10/24/2018. Disclosures. What is exertion? Objectives. Which athletes should be exerted? Exertion: Just Do It! No disclosures to report

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1 Disclosures No disclosures to report Exertion: Just Do It! Annie Doda, DPT TRIA Orthopedic Center October 26, 2018 Objectives What is exertion? 1. Define exertion as it relates to concussion. 2. Discuss the value of exercise during acute and protracted recoveries during concussion treatment/management. 3. Demonstrate understanding of formal exertion therapy, various tools utilized for exertion assessment, and value of sport specificity. Exertion Definition the act or an instance of exerting; especially : a laborious or perceptible effort Exert a : to put forth (strength, effort, etc.) b : to put (oneself) into action or to tiring effort ( 2018) Which athletes should be exerted? All Sports Concussion Athletes Often overlooked Graduated RTS Strategy (McCrory et al, 2017) 1

2 Who can assist athletes with exertion/rtp? Multi-disciplinary recommendations: Rehab Exertion Patient Parent Coach AT PT Berlin consensus (McCrory et al, 2017) closely monitored active rehabilitation programmeinvolving controlled sub-symptom-threshold, submaximal exercise have been shown to be safe and may be of benefit in facilitating recovery More research needed in this domain CDC statement (Lumba-Brown et al, 2018) Optimal timing not established inactivity beyond initial 3 days post concussion may worsen their self-reported symptoms Multi-disciplinary Rehab recommendations (continued) University of Pittsburgh--Targeted Evaluation and Active Management (TEAM) Approach (Collins et al., 2015) Are we behind? Typical course of medicine 71% of US adults did not recognize concussion as treatable (Poll, Harris, 2015) Pathophsyiology vs. symptoms and impairments Need to find level of activity that is just right for patient-not too little, not too much Avoiding contact remains important For most cases, would we totally shut down an orthopedic patient for weeks after surgery/injury? Optimal Loading Timing for activity? Current practice and a building body of evidence now encourage optimal loading as opposed to rest; even for concussions patients Can be applied to nonsport activities as wellchoir, band, theater, etc. Great question! Research for timing and type of exertion still needed and are multicenter studies currently recruiting What we do know After hour acute phase-gradual and progressive light aerobic activity (McCory et al, 2017) Shorter time initiation of aerobic exercise= faster full return to sport and school/work Bed rest 5 days= situational depression (Thomas, Apps, Hoffmann, NcCrea&Hammeke, 2015) 2

3 Evidence to support active treatment during the Acute/Sub-acute phase of recovery 2 objectives Safe to perform Buffalo Concussion Treadmill Test (BCTT) acute phase? Prognostic factors? Results: No difference in recovery period NO ADVERSE EFFECTS Heart rate strongly predicted recovery prognosis Clinical Take Away Proposed- start day 6 post concussion: 8 sessions 10 minutes in duration and exercise intensity 50% HRM Next session 20 mins, same 50% Following sessions at 30 mins, 5% increase in HRM up to 70% Take away points: Everyone completed safely! Not formal PT- physician progressed Reduction in symptom severity scores Using symptom threshold light aerobic activity is safe and beneficial even assessments Improves patient s self-report of symptoms on Post- Concussion Symptom Scale More structure-fitt principles need to be applied and investigated (Lawrence, Richards, Comper& Hutchinson, 2018) Benefits of Exercise: General Favorable effects on brain neuroplasticity Improved neuronal functioning Aerobic exercise cognitively protective Associated with greater levels BDNF Promotes conditioning of CV system Mood/overall well being Active treatment with prolonged recovery (Leddy et al, 2016) ) 3

4 Aerobic Activity and Protracted Recovery (>3-4 weeks) For consideration Important to identify concurrent ocular, vestibular, and cervical symptom contributions Previous recommendations: rest until asymptomatic Rat vs. Human Models- Humans can identify symptom= SUB- SYMPTOM THRESHOLD Use BCTT to identify physiologic response (Leddy, Baker, Haider, Hinds & Wiler, 2017) Not always long intervention-4 week program improved symptoms in adolescents with mean 7 weeks of persistent symptoms (Gagnon, Galli, Friedman, Grilli& Iverson, 2009) Formal Exertion Therapy Formal Exertion Therapy: Who? Autonomic Dysregulation Theory normal progression of Return to Sport Strategy previous history of concussion or other co-morbidities- want formal evaluation progression from basic vestibular interventions to higher level vestibular with exertion emphasis Deconditioning Increased fear/anxiety Address physiologic intolerance to exercise due to concussion sequelae-autonomic dysregulation Initial decreased Cerebral Blood Flow Altered ANS connections to cardiac system Increased cerebral blood flow during exercise= symptoms Assessed: Buffalo Concussion Treadmill Test (Leddy, Hinds, Sirica, Willer, 2016) Formal Exertion Therapy: When to initiate? Formal Exertion Therapy: Exertion tools utilized Major vestibular, ocular or cervical identified Exertion/Sport specificity can be concurrent Clinical Pearl: Low symptom profile, Timeline varies Buffalo Concussion Treadmill Test TRIA Active Assessment TRIA Clearance Test Sport specificity Graduated RTP strategy 4

