Emerging Topics in Concussion Treatment: Lower Extremity Injury and Active Recovery

Transcription

1 Emerging Topics in Concussion Treatment: Lower Extremity Injury and Active Recovery 11 th Annual Sports Medicine Conference Saturday, June 17, 2017 Taeopae Wetterman, ATC & Laura Most, ATC

2 Objectives Describe the correlation between post-concussion athletes and lower extremity injuries. Explain active recovery and the application of protocol for concussed athletes. Footnote, Presentation or Section Title 2

3 Overview Estimated 1.6 to 3.8 million sport-related concussions in US yearly After sport-related concussion probability of 2 nd increases 3-fold Most clinical symptoms resolving by 7 days Emerging evidence that brain and motor function persists well beyond resolution of clinical recovery / deficits in cerebral performance Reaction time Processing speed Verbal and visual memory Gait patterns Movement patterns Correlation of deficits s/p concussion to increased risk of LE musculoskeletal injury

4 Concussion Increases Odds of Sustaining a LE Musculoskeletal Injury After RTP Among Collegiate Athletes Study: UW-Madison D1 soccer, football, hockey, basketball, wrestling, volleyball, softball 87 concussions (all compared with 1 3 controls) LE injuries Acute fractures, muscle strains/tears, ligament sprains/ruptures Hip, groin, thigh, knee, shin, ankle, feet Odds of sustaining LE injury within 90 days s/p concussion Results: Odds of sustaining a LE injury are 2.48 times higher in concussed athletes than in controls Discussion: Detraining due to missed time for recovery from concussion Altered gait patterns Decreased capacity for motor planning Brooks et al, 2016

5 Acute LE Injury Rates Increase after Concussion in College Athletes Study: North Carolina XC, field hockey, football, lacrosse, soccer, swimming, rowing, softball, wrestling, basketball, tennis 44 concussion group (compared to 58 controls) LE injuries at 90 day / 180 day / 365 days s/p concussion Results: Significantly higher rate of acute LE injury s/p concussion at 180 days, 365 days. No significant difference at 90 day Discussion: Time away from training due to recovery? Athletes with concussion more injury prone? Reduced cortical excitability associated with functional disability? Disruption of cortical pathways increase interval time between reaction and movement time Difficult to measure. Static balance testing not sensitive enough to detect impairments More pronounce (difficult to measure) during athletic tasks Lynall et al, 2015

6 Sports Related Concussion Increases the Risk of Subsequent Injury by about 50% in Elite Male Football Players Study: Union of European Football Associations Long term prospective observational cohort study 46 professional European football teams form 10 countries July 2001 June 2012 All injuries preventing players from full participation recorded Following 1 year s/p concussion Results: 66 players with concussion were more prone to injury than the rest of cohort (11.5 vs. 5.0 injuries) 66 players sustained 127 injuries prior to concussion, 153 injuries post Increased risk for sudden onset injuries, not gradual onset injuries More prone to injury in general 2.2 times greater risk s/p concussion Discussion: current tests insufficiently sensitive to subtle changes in neuropsychological domains ( reaction time, decision making, perception) Nordstrom et al, 2014

7 Concussion May Increase the Risk of Subsequent LE Musculoskeletal Injury in Collegiate Athletes Study: U of FL DI football, women s basketball, soccer, lax 90 cases of concussion in 73 athletes (52 male, 21 female) 90 day follow up s/p concussion Same period studied in 1 2 control athletes Based on sport, starting status, position Results: 3.39 times higher odds of sustaining LE injury s/p concussion 45/90 concussed athletes vs. 30/148 non-concussed athletes First study to demonstrate increased odds of in-season LE injury after RTP s/p concussion in females greater than in males Athletes who have had ACL injuries previously been found to have worse performance in all components of pre-season neurocognitive testing Poor testing is predictive of LE strains and sprain in college football players Discussion: Future research should include age, sport, sex as modifiers Herman et al, 2016

8 LE Stiffness Changes after Concussion in Collegiate Football Players Study: DI Football players 13 concussed, 26 uninjured Pre-season / post-season testing LE stiffness changes during jump-landing tasks Jumping on 1 limb onto force plate. Stiffness measured at hip, knee, ankle Results: Concussion group had increase in hip stiffness, decrease in knee stiffness, no change at ankle Discussion: LE stiffness changes could contribute to increased injury risk Stiffness of LE is controlled by the neuromuscular system Findings provide further evidence of changes in the neuromuscular function after return to play from concussion Landing with decreased knee angular excursion reflects an attempt to increase knee stability / rely more on ligamentous tissue for stability Gait changes s/p concussion, athletes adopting more conservative movement patterns

