HELPING YOU REACH YOUR PEAK PERFORMANCE IN RECORD TIME!

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Delilah Alison McBride
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RECORD TIME! CONCUSSION REHAB PEAK PERFORMANCE PHYSICAL THERAPISTS ARE CREDENTIALED IMPACT TRAINED PHYSICAL THERAPISTS According to the Center of Disease Control, between 1.6 to 3.

5% of sports/recreational traumatic brain injuries treated in the emergency departments were among persons 10-19 years old.

The Dylan Steigers Concussion Project In 2010, Sentinel High School graduate Dylan Steigers died after a traumatic brain injury suffered during a spring football scrimmage at Eastern Oregon

In Dylan s honor, Peak Performance Physical therapy launched the nonprofit Dylan Steigers Concussion Project (DSCP) to provide a resource for coaches, parents, and athletes to learn more about

1 NOVEMBER CAVE THERAPY MAY NOT BE TREATMENT OF CHOICE CONCUSSION TRAJECTORIES THE DYLAN STEIGERS CONCUSSION PROJECT RETURN TO SPORT HELPING YOU REACH YOUR PEAK PERFORMANCE IN RECORD TIME! CONCUSSION REHAB PEAK PERFORMANCE PHYSICAL THERAPISTS ARE CREDENTIALED IMPACT TRAINED PHYSICAL THERAPISTS According to the Center of Disease Control, between 1.6 to 3.8 million sports and recreation-related concussions occur annually. Concussions are a mild traumatic brain injury (mtbi). 80% are seen in the emergency department. 70.5% of sports/recreational traumatic brain injuries treated in the emergency departments were among persons years old. Mild traumatic brain injuries are a contributing factor to approximately 30% of all injury-related deaths in the U.S. 75% of traumatic brain injuries each year are concussions. The Dylan Steigers Concussion Project In 2010, Sentinel High School graduate Dylan Steigers died after a traumatic brain injury suffered during a spring football scrimmage at Eastern Oregon University. In Dylan s honor, Peak Performance Physical therapy launched the nonprofit Dylan Steigers Concussion Project (DSCP) to provide a resource for coaches, parents, and athletes to learn more about concussions and traumatic brain injuries. Since then, Dylan s family, friends and a core group of professionals have worked tirelessly to raise awareness about the dangers of concussions especially undetected concussions. Through the DSCP, area athletes have access to low- or no-cost ImPACT neuropsych baseline concussion testing. This neuropsych computerized individualized test serves as one of many tools in guiding a full and efficient return of the athlete to school and sports competition. With the mission to Educate, Test, and Protect The Dylan Steigers Concussion Project works closely with Peak Performance Physical Therapists to keep Missoula at the Gold Standard of concussion care. They provide extensive education, resources, and training for coaches, teachers, athletes, parents, and surrounding healthcare providers in concussion identification and management. To date the DSCP has obtained over 4000 ImPACT baseline tests on area athletes and has helped manage over 400 concussions. Post Concussion Syndrome Post-concussion syndrome is a complex disorder in which various symptoms such as headaches and dizziness last for weeks and sometimes months after the injury that caused the concussion. 80% of concussed individuals will recover from concussion within 21 days. 20% will have lingering symptoms with a protracted recovery. 15% will suffer from deficits 1 year after injury. Individuals with a prior history of migraine, depression, anxiety, mental health disorders, ADHD, and sleep disorders tend to have a longer recovery time and a higher rate of post concussion syndrome.

