PCS T –INTRO & VISIT #1 · 2020. 4. 17. · such as being tired (“lazy eye”) •Cross-Cover...

4/17/20

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PCS TREATMENT – INTRO & VISIT #1Evidence-Based Concussion Care

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Complete Concussion Management Inc. © 2019. All rights reserved

Presentation• Dx criteria are ICD-10 and DSM – (1-3 months or

greater)– Berlin à 14 days for adults & 1 month for children

• Pts will present with any number of symptoms–M/C HA, dizziness, concentration/memory difficulties– Anxiety, depression– Visual probs

• I start treating people as if they are PCS if they are still having symptoms after 10 days!

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Rehabilitation & Persistent Symptoms• Persistent Symptoms:– “Persistent symptoms do not reflect a single

pathophysiological entity, but describes a constellation of non-specific post-traumatic symptoms that may be linked to coexisting and/ or confounding factors, which do not necessarily reflect ongoing physiological injury to the brain.”

• Assessment of Persistent Symptoms:– At a minimum, the assessment should include a

comprehensive history, focused physical examination, and special tests where indicated (eg, graded aerobic exercise test). Currently, while there is insufficient evidence for investigations, such as EEG, advanced neuroimaging techniques, genetic testing and biomarkers, to recommend a role in the clinical setting, their use in the research setting is encouraged.

McCrory et al., 2017

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Rehabilitation & Persistent Symptoms• Treatment should be individualized and target-specific

medical, physical and psychosocial factors identified on assessment. – There is preliminary evidence supporting the use of:

• an individualized symptom-limited aerobic exercise program in patients with persistent post-concussive symptoms associated with autonomic instability or physical deconditioning

• a targeted physical therapy program in patients with cervical spine or vestibular dysfunction

• a collaborative approach including cognitive behavioural therapy to deal with any persistent mood or behavioural issues.

• Limited evidence to support the use of pharmacotherapy• “Overall, these are difficult cases that should be managed in

a multidisciplinary collaborative setting, by healthcare providers with experience in SRC.”

McCrory et al., 2017

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Practice Patterns in Pharmacologic and Non-pharmacologic Therapies for Children with Mild Traumatic Brain Injury: A survey of 15 Canadian and United States Centers

• This study was a survey sent out to 150 clinicians in the US and Canada who frequently see and treat pediatric mTBI/concussion – Clinicians included pediatricians, ER docs, family and sport medicine physicians,

physiatrists, neurologists, neurosurgeons, OT, PT, etc.• Results:

– Of the 65 (61%; [95% CI: 51,70]) respondents able to prescribe medications, non!steroidal anti!inflammatory medications (55%; [95% CI:42,68]) and acetaminophen (59%; [95% CI:46,71]) were most commonly recommended.

– One in five respondents reported prescribing amitriptyline for headache management after pediatric mTBI, whereas topiramate (8%; [95% CI: 3,17]) was less commonly reported.

– For cognitive problems, methylphenidate (11%; [95% CI: 4,21]) was used more commonly than amantadine (2%; [95% CI:0,8]).

– The most common non!pharmacologic interventions were rest (“always” or “often” recommended by 83% [95% CI: 63,92] of the 107 respondents), exercise (59%; [95%CI: 49,69]), vestibular therapy (42% [95%CI:33,53]) and cervical spine exercises (29% [95%CI:21,39]).

Mannix et al., 2019

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Practice Patterns in Pharmacologic and Non-pharmacologic Therapies for Children with Mild Traumatic Brain Injury: A survey of 15 Canadian and United States Centers

Mannix et al., 2019

Non-Pharmacologic Interventions Recommended

Pharmacologic Interventions Recommended

Notice how many people still do not recommend rehabilitation – we need to continue to educate! Also, there is still very little evidence to support the use of pharmacological interventions for concussion symptoms, yet the majority of physicians surveyed frequently prescribe medications…

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Assessment• Goal for PCS:– Determine what is causing their symptoms and

treat/rehab those mechanisms• May take several visits to determine true cause of

symptoms–My typical schedule:

• Visit 1 – History, Neuro, Education (similar to acute)• Visit 2 – Treadmill Test (similar to acute)• Visit 3 – Visual, Vestibular (VOMS), & Cervical Exams

– Ongoing – treatment and assessments as needed

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History• MOI, location of impact• LOC, PTA, multiple injuries close together – Lazzarino - sig metabolic decline

• Initial symptoms• Imaging? Have they seen other HC professionals for this?• Symptoms they are feeling now (with scores)• Previous hx of concussions, anxiety, depression,

headaches, add/adhd• Be weary of strange/non-descript symptoms – High symptom score (>35) – keep psychological aspects in

mind (somatization, catastrophization, Good Old Days bias)– You’re going to need to REALLY drive home education!

