Concussion Current Research and Best Practice

David Brooks MD Dip Sport Med CIME

Clinical Services Manager WorkSafeBC

November 20 2015 Nanaimo Brain Injury Society

Dr Brooks background experience- MTBI

Research thesis on concussion in young ice hockey players 1999

Computerized neuropsych testing of 100rsquos of hockey players 2000-2010

Consultation to professional and amateur athletes on concussion Medicolegal consultations non-sports head injury consults (falls MVAs)

Work with VAC and RCMP on injured soldierspolice officers

Peer reviewer on head injuries Clinical Journal of Sports Medicine British Journal of Sports Medicine

httpsenwikipediaorgwikiConcussion -accessed Sept 215

3

Dr Brooks background experience- MTBI

Research thesis on concussion in young ice hockey players 1999

Computerized neuropsych testing of 100rsquos of hockey players 2000-2010

Consultation to professional and amateur athletes on concussion Medicolegal consultations non-sports head injury consults (falls MVAs)

Work with VAC and RCMP on injured soldierspolice officers

Peer reviewer on head injuries Clinical Journal of Sports Medicine British Journal of Sports Medicine

httpsenwikipediaorgwikiConcussion -accessed Sept 215

3

httpsenwikipediaorgwikiConcussion -accessed Sept 215

3

Goals

1 Understand the basics of TBI and touch on some of the more complex issues eg PTSD anxiety depression PCS

2 Understand some of the difficulties in diagnosing and managing these cases

3 Whatrsquos new in the research literature

Prepare to be amazed and probably confused

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

mTBI in the Canadian Forces Does Afghanistan Change Things

LCol Rakesh Jetly MD FRCPC

Directorate of Mental Health

Canadian LAV (Nyala light armoured vehicle)

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

1 The US Defense Veteranrsquos and Brain Injury Center (DVBIC) Working Group Definition of mTBI [26] should be adopted by the Canadian Forces The definition is as follows Mild TBI in military operational setting is defined as an injury to the brain resulting from an external force andor accelerationdeceleration mechanism from an event such as a blast fall direct impact or motor vehicle accident which causes an alteration in mental status typically resulting in the temporally related onset of symptoms such as headache nausea vomiting dizzinessbalance problems fatigue insomniasleep disturbances drowsiness sensitivity to lightnoise blurred vision difficulty remembering andor difficulty concentrating

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

2 Baseline neurocognitive testing should

not be done until more rigorous research

has validated the use of these tools in a

military operational setting Until such

time clinicians may use neurocognitive

testing to determine the presence and

magnitude of any impairment and to follow

the clinical course of any impairment

identified

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

3 The DVBIC clinical practice guidelines

and algorithms for mTBI in theatre should

be adopted [26] with some modification

for the purpose of evaluating fitness for

duty in those who may have sustained a

mTBI in an operational setting (Appendix

2)

bull A major modification was the removal of the

recommendation for detailed neurocognitive

testing in the algorithm applicable to the

Role 3 facility

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

7 A systematic approach should be adopted for the

management of those with a history of mTBI identified in the post-deployment period (An algorithm developed by the panel is provided in Appendix 4) The recommended approach follows several key guiding principles which are outlined as follows Provide education and appropriate reassurance

to patients with a history of head trauma

Consider chronic subdural haematoma in patients with chronic headache after head trauma

Post-traumatic headache responds to the usual

approach for chronic headache disorders

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

bull Other somatic symptoms (eg dizziness) should also be approached in a conventional fashion

-Cognitive Behavioural Therapy (CBT) and graded exercise are the most consistently helpful treatments for unexplained symptoms

-Common non-specific mTBI symptoms are more likely to be attributable to mental health problems or to distress than to mTBI per se

-In the presence of a mental health problem treat the problem and follow non-specific symptoms expectantlymdashevaluate those with persistent symptoms or symptoms that are inconsistent with (or out of proportion to) mental health problems

Biomechanical Injury Translation

Coup

site

Contre-

Coup

site

Force vector

Biomechanical Injury Rotation amp Angular Acceleration

Rotation vector

Force vector

Biomechanical Injury Diffuse Axonal Injury (Silver 2003)

Pre-Injury

Acute Injury

TBI Produces Cognitive Emotional Behavioral and Physical Disturbances

Brain Injury

Impaired Attention Memory

Disturbance Language

Impairment Executive

Dysfunction Intellectual Loss

Irritability Rage

Depression Anxiety

Agitation Aggression

Disinhibition Apathy

Sleep Disturbance Headaches

Visual Problems DizzinessVertigo

Seizures Motor Problems

Cognitive Disturbance

Behavioral Disturbance

Emotional Disturbance

Physical Disturbance

(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)

mTBI Definition

bull Loss of consciousness of less than 1 hour and

bull Post-traumatic amnesia of less than 24 hours and

bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)

Glasgow Coma Scale

Severity GCS AOC LOC PTA Imaging

Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg

Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs

gt24 hrs lt7 days

Pos or Neg

Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos

21

GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia

Predisposing Factors Causative Factors Perpetuating and Mitigating Factors

Self-

Expectation

mTBI

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Demographic

Characteristics

Medical

Iatrogenesis

Litigation

Iatrogenesis

Acute

Symptoms Chronic

Symptoms

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Coping

Abilities

Social

Support Coping

Abilities

Problems with ldquomTBIrdquo as diagnostic term

bull Sounds scary

bull Applies to both immediate injury and long-term consequences

bull Gets confused with more severe forms of TBI

bull mTBI itself varies in severity (and consequences)

bull ldquoConcussionrdquo may be a better word

Natural History of Civilian mTBI

bull Populations most studied

bull Serious athletes (pre- and post-)

bull Road traffic accident victims other trauma

bull Full recovery in the vast majority of patients within weeks to months

bull Less recovery after 3 months

24

Causes of Symptoms Seen after mTBI

bull Short-term symptoms are likely directly due to brain trauma

bull Long-term symptoms are ldquomore complexrdquo

bull Rare in concussed athletes

bull Not uncommon in civilian trauma victims

bull Not overly specific to brain injury

bull Psychosocial factors are very important

Frequency of PCS Symptoms following a MTBI

bull Poor concentration 71

bull Irritability 66

bull Tired a lot more 64

bull Depression 63

bull Memory problems 59

bull Headaches 59

bull Anxiety 58

bull Trouble thinking 57

bull Dizziness 52

bull Blurry or double vision 45

bull Sensitivity to bright light 40

Neuropsych Testing for mTBI Evaluation

bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable

bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly

bull CBT is probably helpful for those with persistent concerns regardless of test results

Imaging Tools ndash Old School to Cutting Edge

bull Plain Radiographs

bull Computed Tomography (CT)

bull MRI with standard anatomic sequences

bull Gradient Echo (Blood sensitive) MRI

bull Diffusion Tensor Imaging

bull Spectroscopy

bull fMRI

bull Perfusion Imaging

bull Quantitative techniques

28

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Prepare to be amazed and probably confused

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

mTBI in the Canadian Forces Does Afghanistan Change Things

LCol Rakesh Jetly MD FRCPC

Directorate of Mental Health

Canadian LAV (Nyala light armoured vehicle)

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

1 The US Defense Veteranrsquos and Brain Injury Center (DVBIC) Working Group Definition of mTBI [26] should be adopted by the Canadian Forces The definition is as follows Mild TBI in military operational setting is defined as an injury to the brain resulting from an external force andor accelerationdeceleration mechanism from an event such as a blast fall direct impact or motor vehicle accident which causes an alteration in mental status typically resulting in the temporally related onset of symptoms such as headache nausea vomiting dizzinessbalance problems fatigue insomniasleep disturbances drowsiness sensitivity to lightnoise blurred vision difficulty remembering andor difficulty concentrating

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

2 Baseline neurocognitive testing should

not be done until more rigorous research

has validated the use of these tools in a

military operational setting Until such

time clinicians may use neurocognitive

testing to determine the presence and

magnitude of any impairment and to follow

the clinical course of any impairment

identified

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

3 The DVBIC clinical practice guidelines

and algorithms for mTBI in theatre should

be adopted [26] with some modification

for the purpose of evaluating fitness for

duty in those who may have sustained a

mTBI in an operational setting (Appendix

2)

bull A major modification was the removal of the

recommendation for detailed neurocognitive

testing in the algorithm applicable to the

Role 3 facility

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

7 A systematic approach should be adopted for the

management of those with a history of mTBI identified in the post-deployment period (An algorithm developed by the panel is provided in Appendix 4) The recommended approach follows several key guiding principles which are outlined as follows Provide education and appropriate reassurance

to patients with a history of head trauma

Consider chronic subdural haematoma in patients with chronic headache after head trauma

Post-traumatic headache responds to the usual

approach for chronic headache disorders

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

bull Other somatic symptoms (eg dizziness) should also be approached in a conventional fashion

-Cognitive Behavioural Therapy (CBT) and graded exercise are the most consistently helpful treatments for unexplained symptoms

-Common non-specific mTBI symptoms are more likely to be attributable to mental health problems or to distress than to mTBI per se

-In the presence of a mental health problem treat the problem and follow non-specific symptoms expectantlymdashevaluate those with persistent symptoms or symptoms that are inconsistent with (or out of proportion to) mental health problems

Biomechanical Injury Translation

Coup

site

Contre-

Coup

site

Force vector

Biomechanical Injury Rotation amp Angular Acceleration

Rotation vector

Force vector

Biomechanical Injury Diffuse Axonal Injury (Silver 2003)

Pre-Injury

Acute Injury

TBI Produces Cognitive Emotional Behavioral and Physical Disturbances

Brain Injury

Impaired Attention Memory

Disturbance Language

Impairment Executive

Dysfunction Intellectual Loss

Irritability Rage

Depression Anxiety

Agitation Aggression

Disinhibition Apathy

Sleep Disturbance Headaches

Visual Problems DizzinessVertigo

Seizures Motor Problems

Cognitive Disturbance

Behavioral Disturbance

Emotional Disturbance

Physical Disturbance

(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)

mTBI Definition

bull Loss of consciousness of less than 1 hour and

bull Post-traumatic amnesia of less than 24 hours and

bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)

