Primarily based on animal models that have limitations when extrapolated to humans
Describe the sideline assessment for a concussion.
Primary endpoint to determine the probability that an athlete has sustained a concussion: If unlikely, continued participation should be safe If definite or probable concussion, athlete removed from participation with no same-day return to play
What are the primary focuses of preventing concussions?
Primary focus of prevention --> rule changes, enforcement of existing rules, technique changes, neck strengthening, and equipment modifications Ex: Delaying the introduction of body checking in youth hockey --> moderate evidence that it reduces concussion rates Youth football and soccer practice modification and changes in tackling technique --> initial evidence may reduce injury Mouthguards --> conflicting evidence regarding concussion reduction Helmets --> prevent skull trauma and intracranial bleeding - protective effects for concussion less pronounced Headgear --> mixed results - player behavior can change when wearing new protective equipment, encouraging more aggressive play increasing risk
What is the primary goal of treating a concussion patient with OMT?
Primary goal is maximum function, more than pain relief
What are some findings during a sideline assessment that might make you concerned for more serious head injuries?
Prolonged LOC Severe or worsening headache Repeated emesis Declining mental status Focal neurological deficit Suspicion of significant cervical spine injury
What is the management of PPCS?
Recent systematic reviews have advocated for including vestibular, oculomotor, psychological, sleep, cervical and autonomic nervous system evaluations in the assessment in order to facilitate individualized and targeted management of PPCS It is ideal for those with persistent postconcussive symptoms to be evaluated by a provider or multidisciplinary team with expertise in complicated concussion management
Describe the sixth stage of returning to sports.
Return to sport
Describe the guidelines of returning to sports after a concussion.
Should be individualized based on the injury and patient. Each stage is generally 24 hrs WITHOUT return of concussion symptoms. Repeat stage until then. Stage 1: Symptom-limited activity Stage 2: Light aerobic exercise Stage 3: Sport-specific exercise Stage 4: Non-contact training drills Stage 5: Full contact practice Stage 6: Return to sport
On the SCAT5 sideline assessment, you are assessing delayed recall. What might you be looking for?
Should be performed 5 minutes after the immediate recall. Have patient repeat the words from earlier.
What has been shown in animals models of concussion regarding supplement use?
Some supplements may protect or speed recovery from concussion, specifically focused on certain B vitamins, omega-3 fatty acids, vitamin D, progesterone, N-Methyl-D-aspartate, exogenous ketones and dietary manipulations (eg, ketogenic diet) Gap between experimentally produced injury in an animal model and the heterogeneous mechanisms that cause human concussion during sports activities
Describe the third stage of returning to sports.
Sport-specific exercise Running, skating or sport-specific aerobic exercise avoiding risk of head impact. Symptoms should NOT worsen with activity.
How are mental health problems and depression associated with concussions?
Studies have shown the NFL and college football athletes with a history of concussion are more likely to experience depression BUT NFL players have a LOWER risk of mental health issues than age-matched controls Former high school football players show not difference in cognitive function testing and have lower depression scores when compared with non-contact sport controls. Mental health issues are common, multifactorial and often present independent of participation in contact or collision sport. Longitudinal research on contact sport athletes that addresses multiple variables is needed to understand the long-term risks
What is the recommended sequencing of OMT when treating a concussion patient?
Suboccipital Release Muscle energy of the OA and AA joints Correction of cervicothoracic dysfunctions Myofascial release to trapezius, levator, and cervical soft tissue
Describe the first stage of returning to sports.
Symptom-limited activity Reintroduction of normal activities of daily living. Symptoms should NOT worsen with activity.
What are the most sensitive indicator of concussion
Symptoms are the most sensitive indicator of concussion Reliability of athlete-reports symptoms depends on accurate reporting, which may be affected by a lack of recognition of the signs and symptoms or conscious false reporting to avoid loss of playing time.
What is PPCS?
Symptoms that persist beyond the expected recovery time frame (>2 weeks in adults, >4 weeks in children) Persistent symptoms do not necessarily represent ongoing concussive injury to the brain
What is the role of nutraceuticals to prevent/ameliorate concussions?
There is no HUMAN evidence that nutraceuticals prevent or ameliorate concussion in athletes
What are the correlating biomarkers for diagnosis and prognosis for sports-realted concussions?
There is presently insufficient evidence to correlate any single or combination of body fluid or imaging biomarkers as being diagnostic or prognostic for SRC
What is known about the course of CTE?
Unknown if CTE is a progressive disease, and whether tau deposition is the cause of CTE or a byproduct or marker of a disease
What is the role of physical and vestibular therapy in treatment of concussion?
Vestibular therapy should focus on specific deficits identified and use an 'expose-recover' model performed by clinicians with expertise in vestibular rehabilitation. There is preliminary evidence that addressing cervical spine and/or vestibular dysfunction with a targeted physical therapy program improves outcomes.
Describe VOMS in office/subactue assessment
Vestibular/Ocular Motor Screening (VOMS) Tool offering a brief, standardized way to assess vestibular-ocular function used in athletes older than 10 years of age Evaluation of symptom provocation with smooth pursuits, saccades, the vestibular ocular reflex, vestibular motion sensitivity and convergence distance Vestibular symptoms occur in 67-77% of concussions Ocular impairment occurs in ~45% of concussions
On the SCAT5 sideline assessment, you are assessing observable signs. What might you be looking for?