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Do you need an MRI?• Morgan et al., 2015

– Retrospective study of 23 pediatric patients with persistent PCS (3 months) who were referred for CT or MRI at least 2 weeks post-injury

– 1 of 19 MRI’s, 1 of 8 CT scans, and 0 of 5 X-rays yielded a significant positive finding – NONE of which altered clinical management in any way!

– “We estimate the cost to identify a single positive finding was $21,000 for CT and $104,500 for MRI”

• Bonow et al., 2017– Found that only 2 of the 427 MRI scans (0.47%) revealed possible trauma

related findings (16% demonstrated possible pre-injury findings)• Ellis et al., 2015

– “clinical neuroimaging studies are normal in the majority of pediatric patients with sports related concussion”

• Answer – only in the event of focal neurological issues

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Neuro & Physical• Cranial Nerves• Cerebellar Testing• Upper and Lower Limb Neuro

• Include some visual and vestibular testing as well if warranted– Smooth pursuits, cover-uncover/cross-cover, VOR testing– Dix-Hallpike, Supine Roll– Rule out need for prompt referral

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Visual Acuity• Ask about changes in vision– Blurriness

• Assess with snellen chart (unilaterally)–Make sure they are wearing corrective eye wear– Have they seen an optometrist recently

• Perhaps need a new prescription• Refer for new or worsening acuity problems

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Cover/Uncover Testing• Tropias – Double vision when both eyes attempt to lock

on to an object – always there• Cover/Uncover – cover one eye, then uncover that same

eye, the cover the same eye again, then uncover. Then repeat on opposite side– Esotropia – when one eye is covered, the uncovered eye shifts

outward as correction– Exotropia – when one eye is covered, the uncovered eye shifts

inward as correction– Hypertropia – when one eye is covered, the uncovered eye

shifts downwards as correction– Hypotropia – when one eye is covered, the uncovered eye

shifts upwards as correction

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Cross-Cover Test• Phorias – only get double vision at certain times

such as being tired (“lazy eye”)• Cross-Cover test – done after cover-uncover – only if

cover-uncover negative– Cover right eye then shift the cover right over to the left

eye and watch what happens to the right eye– Esophoria – eyes shift outwards as correction– Exophoria – eyes shift inwards as correction– Hyper/Hypophoria – one eye shifts upwards during cross-

cover and the other shifts downwards – can use either eye as reference point to describe condition

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Videohttp://www.youtube.com/watch?v=TxEQWtlXtrI

Treatment for these would be referral to a neurooptometrist

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Vestibulo-ocular reflex• Reflex eye movement that stabilizes images on the

retina by producing eye movement in the direction opposite to head movement

• Slight head movements are always present and VOR is very important for stabilizing vision

• This reflex happens in all directions• Semicircular canals cause most of the reflexes

which are a response to acceleration• The maintenance of balance is mediated by the

stretch of neck muscles as well as the pull of gravity on the utricle

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VOR pathway• Head is turned to right:– Excitatory impulses are sent from semicircular canals on

the right side via the vestibular nerve (CN VIII) and end in the right vestibular N of the brainstem. From here:• Excitatory signals cross over to the left abducens (CN VI) nucleus

causing stimulation of left lateral rectus• Excitatory signals are also sent via the oculomotor nerve (CN III) to

activate medial rectus on the right• Inhibitory signals are also sent to the right abducens nucleus to

inhibit right lateral rectus

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VOR pathology• Symptoms– Dizziness, Shaky vision (camera), Unable to read signs while walking

• Possible causes– Peripheral vestibular lesions – Vestibular neuritis– Central vestibular lesions (brainstem)– Cerebellar deficits– Age (over 75)

• Tests– VOMS– Dynamic Visual Acuity Testing

(https://www.youtube.com/watch?v=7SJYS37iESg)• Management – Gaze stabilization/Vestibulo-ocular rehab– referral to vestibular therapist with experience in this area if your

rehab is ineffective (4-6 weeks)

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VOR• http://www.youtube.com/watch?v=j_R0LcPnZ_w• http://www.youtube.com/watch?v=4EBwtckFfTo• VOR Cancellation Test (Cerebellum Test)• https://www.youtube.com/watch?v=ExOs7HSHv-c

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Vestibular Assessment for Immediate Treatment• Ongoing vertigo and also nystagmus?

