Shanley Part 1- Epidemiology, Care Team, Return to Play and Learn

Transcription

1 Neural and Vestibular Contributions to Patients with Post Concussive Syndrome Combined Sections Meeting 2018 Jacqueline Davenport, PT, DPT, OCS Thomas Denninger, PT, DPT, OCS, FAAOMPT Ellen Shanley, PhD, PT, OCS Shanley Part 1- Epidemiology, Care Team, Return to Play and Learn Outline o Epidemiology of Concussion o Concussion Care Team o Return to Learn o Return to Play o Youngest & Oldest Americans Risk from Falls Concussions in the workplace o 5,870 occupational concussions involving days away from work (BLS 2014) o Incidence rate/yr time-loss occupational concussions 7/100,000 full-time workers* Concussions in younger individuals o Fifteen to 24 y.o. s o Sports are 2nd leading cause*1 o MVA - leading cause of concussion*2 o * 1 Based on prior estimates o * 2 Most reported TBI from MVA more severe (Amaranath 13) Sport- related concussions (Gessel 10; Marmar 12) o #1 in Adolescent to young adults o Concussion Rate concussions per 10,000 AE s o Games > Practice (all sports except Cheerleading) Concussion Sequela o Within 2 weeks after concussion o RTP timeframe has been mean of 10 days (McCrea 02, 03; Bleiberg 04; Lovell 04) o Variation appears inversely proportional with athlete age (Sims 08, Williams 15, Zemek 16) Factors related to prolonged recovery o Strongest Evidence- Severity of symptoms o Weakest Evidence- Sex, Concussion, ADHD/LD Concussion Care Team- Medical & Educational Resources o Greenville Hospital System/ Steadman-Hawkins Administration Primary Care Sports Medicine/ Orthopedics Athletic Trainers

2 Physical Therapists Researchers o Greenville County School System Administration Coaches Teachers Components of Concussion Program Return to Learn Program o RTL-transitioning back to the classroom following SRC o Full RTL -complete reintegration into the classroom without new accommodations Challenges Return to Learn Program o Team communication Challenges of negotiating HIPPA & FERPA guidelines o Understanding Medical & Educational concerns o Coordinating resources & response Return to Play Program o The process of recovery & RTS after SRC graduated stepwise rehabilitation strategy o Brief period of initial rest (24 48 hours) before beginning stage 1 Denninger Part 2- Connecting the Dots, Impairment Based Assessment Traditional Concussion Diagnostic Testing o ImPact o SCAT2 and 3 o Symptoms Severity Scale o Limitations Generalizability Fall MVA Required baseline testing Cost Stability and reliability Issues Diagnostic thresholds Tracking Limitations Return to play limitations

3 Limited prognostic properties Prognosis o Athletes o Military mild TBI o Pediatric mild TBI Rates of formalized rehabilitation Tribalism within PT for patients with WAD/concussion/vestibular Key Physical Examination Assessment/Findings o Vestibular and Oculomotor Screening VOMS Mucha 2014 o Smooth Pursuit o Horizontal and Vertical Saccades o Near Point convergence o Horizontal Vestibular Ocular reflex o Vertical VOR o Visual Motion Sensitivity Pupillary restriction Extraocular movements Ocular alignment Gaze fixation Smooth Pursuits Optokinetic Nystagmus VOR Cancellation Dix Hallpike Visual Acuity testing Head Impulse Test Head Shake Test o Joint Position Error (de Vries 2015) Cervicocephalic Kinesthetic Sensibility Seated 90cm away from target Eyes closed Typically three trials Normal error is 4.5 degrees (6.3 cm) o Craniocervical Muscle Performance Craniocervical flexion Test (Jull 2008) Cervical Flexor Endurance Test (Harris 2005) Cervical Extensors Endurance Test (Sebastian 2015) o Cervical Mobility and Provocation Testing (Genese 2013) C0-1 C1-2 Middle and lower cervical spine Trigeminal Excitation C203 Trigeminal Nuclei

