Concussion Rehabilitation Specialist

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2 Concussion Rehabilitation Specialist

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4 Complex pathophysiological process affecting the brain, induced by biomechanical forces Common Features Direct or transmitted blow the the head/neck Rapid onset, short-lived neurological impairment May or may not include LOC McCrory et al. British Journal of Sports Medicine

5 Not localized to a specific region or zone Chemical changes resulting from diffuse injury Potassium rushes out, sodium rushes in Increased energy required to restore balance Leads to energy crisis DeFord et al. J Neurotrauma. 2002, Apr;19:

6 Headache Nausea Insomnia Depression Fogginess Impaired memory Dizziness Photophobia Hyperacusis Anxiety Fatigue Impaired concentration

7 Concussion Identification Graded Symptom Checklists Standardized Assessment of Concussion (SAC) Neuropsychological Testing Balance Error Scoring System (BESS) Giza et al. Neurology

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10 Physical & Cognitive Rest Initial rest followed by sub-symptom threshold exercise Utilizing 6 Stage RTP Protocol Address psychiatric symptoms Majority of patients have Sx resolve in 10 days (adults) or 4 weeks (children) 10-15% of patients have a protracted recovery Requires multidisciplinary management Medications/Physical Therapy/Neuropsychology McCrory et al. British Journal of Sports Medicine

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12 Recovery 3 weeks On-field dizziness 6x the likelihood that a patient would have a protracted recovery Other symptoms associated with protracted recovery: Fogginess, impaired concentration, vomiting, post traumatic migraine (severity of initial symptoms per Berlin) Lau B et al. AJSM Lau B et al. CJSM (3):

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14 Sit in a dark room and hope your symptoms go away.

15 Cognitive rest Sleep regulation Gradual return to activities (school, work, etc.) Medication and physical therapy management may begin at around 3 weeks

16 3 Types Vestibular Cervical Exertion

17 Dizziness Fogginess Balance Problems Increased symptoms in busy environments

18 Vestibular System Analysis: Smooth pursuits Saccades VORx1 VOR cancellation Vergence testing BPPV Screen Balance Testing Gait analysis

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20 Reading Scanning (store) Looking into cabinets Walking

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22 Reading Taking notes Jogging/Running Sporting events

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24 Checking blind spot Quick turns in a hallway Walking in a store and looking Sporting events

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26 Busy environment Habituation activities Repeated motions Sit to stand

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28 Reading Taking notes Focusing near to far Seeing layers of objects

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30 Walking-up to 60 degrees/sec Within smooth pursuits Running-begins at 60 degrees/sec Outer limits of smooth pursuits VOR and saccades

31 Modified Clinical Test of Sensory Interaction on Balance (mctsib) 4 conditions Firm and foam Eyes open and closed Feet together Record total time for each trial Average 3 trials if less than 30 seconds

32 Minimize disruptions to student s life May return to school before symptoms resolve Accommodations based on impairments Accommodations No note taking Longer times for exams Oral tests vs. written Leaving class early Halstead ME et al. Pediatrics

33 Balance not typically our focus Optokinetic sensitivity Space & motion discomfort Gaze Stability Vergence Appointments vary according to deficits present Catena 2011, Guskiewicz 2003

34 Habituation Repeated exposure to stimulus Adaptation VOR x 1, VOR x 2 Substitution Smooth pursuits and Saccades Aligene K, Lin E NeuroRehabilitation 2013.

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36 Cervical pain is common s/p May be associated with headaches Ask about neck pain Patients do not realize the two are associated Palpation Focus on restoring mobility and strengthening

37 Proposal of extra step after 4 th stage Intermediate stage Modified contact drills Addition of pads/gear Adherence to guidelines (2009) 1/6 athletes didn t follow RTP guideline Could lead to premature return Mild exertion after initial rest may be beneficial May KH et al. IJSPT 2014, Yard EE Brain Inj. 2009, AAN: Sports Concussion Conference

38 Rule in or out physiologic dysfunction May also be used in clearance in concert with neurocognitive testing Started at 3.6 mph at 0% incline Increase 1% every minute at minute 2 Continue until exhaustion or symptom exacerbation Exacerbation defined as 3 point increase in symptoms Exhaustion is 19 or 20 on RPE scale (6-20) Leddy JJ, Willer B Curr Sports Med Rep 2013

39 Return to sport/work 5 stages of exertion Not based on HR as previously thought Based on motion and more complex exercise Progress from static to dynamic activities Standard Appointment 25 minutes cardio 35 minutes of exercises DeWitt, Prough. J Neurotrauma. 2003;20:

40 RTP: no early weight lifting in stage 2 Therapy: early weight lifting accepted RTP: swimming is acceptable in stage 2 Therapy: early swimming not appropriate Broglio et al Clin Sports Med 2015.

41 Stage 1: quiet area, stationary cardio, limited head movements, possible HR limitations Stage 2: normal gym setting, may involve elliptical, light movement-based activities, easy agility exercises, core with movement Stage 3: TM cardio, high-level agility, plyometrics, mostly movement-based, sport-specific

42 Stage 4: Non-contact, sport-specific drills, highlevel plyometrics Stage 5: Contact sports, clearance needed, any return of symptoms must be reported

43 Cardio: bike, UBE Core: planks, side planks, 6 inches UE work: rows, LPD, bench press, biceps LE work: leg press, stretches, calf raises

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47 Cardio: elliptical Core: Bosu planks with/without WS, PB bridge with curl, plank challenges UE work: pushups, med ball lifts LE work: squats, lunges, side lunges

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50 Cardio: Treadmill Core: Russian Twists, chops, lunge with rotation, wall squat with med ball rotation UE work: plyo-pushups, balance with ball throw LE work: box jumps with/without rotation, burpees, skater bounds

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58 QB: rollout and throw, stationary/moving targets, reactive in pocket, handoffs, play-action pass, throwing progressions RB: straight handoff, handoff with cuts, motion before handoff, catch pass from backfield, spin/ juke moves, react to bouncing ball

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