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Physical Therapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury Clinical Practice Guidelines CATHERINE C. QUATMAN-YATES, PT , DPT , PhD • AIRELLE HUNTER-GIORDANO, PT , DPT KATHY K. SHIMAMURA, PT , DPT , NCS, OCS, CSCS, FAAOMPT • ROB LANDEL, PT , DPT , FAPTA BARA A. ALSALAHEEN, PT , PhD • TIMOTHY A. HANKE, PT , PhD • KAREN L. McCULLOCH, PT , PhD, FAPTA Physical Therapy Evaluation and Treatment After Concussion/ Mild Traumatic Brain Injury Clinical Practice Guidelines (...) & sports physical therapy Concussion: Clinical Practice Guidelines Concussion: Clinical Practice Guidelines Summary of Recommendations* SCREENING AND DIAGNOSIS Diagnosis A Physical therapists must screen all individuals who have experienced a potential concussive event and document the presence or absence of symptoms, impairments, and func- tional limitations that may relate to a concussive event. Screening for Indicators of Emergency Conditions A Physical therapists must screen patients who have
Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial Sport-related concussion (SRC) is a significant public health problem without an effective treatment.To assess the effectiveness of subsymptom threshold aerobic exercise vs a placebo-like stretching program prescribed to adolescents in the acute phase of recovery from SRC.This multicenter prospective randomized clinical trial was conducted at university concussion centers. Male and female adolescent (...) ; 24 female [47%]). Participants in the aerobic exercise group were seen a mean (SD) of 4.9 (2.2) days after the SRC, and those in the stretching group were seen a mean (SD) of 4.8 (2.4) days after the SRC. There were no differences in age, sex, previous concussions, time from injury, initial symptom severity score, or initial exercise treadmill test and physical examination results. Aerobic exercise participants recovered in a median of 13 (interquartile range [IQR], 10-18.5) days, whereas
Continued vs. interrupted direct oral anticoagulants at the time of device surgery, in patients with moderate to high risk of arterial thrombo-embolic events (BRUISE CONTROL-2) Guidelines recommend warfarin continuation rather than heparin bridging for pacemaker and defibrillator surgery, after the BRUISE CONTROL trial demonstrated an 80% reduction in device pocket haematoma with this approach. However, direct oral anticoagulants (DOACs) are now used to treat the majority of patients
Bruising: Scenario: Management of bruising Scenario: Management | Management | Bruising | CKS | NICE Search CKS… Menu Scenario: Management Bruising: Scenario: Management of bruising Last revised in March 2016 Scenario: Management of bruising When should I admit or refer a person with abnormal bruising? Admit the person if they have significant active bleeding and are not responding to simple measures (such as local compression). If is suspected in children and young people, the elderly (...) if they have : Unexplained petechiae or Hepatosplenomegaly or Full blood count results suggestive of . For more information, see the CKS topic on . Refer children with periorbital bruising urgently (for an appointment within 48 hours) for specialist assessment for if they have: A palpable abdominal mass or An unexplained enlarged abdominal organ. For all other children, liaise with a paediatrician or paediatric haematologist to arrange venepuncture and further investigations as needed. Refer adults
Bruising: How should I investigate a person with bruising? How should I investigate a person with bruising? | Diagnosis | Bruising | CKS | NICE Search CKS… Menu How should I investigate a person with bruising? Bruising: How should I investigate a person with bruising? Last revised in March 2016 How should I investigate a person with bruising? Arrange a urine dipstick test to check for non-visible haematuria which may suggest an underlying bleeding disorder or vasculitis. In adults (...) with unexplained bruising, bleeding, petechiae, or hepatosplenomegaly consider arranging: A very urgent full blood count including platelet count (within 48 hours) and blood film. Clotting screen (prothrombin time [PT], activated partial thromboplastin time [aPTT], and international normalized ratio [INR] if the person is taking warfarin). Liver, renal, and thyroid function tests, depending on clinical judgement. In children and young people with unexplained bruising or bleeding offer: A very urgent full blood