2 The Vestibular System Current research indicates that dizziness, immediately after a concussion, is an indicator for protracted recovery. Concussed individuals use many different words to describe dizziness including: lightheadedness, blurry vision, imbalance, weakness in legs, headache, vertigo, feeling out of it, slowed down, foggy, or one step behind themselves. Dizziness following concussions can be driven from many areas including: Benign Paroxysmal Positional Vertigo Labyrinthine Concussion Perilymphatic Fistula Post Traumatic migraine Brainstem concussion Ocular motor problems Cervicogenic dizziness Autonomic/orthostatic hypotension The Vestibular System has two primary functions: VOR 1. Stabilizes vision, while the head moves, through the inner ear and the Vestibulo- Ocular Reflex (VOR) 2. Creates postural response and balance control through the Vestibulo Spinal Reflex (VSR) Subjective complaints of vestibular system injuries from concussion include: Dizziness Impaired balance (especially in the dark) Blurry vision and difficulty focusing Motion sickness Height phobia Diffiuclty in busy environments Easily overwhelmed Anxiety Migraines Nausea Vestibular system disorders, following concussions, could impact four different areas. 1. Benign Paroxysmal Postional Vertigo (BPPV) 2. Vestibulo-Ocular Impairment (VOR) 3. Balance Impairment (VSR) 4. Visual Motion Sensitivity Impairment VISUAL MOTION SENSITIVITY is also referred to as visual vertigo or chronic subjective dizziness. This disorder is a hypersensitivity to normal visual motion with an impaired tolerance to busy environments, driving, heights, and flashing lights. Causes include post-concussive syndrome, cervicogenic dizziness/ whiplash associated dizziness, and anxiety disorders. Cave Therapy is No Longer Recommended Placing on athlete on complete rest with no intervention can lead to increased anxiety, depression, headaches, and insomnia. Early intervention can assist to differentiate what is driving the symptoms and initiate effective strategies and treatment to promote healing. The right rest is imperative, and the right stimulation is healing. I want to work on recovery not wait to recover Ryan Burke, Grizzly WR Balance: Sensory Organization Ability of the balance system to utilize sensory inputs appropriately to maintain postural control through 3 sensory inputs: Vision Somatosensation (how the body surface reacts with the environment) Vestibular Benign Paroxysmal Positional Vertigo (BPPV) is often described as increased spinning sensation with looking up, turning over in bed, getting out of bed, and/or lying down. You ve got some loose rocks in your noggin! BPPV is a mechanical problem in the inner ear. It occurs when some of the calcium carbonate crystals (otoconia) that are normally embedded in gel in the utricle become dislodged from the concussion and migrate into one or more of the 3 fluid-filled semicircular canals, where they are not supposed to be. When enough of these particles accumulate in one of the canals they interfere with the normal fluid movement that these canals use to sense head motion, causing the inner ear to send false signals to the brain. This false information does not match with what the other ear is sensing, with what the eyes are seeing, or with what the muscles and joints are doing, and this mismatched information is perceived by the brain as a spinning sensation, or vertigo. BPPV can often resolve quickly with Epley Maneuvers and other treatments provided by Peak Performance Physical Therapy s Concusssion Specialists.

Concussion Trajectories 26 SIGNS & SYMPTOMS OF CONCUSSION Exertion Anxiety/ Mood Sleep disorder Vestibular Ocular Motor Concussion Cognitive Migraine Cervical Whiplash PHYSICAL SYMPTOMS HEADACHE

DIFFICULTY REMEMBERING INCREASED CONFUSION SLOWED SPEECH REPEATS QUESTIONS EMOTIONAL SYMPTOMS INCREASED IRRITABILITY INCREASED SADNESS MORE EMOTIONAL INCREASED ANXIETY NERVOUSNESS SLEEP DISTURBANCES

producing eye movements in the direction opposite to head movement, thus preserving the image on the center of the visual field(s).

3 Concussion Trajectories 26 SIGNS & SYMPTOMS OF CONCUSSION Exertion Anxiety/ Mood Sleep disorder Vestibular Ocular Motor Concussion Cognitive Migraine Cervical Whiplash PHYSICAL SYMPTOMS HEADACHE NAUSEA VOMITING FATIGUE BALANCE PROBLEMS VISUAL PROBLEMS SENSITIVITY TO LIGHT SENSITIVITY TO NOISE DAZED STUNNED COGNITIVE SYMPTOMS FEELING FOGGY FEELING SLOWED DOWN DIFFICULTY CONCENTRATING DIFFICULTY REMEMBERING INCREASED CONFUSION SLOWED SPEECH REPEATS QUESTIONS EMOTIONAL SYMPTOMS INCREASED IRRITABILITY INCREASED SADNESS MORE EMOTIONAL INCREASED ANXIETY NERVOUSNESS SLEEP DISTURBANCES DROWSINESS SLEEPING MORE THAN USUAL SLEEPING LESS THAN USUAL DIFFICULTY FALLING ASLEEP Vestibulo-Ocular Reflex This reflex functions to stabilize images on the retinas during fast head movement by producing eye movements in the direction opposite to head movement, thus preserving the image on the center of the visual field(s). For example, when the head moves to the right, the eyes move to the left, and vice versa. Since slight head movement is present all the time, the VOR is very important for stabilizing vision: patients whose VOR is impaired find it difficult to read using print, because they cannot stabilize the eyes during small head movements. The vestibulo-ocular reflex triggers an inhibitory signal to the extraocular muscles on one side and an excitatory signal to the muscles on the other side. The result is a compensatory movement of the eyes. When the VOR is injured from a concussion symptoms of dizziness, blurred vision, anxiety, nausea, tinnutis, and/or headache may be provoked with activities such as walking and turning the head or looking up and down, riding a bike over a bridge, running on a narrow sidewalk by busy traffic, walking by water, going to busy places like Target, football games, or concerts. Students often have increased symptoms during class transistions when they have to walk in busy halls. Vestibular dysfunction is often associated with migraine and anxiety and can be a key player, if not a cause of both of these ailments.