5 Formal Exertion Therapy: Buffalo Concussion Treadmill Test Validated and reliable (Leddy, Willer, 2013) Safe with pediatric population (Cordinglyet al, 2016) Exercise induced vs. concussive related (Leddy & Willer, 2013) Formal Exertion Therapy: Sport Specific Circuits/Activities Demands of each sport/activities can vary, but also have commonalities (swimmer vs gymnast vs football vs lacrosse) Common: reaction time, turns, aerobic demands Sport Specific: Swimmer: horizontal, vestibular rich environment Gymnast: space/body awareness, inverted movements Football: contact, designed plays, position dependent Lacrosse: contact, position dependent, use of stick *Typically most motivating to pts Formal Exertion Therapy: PT sessions Formal Exertion Therapy All PTs capable of performing all aspects of concussion management Vestibular Cervical Exertion Clinic Athletic Trainers lead progression/sport specificity Breakdown to the various treatment aims Typically a combination Targeted limitations to be addressed: High Level Vestibular sensitivity with exertion emphasis Autonomic Dysregulation Deconditioning Anxiety/Fear Treatment: High Level Vestibular sensitivity with exertion emphasis Treatment: Autonomic Dysregulation (+) BCTT Identify sub-maximal threshold 20 minutes subthreshold intensity (80% of HR achieved on BCTT) 5-6 days/week Increased 5-10 bpm every 2 weeks Physiologic resolution voluntary exhaustion 85-90% HR for 20 mins w/o symptoms (Leddy & Willer, 2013) 5

6 Treatment: Deconditioning Treatment: Anxiety/Fear General Strength and conditioning Exercises 0-100% where are you at? What is that remaining 10% Often times contact/game intensity Summary Thank you! All concussed athletes need to pass RTS Includes exertion components! PT can help with RTS, further assessment of prolonged symptoms High level vestibular sensitivity Autonomic Dysregulation Deconditioning Anxiety/Fear Formal assessments tease sensitivities BCTT TRIA Active Assessment Sport specificity is key More research needed References Baker JG, Freitas MS, Leddy JJ, Kozlowski KF, Willer BS. Return to full functioning after graded exercises assessment and progressive exercise treatment of postconcussion syndrome. Rehab Res Pract. 2012; Collins M, KontosA, Okonkwo D, Almquist J, Bailes J, BarisaM, et al. Concussion is Treatable: Statements of Agreement form the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting held in Pittsburgh, October 15-16, NeuroSurgery2016 December; 79(6): doi: /neu Cordingley D, Girardin R, Reimer K, et al. Graded aerobic treadmill testing in pediatric sports-related concussion: safety, clinical use, and patient outcomes. J Neurosurg Pediatr2016;18: Gagnon I, Galli C, Freidman D, GrilliL, Iverson GL. Active rehabilitation for children who are slow to recover following sport-related concussion, Brain Injury 2009;23(12): Lawrence DW, Richards D, Comper P, Hutchinson MG (2018) Earlier time to aerobic exercise is associated with faster recovery following acute sport concussion. PLoS ONE 13(4): e Leddy JJ, Baker J, Haider MN, Hinds A, Willer B. A Phsyiologic Approach to Prolonged Recovery from Sport-Related Concussion. Journal of Athletic Training 2017;52(3): Leddy JJ, Hinds A, Miecznikowski J, Darling S, MatuszakJ, Baker J, et al. Safety and Prognostic Utility of Provocative Exercise Testing in Acutely Concussed Adolescents: a Randomized Trial. Clin J Sport Med 2017;0:1-8. Leddy JJ, Hinds A, SiricaD, Willer B. The Role of Controlled Exercise in Concussion Management. PM R2016;S91-S100 Leddy JJ, Kozlowski K, Donnelly JP, et al. A preliminary study of subsymptom threshold exercise training for refractory post-concussion syndrome. Clin. J. Sport Med. 2010;20:21-7. Leddy JJ, Willer B. Use of Graded Exercise Testing in Concussion and Return-to-Activity Management. American College of Sports Medicine 2013; 12(6); Lumba-Brown A, Yeates K, Sarmiento K, Breiding M, Haegerich T, Gioia G, et al. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain injury Among Children. JAMA Pediatr2018; doi: /jamapediatrics McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport the 5 th international conference on concussion in sport held in Berlin, October Br J Sports Med 2017; 51: Merriam-Webster (2018) Accessed 10/14/18. MicayR, Richards D, Hutchinson MG. Feasibility of a post-acute structured aerobic exercise intervention following sport concussion in symptomatic adolescents: a randomized controlled study. BMJ Open Sport & Exercise Medicine 2018;4:e doi: /bmjsem Poll, Harris. How knowledgeable are American about concussions?. Assessing and recalibrating the public s knowledge Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sports-related concussion: a systematic review. Br J Sports Med2017;51: Thomas DG, Apps JN, Hoffman RG, McCrea M, Hammeke T. Benefits of strict rest after acute concussion: a randomized controlled trail. Pediatrics. 2015;135(2):