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Cat C

on 9 May 2014

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Transcript of Concussion

What every physiotherapist should know
How do we Assess and Manage Acute Concussion?
Physiotherapy and
Post Concussion Syndrome

Recognize a Concussion
Catherine Chan
Step Up 2013
“Concussion is a brain injury and is defined as a complex pathophysiologicial process affecting the brain, induced by biomechanical forces…”
McCrory P et al. 2013
Step Up 2013
Concussion vs. mild TBI
Step Up 2013
Altered membrane conductivity (abrupt neuronal depolarization with release of neurotransmitter, followed by depression of neuron activity
Altered glucose metabolism
Altered membrane protein expression with subsequent impaired axonal function
Alterations in regional cerebral blood flow
Pathophysiology of Concussion
Unsafe to return to sport until brain activity has returned to normal
Period between concussion and recovery: “window of vulnerability” (return to play during this time could cause more severe or even catastrophic brain injury.)
Why are individuals post concussion so tired?
Energy Crisis in the Brain
Neurometabolic Cascade following TBI (Giza & Hovda, 2001)
Step Up 2013
Concussion is a clinical diagnosis.

Clinicians need to consider one or more of the following:
Observed mechanism
Neurological examination - Physical signs
Behavioural changes
Cognitive impairment
Balance evaluation
Sleep disturbance
Step Up 2013
Pocket Concussion Recognition Tool
Step Up 2013
Somatic symptoms
Visual disturbances, dizziness, balance difficulties, headaches, light sensitivity, nausea/vomiting, phonophobia
Anxiety, emotional lability, sadness, irritability, fatigue
Cognitive Symptoms
Attention problems, memory dysfunction (amnesia), “fogginess”, fatigue, cognitive slowing, confusion, LOC, disorientation, "zoned out", vacant stare (inability to focus), delayed verbal and motor responses (slurred/incoherent speech), excessive drowsiness
Sleep Disturbance
Difficulty falling asleep, sleeping more/less than usual
Symptoms of Concussion
Step Up 2013
Reduced planning and ability to switch mental set
Impaired memory and learning
Reduced attention and ability to process information
Slowed reaction times, and increased variability of responses
Neuropsychological deficits in acute concussion
Step Up 2013
If you suspect a concussion:
Evaluation by physician or other healthcare provider on site (exclude Csp involvement)
Determine appropriate disposition
Address first aid issues
Perform assessment tool (SCAT3)
If diagnosed concussion, player should not be allowed to Return to Play on the day of injury
On field or sideline evaluation of acute concussion
Step Up 2013
4 page recently updated document

SCAT 3 is the product of experts with the goal of producing the most sensitive and reliable concussion assessment

Good evidence to support the use of each component (scored independently)

Child SCAT3 available
Step Up 2013
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Return to Learn/School should precede return to activity

“Communication and collaboration between student, parents, educators and health care providers is vital”
Return to Learn
Step Up 2013
Return to Activity
Step Up 2013
Do not drive for at least the first 24 hours post injury
Avoid alcohol and other recreational drugs
Do not attempt to resume all of your usual activities at the pace prior to the concussion
Reduce distractions in your environment
Pre-plan your activities – give yourself more time
Eat a balanced and nutritious diet
Patient Education
Focus is to reduce the potential of further injury/stress to the brain.
Resting the brain (limit screen time, texting, video games, reading, being in a stimulating environment e.g. the mall, a hockey game..) and getting a good rest (restorative sleep).
No additional forces to the head/brain.
No interference with physiological recovery.
Avoiding activities that produce symptoms.
Avoiding over-exertion of the body or brain.
Ways to over-exert: physical; emotional; cognitive
Keys to Recovery
(Gioia, 2009)
Colorado Dept. of Education: Concussion Management Guidelines, 2012
Authors: Karen McAvoy, PsyD and Kristina Werther, LCSW
Step Up 2013
Provide information and reassurance routinely
Don’t wait for failure
Provide active management of a gradual process
Encourage support from the family and significant others
Provide treatment for specific symptoms
Understand the true essence of the individual’s type of work
Return to Work
Concussion 101: A Primer for Kids and Parents (Uploaded by Doc Mike Evans Dec. 2011)
Concussion Education for All
Purcell 2012
Step Up 2013
Multifactorial approach
Education – website resources
BC Injury Prevention Centre (based in VGH)
Includes free games and wipeout videos for sport and recreation.
Protective equipment, engineering
Wear a seat belt and use correctly sized child car seats
Proper sport techniques
Rule changes, sportsmanship and Legislation
Baseline testing
Concussion policy and Action Plan
Step Up 2013
Step Up 2013
“The majority (80-90%) of concussions resolve in a short (7-10 day) period, although the recovery time frame may be longer in children and adolescents” (McCrory et al 2013)
Concussion recovery
Step Up 2013
Constellation of symptoms that persist from days to weeks following injury
“slow to recover”; “difficult patient”
Defined as symptoms persisting for greater than a month or 3 months