Glasgow Coma Scale

Severity GCS AOC LOC PTA Imaging

Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg

Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs

gt24 hrs lt7 days

Pos or Neg

Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos

21

GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia

Predisposing Factors Causative Factors Perpetuating and Mitigating Factors

Self-

Expectation

mTBI

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Demographic

Characteristics

Medical

Iatrogenesis

Litigation

Iatrogenesis

Acute

Symptoms Chronic

Symptoms

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Coping

Abilities

Social

Support Coping

Abilities

Problems with ldquomTBIrdquo as diagnostic term

bull Sounds scary

bull Applies to both immediate injury and long-term consequences

bull Gets confused with more severe forms of TBI

bull mTBI itself varies in severity (and consequences)

bull ldquoConcussionrdquo may be a better word

Natural History of Civilian mTBI

bull Populations most studied

bull Serious athletes (pre- and post-)

bull Road traffic accident victims other trauma

bull Full recovery in the vast majority of patients within weeks to months

bull Less recovery after 3 months

24

Causes of Symptoms Seen after mTBI

bull Short-term symptoms are likely directly due to brain trauma

bull Long-term symptoms are ldquomore complexrdquo

bull Rare in concussed athletes

bull Not uncommon in civilian trauma victims

bull Not overly specific to brain injury

bull Psychosocial factors are very important

Frequency of PCS Symptoms following a MTBI

bull Poor concentration 71

bull Irritability 66

bull Tired a lot more 64

bull Depression 63

bull Memory problems 59

bull Headaches 59

bull Anxiety 58

bull Trouble thinking 57

bull Dizziness 52

bull Blurry or double vision 45

bull Sensitivity to bright light 40

Neuropsych Testing for mTBI Evaluation

bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable

bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly

bull CBT is probably helpful for those with persistent concerns regardless of test results

Imaging Tools ndash Old School to Cutting Edge

bull Plain Radiographs

bull Computed Tomography (CT)

bull MRI with standard anatomic sequences

bull Gradient Echo (Blood sensitive) MRI

bull Diffusion Tensor Imaging

bull Spectroscopy

bull fMRI

bull Perfusion Imaging

bull Quantitative techniques

28

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

mTBI in the Canadian Forces Does Afghanistan Change Things

LCol Rakesh Jetly MD FRCPC

Directorate of Mental Health

Canadian LAV (Nyala light armoured vehicle)

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

1 The US Defense Veteranrsquos and Brain Injury Center (DVBIC) Working Group Definition of mTBI [26] should be adopted by the Canadian Forces The definition is as follows Mild TBI in military operational setting is defined as an injury to the brain resulting from an external force andor accelerationdeceleration mechanism from an event such as a blast fall direct impact or motor vehicle accident which causes an alteration in mental status typically resulting in the temporally related onset of symptoms such as headache nausea vomiting dizzinessbalance problems fatigue insomniasleep disturbances drowsiness sensitivity to lightnoise blurred vision difficulty remembering andor difficulty concentrating

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

2 Baseline neurocognitive testing should

not be done until more rigorous research

has validated the use of these tools in a

military operational setting Until such

time clinicians may use neurocognitive

testing to determine the presence and

magnitude of any impairment and to follow

the clinical course of any impairment

identified

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

3 The DVBIC clinical practice guidelines

and algorithms for mTBI in theatre should

be adopted [26] with some modification

for the purpose of evaluating fitness for

duty in those who may have sustained a

mTBI in an operational setting (Appendix

2)

bull A major modification was the removal of the

recommendation for detailed neurocognitive

testing in the algorithm applicable to the

Role 3 facility

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

7 A systematic approach should be adopted for the

management of those with a history of mTBI identified in the post-deployment period (An algorithm developed by the panel is provided in Appendix 4) The recommended approach follows several key guiding principles which are outlined as follows Provide education and appropriate reassurance

to patients with a history of head trauma

Consider chronic subdural haematoma in patients with chronic headache after head trauma

Post-traumatic headache responds to the usual

approach for chronic headache disorders

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

bull Other somatic symptoms (eg dizziness) should also be approached in a conventional fashion

-Cognitive Behavioural Therapy (CBT) and graded exercise are the most consistently helpful treatments for unexplained symptoms

-Common non-specific mTBI symptoms are more likely to be attributable to mental health problems or to distress than to mTBI per se

-In the presence of a mental health problem treat the problem and follow non-specific symptoms expectantlymdashevaluate those with persistent symptoms or symptoms that are inconsistent with (or out of proportion to) mental health problems

Biomechanical Injury Translation

Coup

site

Contre-

Coup

site

Force vector

Biomechanical Injury Rotation amp Angular Acceleration

Rotation vector

Force vector

Biomechanical Injury Diffuse Axonal Injury (Silver 2003)

Pre-Injury

Acute Injury

TBI Produces Cognitive Emotional Behavioral and Physical Disturbances

Brain Injury

Impaired Attention Memory

Disturbance Language

Impairment Executive

Dysfunction Intellectual Loss

Irritability Rage

Depression Anxiety

Agitation Aggression

Disinhibition Apathy

Sleep Disturbance Headaches

Visual Problems DizzinessVertigo

Seizures Motor Problems

Cognitive Disturbance

Behavioral Disturbance

Emotional Disturbance

Physical Disturbance

(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)

mTBI Definition

bull Loss of consciousness of less than 1 hour and

bull Post-traumatic amnesia of less than 24 hours and

bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)

Glasgow Coma Scale

Severity GCS AOC LOC PTA Imaging

Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg

Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs

gt24 hrs lt7 days

Pos or Neg

Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos

21

GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia

Predisposing Factors Causative Factors Perpetuating and Mitigating Factors

Self-

Expectation

mTBI

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Demographic

Characteristics

Medical

Iatrogenesis

Litigation

Iatrogenesis

Acute

Symptoms Chronic

Symptoms

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Coping

Abilities

Social

Support Coping

Abilities

Problems with ldquomTBIrdquo as diagnostic term

bull Sounds scary

bull Applies to both immediate injury and long-term consequences

bull Gets confused with more severe forms of TBI

bull mTBI itself varies in severity (and consequences)

bull ldquoConcussionrdquo may be a better word

Natural History of Civilian mTBI

bull Populations most studied

bull Serious athletes (pre- and post-)

bull Road traffic accident victims other trauma

bull Full recovery in the vast majority of patients within weeks to months

bull Less recovery after 3 months

24

Causes of Symptoms Seen after mTBI

bull Short-term symptoms are likely directly due to brain trauma

bull Long-term symptoms are ldquomore complexrdquo

bull Rare in concussed athletes

bull Not uncommon in civilian trauma victims

bull Not overly specific to brain injury

bull Psychosocial factors are very important

Frequency of PCS Symptoms following a MTBI

bull Poor concentration 71

bull Irritability 66

bull Tired a lot more 64

bull Depression 63

bull Memory problems 59

bull Headaches 59

bull Anxiety 58

bull Trouble thinking 57

bull Dizziness 52

bull Blurry or double vision 45

bull Sensitivity to bright light 40

Neuropsych Testing for mTBI Evaluation

bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable

bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly

bull CBT is probably helpful for those with persistent concerns regardless of test results

Imaging Tools ndash Old School to Cutting Edge

bull Plain Radiographs

bull Computed Tomography (CT)

bull MRI with standard anatomic sequences

bull Gradient Echo (Blood sensitive) MRI

bull Diffusion Tensor Imaging

bull Spectroscopy

bull fMRI

bull Perfusion Imaging

bull Quantitative techniques

28

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Canadian LAV (Nyala light armoured vehicle)

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

1 The US Defense Veteranrsquos and Brain Injury Center (DVBIC) Working Group Definition of mTBI [26] should be adopted by the Canadian Forces The definition is as follows Mild TBI in military operational setting is defined as an injury to the brain resulting from an external force andor accelerationdeceleration mechanism from an event such as a blast fall direct impact or motor vehicle accident which causes an alteration in mental status typically resulting in the temporally related onset of symptoms such as headache nausea vomiting dizzinessbalance problems fatigue insomniasleep disturbances drowsiness sensitivity to lightnoise blurred vision difficulty remembering andor difficulty concentrating

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

2 Baseline neurocognitive testing should

not be done until more rigorous research

has validated the use of these tools in a

military operational setting Until such

time clinicians may use neurocognitive

testing to determine the presence and

magnitude of any impairment and to follow

the clinical course of any impairment

identified

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

3 The DVBIC clinical practice guidelines

and algorithms for mTBI in theatre should

be adopted [26] with some modification

for the purpose of evaluating fitness for

duty in those who may have sustained a

mTBI in an operational setting (Appendix

2)

bull A major modification was the removal of the

recommendation for detailed neurocognitive

testing in the algorithm applicable to the

Role 3 facility

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

7 A systematic approach should be adopted for the

management of those with a history of mTBI identified in the post-deployment period (An algorithm developed by the panel is provided in Appendix 4) The recommended approach follows several key guiding principles which are outlined as follows Provide education and appropriate reassurance

to patients with a history of head trauma

Consider chronic subdural haematoma in patients with chronic headache after head trauma

Post-traumatic headache responds to the usual

approach for chronic headache disorders

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

bull Other somatic symptoms (eg dizziness) should also be approached in a conventional fashion

-Cognitive Behavioural Therapy (CBT) and graded exercise are the most consistently helpful treatments for unexplained symptoms

-Common non-specific mTBI symptoms are more likely to be attributable to mental health problems or to distress than to mTBI per se

-In the presence of a mental health problem treat the problem and follow non-specific symptoms expectantlymdashevaluate those with persistent symptoms or symptoms that are inconsistent with (or out of proportion to) mental health problems

Biomechanical Injury Translation

Coup

site

Contre-

Coup

site

Force vector

Biomechanical Injury Rotation amp Angular Acceleration

Rotation vector

Force vector

Biomechanical Injury Diffuse Axonal Injury (Silver 2003)

Pre-Injury

Acute Injury

TBI Produces Cognitive Emotional Behavioral and Physical Disturbances

Brain Injury

Impaired Attention Memory

Disturbance Language

Impairment Executive

Dysfunction Intellectual Loss

Irritability Rage

Depression Anxiety

Agitation Aggression

Disinhibition Apathy

Sleep Disturbance Headaches

Visual Problems DizzinessVertigo

Seizures Motor Problems

Cognitive Disturbance

Behavioral Disturbance

Emotional Disturbance

Physical Disturbance

(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)

mTBI Definition

bull Loss of consciousness of less than 1 hour and

bull Post-traumatic amnesia of less than 24 hours and

bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)

Glasgow Coma Scale

Severity GCS AOC LOC PTA Imaging

Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg

Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs

gt24 hrs lt7 days

Pos or Neg

Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos

21

GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia

Predisposing Factors Causative Factors Perpetuating and Mitigating Factors

Self-

Expectation

mTBI

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Demographic

Characteristics

Medical

Iatrogenesis

Litigation

Iatrogenesis

Acute

Symptoms Chronic

Symptoms

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Coping

Abilities

Social

Support Coping

Abilities

Problems with ldquomTBIrdquo as diagnostic term

bull Sounds scary

bull Applies to both immediate injury and long-term consequences

bull Gets confused with more severe forms of TBI

bull mTBI itself varies in severity (and consequences)

bull ldquoConcussionrdquo may be a better word

Natural History of Civilian mTBI

bull Populations most studied

bull Serious athletes (pre- and post-)

bull Road traffic accident victims other trauma

bull Full recovery in the vast majority of patients within weeks to months

bull Less recovery after 3 months

24

Causes of Symptoms Seen after mTBI

bull Short-term symptoms are likely directly due to brain trauma

bull Long-term symptoms are ldquomore complexrdquo

bull Rare in concussed athletes

bull Not uncommon in civilian trauma victims

bull Not overly specific to brain injury

bull Psychosocial factors are very important

Frequency of PCS Symptoms following a MTBI

bull Poor concentration 71

bull Irritability 66

bull Tired a lot more 64

bull Depression 63

bull Memory problems 59

bull Headaches 59

bull Anxiety 58

bull Trouble thinking 57

bull Dizziness 52

bull Blurry or double vision 45

bull Sensitivity to bright light 40

Neuropsych Testing for mTBI Evaluation

bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable

bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly

bull CBT is probably helpful for those with persistent concerns regardless of test results

