THE ROLE OF THE PHYSICAL THERAPIST IN MANAGEMENT OF CONCUSSIONS

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Roland Blankenship
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BEFORE WE GET STARTED THE ROLE OF THE PHYSICAL THERAPIST IN MANAGEMENT OF CONCUSSIONS DISCLOSURES No.

we been? have a working knowledge of the current research regarding concussion rehabilitation Where are we going? Where are we now? What can we do?

of a concussion management team A VERY GOOD PLACE TO START SURVEY SAYS BACK TO THE BEGINNING 2001 VIENNA GUIDELINES (CONCUSSION IN SPORT) Defined concussion Utilize sideline and repeated

1 BEFORE WE GET STARTED THE ROLE OF THE PHYSICAL THERAPIST IN MANAGEMENT OF CONCUSSIONS DISCLOSURES No. Open to entertaining any offers CORINA MARTINEZ PT,DPT,SCS,LAT,ATC DUKE SPORTS MEDICINE PT 10/12/2017 AND SO IT BEGINS MORE SPECIFICALLY OBJECTIVES BY THE END OF THIS SESSION YOU WILL: Where have we been? have a working knowledge of the current research regarding concussion rehabilitation Where are we going? Where are we now? What can we do? understand how to perform a clinical concussion examination be able to provide appropriate patient education for concussion recovery recognize the role of various healthcare providers as members of a concussion management team A VERY GOOD PLACE TO START SURVEY SAYS BACK TO THE BEGINNING 2001 VIENNA GUIDELINES (CONCUSSION IN SPORT) Defined concussion Utilize sideline and repeated assessment of signs and symptoms Post-concussion symptoms scale Neuropsychological testing is one of the cornerstones of concussion evaluation Graded RTP progression When in doubt, sit them out Bailes JE, Hudson V. Classification of Sport-Related Head Trauma: A Spectrum of Mild to Severe Injury. Journal of Athletic Training. 2001;36(3):

2 ATC = FRONT LINES 2004 NATA POSITION STATEMENT Moving away from grading systems Initial symptom severity > LOC for predictor of recovery Use of objective measures: Cognition (SAC) Postural Stability (BESS) Neuropsychological testing (ImPACT) IT S SIMPLE 2004 PRAGUE (CONCUSSION IN SPORT) 2004 Prague (Concussion in Sport) LOC not indicator of concussion severity modification of scholastic activities simple concussion 7-10 days complex concussion >10 days or LOC >1 minute neuropsych testing is one piece of puzzle, but not only SCAT - sx score, SAC BEEP BOP 2008 ZURICH GUIDELINES SCAT 2 neuroimaging - limited utility, specific cases balance and neuropsychological testing pediatric vs adult considerations still allowed adults same day RTP with medical monitoring cornerstone of concussion management is physical and cognitive rest until symptoms resolve a then a graded program of exertion prior to medical clearance and return to play PT MAKES AN APPEARANCE! 2012 ZURICH GUIDELINES SCAT3 and ChildSCAT3 (5-12y) 80-90% resolve in 7-10 days, persistent 10-15% clinical domains: symptoms, physical signs, behavioral changes, cognitive impairment, sleep disturbance no same day RTP baseline NP testing not recommended due to lack of evidence 24-48h rest, but then exercise recommendation? Factors contributing to prolonged recovery PT for vestibular and cervical may be beneficial AND HERE WE ARE 2016 BERLIN GUIDELINES SCAT5 and Child SCAT5 (ESSENTIAL READING!) NP testing not mandatory initial rest followed by sub-symptomatic activity 10-14d clinical recovery adults, 4w recovery children initial symptom severity good predictor of recovery rehabilitation with physical therapy to treat cervical and vestibular impairments controlled sub-symptomatic sub-maximal exercise for recovery HOT TOPIC VESTIBULAR-OCULAR Master CL, et al. Early vestibular and visual dysfunction predicts prolonged symptomatology following pediatric concussion. Br J Sports Med 51(11):A15- A15 Kontos AP, et al. Review of vestibular and oculomotor screening and concussion rehabilitation. J Athletic Training 52(3): Olsen BL, et al. Effectiveness of Vestibular Rehabilitation Therapy for treatment of concussed athletes with persistent symptoms of dizziness and imbalance. Journal of Sports Rehabilitation (2017) Anzalone AJ, et al. A positive vestibular/ocular motor screening is associated with increased recovery time after sports-related concussion in youth and adolescent athletes. The American Journal of Sports Medicine. 45(2):

MOVE IT MOVE IT WE TREAT THESE! CARDIO Chan C, et al. Safety of active rehabilitation for persistent symptoms after pediatric sport-related concussion: A randomized controlled trial.

