The Value of Rest. Makdissi- Zurich A brief period of rest is important in the acute period following concussion.

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2 Treatment 2

3 The Value of Rest Makdissi- Zurich 2012 A brief period of rest is important in the acute period following concussion. There is no evidence however that prolonged rest is beneficial for athletes with persistent symptoms. Preliminary studies show that graded activity is beneficial in cases with persistent symptoms. 3

4 Rationale for Rest? Rest Iverson- Zurich 2012 The injured brain might be in a state of neurometabolic crisis. Assuming that neurometabolic crisis involves an energy crisis, then vigorous activity might compound or magnify the energy crisis. Passing another mechanical force through he injured brain, while it is in a state of neurometabolic crisis, might result in magnified pathophysiology. 4

5 Rest Iverson- Zurich 2012 Exercise is good for the injured brain (but not if done too soon). Greisbach et al, - exercise appears to promote neuroplasticity in the injured rodent brain. Temporal Window. If the injured rodent exercises too soon, the molecular markers of neuroplasticity are suppressed. 5

6 Rest Iverson- Zurich 2012 Critical Questions How do we define rest? How long should an athlete rest? How do we define gradual resumption of activities? How much rest is too much rest? When should we begin active rehabilitation? 6

7 Rest Iverson- Zurich

8 Rest Iverson- J Head Trauma Rehab There is no evidence that complete rest (recumbance in bed and avoidance of cognitive stimulation) for any duration improves or adversely impacts outcome after MTBI. The only randomized controlled trial had null results. Multiple systematic reviews for many health conditions other than MTBI have concluded that full bed rest beyond 1 to 2 days is unhelpful and potentially harmful. Negative physiological consequences of prescribed rest are evident after as little as 3 days. 2. Returning to competitive sports within the first week following injury is associated with an elevated risk of repeat concussion, regardless of whether the athlete is symptomatic or asymptomatic. 8

9 Rest Iverson- J Head Trauma Rehab Vigorous exercise within the first 2 weeks following injury might delay recovery in some people, particularly those who are more seriously injured. This is based on experimental research with rats and one observational study with student athletes. 4. Graded resumption of regular pre injury activities (with exception of competitive sports) as tolerated within the first few days to weeks post injury, regardless of symptomatic status, is more likely to speed up the delay of recovery. Multiple randomized clinically trials of early intervention included a guided activation component and found benefit for the full (multicomponent) intervention package. In one study, starting this process on day after injury temporarily exacerbated symptoms but achieved the same long-term outcome as delaying it by a few days. Delaying graded resumption of regular pre injury activities beyond a month may worsen outcome. 9

10 Rest Iverson- J Head Trauma Rehab Physical mobilization can facilitate recovery from cervical soft tissue injury and vestibular disorders, which often co-occur with MTBI and contribute to persistent symptoms. 6. Regular engagement in valued activities may guard against the development of depression and anxiety after MTBI. 10

11 Rest Iverson- J Head Trauma Rehab Exercise that is below the threshold to exacerbate symptoms is probably safe and potentially beneficial after 1-month post injury. This is based on experimental research with rats and 2 human case series. 8. Physical and/or mental exertion can temporarily exacerbate post concussion symptoms at any stage of recovery (as well as elicit postconcussionlike symptoms of uninjured adults). It is unclear whether this has any long-term consequences. 11

12 Rest Iverson- Zurich 2012 McCrea et al 2009 Risk of repeat concussion was highest in athletes who returned to competition within the first week following injury, REGARDLESS of their symptomatic status. Requiring symptom-free waiting period before return to sports did not confer protection against repeat concussion. Their data suggest that rest from risk may be best achieved by a universal period of 7-10 days rather than by symptom monitoring. 12

13 Physiotherapy Dr. Schneider 13

14 Graded rehabilitation for prolonged symptoms Makdissi/Schneider- Zurich 2012 Gagnon et al (2009) Start with submaximal aerobic training (50-60% HR max) on treadmill or stationary bike. Add up to 10 min light sports specific drills Followed weekly until asymptomatic and then standard return to activity protocol Significant reduction in symptom scores in a small cohort if children and adolescents with persistent symptoms. 14