Post concussion syndrome
Acute Concussion Management
Step Up 2013
Low intensity aerobic exercise may be of benefit (Schneider 2013)
Gagnon et al. 2009
Leddy et al – Subsymptom exercise
Exertional testing
VCHRI Team grant RCT
Active Rehabilitation post concussion
Step Up 2013
Functional Gait Assessment
Sensory Organization Test
Community Mobility and Balance Scale
Components of the BOT-2
Functional Movement screen - jumping jacks, single leg hops, running
Non-formal testing
PCS: Balance and Coordination
Step Up 2013
Modified Shear tests
Cervical Rotation Test, smooth pursuit torsion test
Screen for Cervicogenic dizziness
Deep neck flexors
General mobilisation and stretching
Cervicogenic contributions to PCS
Step Up 2013
Causes: Post traumatic BPPV, peripheral vestibular, anxiety related dizziness, cervicogenic dizziness, autonomic dysregulation, oculomotor abnomalities, central gaze stability impairment, medication, and migraine related dizziness

Screen for BPPV
Convergence impairments
Test dynamic visual acuity

Treatment: Schneider K 2012.
Dizziness and Concussion
Step Up 2013
Occulomotor Screen
Dizziness Handicap Inventory
Motion Sensitivity Questionnaire
Visual Analog Scale
Adaptation Exercises
Habituation Exercises
Substitution Exercises
Vestibular Rehabilitation
Step Up 2013
Traumatic Brain Injury Resource Network (Colorado-based)http://cokidswithbraininjury.com/
A guideline on concussion management for the whole team
US Centers for Disease Control and Prevention www.cdc.gov/concussion/index.html
Excellent site includes Heads Up for Schools information materials, online training for coaches, information for athletes and families.
WETA (part of PBS in Washington,DC) project for preventing, treating and living with TBI http://www.brainline.org/landing_pages/features/blkids.html
Step Up 2013
Sports Concussion Library
Canadian site with access to research, concussion info for children, youth and their parents, SCAT -3 for sports teams)
Sun Life Financial Chair in Adolescent Mental Health
excellent Canadian site utilizing ‘best scientific evidence translated to programs/resources/tools for teens, families, educators, health care professionals’
Link to brain injury and video on ‘The Teenage Brain’
Mental Health and High School curriculum includes Teacher training modules
Concussion resources (not inclusive)
Step Up 2013
Parachute – Leaders in Injury Prevention (amalgamation of Thinkfirst Canada, Safe Kids Canada, Safe Communities Canada, and SMARTRISK)
Thinkfirst has downloadable concussion cards
Concussion Awareness Training Toolkit (CATT)
TBI Focus Rehabilitation Research and Training Center on Interventions for Children and Youth with Traumatic Brain Injury http://tbifocus.org
Concussion and neurotrauma education site started by former Philadelphia Flyer Keith Primeau (Toronto-based, not-for-profit)
Concussion resources (not inclusive)
Step Up 2013
BC Injury Prevention Centre (based in VGH)
Free games and wipeout videos for injury prevention in sports and recreation www.injuryfreezone.com
Brainstreams – project of The Pacific Coast Brain Injury Conference Society http://www.brainstreams.ca/
BC Brain Injury Association
Brain Injury Association of Canada http://biac-aclc.ca/en/
Center on Brain Injury Research and Training, Western Oregon University http://cbirt.org/
Concussion resources (not inclusive)
Step Up 2013
Community Brain Injury Program for Children and Youth (up to 19 years of age for all of BC 604-45-.5511)