The Eyes Are A Portal To The Brain OCULAR MOTOR INJURIES VISUAL EFFECTS OF A CONCUSSION 67% of the neural connections within the brain are involved with some aspect of vision, whether it is visual

With so many of the connections within the brain involved with the process of vision, it is no wonder that vision problems are so common following an acquired brain injury.

Some of these may improve with time, others may be unchanging, while others respond very well to active treatment.

athletes. Near vision may be constantly blurry or may pulse in and out of clarity during near activities like reading.

4 The Eyes Are A Portal To The Brain OCULAR MOTOR INJURIES VISUAL EFFECTS OF A CONCUSSION 67% of the neural connections within the brain are involved with some aspect of vision, whether it is visual input, visual perception, or visual integration. With so many of the connections within the brain involved with the process of vision, it is no wonder that vision problems are so common following an acquired brain injury. There are several potential visual side effects of a concussion that are consistent with other forms of mild traumatic brain injury. Some of these may improve with time, others may be unchanging, while others respond very well to active treatment. Concussions can have the following effects on the visual system: Accommodative Insufficiency This condition is a reduction in eye focusing ability that results in blurry vision at near, even in young athletes. Near vision may be constantly blurry or may pulse in and out of clarity during near activities like reading. Blurry Vision - Blurry vision following a concussion can occur at distance, near, or both. Convergence Insufficiency This inability to use the eyes comfortably at near can result in a number of symptoms including: headaches, eyestrain, fatigue, or even double vision during near activities. Double Vision There are several causes of double vision, which is why anyone who sees double (even intermittently) should be evaluated by an optometrist with advanced training in neuro-optometry, binocular vision, and vision therapy. Light Sensitivity Photophobia, or light sensitivity, can result from various types of acquired brain injuries (including concussions). Ocular-Motor Dysfunction Deficiencies in eye movement abilities are quite common following concussions and other forms of mild traumatic brain injuries. These eye movement deficits can pose challenges with many activities of daily life, including reading and driving. Reduced Cognitive Abilities With Visual Tasks - Visual perceptual deficits can be caused by concussions and have dramatic effects on academic and even athletic success. Reduced Visual Processing Speed or Reaction Time Prolonged visual processing speed can slow down an athlete both on and off the field. The speed with which an athlete processes visual information affects many aspects of athletic competition, including: reading the field of play, judging the speed of a moving ball or puck, and judging the speed of other players on the field. VOMS Test The Vestibular Ocular Motor Screening (VOMS) is an effective tool Peak Performance Physical Therapists use to identify a person with a concussion by observing symptoms and findings associated with specific eye and head movements. The VOMS test includes assessment of both the vestibular system and ocular motor system. Tests include: Smooth Pursuits Horizontal Saccades Vertical Saccades Horizontal VOR Vertical VOR Visual Motion Sensitivity Near Point Convergence Once areas of hyofunction are identified, then specific eye, neck, and balance exercises are incorporated into our treatments to address these areas.

Symptoms of Impaired Saccades, Pursuits and Vergence System Post Concussion Migraines Blurred Vision Headaches (especially behind the eyes and at the top of the head) Eye strain Sensitivity to light

5 Symptoms of Impaired Saccades, Pursuits and Vergence System Post Concussion Migraines Blurred Vision Headaches (especially behind the eyes and at the top of the head) Eye strain Sensitivity to light Pulling sensation around eyes Trouble reading and focusing Trouble focusing far to near Trouble taking notes in class or catching a ball Avoidance of reading Comprehensioon deficits over time Migraines are headaches that occur with other symptoms including nausea, photo/phonphobia, dizziness, and visual aura. Migraines often involve the vestibulo-ocular system and they may or may not involve headaches. Post concussion migraines can be indicative of a longer recovery rate. If the athlete suffered from migraines prior to the concussion then they have a higher chance off having post concussion migraines. Concussed athletes with dizziness often have migraines. Migraines often include components of dizziness, anxiety, and sleep disorders, and whiplash injuries. These issues must be assessed indiviually to fully understand and treat the underlying drivers of post-concussion migraine. Effective treatments for migraine include: Controlled exercise (oxygenation to the brain, at the right levels, can decrease headache) Manual therapy Dry needling ASTYM Cervical neck strengthening Core strengthening Therapeutic exercise Migraine medication The Terrible Quartet Fed * Watered * Restored These four disorders are often layered upon each other, escalating symptoms, and need a close differential diagnosis and treatment plan. Follow these four recommendations to optimize healing of concussions and prevent migraines and tanking : 1. Maintain a steady diet of nutritional protein-rich snacks throughout the day. Don t let blood sugars bounce! Sleep Disorder Anxiety Migraine Vestibulo- Ocular 2. Drink lots of water. Concussed brains are extremely sensative to even the slightlest amount of dehydration. Frequent sips of water can often keep the headaches at bay. 3. Regulate sleep cycle and stay on a regular schedule. Disrupted sleep and irregular sleep patterns can be a leading contributer to migraine headaches and brain fatigue. 4. Take regular rest breaks to quiet the brain, but avoid naps! Napping during the day can contribute to insomnia at night.