(spontaneous or on gaze exam)– Vestibular Neuritis OR stroke– Perform HINTS exam to rule out or send to ER

https://www.youtube.com/watch?v=1q-VTKPweuk• Vertigo only coming on when in certain positions

and no nystagmus on gaze exam?– BPPV!– Posterior canals (85-90%) or Horizontal canals (10-15%)

• Can move between canals during procedures so important to know what to do!

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BPPV• Canalithiasis (loose debris)–More common– Latency of nystagmus (5 to 10 seconds)– Nystagmus decreases over time during testing (30-60

seconds)• Cupulolithiasis (stuck – adhered to cupula)– Rare– No latency of nystagmus– No decrease in nystagmus over time during testing

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Vertigo Assessment– Dix-Hallpike – used to assess posterior canals (85-90%)– Looking for upward beating nystagmus – expect strong

sensation of dizziness & nauseousness• 300 neck extention & 450 rotation and quickly lay the patient down

on to their back – Unaffected side 1st!• Observing for nystagmus/dizziness – some patients can suppress

nystagmus by focusing their gaze on an object in the room (Frenzel goggles or a piece of blank paper)– May be a latency for nystagmus so hold them in position for up to 30

seconds• Next we are going to put them towards the affected side – prepare

them that this is likely going to make them feel worse if this is the problem• Also be prepared to go right into the Epley’s repositioning

manoeuver from here.

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Epley’s Manouever• Effective for posterior canals only (ie. positive Dix-

Hallpike) - Canalithiasis• Hold each position for 2 mins

– Pos. 1 – 300 neck ext, 450 rotation to affected side in supine position

– Pos. 2 – 300 neck ext, 450 rotation to opposite side in supine position

– Pos. 3 – pt rolls on to unaffected side while maintaining 450 of neck rotation (looking down at floor)

– Pos. 4 – sit patient up so legs are off the table – keep head rotated 450 while bringing them up to sitting position• Seated for 2 minutes

• Re-test Dix to see if they still get nystagmus/dizziness• If no, they are done. If yes, repeat Epley’s again up to a

max of 3 times• Lightheadedness, postural vertigo and gait instability

can occur 1-3 days after procedure even when successful.

• Reoccurrence rate is approximately 50%

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Dix-Hallpike & Epley Maneuver Video

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Vertigo Assessment• If Dix-Hallpike normal but still suspecting BPPV• Supine Roll test – for horizontal canal BPPV• Looking for a lateral beating nystagmus– Head in slight cervical flexion

• rotate head quickly towards the left 900 and look for nystagmusand/or dizzy sensation• Bring head back to starting position and then quickly rotate head

to right 900 and observe for nystagmus and/or dizziness• Will likely be positive bilaterally however the “affected” side will be

the side that is the MOST AFFECTED– Treatment for horizontal canal BPPV:

• BBQ Roll manoeuver

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Nystagmus types• For lateral canal BPPV– Geotropic – typical - crystals located in the posterior

aspect of the horizontal canal (more common)• Nystagmus = fast component towards the ground• The downward ear on the side where the nystagmus is more

intense is the affected ear– Apogeotropic – less common - crystals are located in the

anterior aspect of the horizontal canal• Nystagmus = fast component away from the ground• Affected ear is the one with the less intense nystagmus when

lying on it

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BBQ-Roll Manoeuver• BBQ Roll• For each position wait for symptoms to

subside plus an additional 30 seconds– Pos. 1 – lay pt on their affected side with their

head in a neutral position– Pos. 2 – supine, head neutral– Pos. 3 – side lying towards unaffected side– Pos. 4 – prone lying up on elbows– Pos. 5 – Roll on to affected side again– Pos. 5 – sit up

• Re-test roll test – repeat procedure up to 3 times in one visit if necessary – If still positive try Gufoni Manouever

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Gufoni Manoeuver• Lateral Canal BPPV if BBQ roll unsuccessful• Geotropic Nystagmus (towards the ground)– Lay patient on UNAFFECTED side for 2 mins– Turn head 45 degrees towards the table for 2 mins – then

sit up – retest supine roll test • Apogeotropic Nystagmus (towards the sky)– Lay patient on AFFECTED side (side with LESS intense

nystagmus on roll test) for 2 mins– Turn head 45 degrees towards sky for 2 mins – sit up and

retest roll test

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Supine Roll Test, BBQ Roll, and Gufonivideos