Imaging Tools ndash Old School to Cutting Edge

bull Plain Radiographs

bull Computed Tomography (CT)

bull MRI with standard anatomic sequences

bull Gradient Echo (Blood sensitive) MRI

bull Diffusion Tensor Imaging

bull Spectroscopy

bull fMRI

bull Perfusion Imaging

bull Quantitative techniques

28

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

1 The US Defense Veteranrsquos and Brain Injury Center (DVBIC) Working Group Definition of mTBI [26] should be adopted by the Canadian Forces The definition is as follows Mild TBI in military operational setting is defined as an injury to the brain resulting from an external force andor accelerationdeceleration mechanism from an event such as a blast fall direct impact or motor vehicle accident which causes an alteration in mental status typically resulting in the temporally related onset of symptoms such as headache nausea vomiting dizzinessbalance problems fatigue insomniasleep disturbances drowsiness sensitivity to lightnoise blurred vision difficulty remembering andor difficulty concentrating

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

2 Baseline neurocognitive testing should

not be done until more rigorous research

has validated the use of these tools in a

military operational setting Until such

time clinicians may use neurocognitive

testing to determine the presence and

magnitude of any impairment and to follow

the clinical course of any impairment

identified

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

3 The DVBIC clinical practice guidelines

and algorithms for mTBI in theatre should

be adopted [26] with some modification

for the purpose of evaluating fitness for

duty in those who may have sustained a

mTBI in an operational setting (Appendix

2)

bull A major modification was the removal of the

recommendation for detailed neurocognitive

testing in the algorithm applicable to the

Role 3 facility

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

7 A systematic approach should be adopted for the

management of those with a history of mTBI identified in the post-deployment period (An algorithm developed by the panel is provided in Appendix 4) The recommended approach follows several key guiding principles which are outlined as follows Provide education and appropriate reassurance

to patients with a history of head trauma

Consider chronic subdural haematoma in patients with chronic headache after head trauma

Post-traumatic headache responds to the usual

approach for chronic headache disorders

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

bull Other somatic symptoms (eg dizziness) should also be approached in a conventional fashion

-Cognitive Behavioural Therapy (CBT) and graded exercise are the most consistently helpful treatments for unexplained symptoms

-Common non-specific mTBI symptoms are more likely to be attributable to mental health problems or to distress than to mTBI per se

-In the presence of a mental health problem treat the problem and follow non-specific symptoms expectantlymdashevaluate those with persistent symptoms or symptoms that are inconsistent with (or out of proportion to) mental health problems

Biomechanical Injury Translation

Coup

site

Contre-

Coup

site

Force vector

Biomechanical Injury Rotation amp Angular Acceleration

Rotation vector

Force vector

Biomechanical Injury Diffuse Axonal Injury (Silver 2003)

Pre-Injury

Acute Injury

TBI Produces Cognitive Emotional Behavioral and Physical Disturbances

Brain Injury

Impaired Attention Memory

Disturbance Language

Impairment Executive

Dysfunction Intellectual Loss

Irritability Rage

Depression Anxiety

Agitation Aggression

Disinhibition Apathy

Sleep Disturbance Headaches

Visual Problems DizzinessVertigo

Seizures Motor Problems

Cognitive Disturbance

Behavioral Disturbance

Emotional Disturbance

Physical Disturbance

(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)

mTBI Definition

bull Loss of consciousness of less than 1 hour and

bull Post-traumatic amnesia of less than 24 hours and

bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)

Glasgow Coma Scale

Severity GCS AOC LOC PTA Imaging

Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg

Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs

gt24 hrs lt7 days

Pos or Neg

Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos

21

GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia

Predisposing Factors Causative Factors Perpetuating and Mitigating Factors

Self-

Expectation

mTBI

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Demographic

Characteristics

Medical

Iatrogenesis

Litigation

Iatrogenesis

Acute

Symptoms Chronic

Symptoms

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Coping

Abilities

Social

Support Coping

Abilities

Problems with ldquomTBIrdquo as diagnostic term

bull Sounds scary

bull Applies to both immediate injury and long-term consequences

bull Gets confused with more severe forms of TBI

bull mTBI itself varies in severity (and consequences)

bull ldquoConcussionrdquo may be a better word

Natural History of Civilian mTBI

bull Populations most studied

bull Serious athletes (pre- and post-)

bull Road traffic accident victims other trauma

bull Full recovery in the vast majority of patients within weeks to months

bull Less recovery after 3 months

24

Causes of Symptoms Seen after mTBI

bull Short-term symptoms are likely directly due to brain trauma

bull Long-term symptoms are ldquomore complexrdquo

bull Rare in concussed athletes

bull Not uncommon in civilian trauma victims

bull Not overly specific to brain injury

bull Psychosocial factors are very important

Frequency of PCS Symptoms following a MTBI

bull Poor concentration 71

bull Irritability 66

bull Tired a lot more 64

bull Depression 63

bull Memory problems 59

bull Headaches 59

bull Anxiety 58

bull Trouble thinking 57

bull Dizziness 52

bull Blurry or double vision 45

bull Sensitivity to bright light 40

Neuropsych Testing for mTBI Evaluation

bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable

bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly

bull CBT is probably helpful for those with persistent concerns regardless of test results

Imaging Tools ndash Old School to Cutting Edge

bull Plain Radiographs

bull Computed Tomography (CT)

bull MRI with standard anatomic sequences

bull Gradient Echo (Blood sensitive) MRI

bull Diffusion Tensor Imaging

bull Spectroscopy

bull fMRI

bull Perfusion Imaging

bull Quantitative techniques

28

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

2 Baseline neurocognitive testing should

not be done until more rigorous research

has validated the use of these tools in a

military operational setting Until such

time clinicians may use neurocognitive

testing to determine the presence and

magnitude of any impairment and to follow

the clinical course of any impairment

identified

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

3 The DVBIC clinical practice guidelines

and algorithms for mTBI in theatre should

be adopted [26] with some modification

for the purpose of evaluating fitness for

duty in those who may have sustained a

mTBI in an operational setting (Appendix

2)

bull A major modification was the removal of the

recommendation for detailed neurocognitive

testing in the algorithm applicable to the

Role 3 facility

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

7 A systematic approach should be adopted for the

management of those with a history of mTBI identified in the post-deployment period (An algorithm developed by the panel is provided in Appendix 4) The recommended approach follows several key guiding principles which are outlined as follows Provide education and appropriate reassurance

to patients with a history of head trauma

Consider chronic subdural haematoma in patients with chronic headache after head trauma

Post-traumatic headache responds to the usual

approach for chronic headache disorders

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

bull Other somatic symptoms (eg dizziness) should also be approached in a conventional fashion

-Cognitive Behavioural Therapy (CBT) and graded exercise are the most consistently helpful treatments for unexplained symptoms

-Common non-specific mTBI symptoms are more likely to be attributable to mental health problems or to distress than to mTBI per se

-In the presence of a mental health problem treat the problem and follow non-specific symptoms expectantlymdashevaluate those with persistent symptoms or symptoms that are inconsistent with (or out of proportion to) mental health problems

Biomechanical Injury Translation

Coup

site

Contre-

Coup

site

Force vector

Biomechanical Injury Rotation amp Angular Acceleration

Rotation vector

Force vector

Biomechanical Injury Diffuse Axonal Injury (Silver 2003)

Pre-Injury

Acute Injury

TBI Produces Cognitive Emotional Behavioral and Physical Disturbances

Brain Injury

Impaired Attention Memory

Disturbance Language

Impairment Executive

Dysfunction Intellectual Loss

Irritability Rage

Depression Anxiety

Agitation Aggression

Disinhibition Apathy

Sleep Disturbance Headaches

Visual Problems DizzinessVertigo

Seizures Motor Problems

Cognitive Disturbance

Behavioral Disturbance

Emotional Disturbance

Physical Disturbance

(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)

mTBI Definition

bull Loss of consciousness of less than 1 hour and

bull Post-traumatic amnesia of less than 24 hours and

bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)

Glasgow Coma Scale

Severity GCS AOC LOC PTA Imaging

Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg

Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs

gt24 hrs lt7 days

Pos or Neg

Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos

21

GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia

Predisposing Factors Causative Factors Perpetuating and Mitigating Factors

Self-

Expectation

mTBI

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Demographic

Characteristics

Medical

Iatrogenesis

Litigation

Iatrogenesis

Acute

Symptoms Chronic

Symptoms

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Coping

Abilities

Social

Support Coping

Abilities

Problems with ldquomTBIrdquo as diagnostic term

bull Sounds scary

bull Applies to both immediate injury and long-term consequences

bull Gets confused with more severe forms of TBI

bull mTBI itself varies in severity (and consequences)

bull ldquoConcussionrdquo may be a better word

Natural History of Civilian mTBI

bull Populations most studied

bull Serious athletes (pre- and post-)

bull Road traffic accident victims other trauma

bull Full recovery in the vast majority of patients within weeks to months

bull Less recovery after 3 months

24

Causes of Symptoms Seen after mTBI

bull Short-term symptoms are likely directly due to brain trauma

bull Long-term symptoms are ldquomore complexrdquo

bull Rare in concussed athletes

bull Not uncommon in civilian trauma victims

bull Not overly specific to brain injury

bull Psychosocial factors are very important

Frequency of PCS Symptoms following a MTBI

bull Poor concentration 71

bull Irritability 66

bull Tired a lot more 64

bull Depression 63

bull Memory problems 59

bull Headaches 59

bull Anxiety 58

bull Trouble thinking 57

bull Dizziness 52

bull Blurry or double vision 45

bull Sensitivity to bright light 40

Neuropsych Testing for mTBI Evaluation

bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable

bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly

bull CBT is probably helpful for those with persistent concerns regardless of test results