3 MOVE IT MOVE IT WE TREAT THESE! CARDIO Chan C, et al. Safety of active rehabilitation for persistent symptoms after pediatric sport-related concussion: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation (2017) Lempke L, Jaffri A, Erdman N. The effects of early physical activity compared to early physical rest on concussion symptoms. Journal of Sports Rehabilitation. (2017):1-18 Zemek R, et al. Relationship of early participation in physical activities to persistent post-concussive symptoms following acute pediatric concussion. Br J Sports Med. 51(11):A20-A20 Lal A, et al. The effect of physical exercise after a concussion: a systematic review and meta-analysis. The American Journal of Sports Medicine. (2017): GAME TIME LET S GET DOWN TO BUSINESS PIECES OF THE PUZZLE CONCUSSION EVALUATION Vestibular Emotional Vision History Symptom Score Neurological Screen Cognitive Sleep Cervical Cervical Screen VOMS Cognitive Cardio Balance Cardiovascular (if appropriate) DETAILS PLEASE RISK FACTORS HISTORY (INJURY-SPECIFIC) HISTORY (PAST MEDICAL) Mechanism Previous concussions Emotional/personality changes Amnesia LOC Early signs Seizures Headache history/migraines (self vs family) LD/ADD/ADHD/dyslexia Psychiatric History/anxiety/depression Recent vision screen LE injury

TELL ME HOW YOU FEEL SYMPTOM SCORE Time of injury vs time of appointment Track symptom progression (worsening vs improvement) High initial symptom score predictive of longer recovery time REMEMBER

patient, may want to screen for cognitive deficits Normal score >25pts Validity decreases with increased time after injury 5 components (30pts total) Orientation (5pts) Immediate Recall (15pts)

4 TELL ME HOW YOU FEEL SYMPTOM SCORE Time of injury vs time of appointment Track symptom progression (worsening vs improvement) High initial symptom score predictive of longer recovery time REMEMBER YOUR MNEMONICS NEUROLOGICAL SCREEN Cranial Nerves Motor Deep Tendon Reflexes Sensory Coordination LET S THINK COGNITIVE (SAC) Standardized Assessment of Concussion (part of SCAT5) If direct access patient, may want to screen for cognitive deficits Normal score >25pts Validity decreases with increased time after injury 5 components (30pts total) Orientation (5pts) Immediate Recall (15pts) Digits Backwards (4pts) Months Backwards (1pts) Delayed Recall (5pts) ORIENTATION (5PTS) What month is it? What is the date today? What is the day of the week? What year is it? What time is it? IMMEDIATE RECALL (15PTS) DIGITS BACKWARDS (4PTS) Pick from word list I am going to say 5 words. I would like you to repeat them back to me in any order. 1 second per word 3 trials (same word list) I am going to give you a set of numbers and I want you to repeat them back to me in reverse. So if I say 1-2-3, you would say? From 3 and up to 6 digit strings Get 2 chances to correctly respond. If correct, move to next string length. If 2 incorrect responses, for same string length, stop test Pediatric patients (2 to 5 digits)

MONTHS BACKWARDS (1PT) Can you name all the months of the year backwards?

concussion injury similar to whiplash injury Rule out C-spine injury AROM, palpation, strength OH CANADA

to opposite side during cervical sidebend Transverse Ligament - supine anterior translation of C1 on C2

related to cervical involvement Head/Neck Differentiation test Cervical Flexion/Rotation test Joint Position

5 MONTHS BACKWARDS (1PT) Can you name all the months of the year backwards? Must get all correct to get 1 point Pediatric patients: Use days of the week CERVICAL SCREEN Mechanism of concussion injury similar to whiplash injury Rule out C-spine injury AROM, palpation, strength OH CANADA CERVICAL INSTABILITY TESTS Sharp-Purser -reduces subluxation of C1 on C2 Alar Ligament -should feel C2 SP move to opposite side during cervical sidebend Transverse Ligament - supine anterior translation of C1 on C2 reproduces symptoms PAIN IN THE NECK VISION KING-DEVICK Testing tips: Useful to determine concussion symptoms related to cervical involvement Head/Neck Differentiation test Cervical Flexion/Rotation test Joint Position Error test Don't use fingers to track place Don't let head move Start timer at 1st # on card, Stop at last # on card Time is cumulative for 3 test cards Smooth Pursuit Neck/Torsion test

KING-DEVICK Assesses visual processing Baseline test performed 2x when asymptomatic Used as "sideline concussion screening test" Post-injury time > baseline = Increased likelihood of concussion VOMS

6 KING-DEVICK Assesses visual processing Baseline test performed 2x when asymptomatic Used as "sideline concussion screening test" Post-injury time > baseline = Increased likelihood of concussion VOMS VESTIBULAR OCULOMOTOR SCREEN Smooth Pursuit Saccades Near Point of Convergence VOR SMOOTH OPERATOR SMOOTH PURSUIT H pursuits Look for ability to track target without jumps or nystagmus Consider extra ocular muscles involved in provocative movements VOR cancellation Mucha, Anne, et al. "A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions: preliminary findings." The American journal of sports medicine (2014): SHIFTY EYES SACCADES - H AND V Testing ability to focus between 2 targets without moving head Should move eyes about 30 degrees in each direction YOUR TURN! Hold index fingers out away from you about 3 ft apart Count number of total cycles (Left+Right=1 cycle) Then hold one finger at height equal to top of head and other around chest height (3 ft apart) Count number of total cycles (Up+Down=1 cycle)

work in sync to track an object coming towards you Ability for eyes to stay focused on a

to difficulty focusing Looking to see if vestibular and visual system can work in sync