GF Strong Rehab Centre: Early Response Concussion Service – Adolescents and adults (ages 12 and up) 604-734-1313

GF Strong Rehab Centre: Adolescent/Young Adult Services Outpatient Program (for slow to recover youth 12 – 18 years). Referral by physician 604-737-6291

Fraser Health Concussion Clinic (16 years and up for those living in Fraser Health Region) 604-520-4175
Concussion Services
Concussion Resources
Step Up 2013
Adolescent and Young Adult team at GF Strong
Kathy Wong OT), Dr. Jacqueline Purtzki (Physiatry), Dr. Larissa Mead-Wescott (Neuropsychologist), Veronika Larson (SLP), Erin Crawford (OT), Harjit Dhaliwal (SW), Lara Heller (RecT), Haley Wicklow (RecT), Carley Gabbott (OT), Jennifer Loffree (OT), Helen Salatellis (Teacher), Robyn Littleford (Teacher)
Affiliated Researchers
Dr. Noah Silverberg, Dr. Grant Iverson, Dr. Isabelle Gagnon
Step Up Committee – THANK YOU!
Recently revised at the 4th International Conference on concussion (Nov 2013)

Apps, Jennifer and Walter, K. (2012) Pediatric and Adolescent Concussion: Diagnosis, Management, and Outcomes. Springer, 2012.
Bakhos, L.L., Lockhart, G.R., et al. (2010). Emergency department visits for concussion in young athletes. Pediatrics, 126 (3), e550-e556.
Barlow K, Crawford S, Stevenson A, Sandhu S, Belanger F, Dewey D. (2010)Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury. Pediatrics: 12610 (2), 374 – 381
Benson BW, McIntosh AS, Maddocks D et al. What are the most effective risk-reduction strategies in sport concussion? Br J Sports Med 2013; 47:321-326
DeMatteo, C.A., Hanna, S.E., Mahoney, W.J., Hollener, W.J., Hollebery, R.D., Scott, L.A., et al. (2010), My child doesn’t have a brain injury, he only has a concussion. Pediatrics.125 (2). 327-34
Echlin P, Tator C et al. (2010)Return to play after an initial or recurrent concussion in a prospective study of physician-observed junior ice hockey concussions: implications for return to play after a concussion. Neurosurgery Focus. 29 (5). 1 – 5
Gessel, L.M., Fields, J.D. , Collins, C.L., et al. (2007). Concussions among United States high school athletes, Journal of Athletic Training, 46(4), 495-503.
Gioia G. The latest guidelines of concussions in the Young Student-Athlete. Children’s National Medical Center, Retrieved online Oct. 2011.Gioia G, Collins M, Isquith P. (2008) Improving identification and diagnosis of mild traumatic brain Injury with evidence: psychometric support for the acute concussion evaluaton. Journal of Head Trauma Rehabilitation. 23 (4), 230 – 242
Gioia G.A., Schneider, J.C., Vaughan, C.G. et al. (2009). Which symptom assessments and approaches are uniquely appropriate for pediatric concussion? British Journal of Sports Medicine, 43 (suppl 1), i13-i22.
Halstead M, Walter K and Council on Sports Medicine and Fitness. (2010) Sport-related concussion in children and adolescents. Pediatrics. 126 (3). 597-612
Iverson, G., Gagnon, I. And Griesbach, G. (2011) Active Rehabilitation for Slow-to-Recover Children Following Mild Traumatic Brain Injury.
Draft book chapter. 1 – 19Johnson K, Davidson L. (2005) Concussion information for athletes. Think First – SportSmart Concussion Education and Awareness Program. 125 (2). 1 – 7
