Active rehabilitation for youth who are slow to recover from concussion

Transcription

1 Active rehabilitation for youth who are slow to recover from concussion Isabelle Gagnon Kids and Teens Concussion Research Lab Trauma Center Montreal Children s Hospital-MUHC School of Physical and Occupational Therapy McGill University

2 Acknowledgements Canadian Institutes of Health Research Fonds de la recherche du Québec-Santé Research Institute of the McGill University Health Center Montreal Children s Hospital, MUHC REPAR Ontario Neurotrauma Foundation The Montreal Children s Hospital Trauma Research Lab Debbie Friedman Lisa Grilli Laurie-Ann Corbin Berrigan Helen Kocilowicz Jérôme Gauvin Lepage Shikha Saxena Danielle Dobney Diane Richard Eda Cinar

3 Potential conflict of interests disclosure I do not declare any potential conflict of interest

4 What do we call active rehab?

5 Rehabilitation: enabling individuals to reach and maintain their optimal physical, sensory, intellectual, psychological and social functional levels. provides people with the tools they need to attain independence and self-determination. Active: Exercise-based Co-constructed Empowering Engaging

6 Challenging the rest approach

7 Current management recommendations Cognitive rest prescribed initially then gradual return allowed, with full return when symptom free Physical rest until symptom free, (symptom-free waiting period?) then gradual return Other considerations Sleep hygiene Hydration Headache management General leisure recommendations

8 Confusion around rest Strict rest vs METs measurement Duration Domains of activity Animal evidence re timing: temporal window Emerging contradictory evidence re timing in humans

9 challenge return kids too quickly withold them from participating unecessarily

10 General Concussion Management Early Screening Early Action Plan Concussion and personal history Current concussion details Current functioning and triggers for immediate consults If referred > 1 week after injury: add PT assessment Activity management Education to parents Reassurance to kids Return to life Neurological screening exam Activity management Visual function Early assessment High Cervical function Early Treatment Visual function High Cervical function Headache management Vestibular function Vestibular function Return to school and full load Return to life Return to everything else Exertion and return to sports

11 Activity Management Early Action Plan Early Treatment Restriction not complete removal allowed walking, light swimming, etc protection from second injury Return to school gradually Active Rehabilitation 3-4 weeks post-injury Pushing beyond symptoms

12 Active rehabilitation vestibular oculomotor Gagnon et al., 2009, 2012, 2016 cervical

13 Aerobic component Submaximal ( 50-60% age-adjusted max. capacity) aerobic training on a treadmill, stationary bike or videogame based activity for up to 15 mins The HR is measured continuously throughout session The Pictorial Children s Effort Rating Table used to measure the patient s perceived effort Tolerance to exertion measured with respect to the presence of selected symptoms If symptoms increase during aerobic activity, the activity is stopped. The duration is recorded.

14 Sport-specific component Sport-specific coordination skills, resistance exercises for 5-10 minutes. ball activities, obstacle courses, sport specific maneuvers depending on the child s preference and sport practiced. If symptoms increase during coordination drills, the activity is stopped. The duration is recorded.

15 Mental imagery component PT discusses technique of positive visualization and mental imagery The patient chooses a motor component of his/her sport or favorite activity (successful for them, finite in duration) The patient practices visualization at home which includes visualizing performing sport specific activities in each of the steps of the Return to Sports following a Concussion Guidelines for 10 minutes. Visualization of Steps 1, 2 and 3 are practiced until the patient can reach 15 mins of aerobic activity without provoking symptoms After the 15 minutes of aerobic activity is achieved, the patient can now visualize him/herself in step 4 and 5

16 Education/Motivation component Review info given to them (common post-concussion Sx s, likely time course of recovery, and general coping strategies) Determine the personal meaning and impact of the MTBI on the patient and parents and its consequences on their daily lives. Include patient s own goals Recognize evolving or progressing Sx s (eg. perpetuating thoughts and behaviors such as catastrophic misinterpretation of Sx s) Teach coping skills to patient and parent to reduce stress and anxiety. Normalize sleeping patterns

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19 Progression Physiotherapy: Active Rehabilitation Followed weekly by PT and progressed until symptom-free at rest for 5-7 days. Then reassessed for exertion testing (physical and cognitive) in the concussion clinic When passed the exertion testing, child follows the return to activities protocol

20 Does it work? Evidence from Clinical experience (almost 10 years) Case series #1: 16 participants Case series #2: 10 participants Clinical trial Comparative effectiveness

21 What are you currently doing to address Case series concussion in kids? Scand J Med Sci Sports, 2016 Decreased fatigue PedsQL score pre intervention post-intervention Decreased Symptoms 0 general fatigue cognitive fatigue sleep/rest fatigue Total

22 Non-randomized clinical trial Primary Outcome: PCSI Main outcomes: post-concussion symptoms and Quality of life

23 Non-randomized clinical trial Post-concussion symptoms total score (mean) Baseline 2-Week 6-Week Time point of assessment No group differences on PCSI score PCS-Parents Hamilton PCS-Children Hamilton PCS-Parents Montreal PCS-Children Montreal QOL TOTAL Mtl Ham 74,69 70,29 82,25 73,24 group differences on PedsQL score 6 weeks after initiation Time effect for concussion group PRE POST

24 Comparative effectiveness (5P study sample) (JAMA, 2016)

25 Comparative effectiveness (5P study sample) AR N=50; Controls N=518 Difference in slopes is highly significant

26 Seems to work at 4 weeks but we have more questions! Do we have to wait until 4 weeks to push kids through their symptoms? Do girls and boys respond the same way? What is the active ingredient of the rehabilitation approach?

27 When can we start? Symptoms at 6 week visit Symptoms at follow-up visit Symptom score Data from trial (N= 50) shows that earlier initiation (closer to 4 weeks) leads to less symptoms at 6 weeks Data from our clinical database (N= 569) points in same direction 2 to 4 weeks lead to better outcomes Non-inferiority pilot RCT ongoing 2 vs 4 weeks initiation

28 Sex/Gender and active rehab? pre 2weeks post 6weeks post male female Data from trial (N= 50) shows that Girls start out with more symptoms but end at the same level 6 weeks later Data from our clinical database (N= 455) points in same direction, with slopes of recovery differing by gender Power our studies to be able to look at sex/gender

29 Zurich, 2012 Berlin, 2016???