Imaging Tools ndash Old School to Cutting Edge

bull Plain Radiographs

bull Computed Tomography (CT)

bull MRI with standard anatomic sequences

bull Gradient Echo (Blood sensitive) MRI

bull Diffusion Tensor Imaging

bull Spectroscopy

bull fMRI

bull Perfusion Imaging

bull Quantitative techniques

28

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

3 The DVBIC clinical practice guidelines

and algorithms for mTBI in theatre should

be adopted [26] with some modification

for the purpose of evaluating fitness for

duty in those who may have sustained a

mTBI in an operational setting (Appendix

2)

bull A major modification was the removal of the

recommendation for detailed neurocognitive

testing in the algorithm applicable to the

Role 3 facility

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

7 A systematic approach should be adopted for the

management of those with a history of mTBI identified in the post-deployment period (An algorithm developed by the panel is provided in Appendix 4) The recommended approach follows several key guiding principles which are outlined as follows Provide education and appropriate reassurance

to patients with a history of head trauma

Consider chronic subdural haematoma in patients with chronic headache after head trauma

Post-traumatic headache responds to the usual

approach for chronic headache disorders

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

bull Other somatic symptoms (eg dizziness) should also be approached in a conventional fashion

-Cognitive Behavioural Therapy (CBT) and graded exercise are the most consistently helpful treatments for unexplained symptoms

-Common non-specific mTBI symptoms are more likely to be attributable to mental health problems or to distress than to mTBI per se

-In the presence of a mental health problem treat the problem and follow non-specific symptoms expectantlymdashevaluate those with persistent symptoms or symptoms that are inconsistent with (or out of proportion to) mental health problems

Biomechanical Injury Translation

Coup

site

Contre-

Coup

site

Force vector

Biomechanical Injury Rotation amp Angular Acceleration

Rotation vector

Force vector

Biomechanical Injury Diffuse Axonal Injury (Silver 2003)

Pre-Injury

Acute Injury

TBI Produces Cognitive Emotional Behavioral and Physical Disturbances

Brain Injury

Impaired Attention Memory

Disturbance Language

Impairment Executive

Dysfunction Intellectual Loss

Irritability Rage

Depression Anxiety

Agitation Aggression

Disinhibition Apathy

Sleep Disturbance Headaches

Visual Problems DizzinessVertigo

Seizures Motor Problems

Cognitive Disturbance

Behavioral Disturbance

Emotional Disturbance

Physical Disturbance

(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)

mTBI Definition

bull Loss of consciousness of less than 1 hour and

bull Post-traumatic amnesia of less than 24 hours and

bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)

Glasgow Coma Scale

Severity GCS AOC LOC PTA Imaging

Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg

Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs

gt24 hrs lt7 days

Pos or Neg

Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos

21

GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia

Predisposing Factors Causative Factors Perpetuating and Mitigating Factors

Self-

Expectation

mTBI

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Demographic

Characteristics

Medical

Iatrogenesis

Litigation

Iatrogenesis

Acute

Symptoms Chronic

Symptoms

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Coping

Abilities

Social

Support Coping

Abilities

Problems with ldquomTBIrdquo as diagnostic term

bull Sounds scary

bull Applies to both immediate injury and long-term consequences

bull Gets confused with more severe forms of TBI

bull mTBI itself varies in severity (and consequences)

bull ldquoConcussionrdquo may be a better word

Natural History of Civilian mTBI

bull Populations most studied

bull Serious athletes (pre- and post-)

bull Road traffic accident victims other trauma

bull Full recovery in the vast majority of patients within weeks to months

bull Less recovery after 3 months

24

Causes of Symptoms Seen after mTBI

bull Short-term symptoms are likely directly due to brain trauma

bull Long-term symptoms are ldquomore complexrdquo

bull Rare in concussed athletes

bull Not uncommon in civilian trauma victims

bull Not overly specific to brain injury

bull Psychosocial factors are very important

Frequency of PCS Symptoms following a MTBI

bull Poor concentration 71

bull Irritability 66

bull Tired a lot more 64

bull Depression 63

bull Memory problems 59

bull Headaches 59

bull Anxiety 58

bull Trouble thinking 57

bull Dizziness 52

bull Blurry or double vision 45

bull Sensitivity to bright light 40

Neuropsych Testing for mTBI Evaluation

bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable

bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly

bull CBT is probably helpful for those with persistent concerns regardless of test results

Imaging Tools ndash Old School to Cutting Edge

bull Plain Radiographs

bull Computed Tomography (CT)

bull MRI with standard anatomic sequences

bull Gradient Echo (Blood sensitive) MRI

bull Diffusion Tensor Imaging

bull Spectroscopy

bull fMRI

bull Perfusion Imaging

bull Quantitative techniques

28

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

7 A systematic approach should be adopted for the

management of those with a history of mTBI identified in the post-deployment period (An algorithm developed by the panel is provided in Appendix 4) The recommended approach follows several key guiding principles which are outlined as follows Provide education and appropriate reassurance

to patients with a history of head trauma

Consider chronic subdural haematoma in patients with chronic headache after head trauma

Post-traumatic headache responds to the usual

approach for chronic headache disorders

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

bull Other somatic symptoms (eg dizziness) should also be approached in a conventional fashion

-Cognitive Behavioural Therapy (CBT) and graded exercise are the most consistently helpful treatments for unexplained symptoms

-Common non-specific mTBI symptoms are more likely to be attributable to mental health problems or to distress than to mTBI per se

-In the presence of a mental health problem treat the problem and follow non-specific symptoms expectantlymdashevaluate those with persistent symptoms or symptoms that are inconsistent with (or out of proportion to) mental health problems

Biomechanical Injury Translation

Coup

site

Contre-

Coup

site

Force vector

Biomechanical Injury Rotation amp Angular Acceleration

Rotation vector

Force vector

Biomechanical Injury Diffuse Axonal Injury (Silver 2003)

Pre-Injury

Acute Injury

TBI Produces Cognitive Emotional Behavioral and Physical Disturbances

Brain Injury

Impaired Attention Memory

Disturbance Language

Impairment Executive

Dysfunction Intellectual Loss

Irritability Rage

Depression Anxiety

Agitation Aggression

Disinhibition Apathy

Sleep Disturbance Headaches

Visual Problems DizzinessVertigo

Seizures Motor Problems

Cognitive Disturbance

Behavioral Disturbance

Emotional Disturbance

Physical Disturbance

(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)

mTBI Definition

bull Loss of consciousness of less than 1 hour and

bull Post-traumatic amnesia of less than 24 hours and

bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)

Glasgow Coma Scale

Severity GCS AOC LOC PTA Imaging

Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg

Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs

gt24 hrs lt7 days

Pos or Neg

Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos

21

GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia

Predisposing Factors Causative Factors Perpetuating and Mitigating Factors

Self-

Expectation

mTBI

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Demographic

Characteristics

Medical

Iatrogenesis

Litigation

Iatrogenesis

Acute

Symptoms Chronic

Symptoms

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Coping

Abilities

Social

Support Coping

Abilities

Problems with ldquomTBIrdquo as diagnostic term

bull Sounds scary

bull Applies to both immediate injury and long-term consequences

bull Gets confused with more severe forms of TBI

bull mTBI itself varies in severity (and consequences)

bull ldquoConcussionrdquo may be a better word

Natural History of Civilian mTBI

bull Populations most studied

bull Serious athletes (pre- and post-)

bull Road traffic accident victims other trauma

bull Full recovery in the vast majority of patients within weeks to months

bull Less recovery after 3 months

24

Causes of Symptoms Seen after mTBI

bull Short-term symptoms are likely directly due to brain trauma

bull Long-term symptoms are ldquomore complexrdquo

bull Rare in concussed athletes

bull Not uncommon in civilian trauma victims

bull Not overly specific to brain injury

bull Psychosocial factors are very important

Frequency of PCS Symptoms following a MTBI

bull Poor concentration 71

bull Irritability 66

bull Tired a lot more 64

bull Depression 63

bull Memory problems 59

bull Headaches 59

bull Anxiety 58

bull Trouble thinking 57

bull Dizziness 52

bull Blurry or double vision 45

bull Sensitivity to bright light 40

Neuropsych Testing for mTBI Evaluation

bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable

bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly

bull CBT is probably helpful for those with persistent concerns regardless of test results

Imaging Tools ndash Old School to Cutting Edge

bull Plain Radiographs

bull Computed Tomography (CT)

bull MRI with standard anatomic sequences

bull Gradient Echo (Blood sensitive) MRI

bull Diffusion Tensor Imaging

bull Spectroscopy

bull fMRI

bull Perfusion Imaging

bull Quantitative techniques

28

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Promote Protect and Heal

Promouvoir proteacuteger et gueacuterir

Recommendations from CF working group

bull Other somatic symptoms (eg dizziness) should also be approached in a conventional fashion

-Cognitive Behavioural Therapy (CBT) and graded exercise are the most consistently helpful treatments for unexplained symptoms

-Common non-specific mTBI symptoms are more likely to be attributable to mental health problems or to distress than to mTBI per se

-In the presence of a mental health problem treat the problem and follow non-specific symptoms expectantlymdashevaluate those with persistent symptoms or symptoms that are inconsistent with (or out of proportion to) mental health problems

Biomechanical Injury Translation

Coup

site

Contre-

Coup

site

Force vector

Biomechanical Injury Rotation amp Angular Acceleration

Rotation vector

Force vector

Biomechanical Injury Diffuse Axonal Injury (Silver 2003)

Pre-Injury

Acute Injury

TBI Produces Cognitive Emotional Behavioral and Physical Disturbances

Brain Injury

Impaired Attention Memory

Disturbance Language

Impairment Executive

Dysfunction Intellectual Loss

Irritability Rage

Depression Anxiety

Agitation Aggression

Disinhibition Apathy

Sleep Disturbance Headaches

Visual Problems DizzinessVertigo

Seizures Motor Problems

Cognitive Disturbance

Behavioral Disturbance

Emotional Disturbance

Physical Disturbance

(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)

mTBI Definition

bull Loss of consciousness of less than 1 hour and

bull Post-traumatic amnesia of less than 24 hours and

bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)

Glasgow Coma Scale

Severity GCS AOC LOC PTA Imaging

Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg

Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs

gt24 hrs lt7 days

Pos or Neg

Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos

21

GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia

Predisposing Factors Causative Factors Perpetuating and Mitigating Factors

Self-

Expectation

mTBI

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Demographic

Characteristics

Medical

Iatrogenesis

Litigation

Iatrogenesis

Acute

Symptoms Chronic

Symptoms

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Coping

Abilities

Social

Support Coping

Abilities

Problems with ldquomTBIrdquo as diagnostic term

bull Sounds scary

bull Applies to both immediate injury and long-term consequences

bull Gets confused with more severe forms of TBI

bull mTBI itself varies in severity (and consequences)

bull ldquoConcussionrdquo may be a better word

Natural History of Civilian mTBI

bull Populations most studied

bull Serious athletes (pre- and post-)

bull Road traffic accident victims other trauma

bull Full recovery in the vast majority of patients within weeks to months

bull Less recovery after 3 months

24

Causes of Symptoms Seen after mTBI

bull Short-term symptoms are likely directly due to brain trauma

bull Long-term symptoms are ldquomore complexrdquo

bull Rare in concussed athletes

bull Not uncommon in civilian trauma victims

bull Not overly specific to brain injury

bull Psychosocial factors are very important

Frequency of PCS Symptoms following a MTBI

bull Poor concentration 71

bull Irritability 66

bull Tired a lot more 64

bull Depression 63

bull Memory problems 59

bull Headaches 59

bull Anxiety 58

bull Trouble thinking 57

bull Dizziness 52

bull Blurry or double vision 45

bull Sensitivity to bright light 40

Neuropsych Testing for mTBI Evaluation

bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable

bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly

bull CBT is probably helpful for those with persistent concerns regardless of test results

