Brain Work: Concussion Evaluation for Physical Therapists

Welp….I owe you all an apology.  You may have noticed that I’ve been a little inconsistent with my posting this month (or maybe only my boyfriend and my mom read this regularly, who knows…).  I don’t really have a good excuse, just that PT school has been pretty rough this semester. I’ve been struggling to balance class, clinic, study time, being a new dog mom, and surgery rehab (read: getting my fat ass back in shape after 3 months with no intense cardio LOL) and there has been very little space left in my brain for blog creativity. Aimee has a better excuse, she’s been kicking ass on her last clinical rotation and getting ready to GRADUATE in just two months!

But anyway:  I have the day off from class today, and I also have a Neurological Patient Management written exam next week, so….what better way to procrastinate actual studying than by providing you all with some pro tips on concussion management? Today, we will talk about how to recognize and differentially diagnose concussion, and I’ll present a comprehensive list of things you MUST examine in a concussed athlete.  Next week, we’ll cover treatment.

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How often have you sports nerds sat in your Neuro Patient Management course and thought “ugh why is this relevant to me? I want to work with ATHLETES, not stroke patients!”  Well…first, it’s actually highly relevant to you if you want to pass your board exam and actually be allowed to practice, as I talked about here.  But it’s also ESPECIALLY relevant if you want to be a sport specialist clinician.  Especially if you want to be an on-the-field provider.  Athletes are going to bump into each other every now and then, especially in sports like football, soccer, and rugby, and so you need to be able to perform a class-act neurological screen to properly diagnose and intervene in the concussed athlete.

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I’ve suffered two concussions in my life.  The first was while skiing down a black diamond slope as a sixteen year old – I had to swerve out of someone’s way and swerved right into a fence.  I lost consciousness for about two minutes.  The second time was not as badass – I was running on a treadmill at the gym and a really hot guy walked by me and swept me off my feet.  literally LOL. I didn’t lose consciousness that time, but I kinda wish I had to avoid the embarrassment?

Here’s the interesting thing about concussions.  You don’t actually need to collide with anyone or anything to get them.  Concussions occur via  a “coup-contracoup” mechanism whereby a force applied to the body throws the head forward or backward, and the brain collides with the skull and/or experiences shearing force from the movement. Concussions can occur just as easily with  whiplash as they can with a poorly executed soccer header (and, further, a well executed soccer header need not cause concussion!)

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The other important thing to note: The severity of the impact does not matter, and you DO NOT NEED TO LOSE CONSCIOUSNESS to have a concussion!

But anyway, some of the symptoms I experienced afterword, which are indicative of concussion, included:

-Raging headache

-Dizziness

-Fatigue and generally feeling “out of it”

-Irritability (I was very snappy and impatient with people)

-Insomnia

-Trouble concentrating on my schoolwork

-Memory difficulty

-Trouble handling my normal stress and schoolwork load without feeling overwhelmend

-Light sensitivity

-Sensitivity to loud noises.

Sounds….kinda like a migraine, right? This isn’t so much important for on the field analysis, but if an athlete is coming to you in an outpatient setting, you need to be able to differentially diagnose!

Consider this case:  Sixteen year old female soccer player comes to your clinic with a primary complaint of medial knee pain following a collision with another teammate during soccer practice one week ago. Past medical history is significant for migraines. In the past week, she has also been experiencing dizziness, fatigue, mood swings, difficulty concentrating, sensitivity to light, and intolerance of loud noises. she has had difficulty reading things close up.

First, your subjective history and interview is crucial.  You’ll want to know:

-The DETAILS of that collision. How forceful? was there any direct contact to the head?

-Was she screened for concussion at the time of injury? (if it was in practice, this is actually unlikely – most high schools do NOT have an athletic trainer at every practice, especially if the sport isn’t football!)

-How frequently does she typically experience migraines? What are her typical migraine symptoms like?

-What does she think is going on? Does she think this is a migraine? What does she know about concussion?

Take notes – her answers will tell you what kind of education you provide, and where to start your interventions.  But first – the physical exam.