15 Graded rehabilitation for Leddy et al (2010) prolonged symptoms Makdissi- Zurich 2012 Treadmill test to determine symptom exacerbation threshold Subjects exercise at 80% intensity of threshold (once per day for 5-6 days per week) Treadmill test repeated every 3 weeks 12 Subjects with symptoms lasting longer than 6 weeks post concussion Resolution of symptoms at rest in 10/12 subjects 15

16 Vestibular Rehab Makdissi- Zurich 2012 Gottshall & Hoff 2010 If dizziness or disequilibrium is a prominent feature. 16

17 Pharmacological Treatment Zurich 2012 Pharmacological Treatment in TWO distinct situations. Management of specific, prolonged symptoms. Drug therapy used to modify the underlying pathophysiology of the condition with the aim of shortening the duration of the concussion symptoms. 17

18 Pharmacological Treatment Meehan 2011 Medication for Sport Related Concussion Symptoms have persisted beyond the typical recovery period. Symptoms are interfering with the athlete s life. The treating physician is knowledgable and experienced with SRC. 18

19 Pharmacological Treatment Makdissi- Zurich 2012 Numerous medications available - but limited data on use in persistent symptoms following concussion Sertraline: improvement in symptoms and function in a cohort of patients diagnosed with depression following mild TBI (Fann et al 2000) Amantadine: improved symptoms and reaction times when compared to historical controls (Leddy et al 2012) Anti-Migraine treatments (propranolol, dihydroergotamine, valproate) - reduce headaches following mild TBI 19

20 Pharmacological Treatment Sleep Disturbance Melatonin Trazadone Zolpidem Tricyclics 20

21 Pharmacological Treatment Headache NSAID s Triptans? Emotional Symptoms SSRI Cognitive Symptoms Stimulants- methylphenidate Nonstimulating dopamine agonists - amantadine 21

22 Pharmacological Treatment Future Directions? omega-3 fatty acids DHA - docosahexaenoic acid EPA - eicosapentaenoic acid Animal studies - fewer markers of axonal injury. Anecdotal use by physicians Post injury Prophylactically? 22

23 The Difficult Concussion Makdissi- Zurich 2012 Incidence of persistent symptoms 10-15% American Football (McRae et al 2003, Guskiewicz et al 2003, Pellman et al 2004) 10-15% Australian Football (McCrory et al 200, Makdissi 2010) 30% Ice Hockey (Benson et al 2011) 50% high school athletes (Iverson 2007, Lau et al 2011) 23

24 The Difficult Concussion Makdissi- Zurich 2012 Symptoms Typically persistent symptoms are vague/ ill-defined (difficulty concentrating, difficulty sleeping, fatigue or low energy, not quite right) 24

25 The Difficult Concussion Makdissi- Zurich 2012 Symptoms Reporting affected by numerous factors: Method of reporting (questionnaire vs interview) Sex (female > male) Education and socioeconomic factors General health status Psychological factors (co-existing anxiety or depression) Intercurrent illness or musculoskeletal injury Exercise 25

26 The Difficult Concussion Makdissi- Zurich 2012 Symptoms Symptoms are not - specific to concussion Commonly reported at baseline Overlap with other conditions Illness or other musculoskeletal injury Anxiety and depression Post-traumatic stress disorder Chronic pain syndromes Whiplash 26

27 The Difficult Concussion Makdissi- Zurich 2012 Imaging? Conventional neuroimaging To exclude structural pathologytiming? Functional MRI (fmri) Reduced brain activity in the prefrontal cortex with a working memory task in patients with prolonged symptoms (Chen et al 2000) Brain activity changes correlate with severity of symptoms (Gosselin et al 2011) 27

28 The Difficult Concussion Makdissi- Zurich 2012 Imaging? Diffusion Tensor Imaging Changes in signal of fibre tracts with prolonged symptoms (Cubon et al 2011) Trans-cranial magnetic stimulation (TMS) Reduced motor thresholds following mild TBI Changes did not follow symptomatic recovery (Tallus et al 2012) 28