EXERCISE AS CONCUSSION TREATMENT

Transcription

1 EXERCISE AS CONCUSSION TREATMENT A CHANGING PARADIGM DISCLOSURES I have no financial relationships to disclose Drugs: I will not discuss off label use and/or investigational use in my presentation Suzanne Hecht, MD, FACSM UM Sports Medicine Fellowship Director UM Team Physician GOALS 1997 CONCUSSIONS 1. Appreciate the shifting paradigm to incorporate exercise as a treatment modality for concussions. 2. Learn the evidence-based exercise protocol for treating athletes w/ prolonged concussions. 3. Recognize the emerging role of exercise in early concussion treatment CONCUSSION RTP 1

2 Summary and Agreement Statement of the First International Conference on Concussion in Sport, Vienna 2001 ~Concussion in Sport Group Aubry, Cantu Phys Sports Med 2002 VIENNA 2001 RTP/REHAB Important principles state that the athlete be completely asymptomatic & have normal neurological & cognitive evaluations prior to the start of the rehabilitation program. VIENNA RTP PROTOCOL The return to play following a concussion follows a stepwise process: No activity, complete rest. Once asymptomatic, proceed to level 2 2. Light aerobic exercise such as walking or stationary cycling 3. Sport-specific training (eg, skating in hockey, running in soccer) 4. Non-contact training drills 5. Full-contact training after medical clearance 6. Game play MIKE LEACH ADAM JAMES VIENNA 2001 BUT EXERCISE IS GOOD FOR THE BRAIN! Improves ANS balance & CO2 sensitivity Improves CBF Regulation Upregulates BDNF genes Better mood Better sleep subjects (6 athletes & 6 nonathletes) ~Post concussive syndrome of at least 6 wks ~Exercised to symptom exacerbation ~Exercise 5-6 d/wk to 80% of HR at symptom exacerbation 2

3 STUDIES ON EXERCISE & CONCUSSION RX 17 total studies 13 dated showed no harm 6 showed benefit POST CONCUSSIVE SYNDROME & EXERCISE Moderate evidence to support sub-symptomatic aerobic exercise as a PCS treatment Consider it as a clinical option Ritter J Sports Rehabil 2017 Consensus statement on concussion in sport the 5 th international conference on concussion in sport held in Berlin, October 2016 McCrory P, Meeuwisse W BERLIN 2016 on REST There is currently insufficient evidence that prescribing complete rest achieves these objectives. After a brief period of rest during the acute phase (24 48 hours) after injury, patients can be encouraged to become gradually and progressively more active while staying below their cognitive and physical symptomexacerbation thresholds. BERLIN 2016 RTP 1 Symptom-limited activity ~Daily activities that do not provoke symptoms ~Gradual reintroduction of work/school activities 2 Light aerobic exercise ~Walking or stationary cycling at slow to medium pace. ~No resistance training ~Increase heart rate 3 Sport-specific exercise ~Running or skating drills. No head impact activities ~Add movement BERLIN 2016 RTP 4 Non-contact training drills ~Harder training drills, eg, passing drills. ~May start progressive resistance training ~Exercise, coordination and increased thinking 5 Full contact practice ~Following medical clearance, participate in normal training activities ~Restore confidence and assess functional skills by coaching staff 6 Return to sport ~Normal game play 3

4 PROLONGED REST Prolonged rest adversely affects the pathophysiology of concussion, delays the institution of effective therapies, and may be detrimental to recovery. Leddy & Baker; JATA 2017 Buffalo Concussion Treadmill Test (BCTT) Assess exercise tolerance in PCS or acute concussion Based on Balke Cardiac Treadmill test Gradual increase in cardiac workload mph; 0% incline 1% incline increase/min & no change in speed HR when symptoms worsen is the threshold Safe for PCS & acute concussion EXERCISE INTOLERANCE Symptom-limited cessation of exercise at a submaximal exercise intensity before reaching Physical exhaustion or Maximum age-predicted HR or Both BCTT Exercise Prescription 80-90% of HR threshold 30 min/day 6-7d/wk for 12 wks Use HR monitor Increase target HR 5-10 beats/min q 1-2 wks Goal: exercise at > 85% of the age-predicted max HR for 20 min w/o symptoms for 2-3 days in a row BCTT: Acute Concussion CONCUSSION & REST Prospective RCT 54 adolescents w/ SRC w/in 9 days of injury 2 groups: +BCTT & no BCTT +BCTT group stopped exercise at a mean of 70% of max pred heart rate due to increased concussion symptoms No short-term increase in symptoms or delayed recovery compared to controls Leddy; CJSM, in press yo w/ concussion 2 groups (N=88) Rest 2 days & then do normal activities as symptoms allowed 5 days of strict bed rest Shorter resting time group recovered faster. Thomas; Pediatrics

5 CONCUSSION & REST 2 groups (N=50) Rest on day of injury + 1 more day (physical & cognitive) No rest No rest group recovered faster by one day Buckley; J Head Trauma 2016 EARLY EXERCISE Does early exercise (w/in 7 days) p concussion help prevent prolonged symptoms in children & adolescents compared to rest? Multi-centered cohort study 9 EDs >3000 athletes w/ acute concussion 5-18 yo Symptoms at 28 days p concussion Exercise: 29% w/symptoms No physical activity: 40% w/ symptoms Grool et al JAMA 2016 RTC: Early Exercise Active vs Passive Recovery of SRC RCT; pilot Aerobic exercise/stretching N=39; mean 15.8 yrs Relative rest N=48 mean 15 yrs Recovered Active 10.5 days Passive: 14.1 days Leddy; CJSM, in press PROGNOSING RECOVERY TIME? RCT Exercise tolerance (ET) was strongest predictor of early recovery Lower tolerance = longer recovery BCTT w/ heart rate threshold >135 beats/min recovered quicker ET + Cervical + Vestibular + Oculomotor Exam = Good predictor of who will recover w/in 1 wk Leddy; CJSM, in press THANKS!! REFERENCES Buckley TA, Munkasy BA, Clouse BP. Acute cognitive and physical rest may not improve concussion recovery time. J Head Trauma Rehabil. 2016;31(4): Cordingley D, Girardin R, et al: Graded aerobic treadmill testing in pediatric sports-related concussion: safety, clinical use, and patient outcomes. J Neurosurg: Ped, Dec :6; Grool AM, Aglipay M, Momoli F, Meehan WP, Freedman SB, Yeates KO, Gravel J, Gagnon I, Boutis K, Meeuwisse W, Barrowman N, Ledoux A, Osmond MH, Zemek R, for the Pediatric Emergency Research Canada (PERC) Concussion Team. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA. 2016;316(23): doi: /jama Leddy J, Hinds AL, Miecznikowski J, et al. Safety and prognostic utility of provocative exercise testing in acutely concussed adolescents: a randomized trial. Clin J Sport Med. In press. Makdissi M, Schneider KJ, Feddermann-Demont N, et alapproach to investigation and treatment of persistent symptoms following sport-related concussion: a systematic reviewbr J Sports Med 2017;51: Sawyer Q, Vesci B, McLeod TCV. Physical Activity and Intermittent Postconcussion Symptoms After a Period of Symptom-Limited Physical and Cognitive Rest. Journal of Athletic Training. 2016;51(9): doi: /

6 REFERENCES Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics. 2015;135(2):