9 Analysis of Central and Peripheral Vision Reaction Times in Patients with Postconcussion Visual Dysfunction Visual dysfunctions s/p concussion Peripheral vision most concerning due to athlete safety RTP considerations Visual dysfunction associated with patient feeling slowed down, slower reaction time feeling one step behind themselves Study: 23 concussion patients with post-concussive visual symptoms Tested 3 days to 11 months s/p injury Compared to 30 control individuals Results: CVRT and PVRT are both prolonged in patients with postconcussive visual dysfunction, PVRT being proportionately prolonged Discussion: Prolonged CVRT and PVRT may have RTP implications Show improvement over time, indicating improvement in postconcussive symptoms Clark et al, 2017

10 Sex Differences in Vestibular/Ocular and Neurocognitive Outcomes after Sport-Related Concussion Female athletes reporting greater symptoms and slower resolution of symptoms s/p SRC Symptoms reported more cognitive symptoms, migraine, dizziness Greater decline in neurocognitive scores compared to baseline scores 60-70% of children experience vestibular and/or oculomotor impairments s/p SRC Study: Assessed with VOMS, VOR, PCSS, BESS, ImPACT <21 days s/p injury 64 athletes age 9 18 (36 male, 28 female) Results: Higher mean total concussion symptoms reported for females on VOR of VOMS Discussion: Clinicians should pay close attention to VOR in females after injury, Sex differences may be specific to certain types of vestibular/oculomotor impairments and symptoms Sufrinko, et al, 2017

11 Summary History of concussion shows correlation with increased risk for acute musculoskeletal LE injuries Research moving forward: What specifically is causing increased risk How long is the duration of increased risk How does gender play a role How will our practice for concussion care change as a result Considering the increased risk of LE injury after concussion, RTP guidelines may be improved by the inclusion of neuromuscular evaluations

12 References Brooks, M. A., Peterson, K., Biese, K., Sanfilippo, J., Heiderscheit, B. C., & Bell, D. R. (2016). Concussion increased odds of sustaining a lower extremity musculoskeletal injury after return to play among collegiate athletes. The American Journal of Sports Medicine, 44(3), Clark, J. F., Ellis, J. K., Burns, T. M., Childress, J. M., & Divine, J. G. (2017). Analysis of central and peripheral vision reaction times in patients with postconcussion visual dysfunction. Clinical Journal of Sports Medicine, 0, 1-5. Dubose, D. e. (2016). Lower extremity stiffness changes after concussion in collegiate football players. Medicine & Science in Sports & Exercise, 49(1), Herman, D. C. (2016). Concussion may increase the risk of subsequent lower extremity musculoskeletal injury in collegiate athletes. Sports Medicine, 1-8. doi: /s Lynall, R. C., Mauntel, T. C., Padua, D. A., & Mihalik, J. P. (2015). Acute lower extremity injury rates increase after concussion in college athletes. Medicine & Science in Sports & Exercise, 47(12), Sufrinko, A. M., Mucha, A., Covassin, T., Marchetti, G., Elbin, R. J., Collins, M. W., & Kontos, A. P. (2017). Sex differences in vestibular/ocular and neurocognitive outcomes after sport-related concussion. Clinical Journal of Sports Medicine, 27(2),

13 Current consensus 5 th International Consensus Statement, Berlin 2016 Timing and amount of rest after a concussion is not established Excessive cognitive and physical activity after injury may exacerbate symptoms and delay recovery However, relying on exercise exacerbated symptoms and symptoms resolution may be counterproductive Initial period relative physical and cognitive rest in the acute symptomatic period following the injury (24-48 hours) is recommended Duration of rest after a SRC is generally interpreted as until asymptomatic and includes both physical and cognitive rest However, too much rest may contribute to prolonged symptoms and result in adverse physiological and psychological consequences Physical deconditioning, metabolic disturbances, depression/anxiety, fatigue, stress (Leddy, J.J, Baker, J.G., & Willer, B, 2016; Kozlowski, 2014; McCroy et al. 2017) 13