BruisingBruising | Topics A to Z | CKS | NICE Search CKS… Menu BruisingBruising Last revised in March 2016 A bruise is a haematoma which forms due to bleeding under intact skin into subcutaneous tissue, due to vascular damage or injury Diagnosis Management Background information Bruising: Summary A bruise is a haematoma which forms due to bleeding under intact skin into subcutaneous tissue, due to vascular damage or injury. Bruising usually occurs as a result of accidental trauma, but may (...) be non-accidental. Bruising is the most common injury sustained by children who have been subject to physical abuse. Excessive bruising, or bruising which occurs as a result of minimal or no recognized trauma, may be caused, or exacerbated by, an underlying bleeding disorder or medical condition, including: Vascular disorders (for example senile or simple purpura). Platelet disorders (for example idiopathic thrombocytopenic purpura, leukaemia, or liver disease). Coagulation disorders (for example
Bruising: How should I assess a person with bruising? How should I assess a person with bruising? | Diagnosis | Bruising | CKS | NICE Search CKS… Menu How should I assess a person with bruising? Bruising: How should I assess a person with bruising? Last revised in March 2016 How should I assess a person with bruising? Ask about symptoms which suggest an underlying platelet or coagulation disorder: Nosebleeds or gingival bleeding (mucocutaneous bleeding). Excessive or prolonged bleeding from (...) haemorrhoids, other rectal bleeding, haematuria, or menorrhagia. Previous excessive bruising, or excessive or prolonged bleeding, that: Occurs soon after trauma (particularly if it is associated with a petechial rash or mucocutaneous bleeding) — suggests a . Is delayed, such as haemorrhage occurring 24 hours after a dental extraction (particularly if it is associated with bruises, haemarthrosis, or muscle haematomas) — suggests a coagulation disorder, such as . Is new in onset, following previously normal
Living Guideline for Diagnosing and Managing Pediatric Concussion LIVING GUIDELINE FOR DIAGNOSING AND MANAGING PEDIATRIC CONCUSSION Reed, N.*, Zemek, R.*, Dawson, J., Ledoux, AA., et al. (2019). Living Guideline for Diagnosing and Managing Pediatric Concussion. Toronto, ON: Ontario Neurotrauma Foundation * These authors contributed equally. 1 Guideline for Diagnosing and Managing Pediatric Concussion – Recommendations / Tools TABLE OF CONTENTS Disclaimer…………………………………………………………………………. 2 Guideline (...) Overview……………………………………………………… 3 List of Recommendations……………………………………………….. 4 Recommendations……………………………………………….………….. 12 List of Tools……….…………………………………….……………………….. 55 References……………………………………………………………………….. 56 2 Guideline for Diagnosing and Managing Pediatric Concussion – Recommendations / Tools DISCLAIMER: The recommendations and resources found within the Living Guideline for Diagnosing and Managing Pediatric Concussion are intended to inform and instruct care providers and other stakeholders who
Guidelines for diagnosing and managing pediatric concussion Guidelines for Diagnosing and Managing Pediatric Concussion First edition, June 2014, v1.1 Recommendations for Health Care Professionals This document is intended to guide health care professionals in diagnosing and managing pediatric—not adult—concussion. It is not for self-diagnosis or treatment. Parents and/or caregivers may bring it to the attention of their child/adolescent’s health care professionals. The best knowledge available (...) or damage arising from any claims made by a third party. Also, as the sponsor of this document, the Ontario Neurotrauma Foundation assumes no responsibility or liability whatsoever for changes made to the guidelines without its consent. Any changes must be accompanied by the statement: “Adapted from Guidelines for Diagnosing and Managing Pediatric Concussion with/without permission,” according to whether or not permission was sought and/or given. About the Ontario Neurotrauma Foundation The Ontario
Assessment of easy bruising Assessment of easy bruising - Differential diagnosis of symptoms | BMJ Best Practice You'll need a subscription to access all of BMJ Best Practice Search Assessment of easy bruising Last reviewed: February 2019 Last updated: September 2018 Summary A bruise (ecchymosis) is caused by bleeding beneath the skin as a result of extravasation of blood from surrounding blood vessels. It may develop due to abnormalities in haemostasis or alteration in the structural (...) integrity of the blood vessel wall and surrounding subcutaneous tissue. Easy bruising implies that no significant trauma has occurred to the skin or soft tissue to cause the bruise, and the bruises are larger and/or more frequent than what would normally be seen. It is a common complaint of patients seen in a medical practice. Surveys of normal healthy individuals report the frequency of easy bruising to range from 12% to 55%. Srámek A, Eikenboom JC, Briët E, et al. Usefulness of patient interview