Witnessed or observed on video Lying motionless on the playing surface Balance/gait difficulties/motor incoordination: stumbling, slow or laboured movements Disorientations or confusions, or an inability to respond appropriately to questions Blank or vacant look Facial injury after head trauma
What is Zack Lystedt Law?
Zach prematurely returned to a football game --> costing him time and function in his young life (House Bill 1824) prohibits young athletes who were suspected of sustaining a concussion from returning to the game without the approval of a licensed healthcare provider
What is the ideal time frame for using OMT after concussion?
uInitial application of procedures is ideally 24-36 hours after injury.
When should you stop OMT treatment on a concussion patient?
If the patient feels that the intervention is too uncomfortable, stop and choose another approach, or wait and try again later
Who should be doing the sideline assessment?
A healthcare professional familiar with the athlete is best suited to detect subtle changes in the athlete's personality or test performance that may suggest concussion
What is "Second Impact Syndrome"?
A rare and controversial condition. Considered by some to be a potentially life-threatening complication of re-injury during the initial post-injury time period Not fully understood Appears primarily limited to pediatric and adolescent athletes
Define concussion.
A traumatically induced transient disturbance of brain function that involves a complex pathophysiological process. Signs or symptoms that are not explained by other medical issues or other co-morbidities. It is a subset of mild traumatic brain injury which is classified based on acute injury characteristics at the less severe end of the brain injury spectrum.
Describe how biomarkers can be used to evaluate for a concussion.
Advanced multimodal MRI technologies (eg, diffusion tensor imaging, resting-state functional MRI, quantitative susceptibility imaging, magnetic resonance spectroscopy, arterial spin labelling) Fluid biomarkers (blood, saliva, cerebrospinal fluid)
What are the recommendations regarding activity and exercise after a concussion?
Emerging data suggest that symptom-limited activity, including activities of daily living and non-contact aerobic exercise, may begin as soon as tolerated after an initial brief period (24-48hours) of cognitive and physical relative rest Early activity and exercise do not take the place of a graded return to sport
How does exercise affect the body?
Exercise improves autonomic nervous system balance and CO2 sensitivity, cerebral blood flow regulation, brain-derived neurotrophic factor gene upregulation, and both mood and sleep
On the SCAT5 sideline assessment, you are assessing using GCS. What are you looking at?
Eye response Verbal response Motor response
Describe the return to learning after a concussion.
Facilitate communication and transition back to school by (1) notifying school personnel after injury to help preparation, (2) designate point person to monitor the student's status related to academic, recovery/coping with injury, & communicate with medical team, (3) develop a plan for missed assignments/exams, & (4) adjust schedule to accommodate reduce or modified attendance if needed
On the SCAT5 sideline assessment, you are assessing memory. What might you ask the patient?
First have them tell you what happened... Ask them: What venue are we at today? What half is it now? Who scored last in this match? What team did you play last week/game Did your team win the last game?
How does a concussion affect a neuron?
Force delivered to the brain --> disruptive stretching of neuronal cell membranes and axons --> complex cascade of ionic, metabolic and pathophysiological event
Describe the fifth stage of returning to sports.
Full contact practice Return to normal training activities. Assess psychological readiness. Symptoms should NOT worsen with activity.
What are the indications for OMT in concussion?
Headache, Dizziness, Visual Disturbances, Balance Issues, Depression, Fatigue, Neck Pain
What should your focus be in the patient has ongoing symptoms during the office/subacute assessment of a concussion?
If an athlete has ongoing symptoms, focus on excluding other pathologies and providing anticipatory guidance. Cervicogenic pain, headache/migraine disorder, mood disorders and peripheral vestibular conditions may either be the cause or may represent previous pathology worsened or unmasked by concussion
What might happen before the office/subacute assessment of a concussion?
It is not unusual for symptoms, signs, and testing to normalize by the time an office visit occurs --> focus on recommendations for safe return to school/sport/driving
What are some emerging concussion evaluation tools?
King-Devick Test Neurocognitive Test Apps Biomarkers
What are things that can complicate the diagnosis of concussion?
Lack of validated, objective diagnostic tests Reliance on self-reported symptoms Confounding symptoms caused by other commons conditions Symptoms delayed in onset or initially unrecognized by athlete
Describe the second stage of returning to sports.
Light aerobic exercise Walking, stationary biking, controlled activities that increase heart rate. Symptoms should NOT worsen with activity.
Describe the epidemiology of concussions.
Llimitations in SRC data due to injury definition, selection bias, reporting bias, incomplete surveillance Because of non-specific symptoms and lack of objective biomarkers, the true incidence and prevalence remains unknown Heightened awareness of and concern about SRC is associated with increased symptom reporting, which may not represent SRC
Describe the fourth stage of returning to sports.
Non-contact training drills Sport-specific, non-contact training drills that involve increased coordination and thinking. Progressive introduction of resistance training. Symptoms should NOT worsen with activity.
How can recovery be predicted in concussion patients?
The most consistent predictor of recovery from concussion is the number and severity of acute and subacute symptoms: - Subacute headache and depression after injury are risk factors for symptoms persisting for >1month - A preinjury history of mental health problems, particularly depression, appears to increase the risk for prolonged symptoms - Athletes with learning disabilities or attention deficit/hyperactivity disorder do not appear to be at risk for prolonged recovery
What is the risk factor of CTE?
The most widely described risk factor to date is extensive exposure to both multiple concussions and repetitive head impacts The degree of necessary exposure is likely specific to the individual and subject to multiple modifying risk factors