This is where your NEURO SCREEN comes in!  With concussion, you will likely have positive results on some of these tests. With migraine, you won’t.  If you suspect concussion at ANY point along the patient’s continuum of care – whether you’re on the field and watch them crack skulls with an opponent or you’re seeing them weeks later for persistent concussion symptoms, orthopedic injuries, or performance coaching (YES PHYSICAL THERAPISTS DO THIS), you need to be proficient at the following elements of a neuro screen to correctly diagnose and manage your athletes:

  • The Glasgow Coma Scale.  Guys, another important note: Concussion is NOT the same as a traumatic brain injury (be glad for that!).  An individual with concussion will score between a 13-15 on the GCS.  Any score below that and they are classified as  TBI and you need to get them to an emergency room asap.
  • coma_scale
  • Cranial Nerve Exam.  This should take you less than two minutes, so get good at it.  As the cranial nerves come from the brain (hence their name, you know), there is potential for cranial nerve injury with concussion.  Make sure you check this.
  • Check out this video for the Cranial Nerve Exam: 
  • Vestibular/Oculomotor Screen (VOMS): Again, there is potential for damage to the vestibular and ocular systems following a concussion.  Things you need to check:
    • Smooth Pursuits (how well can they track a target with their eyes? If it’s jerky/they need to use saccades to do it, or if they’re unable to maintain focus, that’s a problem)
    • Saccaddes (how well they are able to jump from one visual target to another without moving their head)
    • Convergence (when you bring a target closer to their nose, at what point do they begin to see double?)
    • Vestibulo-Ocular Reflex (VOR): Can they keep their eyes fixed on a target while their head is moving?
    • Visual Motion Sensitivity 
  • (See the link to the Duke Concussion Testing video below for examples of how to perform these tests) 
  • Cognition:   Notice how some of the symptoms listed above include non-physical symptoms like irritability, insomnia, fatigue, and difficulty concentrating? Cognition can sometimes be a little sluggish after trauma to the brain, so you will need to assess this in order for the athlete to make a full return to work or school. Some assessments to consider:
    • A&O x 4
    • Immediate Recall (“I’m going to read three words; repeat them back to me”)
    • Delayed Recall (5-10mins later: “remember those three words we read earlier? Repeat them back to me again”)
    • Concentration ( count backwards from 100 by 7s)
  • Coordination and Balance:  This is all based on your brain’s ability to interpret visual, sensory, and proprioceptive signals!
    • the BESS (Balance Error Scoring System) is a good outcome to use that is challenging enough to capture deficits in an athlete (most of my classmates and I had a lot of trouble with this)
    • You can also use the Romberg Test
    • Also, the Sway Balance App – which you do have to pay for but it’s a much more objective measure of postural sway than the BESS and ROMBER

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  • BPPV Testing:  impact to or forceful motion of the brain can sometimes result in BPPV (Benign Paroxysmal Positional Vertigo), which causes a lot of nausea and dizziness with certain head movements.  BPPV can really detract from your ability to treat concussion, so if it’s present you need to treat it first! Fortunately, BPPV is a quick fix for most patients – all you have to do is body slam em (but actually).
  • Cervical Exam – Your head is attached to your neck right?? This can also help you differentially diagnose concussion headache from cervicogenic headache! The treatment, after all, would be very different for those two. A good cervical exam includes:
    • AROM (with overpressure if pain free; also assess the effect of repeated motions)
    • Spurling’s and ULTT
    • PROM
    • Passive Accessory motion (joint play)
    • Strength testing of the cervical musculature
    • PALPATION

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Stay tuned! Now that you’ve completed a thorough examination of your athlete, next week we will talk about treatment options and why physical therapists are the provider of choice for the athlete dealing with post-concussion syndrome!

 

Special thanks to:

-Dr. Corinna Martinez, PT, DPT, SCS, LAT, ATC

-Dr. Jeff Hoder, PT, DPT, NCS

REFERENCES:  Please check out the Duke University K-Lab’s Concussion Testing Videos for more info

 

 

 

 

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