CERVICOGENIC DIZZINESS Neck pain often accompanies dizziness, but it may be difficult to tell whether the dizziness and the neck pain are related or just coincidental.

People with cervicogenic dizziness tend to complain of dizziness (a sensation of movement of the self or the environment) that is worse during head movements or after maintaining one head position

6 CERVICOGENIC DIZZINESS Neck pain often accompanies dizziness, but it may be difficult to tell whether the dizziness and the neck pain are related or just coincidental. The head position has a great influence on equilibrium. People with cervicogenic dizziness tend to complain of dizziness (a sensation of movement of the self or the environment) that is worse during head movements or after maintaining one head position for a long time. The dizziness usually occurs after the neck pain and may be accompanied by a headache. Often the dizziness will decrease if the neck pain decreases. The symptoms of dizziness usually last minutes to hours. Cervicogenic dizziness is often resolved with physical therapy including: Joint mobilization Myofascial release ASTYM Dry needling Cervical/scapular/core stabilization program Strengthening of deep neck flexors Postural strengthening Ergonomic training Whiplash Injuries Whiplash is a relatively common immobilization or use of a injury that occurs to a person s cervical collar. neck following a sudden acceleration-deceleration force Failure to properly educate and that causes unrestrained, rapid treat patients with whiplash can forward and backward (or lead to chronic psychosocial lateral/rotational) movement of symptoms including depression the head and neck. It usually and anxiety. accompanies concussions. This relatively common injury is Trigger points in traumatized often ignored or mistreated due muscles often reproduce to lack of understanding of the headache pain. For example, condition. the sternocleidomastoid muscle is nortorious for referring pain Early physical therapy and pulling behind the eyes and intervention can lead to a more radiating pain up the back of rapid recovery than prolonged the head into the forehead. It can also cause dizziness and nausea. These are common concussion symptoms that can be inaccurately attributed to other disorders (ie, migraine, vestibular, or ocular) if not properly diagnosed. DEPRESSION Anxiety IRRITABILITY FOLLOWING CONCUSSION Depression is one of a number of persisting symptoms experienced by athletes following sports concussion. The prevalence of depression in the general population is around 5%, while the prevalence of depression in head trauma patients can reach an astounding 40 %. Anxiety is a common symptom of Post Concussion Syndrome. People can express anxiety in both emotional and physical ways from being inordinately irritable to experiencing shortness of breath or feelings of panic. Anxiety becomes a significant concern when these feelings intensify to a point where they interfere with the tasks of life. Anxiety can also be a symptom of vestibulo-ocular disorders and physical therapy can be very effective in treating this.

I m PACT NEUROPSYCH BASELINE TESTING RETURN TO SCHOOL CONSIDERATIONS THE DYLAN STEIGERS CONCUSSION PROJECT, TOGETHER WITH PEAK PERFORMANCE PHYSICAL THERAPY, HAVE OBTAINED IMPACT BASELINE TESTS ON

This scientifically researched concussion management tool helps health care professionals track recovery of cognitive processes following concussion and helps communicate post-concussion status to

It records pre and post-test concussion symptoms. The cognitive tests include attention, memory, processing speed, and reaction time.

effects of testing, being less expensive, and providing instant data without the need for long scoring and interpretation lag time.

In the unfortunate event of a concussion, Peak Performance Physical Therapist s use the athlete s individual baseline to compare their post-concussion test results.