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Great Case• https://www.youtube.com/watch?v=iOJOArGmepM

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Anterior CanalAnterior canal BBPV• Rare, with vertical nystagmus that

beats downward and can have torsional component

1. Patient starts seated, head midline

2. Transition from seated to supine with head hanging slightly off the table – hold for at least 1 minute

3. Patient bows their head 30 degrees toward the chest

4. After 1 minute sit the patient up *Authors note limited studies on this maneuver

Strupp & Brandt, 2018

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Next Steps• How have they been managed so far?– You will see the difficult patients! Especially when starting– Have they been resting since their injury?

• If so, you are going to want to start them on exercise– Have they not rested at all?

• If so - mandatory rest phase (1-2 weeks & re-evaluate)?? (use with caution)

• Education & Reassurance

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Education & Reassurance• What a concussion is?• ATP deficit – 30 day timeline• They are beyond that

– Education/Reassurance are key! – Resilience & psych studies relating to recovery are endless– need to continually reassure at every visit!!

– Drawing – this alone with reduce your patient’s symptoms significantly• 5 Main Causes of PCS & how we are going to tackle each one:

– Blood Flow (treadmill test à next day)– Metabolic/Inflammatory (here is the diet plan – referral to ND if 2 injuries

back to back)– Visual/Vestibular (we can assess and rehab if necessary)– Cervical (overlap between cervical injury and concussion)– Psychological

• Good-ol’ days, Misattribution of symptoms, Media Hype & anxiety, inactivity-related depression, cognitive fatigue and poor concentration (DMN vs. EN)

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What’s wrong with me?• Qualitative study looking at mTBI (42 still having symptoms (PCS), 31 not

having symptoms (non-PCS)• Validation:

– Injured (both PCS and non-PCS) patients described their efforts to seek clarification, explanations, a diagnosis, and a treatment plan • many healthcare providers did not believe them or challenged them, overturned previous

diagnosis, and challenged them again – caused confusion and distress– When patients felt that their symptoms and experiences were validated by

others and acknowledged as consequences of their injury they became reassured and had peace of mind – this allowed for hope and ultimately lead to recovery

– This is very important to keep in mind!! Education and reassurance are the number one ways to help people with concussion. You have to validate what they are feeling, provide possible explanations, and then take them through a concise and systematic plan of attack.• Diet Plan à Treadmill test à Visual & Vestibular à Cervical spine à psych counselling• Education & reassurance at every visit – proper sleep hygiene, meditation, stress

reduction, pacing, “the marathon” and being out of shape– This is tricky to do without completely medicalizing the condition and creating

a worse situation. You need to validate and then educate.

Snell et al., 2016

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What’s wrong with me?• “Feeling supported with a social scaffold, being

validated and reassured, and receiving credible information from health providers had buffering effects for participants. This provided hope and facilitated recovery and development of coherence about their experience”– “Being able to talk to someone and just have that

reassurance that what you were feeling and those kind of things that you experience are quite common and real... and knowing that I was going to get better. Because for a long time, it didn’t feel like I was going to get better.” [Participant 8: Non PCS]

Snell et al., 2016

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Depression & AnxietyTreatment for athletes with anxiety and mood profile• Referral to: Psychoeducation/psychotherapy, psychiatry, social worker• Cognitive Behavioral Treatment• Sleep! – the effect of sleep disturbance on cognitive function and

psychiatric disorders are well documented in the general population. – Disturbances quite common in concussion

• Physical activity! – exercise has been shown to improve mental health outcomes for individuals with psychiatric conditions. This is part of the reason we do the treadmill test! To get them more active

• Desensitization to the environment – it is not uncommon for individuals with anxiety and overlapping vestibular symptoms following a concussion to avoid provoking environments. Systematic desensitization can be used in concussion rehabilitation & is encouraged

• Mindfulness & meditation

Sandel, et al., 2017

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Depression & Concussion Lit Review• Concussion commonly said to lead to depression (bc it’s a

brain injury), but…– Depression is common in everyone (15-30% of college students)– Depression has been shown to occur following any injury to an

athlete• A comparison study between pre- and post-injury depression inventories

showed higher levels of depression in ACL injuries than in concussions (Mainwaring et al., 2010)

• Another study found no difference between non-concussion injuries and concussion injuries in terms of their depression scores at 1 week, 1 month, or 3 months post-injury (Roiger et al., 2014)

– Depression on it’s own has been shown to be correlated with worse neurocognitive performance (Covassin et al., 2012) as well as reaction time (Bailey et al., 2010)

– Pre-existing depression & anxiety is a strong predictor of PCS

Solomon et al., 2015

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Wearing sunglasses may prevent people from recovering from light sensitivity following concussion. Perhaps we should promote a gradual decrease in wear times for these pts!