Imaging Tools ndash Old School to Cutting Edge

bull Plain Radiographs

bull Computed Tomography (CT)

bull MRI with standard anatomic sequences

bull Gradient Echo (Blood sensitive) MRI

bull Diffusion Tensor Imaging

bull Spectroscopy

bull fMRI

bull Perfusion Imaging

bull Quantitative techniques

28

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Biomechanical Injury Translation

Coup

site

Contre-

Coup

site

Force vector

Biomechanical Injury Rotation amp Angular Acceleration

Rotation vector

Force vector

Biomechanical Injury Diffuse Axonal Injury (Silver 2003)

Pre-Injury

Acute Injury

TBI Produces Cognitive Emotional Behavioral and Physical Disturbances

Brain Injury

Impaired Attention Memory

Disturbance Language

Impairment Executive

Dysfunction Intellectual Loss

Irritability Rage

Depression Anxiety

Agitation Aggression

Disinhibition Apathy

Sleep Disturbance Headaches

Visual Problems DizzinessVertigo

Seizures Motor Problems

Cognitive Disturbance

Behavioral Disturbance

Emotional Disturbance

Physical Disturbance

(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)

mTBI Definition

bull Loss of consciousness of less than 1 hour and

bull Post-traumatic amnesia of less than 24 hours and

bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)

Glasgow Coma Scale

Severity GCS AOC LOC PTA Imaging

Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg

Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs

gt24 hrs lt7 days

Pos or Neg

Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos

21

GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia

Predisposing Factors Causative Factors Perpetuating and Mitigating Factors

Self-

Expectation

mTBI

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Demographic

Characteristics

Medical

Iatrogenesis

Litigation

Iatrogenesis

Acute

Symptoms Chronic

Symptoms

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Coping

Abilities

Social

Support Coping

Abilities

Problems with ldquomTBIrdquo as diagnostic term

bull Sounds scary

bull Applies to both immediate injury and long-term consequences

bull Gets confused with more severe forms of TBI

bull mTBI itself varies in severity (and consequences)

bull ldquoConcussionrdquo may be a better word

Natural History of Civilian mTBI

bull Populations most studied

bull Serious athletes (pre- and post-)

bull Road traffic accident victims other trauma

bull Full recovery in the vast majority of patients within weeks to months

bull Less recovery after 3 months

24

Causes of Symptoms Seen after mTBI

bull Short-term symptoms are likely directly due to brain trauma

bull Long-term symptoms are ldquomore complexrdquo

bull Rare in concussed athletes

bull Not uncommon in civilian trauma victims

bull Not overly specific to brain injury

bull Psychosocial factors are very important

Frequency of PCS Symptoms following a MTBI

bull Poor concentration 71

bull Irritability 66

bull Tired a lot more 64

bull Depression 63

bull Memory problems 59

bull Headaches 59

bull Anxiety 58

bull Trouble thinking 57

bull Dizziness 52

bull Blurry or double vision 45

bull Sensitivity to bright light 40

Neuropsych Testing for mTBI Evaluation

bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable

bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly

bull CBT is probably helpful for those with persistent concerns regardless of test results

Imaging Tools ndash Old School to Cutting Edge

bull Plain Radiographs

bull Computed Tomography (CT)

bull MRI with standard anatomic sequences

bull Gradient Echo (Blood sensitive) MRI

bull Diffusion Tensor Imaging

bull Spectroscopy

bull fMRI

bull Perfusion Imaging

bull Quantitative techniques

28

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Biomechanical Injury Rotation amp Angular Acceleration

Rotation vector

Force vector

Biomechanical Injury Diffuse Axonal Injury (Silver 2003)

Pre-Injury

Acute Injury

TBI Produces Cognitive Emotional Behavioral and Physical Disturbances

Brain Injury

Impaired Attention Memory

Disturbance Language

Impairment Executive

Dysfunction Intellectual Loss

Irritability Rage

Depression Anxiety

Agitation Aggression

Disinhibition Apathy

Sleep Disturbance Headaches

Visual Problems DizzinessVertigo

Seizures Motor Problems

Cognitive Disturbance

Behavioral Disturbance

Emotional Disturbance

Physical Disturbance

(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)

mTBI Definition

bull Loss of consciousness of less than 1 hour and

bull Post-traumatic amnesia of less than 24 hours and

bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)

Glasgow Coma Scale

Severity GCS AOC LOC PTA Imaging

Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg

Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs

gt24 hrs lt7 days

Pos or Neg

Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos

21

GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia

Predisposing Factors Causative Factors Perpetuating and Mitigating Factors

Self-

Expectation

mTBI

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Demographic

Characteristics

Medical

Iatrogenesis

Litigation

Iatrogenesis

Acute

Symptoms Chronic

Symptoms

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Coping

Abilities

Social

Support Coping

Abilities

Problems with ldquomTBIrdquo as diagnostic term

bull Sounds scary

bull Applies to both immediate injury and long-term consequences

bull Gets confused with more severe forms of TBI

bull mTBI itself varies in severity (and consequences)

bull ldquoConcussionrdquo may be a better word

Natural History of Civilian mTBI

bull Populations most studied

bull Serious athletes (pre- and post-)

bull Road traffic accident victims other trauma

bull Full recovery in the vast majority of patients within weeks to months

bull Less recovery after 3 months

24

Causes of Symptoms Seen after mTBI

bull Short-term symptoms are likely directly due to brain trauma

bull Long-term symptoms are ldquomore complexrdquo

bull Rare in concussed athletes

bull Not uncommon in civilian trauma victims

bull Not overly specific to brain injury

bull Psychosocial factors are very important

Frequency of PCS Symptoms following a MTBI

bull Poor concentration 71

bull Irritability 66

bull Tired a lot more 64

bull Depression 63

bull Memory problems 59

bull Headaches 59

bull Anxiety 58

bull Trouble thinking 57

bull Dizziness 52

bull Blurry or double vision 45

bull Sensitivity to bright light 40

Neuropsych Testing for mTBI Evaluation

bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable

bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly

bull CBT is probably helpful for those with persistent concerns regardless of test results

Imaging Tools ndash Old School to Cutting Edge

bull Plain Radiographs

bull Computed Tomography (CT)

bull MRI with standard anatomic sequences

bull Gradient Echo (Blood sensitive) MRI

bull Diffusion Tensor Imaging

bull Spectroscopy

bull fMRI

bull Perfusion Imaging

bull Quantitative techniques

28

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Biomechanical Injury Diffuse Axonal Injury (Silver 2003)

Pre-Injury

Acute Injury

TBI Produces Cognitive Emotional Behavioral and Physical Disturbances

Brain Injury

Impaired Attention Memory

Disturbance Language

Impairment Executive

Dysfunction Intellectual Loss

Irritability Rage

Depression Anxiety

Agitation Aggression

Disinhibition Apathy

Sleep Disturbance Headaches

Visual Problems DizzinessVertigo

Seizures Motor Problems

Cognitive Disturbance

Behavioral Disturbance

Emotional Disturbance

Physical Disturbance

(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)

mTBI Definition

bull Loss of consciousness of less than 1 hour and

bull Post-traumatic amnesia of less than 24 hours and

bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)

Glasgow Coma Scale

Severity GCS AOC LOC PTA Imaging

Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg

Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs

gt24 hrs lt7 days

Pos or Neg

Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos

21

GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia

Predisposing Factors Causative Factors Perpetuating and Mitigating Factors

Self-

Expectation

mTBI

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Demographic

Characteristics

Medical

Iatrogenesis

Litigation

Iatrogenesis

Acute

Symptoms Chronic

Symptoms

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Coping

Abilities

Social

Support Coping

Abilities

Problems with ldquomTBIrdquo as diagnostic term

bull Sounds scary

bull Applies to both immediate injury and long-term consequences

bull Gets confused with more severe forms of TBI

bull mTBI itself varies in severity (and consequences)

bull ldquoConcussionrdquo may be a better word

Natural History of Civilian mTBI

bull Populations most studied

bull Serious athletes (pre- and post-)

bull Road traffic accident victims other trauma

bull Full recovery in the vast majority of patients within weeks to months

bull Less recovery after 3 months

24

Causes of Symptoms Seen after mTBI

bull Short-term symptoms are likely directly due to brain trauma

bull Long-term symptoms are ldquomore complexrdquo

bull Rare in concussed athletes

bull Not uncommon in civilian trauma victims

bull Not overly specific to brain injury

bull Psychosocial factors are very important

Frequency of PCS Symptoms following a MTBI

bull Poor concentration 71

bull Irritability 66

bull Tired a lot more 64

bull Depression 63

bull Memory problems 59

bull Headaches 59

bull Anxiety 58

bull Trouble thinking 57

bull Dizziness 52

bull Blurry or double vision 45

bull Sensitivity to bright light 40

Neuropsych Testing for mTBI Evaluation

bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable

bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly

bull CBT is probably helpful for those with persistent concerns regardless of test results

Imaging Tools ndash Old School to Cutting Edge

bull Plain Radiographs

bull Computed Tomography (CT)

bull MRI with standard anatomic sequences

bull Gradient Echo (Blood sensitive) MRI

bull Diffusion Tensor Imaging

bull Spectroscopy

bull fMRI

bull Perfusion Imaging

bull Quantitative techniques

28

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

TBI Produces Cognitive Emotional Behavioral and Physical Disturbances

Brain Injury

Impaired Attention Memory

Disturbance Language

Impairment Executive

Dysfunction Intellectual Loss

Irritability Rage

Depression Anxiety

Agitation Aggression

Disinhibition Apathy

Sleep Disturbance Headaches

Visual Problems DizzinessVertigo

Seizures Motor Problems

Cognitive Disturbance

Behavioral Disturbance

Emotional Disturbance

Physical Disturbance

(Silver 1994 Silver 2000 McAllister 1992 McAllister 1994 Kay and Harrington 1993)

mTBI Definition

bull Loss of consciousness of less than 1 hour and

bull Post-traumatic amnesia of less than 24 hours and

bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)