Using opinion leaders to address intervention gaps in concussion prevention in youth sports: key concepts and foundational theory Behavioral interventions to increase disclosure and proper management of concussion in youth sports have unrealized potential when it comes to preventing concussion. Interventions have focused on changing individual athlete behavior and have fallen short of the potential for sustained systemic behavioral change. One potentially critical reason for this shortfall (...) is that other key determinants of risk behaviors at all levels of the socio-ecological model (e.g. interpersonal, community, policy) are not addressed in extant programming. There is a critical need for theory-driven interventions that address concussion prevention and education at the community level and target sustainable culture change. The Popular Opinion Leader (POL) intervention, a multi-level intervention model previously successfully employed in multiple public health contexts, is theoretically well
Concussion. Concussions are a common injury for which patients often present first to primary care physicians. They can affect the day-to-day function of patients in school and work, as well as in sports and recreational activities. Recognizing common physical signs and symptoms after injury facilitates timely diagnosis and treatment, permitting initiation of an active management approach to recovery while preventing secondary injury. For persons with persistent symptoms, active rehabilitation
Concussion knowledge, attitudes and reporting intention among adult competitive Muay Thai kickboxing athletes: a cross-sectional study Muay Thai kickboxing is a full-contact combat sport with a high incidence of head trauma, yet little is known about these athletes' concussion knowledge and attitudes. This study aims to describe and quantify concussion knowledge, attitudes, and reporting intention among adult competitive Muay Thai kickboxing athletes.This cross-sectional study comprised 193 (...) competitive Muay Thai kickboxing athletes aged ≥18 years registered with the Thai Boxing Association Sanctioning Authority. The mean concussion knowledge score was 19.5 (SD 2.3) out of 25, the mean concussion attitudes score was 62.7 (SD 7.4) out of 75, and 134 (69.4%) of respondents indicated that they were likely to report concussion symptoms. No significant predictors of concussion knowledge, attitudes, or reporting intention were revealed.Competitive Muay Thai kickboxing athletes appear to have
Common data elements collected among universities for sport-related concussion studies Universities are increasingly implementing programs to effectively respond to and manage sport-related concussions (SRCs). One such effort is to develop common data elements (CDEs) and standardize data collection methods. The objectives of this study were to describe CDEs currently collected by Big Ten and Ivy League universities for SRC studies, and to compare the data collected with the core CDEs (...) recommended by the National Institute of Neurological Disorders and Stroke (NINDS).We conducted an anonymous cross-sectional online survey among medical staff at the 14 Big Ten and 8 Ivy League universities (one per university) between September and October 2015. The survey instrument, including 9 questions corresponding to the concussion data collected before, during, and after a concussion, was developed and pilot-tested before field use. We analyzed patterns of the concussion CDEs being collected
Guideline for concussion/mild traumatic brain injury & persistent symptoms - Post-Traumatic Headache Post-Traumatic Headache // Brain Injury Guidelines Toggle navigation NAVIGATION > > > > > > > > > > > > > > > > > > Guideline For Concussion/Mild Traumatic Brain Injury & Persistent Symptoms 3rd Edition, for Adults over 18 years of age Post-Traumatic Headache Headache is the most common and among the most prevalent persistent symptoms following mTBI. 1-4 Studies to date have documented (...) that anywhere from 30-90% of individuals who sustain a mTBI develop post-traumatic headache. 2,5 Interestingly, several researchers have reported that post-traumatic headache is more common after concussion/mTBI than after severe TBI. 5-17 Notably, post-traumatic headache is associated with a high degree of disability 1 and is more chronic and persistent than previously thought. 18 The vast majority of people with post-traumatic headache improve within days or weeks; however, for some individuals, headaches