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PCS drawing

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PCS Management Algorithm

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Main Causes of PCS:2. Metabolic/Inflammatory/Hormonal

• Injury causes metabolic dysfunction as well as an inflammatory response (possibly hormone imbalances)

• Metabolic levels mostly recover with 30 days (ATP), but lack of rest may prevent this

• Inflammation may be chronic – diet plan, referral to naturopath, anti-inflammatory meds, exercise may all

help

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Have they had adequate rest?• Lack of rest may delay metabolic recovery and may

be a reason for having ongoing symptomatology beyond 30 days– Initial case-series showed that rest periods were beneficial

even up to 1 year later in PCS patients!• New study from same authors found improvement in persistent

symptoms w/ mandatory 1-week rest period when paired with education and reassurance!

– So if they never took any time off, the next step is prescribing a week or more off work/school• Rest w/ a gradual re-integration into daily activities• Can also begin other appropriate rehab

Moser et al., 2012 & 2014

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Persistent Inflammation following concussion • Gut-Brain Axis• Brain injury induces neuroinflammation and

activates/primes microglia (macrophages of CNS). – Injections of inflammatory substances into the body ALSO

activates microglial cells on it’s own via pro-inflammatory cytokines influencing the CNS

– Hyperactive microglia predispose individuals to persistent symptoms & neurological disease.

– Head trauma can cause intestinal barrier dysfunction (AKA “Leaky Gut”). Leaky gut causes heightened immune responses and systemic inflammation. Many foods we eat can, over time, also lead to intestinal barrier dysfunction.

– Fig. 1. Proposed Conceptual Model for the Bidirectional Involvement of Gut-Brain-Microbiota Axis (GBMAx) following TBI: • a) Neurotraumatic event occurs. Rotational and/or linear

mechanical forces (e.g., acceleration/deceleration) of the event cause the ‘‘primary injury” to neuronal tissue. Locally, neuroinflammation occurs as a consequence of this mechanical insult and microglia become primed.

• b) Neurotrauma can cause structural (e.g., defective tight gap junctions) and functional (e.g., decreased smooth muscle contractility) damage to the GI tract.

• c) Both the functional and structural changes to the intestinal membrane results in increased intestinal permeability.

• d) Increased intestinal permeability promotes a state of endogenous endotoxemia. Toxins aberrantly permeating across the intestinal membrane trigger a systemic immune response with the release of pro-inflammatory cytokines (e.g., TNF-a, NFKB, IL-6).

• e) Systemic release of pro-inflammatory cytokines peripherally influences the CNS. These inflammatory cytokines act on the microglia to stimulate a state of neuroinflammation.

• f) Upon being peripherally stimulated by this systemic immune response in the gut, the microglial mediated neuroinflammation exacerbates the ongoing local secondary injury mechanisms.

Sundman et al., 2018

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Inflammation in PCS• Due to the possibility for ongoing inflammation as a

potential cause of chronic concussion symptoms, it is very important that we:1. Introduce the diet & it’s importance early in the acute phase

(reduces inflammatory response) – Need 100% uptake!1. No Gluten2. No Dairy3. No Refined Sugars4. No Alcohol

2. Introduce the diet in the chronic phase3. Consider referral for naturopathic or pharmaceutical

intervention if standard rehabilitation not helping with symptoms

4. Implement exercise program! Reduces inflammation and fatigue

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Next steps…• Try to reframe your thinking…– Your brain isn’t “damaged” – Start thinking positively (avoid fear avoidance)

• Self-talk and it’s impact on concentration, memory, & fatigue– Symptoms are ok!

• Diet!! Start today!• Next time I see you, treadmill test– “don’t worry it’s just a walking test”

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PCS T –INTRO & VISIT #1 · 2020. 4. 17. · such as being tired (“lazy eye”) •Cross-Cover...

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Transcript of PCS T –INTRO & VISIT #1 · 2020. 4. 17. · such as being tired (“lazy eye”) •Cross-Cover...