Glasgow Coma Scale

Severity GCS AOC LOC PTA Imaging

Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg

Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs

gt24 hrs lt7 days

Pos or Neg

Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos

21

GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia

Predisposing Factors Causative Factors Perpetuating and Mitigating Factors

Self-

Expectation

mTBI

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Demographic

Characteristics

Medical

Iatrogenesis

Litigation

Iatrogenesis

Acute

Symptoms Chronic

Symptoms

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Coping

Abilities

Social

Support Coping

Abilities

Problems with ldquomTBIrdquo as diagnostic term

bull Sounds scary

bull Applies to both immediate injury and long-term consequences

bull Gets confused with more severe forms of TBI

bull mTBI itself varies in severity (and consequences)

bull ldquoConcussionrdquo may be a better word

Natural History of Civilian mTBI

bull Populations most studied

bull Serious athletes (pre- and post-)

bull Road traffic accident victims other trauma

bull Full recovery in the vast majority of patients within weeks to months

bull Less recovery after 3 months

24

Causes of Symptoms Seen after mTBI

bull Short-term symptoms are likely directly due to brain trauma

bull Long-term symptoms are ldquomore complexrdquo

bull Rare in concussed athletes

bull Not uncommon in civilian trauma victims

bull Not overly specific to brain injury

bull Psychosocial factors are very important

Frequency of PCS Symptoms following a MTBI

bull Poor concentration 71

bull Irritability 66

bull Tired a lot more 64

bull Depression 63

bull Memory problems 59

bull Headaches 59

bull Anxiety 58

bull Trouble thinking 57

bull Dizziness 52

bull Blurry or double vision 45

bull Sensitivity to bright light 40

Neuropsych Testing for mTBI Evaluation

bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable

bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly

bull CBT is probably helpful for those with persistent concerns regardless of test results

Imaging Tools ndash Old School to Cutting Edge

bull Plain Radiographs

bull Computed Tomography (CT)

bull MRI with standard anatomic sequences

bull Gradient Echo (Blood sensitive) MRI

bull Diffusion Tensor Imaging

bull Spectroscopy

bull fMRI

bull Perfusion Imaging

bull Quantitative techniques

28

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

mTBI Definition

bull Loss of consciousness of less than 1 hour and

bull Post-traumatic amnesia of less than 24 hours and

bull Glasgow Coma Scale of 13 to 15 (at most groggyconfused)

Glasgow Coma Scale

Severity GCS AOC LOC PTA Imaging

Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg

Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs

gt24 hrs lt7 days

Pos or Neg

Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos

21

GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia

Predisposing Factors Causative Factors Perpetuating and Mitigating Factors

Self-

Expectation

mTBI

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Demographic

Characteristics

Medical

Iatrogenesis

Litigation

Iatrogenesis

Acute

Symptoms Chronic

Symptoms

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Coping

Abilities

Social

Support Coping

Abilities

Problems with ldquomTBIrdquo as diagnostic term

bull Sounds scary

bull Applies to both immediate injury and long-term consequences

bull Gets confused with more severe forms of TBI

bull mTBI itself varies in severity (and consequences)

bull ldquoConcussionrdquo may be a better word

Natural History of Civilian mTBI

bull Populations most studied

bull Serious athletes (pre- and post-)

bull Road traffic accident victims other trauma

bull Full recovery in the vast majority of patients within weeks to months

bull Less recovery after 3 months

24

Causes of Symptoms Seen after mTBI

bull Short-term symptoms are likely directly due to brain trauma

bull Long-term symptoms are ldquomore complexrdquo

bull Rare in concussed athletes

bull Not uncommon in civilian trauma victims

bull Not overly specific to brain injury

bull Psychosocial factors are very important

Frequency of PCS Symptoms following a MTBI

bull Poor concentration 71

bull Irritability 66

bull Tired a lot more 64

bull Depression 63

bull Memory problems 59

bull Headaches 59

bull Anxiety 58

bull Trouble thinking 57

bull Dizziness 52

bull Blurry or double vision 45

bull Sensitivity to bright light 40

Neuropsych Testing for mTBI Evaluation

bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable

bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly

bull CBT is probably helpful for those with persistent concerns regardless of test results

Imaging Tools ndash Old School to Cutting Edge

bull Plain Radiographs

bull Computed Tomography (CT)

bull MRI with standard anatomic sequences

bull Gradient Echo (Blood sensitive) MRI

bull Diffusion Tensor Imaging

bull Spectroscopy

bull fMRI

bull Perfusion Imaging

bull Quantitative techniques

28

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Glasgow Coma Scale

Severity GCS AOC LOC PTA Imaging

Mild 13 ndash 15 le24 hrs 0 ndash 30 le24 hrs Neg

Moderate 9 ndash 12 gt24 hrs gt30 min lt24 hrs

gt24 hrs lt7 days

Pos or Neg

Severe 3 ndash 8 gt24 hrs ge24 hrs ge7 days Pos

21

GCS ndash Glasgow Coma Score AOC ndash Alteration in consciousness LOC ndash Loss of consciousness PTA ndash Post-traumatic amnesia

Predisposing Factors Causative Factors Perpetuating and Mitigating Factors

Self-

Expectation

mTBI

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Demographic

Characteristics

Medical

Iatrogenesis

Litigation

Iatrogenesis

Acute

Symptoms Chronic

Symptoms

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Coping

Abilities

Social

Support Coping

Abilities

Problems with ldquomTBIrdquo as diagnostic term

bull Sounds scary

bull Applies to both immediate injury and long-term consequences

bull Gets confused with more severe forms of TBI

bull mTBI itself varies in severity (and consequences)

bull ldquoConcussionrdquo may be a better word

Natural History of Civilian mTBI

bull Populations most studied

bull Serious athletes (pre- and post-)

bull Road traffic accident victims other trauma

bull Full recovery in the vast majority of patients within weeks to months

bull Less recovery after 3 months

24

Causes of Symptoms Seen after mTBI

bull Short-term symptoms are likely directly due to brain trauma

bull Long-term symptoms are ldquomore complexrdquo

bull Rare in concussed athletes

bull Not uncommon in civilian trauma victims

bull Not overly specific to brain injury

bull Psychosocial factors are very important

Frequency of PCS Symptoms following a MTBI

bull Poor concentration 71

bull Irritability 66

bull Tired a lot more 64

bull Depression 63

bull Memory problems 59

bull Headaches 59

bull Anxiety 58

bull Trouble thinking 57

bull Dizziness 52

bull Blurry or double vision 45

bull Sensitivity to bright light 40

Neuropsych Testing for mTBI Evaluation

bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable

bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly

bull CBT is probably helpful for those with persistent concerns regardless of test results

Imaging Tools ndash Old School to Cutting Edge

bull Plain Radiographs

bull Computed Tomography (CT)

bull MRI with standard anatomic sequences

bull Gradient Echo (Blood sensitive) MRI

bull Diffusion Tensor Imaging

bull Spectroscopy

bull fMRI

bull Perfusion Imaging

bull Quantitative techniques

28

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Predisposing Factors Causative Factors Perpetuating and Mitigating Factors

Self-

Expectation

mTBI

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Demographic

Characteristics

Medical

Iatrogenesis

Litigation

Iatrogenesis

Acute

Symptoms Chronic

Symptoms

Psychiatric

Conditions

Personality

Traits

Medical

Conditions

Intelligence

Level

Coping

Abilities

Social

Support Coping

Abilities

Problems with ldquomTBIrdquo as diagnostic term

bull Sounds scary

bull Applies to both immediate injury and long-term consequences

bull Gets confused with more severe forms of TBI

bull mTBI itself varies in severity (and consequences)

bull ldquoConcussionrdquo may be a better word

Natural History of Civilian mTBI

bull Populations most studied

bull Serious athletes (pre- and post-)

bull Road traffic accident victims other trauma

bull Full recovery in the vast majority of patients within weeks to months

bull Less recovery after 3 months

24

Causes of Symptoms Seen after mTBI

bull Short-term symptoms are likely directly due to brain trauma

bull Long-term symptoms are ldquomore complexrdquo

bull Rare in concussed athletes

bull Not uncommon in civilian trauma victims

bull Not overly specific to brain injury

bull Psychosocial factors are very important

Frequency of PCS Symptoms following a MTBI

bull Poor concentration 71

bull Irritability 66

bull Tired a lot more 64

bull Depression 63

bull Memory problems 59

bull Headaches 59

bull Anxiety 58

bull Trouble thinking 57

bull Dizziness 52

bull Blurry or double vision 45

bull Sensitivity to bright light 40

Neuropsych Testing for mTBI Evaluation

bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable

bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly

bull CBT is probably helpful for those with persistent concerns regardless of test results

Imaging Tools ndash Old School to Cutting Edge

bull Plain Radiographs

bull Computed Tomography (CT)

bull MRI with standard anatomic sequences

bull Gradient Echo (Blood sensitive) MRI

bull Diffusion Tensor Imaging

bull Spectroscopy

bull fMRI

bull Perfusion Imaging

bull Quantitative techniques

28

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Problems with ldquomTBIrdquo as diagnostic term

bull Sounds scary

bull Applies to both immediate injury and long-term consequences

bull Gets confused with more severe forms of TBI

bull mTBI itself varies in severity (and consequences)

bull ldquoConcussionrdquo may be a better word

Natural History of Civilian mTBI

bull Populations most studied

bull Serious athletes (pre- and post-)

bull Road traffic accident victims other trauma

bull Full recovery in the vast majority of patients within weeks to months

bull Less recovery after 3 months

24

Causes of Symptoms Seen after mTBI

bull Short-term symptoms are likely directly due to brain trauma

bull Long-term symptoms are ldquomore complexrdquo

bull Rare in concussed athletes

bull Not uncommon in civilian trauma victims

bull Not overly specific to brain injury

bull Psychosocial factors are very important

Frequency of PCS Symptoms following a MTBI

bull Poor concentration 71

bull Irritability 66

bull Tired a lot more 64

bull Depression 63

bull Memory problems 59

bull Headaches 59

bull Anxiety 58

bull Trouble thinking 57

bull Dizziness 52

bull Blurry or double vision 45

bull Sensitivity to bright light 40

Neuropsych Testing for mTBI Evaluation

bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable

bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly

bull CBT is probably helpful for those with persistent concerns regardless of test results