7 I m PACT NEUROPSYCH BASELINE TESTING RETURN TO SCHOOL CONSIDERATIONS THE DYLAN STEIGERS CONCUSSION PROJECT, TOGETHER WITH PEAK PERFORMANCE PHYSICAL THERAPY, HAVE OBTAINED IMPACT BASELINE TESTS ON OVER 4000 AREA ATHLETES. The ImPACT Test is an important piece of the overall concussion evaluation and management process. It is a sophisticated computerized test of cognitive abilities. This scientifically researched concussion management tool helps health care professionals track recovery of cognitive processes following concussion and helps communicate post-concussion status to teachers, athletes, coaches, parents, and clinicians. The ImPACT Test takes to complete and assess the athlete s demographics - including age, sex, concussion history, and injury information. It records pre and post-test concussion symptoms. The cognitive tests include attention, memory, processing speed, and reaction time. Computerized neurocognitive tests provide advantages over traditional paper and pencil testing including taking less time to administer, the ability to present randomized stimuli and avoid practice effects of testing, being less expensive, and providing instant data without the need for long scoring and interpretation lag time. The ImPACT cognitive assessment tool is supported by extensive data with respect to prognostic ability, reliability and validity. In the unfortunate event of a concussion, Peak Performance Physical Therapist s use the athlete s individual baseline to compare their post-concussion test results. The ImPACT Test is one of our many evaluation tools that helps us make decisions about academic needs following concussion and return-tosport decisions. No school Partial school days Full school days Preferential seating Limited computer/screen time Dimmer lights/computer screen Allow baseball cap/sunglasses Allow earplugs Provide notes prior to class Provide PowerPoint slides Provide Note-taker Excuse from recess Allow early class transition Allow frequent rest breaks Student to go to RN s station for needed breaks Student only attends class with no note/test taking, or makeup work Student to attend class and take notes with no assignments/tests/make-up work Student to take notes and do assignments with no tests or make-up work Student to take notes, assigments and tests with make-up work as tolerated Excuse from all tests Exams in small/quiet room Excuse from all standardized testing Provide open book testing and extra time Stagger/postpone testing No physical exertion in gym, recess or athletics RETURN TO SCHOOL EARLY INTERVENTION HELPS Early physical therapy assessment to determine concussion trajectories is extremely effective in assisting concussed individuals in a successful return to school program. When athletes are placed on rest until all symptoms subside, then they tend to have increased anxiety and depression and feel very isolated from their peers. A guided recovery plan, with frequent re-assessment and progression allows for ongoing adjustments for necessary accommodations needed as the student recovers.

RETURN TO SPORT Stage I Light aerobic conditioning, balance activities, and exercise in linear planes Avoid head movements Work in quiet, dimly lit spaces Limit coginitive tasks No impact activities

com EARLY INTERVENTION WITH THE RIGHT EXERCISE AND THE RIGHT REST, AS DETERMINED BY THE ATHLETE S CONCUSSION TRAJECTORIES, IS MOST SUCCESSFUL.

8 RETURN TO SPORT Stage I Light aerobic conditioning, balance activities, and exercise in linear planes Avoid head movements Work in quiet, dimly lit spaces Limit coginitive tasks No impact activities Minimal vestibulo-ocular tasks Stage II EARLY INTERVENTION WITH THE RIGHT EXERCISE AND THE RIGHT REST, AS DETERMINED BY THE ATHLETE S CONCUSSION TRAJECTORIES, IS MOST SUCCESSFUL. SUPERVISED EXERTION THERAPY IS SUCCESSFUL IN PROMOTING FAST AND EFFICIENT HEALING. Cardiovascular Activity: Choose from stationary bike, UBE, elliptical, or treadmill (sometimes head bobbing on treadmill provokes symptoms). Initiate when: Athlete has minimal to no symptoms Athlete is symptomatic but has crossed over to chronic stage of post concussion Headache symptoms are more migraine-related and decrease with exertion Symptoms are more anxiety related and decrease with exertion Symptoms are more related to deconditioned state TO SCHEDULE AN APPOINTMENT, PLEASE CALL OR VISIT OPEN MON-FRI 8:00-6:00 Light to moderate aerobic conditioning Begin vestibulo-ocular tasks Intitiate head movements and eye tracking exercises with balance activities, resistance exercise, and walking ie: lateral squats with head movement, low intensity sport specific core ex with head turns Stage III Moderately aggressive aerobic ex with positional changes. Progress to moderate vestibulo-ocular tasks ie: jump progression with head movement, progress to high intensity sport-specific ex with head turns Dual tasking with 1-2 tasks Stage IV Max exertion with sport-specific activities avoiding contact Scrambled Brain Sport-specific complex dual tasking Stage IV Full contact and full return to sport

Beyond the Basics, Bringing Concussion Out of the Dark

Beyond the Basics, Bringing Concussion Out of the Dark Objectives Recognize different types of concussion based on symptomatology Identify risk factors for prolonged recovery after a concussion Predict