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Interventions in the Interventions in the Management of Management of ConcussionsConcussions
Anne Felicia Ambrose M.D., M.S., FABPMRAnne Felicia Ambrose M.D., M.S., FABPMRMedical Director , Traumatic Brain Injury ProgramMedical Director , Traumatic Brain Injury Program
Icahn School of Medicine at Mount Sinai Icahn School of Medicine at Mount Sinai New York, NYNew York, NY
Department of Emergency Medicine
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Approach to the Management of Concussion
1. Pre-Injury1. Create and Implement legal safeguard at state, national, Sporting
Body level2. Changes to the Game-Rules of Play3. Protective equipment; 4. Pre-injury assessments
2. Injury1. Assessments-On the sidelines, ED, Doctor’s Office- Screening,
Imaging
3. Post Injury Interventions1. Rest2. Return to Play Protocol3. Physical and Occupational Therapy4. Cognitive and Behavioral Assessments and Therapy5. Vision Therapy6. Vestibular Therapy7. Drug Therapy8. Retirement
Department of Rehabilitation Medicine
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Features of sport-related concussion
SYMPTOMS/PHYSICAL SIGNS
SLEEP DISTURBANCES
COGNITIVE IMPAIRMENT
EMOTIONAL/ BEHAVIOURAL CHANGES
Loss of consciousnessHeadacheNausea/VomitingDizzinessLoss of balance/poor coordinationVisual disturbancesPhotophobiaAmnesiaDecreased playing ability
DrowsinessTrouble falling asleepSleeping more than usualSleeping less than usual
Slowed reaction timesDifficulty concentratingDifficulty rememberingConfusionFeeling in a fogFeeling dazed
IrritabilityEmotional labilitySadnessAnxietyInappropriate emotions
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Basic Principles-Post Injury Interventions
1. Rest-Physical and cognitive rest until
asymptomatic
2. Graded program of exertion
3. Additional Evaluations and Interventions
4. Medical clearance
5. Return to play.
Department of Rehabilitation Medicine
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Rest-Physical and Cognitive
1. Collegiate and High School students athletes who RTP on
the same day have poorer outcomesNeuropsychological deficits post-injury that may not be evident on the
sidelines and are more likely to have delayed onset of symptoms..
2. Malignant brain edema syndrome-seen rarely, but almost
exclusively in young athletes
3. Second Impact Syndrome
4. Young (<18) elite athlete should be treated more
conservatively even though the resources may be the same
as an older professional athlete
Department of Rehabilitation Medicine
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Fatigue and Sleep
1. Incidence
2. Clinical features
3. Associative factors-Pain, Pain meds, Females, Depression, Anxiety, time from injury
4. Association with cognition-slower in attentional tasks
5. Sleep disturbances-Drowsiness. Trouble falling asleep, Insomnia, Hypersomnia
6. Treatment
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Headaches
Investigation
CT scans be helpful in ruling out serious bleeding injuries, but cannot
diagnose a concussion or headache.
Treatment
1.Rest, Avoid second concussion especially in first 10 days
2.Medications
a. No medicine that clearly alleviates post concussive headache.
b. Regular headache medications may help.
c. Preventive medications if not resolved within a month. (SE-increase fatigue,
weight, or memory, confusion) especially in athletes with long playing history, prior
+/- recent concussions, Apo E
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Cognitive Impairment
1. Incidence
2. Clinical Features-Slowed reaction times, Difficulty concentrating and
remembering, Confusion, Feeling in a fog or dazed
3. Cognitive RestructuringForm of brief psychological counseling that consists
of education, reassurance, and reattribution of symptoms
4. Cognitive And Behavioral Assessments and Remediations
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Visual Deficits
Department of Rehabilitation Medicine
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Approach to Common Vision Deficits Following TBI
Department of Rehabilitation Medicine
Deficit Primary Associated Symptom: Treatment
Accommodation Constant/intermittent blur Lenses, restorative accommodation training
Tear Film Integrity
Distorted clarity/gritty sensation, which varies with blinking
Eye drops
Versional Ocular Motility
Slower, less accurate reading /difficulty sustaining gaze, shifting gaze, or tracking targets
Basic scanning and searching exercises Typoscopic approach
Vergence Ocular Motility
Constant/intermittent eyestrain / diplopia eliminated with monocular occlusion
Fusional prism,;Varying degrees of occlusion ; Vergence stabilizing exercises
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Approach to Common Vision Deficits Following TBI
Deficit Primary Associated Symptom: Treatment
Visual-Vestibular Interaction
Disequilibrium exacerbated in multiply, visually-stimulating environments
Adaptive exercises using graded provocations.correct accommodation
Light-Dark Adaptation
Elevated light sensitivity Tinted lenses
Visual Field Integrity
Missing a portion of vision Yoked or spotted prisms, mirrors, and field expanding lenses ,scanning strategies and compensatory/ adaptation approaches
Visual processing
Slower speed/impaired visual memory and visual-spatial processing
Adaptive and restorative exercises
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Nausea/Dizziness/Vertigo/Loss of BalanceCauses of dizziness, Impaired balance or vertigo