14 Graduated Return-to-Sport Strategy (McCrory et al. 2017) Stage Aim Activity 1 Symptom-Limited Activity Daily activities that do not provoke symptoms 2 Light-aerobic activity Walking or cycling at slow to medium pace 3 Sport-specific activity Running or skating drills. No head impact drills 4 Non-contact training drills Harder training drills. Start progressive resistance training 5 Full-contact practice Normal training activities 6 Return to sport Normal game play

15 What is active recovery? Active adjective 1. engaged in action; characterized by energetic work, participation, etc.; busy 2. being in a state of existence, progress, or motion Ex. Partial or full school attendance, normal daily and social activities, attending/watching sport practices and games, etc. (Dictionary.com, n.d.) 15

16 Current Support in Research Benefits of exercise include: Upregulation of brain-derived neurotropic factor Improved cognitive performance Increased cardiovascular fitness Improved control of brain perfusion Reduced fatigue, stress, anxiety Improved mood Increased self-esteem Brain injury is shown to alter autonomic nervous system Blood pressure, heart rate variability, etc. (Kozlowski, 2014) 16

17 Current Support in Research Patients ages within 24 hours of injury 5 days of strict rest vs. 1-2 days of strict rest No clinically significant difference in neurocognitive or balance outcomes 5 day group reported more daily post-concussive symptoms and slower symptoms resolution (Thomas et al. referenced in Leddy et al. 2016) 17

18 Current Support in Research Berlin et al. (2006) found an increase in negative mood states following a 2- week removal from habitual endurance exercise Participants with the highest level of baseline fitness had the greatest increased in depressive mood and fatigue Retraining ANS to maintain homeostasis during exercise to improve tolerance to activity and stress Buffalo Concussion Treadmill Test Assist with differential diagnoses, physiological dysfunction, and quantify clinical severity Exercise intolerance is a sign of ongoing physiological dysfunction (Kozlowski, 2014; Leddy et al. 2016) 18

19 RTL and RTP Considerations for Now and the Future Advocate for setting up RTL plans/guidelines for concussed athletes Encourage athlete to return to daily activities as tolerated Include active treatments in protocols Sub threshold exercise Cervical, vestibular, cognitive, behavioral, and/or vision therapy Utilize exercise tolerance as a way to determine differential diagnoses for prolonged recovery Administer and follow Buffalo protocol SCAT 5 (Leddy et al. 2016) 19

20 Future Research Appropriate timing, mode, and duration of rest Timeline, intensity, and frequency of exercise 20

21 References Collins, M. W., Kontos, A. P., Okonkwo, D. O., Almquist, J., Bailes, J., Barisa, M.,... Zafonte, R. (2016). Statements of agreement from the targeted evaluation and active management (TEAM) approaches to treating concussion meeting held in Pittsburgh, October 15-16, Neurosurgery, 79(6), Dictionary.com. (n.d.). Active. Retrieved 05 31, 2017, from Dictionary.com: Imhoff, S., Fait, P., Carrier-Toutant, F., & Boulard, G. (2016). Efficiency of an active rehabilitation intervention in a slow-to-recover paediatric population following mild traumatic brain injury: A pilot study. Journal of Sports Medicine, Kurowski, B. G., Hugentobler, J., Quatman-Yates, C., Taylor, J., Gubanich, P. J., Altaye, M., & Wade, S. L. (2016). Aerobic exercise for adolescents with prolonged symptoms after mild traumatic brain injury: An exploratory randomized clinical trail. Journal of Head Trauma Rehabilitation, Leddy, J. J., Baker, J. G., & Willer, B. (2016). Active rehabilitation of concussion and post-concussion syndrome. Physical Medicine and Rehabilitation Clinics of North America, 27(2), McCrory, P., Meeuwisse, W. H., Aubry, M., Cantu, B., Dvořák, J., Echemendia, R. J.,... & Sills, A. (2013). Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November British Journal of Sports Medicine, 47(5), McCrory, P., Meeuwisse, W., Dvořák, J., Aubry, M., Bailes, J., Broglio, S.,... & Davis, G. A. (2017). Consensus statement on concussion in sport the 5th international conference on concussion in sport held in Berlin, October British Journal of Sports Medicine, bjsports

22 Questions?

23 Thank You