Guideline for concussion/mild traumatic brain injury & persistent symptoms - General Recommendations Regarding Diagnosis/Assessment of Persistent Symptoms General Recommendations Regarding Diagnosis/Assessment of Persistent Symptoms // Brain Injury Guidelines Toggle navigation NAVIGATION > > > > > > > > > > > > > > > > > > Guideline For Concussion/Mild Traumatic Brain Injury & Persistent Symptoms 3rd Edition, for Adults over 18 years of age General Recommendations Regarding Diagnosis/Assessment (...) of Persistent Symptoms While full recovery is expected within 3 months after concussion/mTBI, 1,2, not all patients experience such rapid recovery, with minimally 15% or more experiencing persistent symptoms. 3,4 A more recent study showed 20 – 48% of veterans had persistent symptoms up to 60 months post-concussion. 5 A number of factors influence the rate of recovery, including the mechanism and setting for the initial injury; for example, concussion/mTBI due to non-sport-related causes can be unexpected
Guideline for concussion/mild traumatic brain injury & persistent symptoms - General Recommendations Regarding Management of Persistent Symptoms General Recommendations Regarding Management of Persistent Symptoms // Brain Injury Guidelines Toggle navigation NAVIGATION > > > > > > > > > > > > > > > > > > Guideline For Concussion/Mild Traumatic Brain Injury & Persistent Symptoms 3rd Edition, for Adults over 18 years of age General Recommendations Regarding Management of Persistent Symptoms (...) Consistent with general expectations of both patients and healthcare professionals, symptoms following mTBI are anticipated to resolve in a timely fashion in the majority of cases; evidence is emerging that some people (15% or greater) continue to have persistent symptoms. 1-3 There is wide variation in how people recover after concussion/mTBI 4 even when experiencing similar injuries. 2 This guideline has been developed to assist in managing those individuals who continue to have persistent symptoms
Guideline for concussion/mild traumatic brain injury & persistent symptoms - Initial Management of Concussion/mTBI Initial Management of Concussion/mTBI // Brain Injury Guidelines Toggle navigation NAVIGATION > > > > > > > > > > > > > > > > > > Guideline For Concussion/Mild Traumatic Brain Injury & Persistent Symptoms 3rd Edition, for Adults over 18 years of age Initial Management of Concussion/mTBI Whether a patient first presents to the Emergency Department (ED) or to the primary care (...) to specialists should also be considered if symptoms exhibit an atypical pattern or cannot be linked to a concussion event, and/ or when there are other major comorbid conditions present (e.g., depression, PTSD). The majority of patients will be discharged home; it should be noted that a person who remains symptomatic post mTBI should not drive for at least 24 hours. 3-6 Even asymptomatic patients after 48 hours exhibited poorer vehicle control, especially when navigating curves suggesting that driving
Guideline for concussion/mild traumatic brain injury & persistent symptoms - Sport-Related Concussion/mTBI Sport-Related Concussion/mTBI // Brain Injury Guidelines Toggle navigation NAVIGATION > > > > > > > > > > > > > > > > > > Guideline For Concussion/Mild Traumatic Brain Injury & Persistent Symptoms 3rd Edition, for Adults over 18 years of age Sport-Related Concussion/mTBI In the sports literature, the effects of traumatic biomechanical forces on the brain have traditionally been referred (...) to as a concussion. In this Guideline, the term concussion/mTBI will be used to maintain consistency within this document. A sport-related concussion/mTBI is a traumatic brain injury that may be caused by either a direct blow to the head, face, neck or elsewhere on the body as an indirect force being transmitted to the head during sports activity. A sport-related concussion/mTBI can result in a range of clinical signs and symptoms that may or may not involve a loss of consciousness. While the injury may result
Guideline for concussion/mild traumatic brain injury & persistent symptoms - Diagnosis/Assessment of Concussion/mTBI Diagnosis/Assessment of Concussion/mTBI // Brain Injury Guidelines Toggle navigation NAVIGATION > > > > > > > > > > > > > > > > > > Guideline For Concussion/Mild Traumatic Brain Injury & Persistent Symptoms 3rd Edition, for Adults over 18 years of age Diagnosis/Assessment of Concussion/mTBI Diagnosis of mTBI/concussion (Table B) is the first critical step in successful management (...) leading to improved outcomes and prevention of further injury. Patients commonly present to the Emergency Department (ED) or their Primary Care Provider’s (PCP’s) office following trauma and may be unaware that they have sustained concussion/mTBI. A high level of suspicion is required particularly when there is evidence of direct trauma to the head or mechanism of injury 1 that is frequently associated with mTBI, such as motor vehicle collision, falls, assaults and nonintentional strike by/against