Imaging Tools ndash Old School to Cutting Edge

bull Plain Radiographs

bull Computed Tomography (CT)

bull MRI with standard anatomic sequences

bull Gradient Echo (Blood sensitive) MRI

bull Diffusion Tensor Imaging

bull Spectroscopy

bull fMRI

bull Perfusion Imaging

bull Quantitative techniques

28

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Natural History of Civilian mTBI

bull Populations most studied

bull Serious athletes (pre- and post-)

bull Road traffic accident victims other trauma

bull Full recovery in the vast majority of patients within weeks to months

bull Less recovery after 3 months

24

Causes of Symptoms Seen after mTBI

bull Short-term symptoms are likely directly due to brain trauma

bull Long-term symptoms are ldquomore complexrdquo

bull Rare in concussed athletes

bull Not uncommon in civilian trauma victims

bull Not overly specific to brain injury

bull Psychosocial factors are very important

Frequency of PCS Symptoms following a MTBI

bull Poor concentration 71

bull Irritability 66

bull Tired a lot more 64

bull Depression 63

bull Memory problems 59

bull Headaches 59

bull Anxiety 58

bull Trouble thinking 57

bull Dizziness 52

bull Blurry or double vision 45

bull Sensitivity to bright light 40

Neuropsych Testing for mTBI Evaluation

bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable

bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly

bull CBT is probably helpful for those with persistent concerns regardless of test results

Imaging Tools ndash Old School to Cutting Edge

bull Plain Radiographs

bull Computed Tomography (CT)

bull MRI with standard anatomic sequences

bull Gradient Echo (Blood sensitive) MRI

bull Diffusion Tensor Imaging

bull Spectroscopy

bull fMRI

bull Perfusion Imaging

bull Quantitative techniques

28

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Causes of Symptoms Seen after mTBI

bull Short-term symptoms are likely directly due to brain trauma

bull Long-term symptoms are ldquomore complexrdquo

bull Rare in concussed athletes

bull Not uncommon in civilian trauma victims

bull Not overly specific to brain injury

bull Psychosocial factors are very important

Frequency of PCS Symptoms following a MTBI

bull Poor concentration 71

bull Irritability 66

bull Tired a lot more 64

bull Depression 63

bull Memory problems 59

bull Headaches 59

bull Anxiety 58

bull Trouble thinking 57

bull Dizziness 52

bull Blurry or double vision 45

bull Sensitivity to bright light 40

Neuropsych Testing for mTBI Evaluation

bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable

bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly

bull CBT is probably helpful for those with persistent concerns regardless of test results

Imaging Tools ndash Old School to Cutting Edge

bull Plain Radiographs

bull Computed Tomography (CT)

bull MRI with standard anatomic sequences

bull Gradient Echo (Blood sensitive) MRI

bull Diffusion Tensor Imaging

bull Spectroscopy

bull fMRI

bull Perfusion Imaging

bull Quantitative techniques

28

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Frequency of PCS Symptoms following a MTBI

bull Poor concentration 71

bull Irritability 66

bull Tired a lot more 64

bull Depression 63

bull Memory problems 59

bull Headaches 59

bull Anxiety 58

bull Trouble thinking 57

bull Dizziness 52

bull Blurry or double vision 45

bull Sensitivity to bright light 40

Neuropsych Testing for mTBI Evaluation

bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable

bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly

bull CBT is probably helpful for those with persistent concerns regardless of test results

Imaging Tools ndash Old School to Cutting Edge

bull Plain Radiographs

bull Computed Tomography (CT)

bull MRI with standard anatomic sequences

bull Gradient Echo (Blood sensitive) MRI

bull Diffusion Tensor Imaging

bull Spectroscopy

bull fMRI

bull Perfusion Imaging

bull Quantitative techniques

28

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Neuropsych Testing for mTBI Evaluation

bull Ability to distinguish between mTBI-related cognitive impairment and MH-related cognitive impairment in those with clear MH problems is questionable

bull Mismatch between symptoms and test results is common but testing can still be helpful if contextualized properly

bull CBT is probably helpful for those with persistent concerns regardless of test results

Imaging Tools ndash Old School to Cutting Edge

bull Plain Radiographs

bull Computed Tomography (CT)

bull MRI with standard anatomic sequences

bull Gradient Echo (Blood sensitive) MRI

bull Diffusion Tensor Imaging

bull Spectroscopy

bull fMRI

bull Perfusion Imaging

bull Quantitative techniques

28

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Imaging Tools ndash Old School to Cutting Edge

bull Plain Radiographs

bull Computed Tomography (CT)

bull MRI with standard anatomic sequences

bull Gradient Echo (Blood sensitive) MRI

bull Diffusion Tensor Imaging

bull Spectroscopy

bull fMRI

bull Perfusion Imaging

bull Quantitative techniques

28

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

GE 3T MRI Scanner

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Tractography

Superior view color fiber maps Lateral view color fiber maps

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

SPECT Brain Perfusion after mild TBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Management of MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Management of Sensory Disturbance

bull Disequilibrium and Vertigo bull Vestibular rehabilitation Referral ENT and specially trained physical therapist

bull Consider pharmacologic agents(disadvantage is sedation and suppression of adaptive learning)

bull Encourage regular coordinated movement (dance tai-chi etc) Avoid sports prone to new injuries

bull Driving can be an issue

bull Hyperacusis Use of specialty ear plugs in noisy environment Referral Audiologist

bull No Etoh

33

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Post Traumatic VertigoDizziness

Direct injury cochlea or vestibular structure esp with sensorineural hearing loss or fracture of temporal bone

Labyrinthine concussion (vertigo plus ataxia) maximal at onset and abating within weeks

BPPV (benign paroxysmal positional vertigo) due to shearing and displacement of otoconia Can be a hiatus of weeks or months between TBI and development

Perilymphatic fistula due to rupture of oval or round window Unilateral SN hearing loss with persistent vertigo and ataxia characteristic

Other post-traumatic Menierersquos brainstem ischemia with vertebral artery dissection epileptic and migraine related vertigo

Mechanisms of Vertigo

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Post Traumatic VertigoDizziness

Mechanisms of non-vertiginous dizziness is often cervical

bull Aberrant afferent input from positional proprioceptors in C- spine

bull Overstimulation of cervical sympathetic nerves

bull Compromised vertebral arterial flow Probably rare

Mechanisms of Vertigo

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Pharmacologic choices for mild TBI

bull Nortriptyline 10-25 mg qhs for headache sleep pain and potentially anxiety

bull Citalopram (Celexa) 10-20mg escitalopram (Cipralex) 5-10mg or Vanlafaxine (Effexor XR) 375-75 mg for anxiety and depression agitation emotional lability and to improve sense of ldquowell beingrdquo

bull Modinafil (Provigil) 100-200 mg or Budeprion SR (Wellbutrin) 100-150 mg qam for alertness and reduced fatigue

bull Topamax 25mg to 100mg qd if headaches remain intractable

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Cognitive Evaluation of mild TBI

Vulnerable domains to TBI

Attention

Working memory

Processing speed

Reaction time

Not associated with gross deficits of intelligence and memory

Findings can be confused with those of pain syndromes and medication effects as well as psychological illness

May be helpful in differentiating TBI from alternative diagnosis

Neuropsychological Testing

37

Schretlen Shapiro A quantitative review of the effects of traumatic brain injury on cognitive functioning Int Rev Psychiatry 2003 15341

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Lessons learned from mild TBI patients

Family physicians have pleotropic effects

Physician and patient expectations are critical to recovery Set an obtainable expectation at each and every visit First steps first

Donrsquot allow a mild or moderate TBI to become the defining moment of the patients existence So what Is a critical concept to a successful ldquorebootrdquo by a patient with TBI

The human brain is ldquoplasticrdquo

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Recent research

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Return to Work Following mTBI J Head Trauma Rehabil October 2014 Waljas et al

bull Traditional brain injury severity variables (duration LOC GSC and post injury cognitive impairment) have shown limited usefulness in predicting outcome

bull Other factors such as duration of PTA personality characteristics pre and post injury physical functioning psychological status litigation status employment status substance abuse and presence of extracranial injurries are considered potential correlates of outcome

bull Nolin and Heroux study emphasized importance of focusing on subjective complaints and showed the total number of symptoms reported at follow up was related to vocational status Patient characteristics injury severity indicators and cognitive functioning were not associated with vocational status after TBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Waljasrsquo paper (contrsquod 2 )

bull One-week RTW status rates after mTBI vary widely in the literature

bull A Greek study showed the rate was 84 in a very mildly injured population

bull New Zealand study 82 returned in the first week post-injury

bull In contrast researchers in the UK found only 41 returned to work within 5 days of minor head injury In another study 44 of UK patients seen in a rehab clinic returned to work in 2 weeks

bull The percentages returning to work by 1 month also varied widely across studies from 25-100

bull It has also been suggested that differences in study design cultural differences socioeconomic and political factors can also influence results

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Waljas paper contrsquod 3

bull In the current Waljas study they evaluated 17 factors felt to influence RTW rates

bull 145 patients admitted to an ED were enrolled After assessment for exclusion criteria 33 patients removed due to higher severity

bull At 1 week post injury 47 returned to work at 1 month 71 RTW [in contrast in a US study (Iverson 2012 Brain Injury Medicine) only 25 RTW at 1 month]

bull Cultural differences not examined but they stated that past studies have shown that people who expected their symptoms would resolve quickly actually have shorter recovery times (Snell 2011 Whittaker 2007)

bull MRI was performed 3 weeks post injury including SWI

42

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

The presence of multiple bodily injuries was strongly associated with duration of time off work The role of mental health factors in addition to the physical trauma must be considered Various studies have documented fairly high rates of traumatic stress and depression associated with polytrauma (Michaels 2000 Shalev 1998 Zatzick 2002) In the current study though there was not a clear interaction among bodily injuries mental health problems

In this study they could not quantify whether the longer RTW time was due to physical injuries and felt it was impossible to quantify the solo effect of the mTBI

The authors stated ldquoOn the basis of these findings it can be argued that the only mTBI-specific finding that was associated with greater time off work was trauma-related intracranial findingsrdquo

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

44

They commented that it was common to RTW with symptoms and many had returned to work by the time of the neuropsych assessment

The majority of their study population RTW within 2 months Predictors of delayed RTW were sustaining a complicated mTBI having multiple bodily injuries increased age and fatigue

Patients who took longer to RTW did not perform more poorly on neurocogntive testing or report more depressive symptoms (in this study)

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Systematic Review of RTW after MTBI results of International collaboration APMR-Canceliere et al 2014

45

299 articles reviewed relating to MTBI prognosis

Detailed one study showing 50 off compensation benefits after 17 days 75 off benefits after 72 days but 5 still remained on benefits 2 years post injury (done in Ontario Kristman 2010)

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

A review of post-concussion syndrome and psychological factors associated with concussion Brain Injury 2014 Broshek et al

This review study concluded that assessment and treatment of psychological factors may prevent or shorten the length of PCS

The injury itself can trigger and fear reactions and some vulnerable individuals may be at risk of neurobiological depression

Etiology psychological disturbances contribute to symptoms during acute stages of PCS are stable and persistent in prolonged cases of PCS and are predictive of late outcome of PCS