4 o Proposed model for Tinnitus Dry eyes Headache Facial pain Visual disturbances Sinus issues Panic attack o Balance Assessment (Howell 2016, Buckley 2017, Reiman 2000) Balance Error Scoring System (BESS) Additional Berg Tinetti Single and tandem for time Dynamic Gait Index o Psychosocial Assessment (Hutchinson 2017) Depression Kinesiophobia Post-traumatic stress Anxiety Pain catastrophization Davenport Part 3- What do I do with these folks and how do I do it? PCS treatment based classification systems o Physiological o Cervicogenic o Vestibular/Occular Physiological PCS o Exam Findings: Positive Buffalo Treadmill Testing indicates energy problem Clear there is a neurotransmitter and ion disturbance, disruption in cerebral blood flow and changes in autonomic nervous system regulation (Leddy 2007) Subjectively: Cognitive fatigue, worse symptoms at the end of the day, difficulty with increasing physical activity o Buffalo Treadmill Test (Leddy 2013) 3.6 mph at 0% grade for 2 mins 1% increase in grade ever minute, then when maxed, increase speed by.4mph each minute HR, RPE and symptoms are measured every minute of testing BP can be assessed every 2 minutes if possible Testing stops if subject reaches maximum exertion (RPE 19-20), or symptoms increase >3 VAS points from baseline prior to testing

5 Physiological concussions will not be able to exercise to exertion and symptom provocation will be within a certain heart rate/bp range o Treatments Cardiovascular Subthreshold training 30 mins, 5 times a week of heart rate monitored exercise program to progressively condition the patient into tolerance of symptoms and allow better regulation centrally. Literature supports recovery in athletes given similar programs (Leddy et al 2010, Baker et al 2012, Darling et al 2014m Kozlowski et al, 2013) Cerviocogenic PCS o Exam Findings Positive C spine findings ROM loss, or active vs. passive ROM discrepancy Motor Control Abnormalities and poor movement patterns Poor Joint Proprioception and Increased Joint Position Error sense Deep neck flexor and multifidus/neck extensor weakness Positive Cervical Provocation and Mobility Testing Subjectively: Headaches, tension, neck pain, neck fatigue at the end of the day, difficult with reading, driving or sustained postures o Treatment Manual Therapy Plenty of literature to support the use of manual therapy for treatment of the cervical spine. o Manip/mobilize o Soft tissue mobilization o Dry needling o Muscle energy techniques Joint Position Sense Training Progressions o Seated Standing o Wide Base of support Narrow Base of Support o Target in the center Target off center o Steady surface Unsteady surface o Single plane Multiple plane Head on Body Rotation Motor Control Training Assess ability to perform smooth movements and quickly move between targets Tracing a simple line Tracing a simple circle Moving quickly between multiple dots Progress to different surfaces and more complex patterns Vestibular-Occular PCS

6 o Examination Positive VOMS Positive BESS testing Positive Dix-Halpike o Subjectively Patients report trouble reading, pressure behind the eyes, difficulty with focusing their eyes or double vision/oscillopsia, dizziness, general disequilibrium, vertigo o Treatment VOMS Components Eye Tracking o Ball toss o Eye Mazes Saccades o Active Eye Head Movement o Finding p s and q s Convergence Insufficiency: o Pencil Push Ups o Brock String o Eye Mazes VOR Dysfunction o Pt is asked to keep their eyes fixed on a target and rotate their head about 20 degrees each direction at a speed of about 1 head turn/sec o Pt must keep the target in FOCUS at all times o Exercise is best if performed 3 times a day o Changes are usually noticeable in 1-2 weeks o Exercise should provoke symptoms, but they should not last a substantial amount of time (<30min-1hour) so that they can continue to work on it throughout the day o If the exercise does not provoke symptoms, progress with changing the background or position VMS Dysfunction o Large body movements with eye tracking in busy environments Side planks to front planks Lunges with diagonal reaches Single leg RDL with reach up to ceiling Balance Training Eyes: open or closed Head: Stable, Nodding, Shaking, Diagonal Feet: Apart, together, tandem, single leg Surface: Hard, Foam, Balance Board, Bosu Environment: Closed, Open, Busy/distracting Cognition: Focused or distracted