1. Benign paroxysmal positional vertigo (BPPV),
2. Labyrinthine concussion,
3. Perilymphatic fistula (PLF),
4. Post-traumatic Meniere Syndrome (hydrops),
5. Temporal bone fracture,
6. Cervical (cervicogenic) vertigo,
7. Epileptic vertigo,
8. Migraine associated vertigo and ocular motor abnormalities.
Department of Rehabilitation Medicine
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Symptoms of Post-concussive Vestibular And Balance Dysfunction
1. Dizziness (55–78%),
2. Impaired Balance (43–56%),
3. Blurred Vision Or Diplopia (49%)
(Lovell, 2009).
Department of Rehabilitation Medicine
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Approach to Treatment of Vestibular Dysfunction
1. Rest
2. Evaluation if symptoms persist >2 weeks
3. Medications-avoid meclizine, Aspirin
4. Assessments1. Detailed history of concussion occurred,2. Initial presenting symptoms, 3. New or existing medications, 4. Prior history of concussions, or any past imaging or treatment.5. Clinical diagnostic tools are used to determine the severity of the symptoms
to identify potential structural lesions. 1. Balance Error Scoring System (BESS) test, 2. computerized dynamic posturography (CDP) which includes balance tests, the
Sensory Organization Test, and visual tracking technologies
(Lovell, 2009)
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Type and purpose Theoretical description Example
Canalith repositioning maneuver(Curative for BPPV)
Diagnostic and therapeutic maneuvers simple and effective for BPPV
Repetitive head movements
Habituation(For impaired motion sensitivity)
Provocation of stimuli induces symptoms; enhances vestibular compensation; requires repetition; intensity of exercise proportional to severity of symptoms
Head position or movement inducingdizziness or vertigo
Adaptation(For impairments in convergence)
Enhancement of intact vestibular circuits to compensate for loss of function within same system; Use of retinal slip during head movement(verticle or horizontal)
Instructed to move head while maintaining focus on moving (VOR1) or stationary(VOR2) target. Degree of difficulty of exercise increased progressively
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Type and purpose Theoretical description
Example
Substitution(For major vestibularimpairment)
Replacement of deficient vestibular system byenhancement of ocular systems
Exercises that facilitate preprogrammed eyemovements to scan field and detect targetin order to prompt head and neckmovements to override vestibular-ocularreflex
Balance exercises(To enhance supportive balancesystems)
Positional Exercises
Proprioceptive Neuromuscular Facilitation
Static balance= alternating visual and somatosensory input, with change of support base-> Wide vs Narrow
Dynamic balance= higher level of challenge. Head turning while walking; quick head turn (right or left) while walking; incorporating task while walking-> tossing an object or cognitive task while walking
Aerobic exercise(To strengthen balance viamuscle conditioning)
Promotes strengthening of muscle groups to helpimprove balance reaction time
Progressive walking exercise with increasetime and intensity. Advance gradually tosustained aerobic activity.
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Pharmacological therapy in sports concussion
1. Role of pharmacological approach 1. Management of specific prolonged symptoms (e.g. sleep disturbance,
anxiety etc..).2. Modify the underlying pathophysiology of the condition with the aim of
shortening the duration of the concussion symptoms.
2. An important consideration in RTP is that concussed athletes should not
only be symptom free but also should not be taking any pharmacological
agents/medications that may mask or modify the symptoms of
concussion.
3. Where antidepressant therapy may be commenced during the
management of a concussion, the decision to return to play while still on
such medication must be considered carefully by the treating clinician.
Department of Rehabilitation Medicine
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Retirement
1. Professional athletes with a history of multiple
concussions and subjective persistent neurobehavioral
impairments
2. Counseling. about the risk factors for developing
permanent or lasting neurobehavioral or cognitive
impairments and should recommend retirement from
the contact sport to minimize risk for and severity of
chronic neurobehavioral impairments
Department of Rehabilitation Medicine
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Play Safe Program at Mount Sinai