Postulated a dysfunctional cognitive feedback loop as an explanation for PCS which may therefore a target for psychotherapy SSRIrsquos for those who fail to respond

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Continued 47

Predictors pre-injury anxiety and depression and acute post traumatic stress heightened anxiety sensitivity was important also

Cognitive misattribution also an important part of the picture BC study on ldquoGood Old Daysrdquo bias

Treatments Education and reassurance exercise and return to activity

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

The Neuropsychological Outcomes of Concussion A Systematic Review of Meta-analyses on the Cogntive Sequelae of mTBI

Neuropsychologiy 2014 Karr et al

key points made The average prognosis remains positive but a subgroup of

patients with mTBI may remain chronically impaired into the post acute phase but the size and existence of this symptomatic subgroup remains debatable Focusing on mean performances meta-analytic methods may hid the few participants presenting persistent symptoms post mTBI (Iverson 2010)

Further multiple biomarkers (eg DTI eye tracking) have detected nontransient neurological changes following mTBI evidencing the potential for long-term impairment

However these persistent symptoms could also derive from pre-existing psychological factors (eg psychosocial stressors lower cognitive ability) rather than representing outcomes attributable to the mild head injury itself (Larrabee 2013)

Other researchers have posited moderating variables to predict the presence of persistent symptoms eg compensation-seekers (Kashluba 2008)

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Exercise treatment for Postconcussion Syndrome A Pilot Study of Changes in fMRI Imaging Activation Physiology and Symptoms J Head

Trauma Rehabil 2013 Leddy et al

10 patients 5 female ages 17-52 and 5 health controls (4 female) Symptomatic for 6 weeks or more but less than 12 months

Of the 10 patients 2 were dropped after initial MRI (other diagnosis malingering) 1 further dropped out due to scheduling issues

fMRI math test from ANAM (addition and subtraction of 3 numbers) The authors concluded that controlled exercise treatment helped to

restore normal autoregulation of CBF more than placebo stretching They could not be certain of the significance of the fMRI findings They summarized by stating that a larger group should be studied but

that perhaps the same physiologic dysfunctions problems with CBF autoregulation and autonomic imbalance that are associated with exacerbation of symptoms during exercise are responsible also for the symptoms that PCS patients experience during prolonged cognitive memory working tasks such as fatigue and difficulty concentrating

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Coated Platelet Levels are Persistently Elevated in Patients with MTBI J Head Trauma Rehabil

2014 Prodan et al

Study of veterans with TBI

Coated platelet levels are markedly and persistently elevated in patients with mTBI

The authors stated these studies suggest a link to previous findings of increased stroke risk and chronic inflammation among individuals who sustained a MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Dizziness after SRC Can Physiotherapists offer better treatment than just physical and cognitive rest BJSM 2014 Reneker and

Cook

Editorial piece on whether dizzy patients may have altered proprioceptive information of the head and neck

Only one small study has been done to suggestive effectiveness (Schneider 2014)

No agreement on what constitutes a standardized valid assessment approach for cervicogenic dizziness

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

SRC increases the risk of subsequent injury abut about 50 in elite male football (soccer) players BJSM 2014 Nordstrom et al

Authors found that there was an increased risk of subsequent injury within the year following concussion in elite football players

Analysis of previous injury history revealed that those players who subsequently sustained a concussion had also suffered more injuries than their counterparts who did not suffer a concussion (ie concussion may be part of an ldquoinjury pronerdquo phenotypebehaviour)

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Diffusion tensor imaging findings are not strongly associated with

postconcussional disorder 2 months following mild traumatic brain injury J Head Trauma Rehabil 2012 Lange RT1 Iverson GL et al

bull To examine the relation between diffusion tensor imaging (DTI) of

the corpus callosum and postconcussion symptom reporting following mild traumatic brain injury (MTBI)

bull Diffusion tensor imaging of the corpus callosum was undertaken using a Phillips 3T scanner at 6 to 8 weeks postinjury

RESULTS The MTBI group reported more postconcussion symptoms than

the trauma controls There were no significant differences between MTBI and trauma control groups on all DTI measures

CONCLUSIONS These data do not support an association between white matter

integrity in the corpus callosum and self-reported postconcussion syndrome 6 to 8 weeks post-MTBI

Recent VGH Grand Rounds- Dr David Koo Physical Medicine

Whats New in the Diagnosis and Management of Concussion (mild TBI)

bull Key Points made

bull He felt concussion was a subset of mTBI ie at the lower range

bull Noted that the patient may incorporate the memories of observers to form their own impressions

bull Symptom baselines present in non concussed groups eg college students chronic pain and depression

54

Koo Rounds 2

bull Diagnostic accuracy improvements

bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical

bull SWI MRI scans shows hemosiderin persist about 5 years post TBI

bull High rate of questionable lesions on 3 T MRI

bull SPECT scanning failed to differentiate clearly

bull DTI is best tool to detect DAI

bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)

55

VGH Koo Rounds 3

bull He said 85 should get better within 4 weeks and this should be the message

bull Anxious individuals tend to overmonitor their symptoms

bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity

bull PCS incidence reported as 10-15 after a single mTBI

bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014

56

Koo 4

bull Causes of PCS-Neurobiological vs psychogenic vs

bull MRI in some showed a smaller cingulate gyrus 1 year later

bull Several cases of post-mortem diagnoses of DAI

bull Apo E4 influence

bull Levin 2001 showed higher rates of depression and PTSD after 3 months

57

VGH Koo Rounds 5

bull Treatment

bull Early education of critical importance

bull Treat depression and anxiety primarily ie treat what you can treat

bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar

bull He advocated early CBT within 6 weeks if indicated

58

Koo Rounds 6

bull Pharmacology-numerous possibilities

bull He noted a recent study in press using amantadine

bull Increased use in US including stimulants

bull SSRIrsquos if appropriate in my view

bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise

bull Attempt to normalize life asap with early RTW

bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate

bull Mentioned brainstreamsca for patient education

bull Use of early responsive concussion clinics

59

Koo Rounds 2

bull Diagnostic accuracy improvements

bull Borg 2004 CT scan study 5 abnormalities in GCS 15 most non surgical

bull SWI MRI scans shows hemosiderin persist about 5 years post TBI

bull High rate of questionable lesions on 3 T MRI

bull SPECT scanning failed to differentiate clearly

bull DTI is best tool to detect DAI

bull Biomarkers may prove useful He quoted the recent JAMA neurology article on use of Tau protein (inconclusive)

55

VGH Koo Rounds 3

bull He said 85 should get better within 4 weeks and this should be the message

bull Anxious individuals tend to overmonitor their symptoms

bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity

bull PCS incidence reported as 10-15 after a single mTBI

bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014

56

Koo 4

bull Causes of PCS-Neurobiological vs psychogenic vs

bull MRI in some showed a smaller cingulate gyrus 1 year later

bull Several cases of post-mortem diagnoses of DAI

bull Apo E4 influence

bull Levin 2001 showed higher rates of depression and PTSD after 3 months

57

VGH Koo Rounds 5

bull Treatment

bull Early education of critical importance

bull Treat depression and anxiety primarily ie treat what you can treat

bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar

bull He advocated early CBT within 6 weeks if indicated

58

Koo Rounds 6

bull Pharmacology-numerous possibilities

bull He noted a recent study in press using amantadine

bull Increased use in US including stimulants

bull SSRIrsquos if appropriate in my view

bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise

bull Attempt to normalize life asap with early RTW

bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate

bull Mentioned brainstreamsca for patient education

bull Use of early responsive concussion clinics

59

VGH Koo Rounds 3

bull He said 85 should get better within 4 weeks and this should be the message

bull Anxious individuals tend to overmonitor their symptoms

bull No evidence for absolute rest The Gibson 2013 study showed no difference in recovery-the only difference for prognosis was initial severity

bull PCS incidence reported as 10-15 after a single mTBI

bull The Edmed study on PCS showed the symptoms and diagnosis depended very much on the interview type and the questions asked Brain Injury 2014

56

Koo 4

bull Causes of PCS-Neurobiological vs psychogenic vs

bull MRI in some showed a smaller cingulate gyrus 1 year later

bull Several cases of post-mortem diagnoses of DAI

bull Apo E4 influence

bull Levin 2001 showed higher rates of depression and PTSD after 3 months

57

VGH Koo Rounds 5

bull Treatment

bull Early education of critical importance

bull Treat depression and anxiety primarily ie treat what you can treat

bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar

bull He advocated early CBT within 6 weeks if indicated

58

Koo Rounds 6

bull Pharmacology-numerous possibilities

bull He noted a recent study in press using amantadine

bull Increased use in US including stimulants

bull SSRIrsquos if appropriate in my view

bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise

bull Attempt to normalize life asap with early RTW

bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate

bull Mentioned brainstreamsca for patient education

bull Use of early responsive concussion clinics

59

Koo 4

bull Causes of PCS-Neurobiological vs psychogenic vs

bull MRI in some showed a smaller cingulate gyrus 1 year later

bull Several cases of post-mortem diagnoses of DAI

bull Apo E4 influence

bull Levin 2001 showed higher rates of depression and PTSD after 3 months

57

VGH Koo Rounds 5

bull Treatment

bull Early education of critical importance

bull Treat depression and anxiety primarily ie treat what you can treat

bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar

bull He advocated early CBT within 6 weeks if indicated

58

Koo Rounds 6

bull Pharmacology-numerous possibilities

bull He noted a recent study in press using amantadine

bull Increased use in US including stimulants

bull SSRIrsquos if appropriate in my view

bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise

bull Attempt to normalize life asap with early RTW

bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate

bull Mentioned brainstreamsca for patient education

bull Use of early responsive concussion clinics

59

VGH Koo Rounds 5

bull Treatment

bull Early education of critical importance

bull Treat depression and anxiety primarily ie treat what you can treat

bull Leddy 2010 study on subthreshold exercise tolerance (Clin J Sport Medicine) plus more recent publication of similar

bull He advocated early CBT within 6 weeks if indicated

58

Koo Rounds 6

bull Pharmacology-numerous possibilities

bull He noted a recent study in press using amantadine

bull Increased use in US including stimulants

bull SSRIrsquos if appropriate in my view

bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise

bull Attempt to normalize life asap with early RTW

bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate

bull Mentioned brainstreamsca for patient education

bull Use of early responsive concussion clinics

59

Koo Rounds 6

bull Pharmacology-numerous possibilities

bull He noted a recent study in press using amantadine

bull Increased use in US including stimulants

bull SSRIrsquos if appropriate in my view

bull Dr Koo felt that an active rehabilitation program at subthreshold holds the most promise

bull Attempt to normalize life asap with early RTW

bull Increase the frequency of activity more than intensity eg 2 short walks or more per day and gradually amalgamate

bull Mentioned brainstreamsca for patient education

bull Use of early responsive concussion clinics

59