Keenan, H. (2006)Epidemiology and Outcomes of Pediatric Traumatic Brain Injury. Developmental Neuroscience. 28. 256 - 263
Koutures C, Gregory A and Council on Sports Medicine and Fitness.(2010) Injuries in youth soccer. Pediatrics. 125 (2)410 -414L
aker, S. (2011) Return-to-play decisions.. Physical Medicine Rehabilitation Clinics North America: 22 (619-634)Majerske CW, Mihalik JP, Ren D, et al. (2008) Concussion in sports: postconcussive activity levels, symptoms, and neurocognitive performance. J Athl Train 2008; 43 (3); 265 – 74
Makdissi M, Davis G, Jordan B, et al. Revisiting the modifiers: how should the evaluation and management of acute concussions differ in specific groups? Br J Sports Med 2013; 47:314-320.
McAvoy, K. (2009). REAP the benefits of good concussion management. Retrieved from http://www.ochs.orecity.k12.or.us/sites/ochs.orecity.k12.or.us/files//2011-2012-pages/REAP.pdf
McAvoy, K and Werther, K.(2012) Concussion Management Guidelines and Research-Based Practice - Return to Learning:Going Back to School Following a Concussion, Colorado Department of Education.
McRory P, Meeuwisse W, Johnston K et al. (2009) Consensus Statement on Concussion in Sport: 3rd International Conference on Concussion in Sport held in Zurich 2008. British Journal of Sports Medicine: 43 (iSupp). 76 – 84http://www.nimh.nih.gov/health/publications/the-teen-brain-still-under-construction/the-changing-brain-and-behavior-in-teens.shtml (National Institute of Mental Health, 2011)
McCrory P et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in sport held in Zurich, November 2012. Br J Sports Med. 2013;47:250-258.
McCrory P et al. What is the lowest theshold to make a diagnosis of concussion? Br J Sports Med 2013;47:268-271.
Purcell LK. Evaluation and management of children and adolescents with sports-related concussion. Canadian Paediatric Society 2012: 17(1):31-
Putukian M, Raftery M, Guskiewicz K et al. Onfield assessment of concussion in the adult athlete. Br J Sports Med. 2013;47:285-288.
Sabini R., Reddy, C. (2010) Concussion Management and Treatment Considerations in the Adolescent Population.
Sady, M., Vaughan, C, Goioia, G.(2011) School and the Concussed Youth: Recommendations for Concussion Education and Management. Physical Medicine Rehabilitation Clinics North America : 22 (701- 719)
Schneider KJ, Iverson GL, Emery CA et al. The Effects of rest and treatment following sport-related concussion: a systematic review of the literature. Br J Sports Med 2013;47:304-307
Tator, C.H. (2009)Let’s standardize the definition of concussion and get reliable incidence data. Canadian Journal of Neurological Sciences, 36, 405 – 406.
Thomas M., Haas, T., et al. (2011) Epidemiology of Sudden Death in Young, Competitive Athletes Due to Blunt Trauma. Pediatrics, 128www.cdc.gov/concussion/HeadsUp/youth.html Heads up: concussion in high school sports. Accessed April 2012. www.cdc.gov/healthyyouth/adolescenthealth/connectedness.htm School Connectedness. Accessed April 2012.
Putukian 2013
McCrory 2013
McCrory et al. 2013
Sady 2011
Concussion modifiers
Comorbidities and premorbidities
Makdissi 2013
McCrory 2013
McAvoy, K and Werther, K. Colorado Dept of Education: Concussion Management Guidelines, 2012.
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