TRY IT HOW WE ACTUALLY TEST Amplitude of head movement is 20 degrees in either direction.

stay focused on target as patient moves head at self-selected speed Official VOMS

SENSITIVITY ADDITIONAL VESTIBULAR ASSESSMENTS Assesses ability to inhibit VOR mechanism

7 FOLLOW THE TARGET NO.YES. CONVERGENCE INSUFFICIENCY VOR - H AND V Looks at ability of medial rectus muscles to work in sync to track an object coming towards you Ability for eyes to stay focused on a target while head moves Normal is <6cm Positive may need accommodations for reading due to difficulty focusing Looking to see if vestibular and visual system can work in sync to stabilize gaze on target Often very provocative in concussed patients SHAKE IT LET S TRY IT HOW WE ACTUALLY TEST Amplitude of head movement is 20 degrees in either direction. Target held with extended arm in front of nose Cue to shake head no or nod head yes Eyes stay focused on target as patient moves head at self-selected speed Official VOMS testing has head moving at 180 bpm Count number of cycles in 10 seconds VISUAL MOTION SENSITIVITY ADDITIONAL VESTIBULAR ASSESSMENTS Assesses ability to inhibit VOR mechanism Dynamic Visual Acuity Eyes stay focused on moving target while head stays in line with target Head Thrust Test 50bpm and 10 rotations Dix Hallpike Cover Uncover Test

DON T FALL BESS BALANCE ERROR SCORING SYSTEM (BESS) Hold test positions 20 seconds, eyes closed Romberg, tandem, single leg test positions Non-dominant leg in back for tandem and for single leg Count

8 DON T FALL BESS BALANCE ERROR SCORING SYSTEM (BESS) Hold test positions 20 seconds, eyes closed Romberg, tandem, single leg test positions Non-dominant leg in back for tandem and for single leg Count errors: open eyes, hands off hips, stepping/stumbling/ falling out of position, lifting forefoot/heel, >30deg hip abduction, out of test position >5 seconds moderate/good reliability balance Bell DR, Guskiewicz KM, Clark MA, Padua DA. Systematic Review of the Balance Error Scoring System. Sports Health. 2011;3(3): doi: / JUST TO REVIEW DELAYED RECALL (5PTS) Do you remember any of those 5 words that I asked you to repeat when we started? COGNITIVE (SAC) Standardized Assessment of Concussion 5 components (30pts total) Orientation (5pts) Immediate Recall (15pts) Digits Backwards (4pts) Months Backwards (1pts) Delayed Recall (5pts) CARDIOVASCULAR ASSESSMENT Identify HR associated with symptom exacerbation via testing 60-80% of symptomatic HR is target HR for exercise Start min/day or duration tolerated during ETT; may need to do every other day if symptomatic Gradually increase until able to perform 30 minutes continuously without symptom exacerbation Do not let symptoms increased more than 2 points BUFFALO CONCUSSION TREADMILL TEST Starting speed: mph, 0% incline Minute 2: Incline increased to 1% Every minute after: Incline increased by 1% Test stopped with symptom exacerbation or until cannot continue RPE and HR taken at each stage to establish threshold HR Re-evaluate every 2 weeks for new symptom threshold HR

DUKE CONCUSSION BIKE TEST Maintain speed between 70-80 RPM Stationary bike: Starting at 2.0 resistance for 2 min warmup Every minute: Increase resistance by 1.0 Evaluation Complete!

9 DUKE CONCUSSION BIKE TEST Maintain speed between RPM Stationary bike: Starting at 2.0 resistance for 2 min warmup Every minute: Increase resistance by 1.0 Evaluation Complete! Continue until fatigue or symptom exacerbation 2 minute cooldown at 2.0 Now what? Continue to monitor for 5-10 minutes for HR recovery RPE, HR, symptoms taken prior to increasing resistance BEFORE YOU LEAVE PRIORITIZE IMPAIRMENTS Utilize information from examination to prescribe exercises that do not provoke baseline symptoms Cervical Vestibular Oculomotor DISCHARGE INSTRUCTIONS Important to provide appropriate education at discharge Functional recommendations Return to school recommendations Activity modifications Cardiovascular Balance??? Is it a concussion? Kutcher JS, Giza CC. Sports Concussion Diagnosis and Management. Continuum : Lifelong Learning in Neurology. 2014;20(6 Sports Neurology): doi: /01.CON

AND SO IT BEGINS DIFFERENTIAL DIAGNOSES Cervical strain, injury Sleep deprivation Do I need a CT or MRI? Migraine NICE PECARN MRI? 3,338 children identified with concussion 427 received MRI 2 (0.

10 AND SO IT BEGINS DIFFERENTIAL DIAGNOSES Cervical strain, injury Sleep deprivation Do I need a CT or MRI? Migraine NICE PECARN MRI? 3,338 children identified with concussion 427 received MRI 2 (0.5%) had findings compatible with traumatic injury both of microhemorrhage both had had 3 prior concussions 61 patients (14.3%) had abnormal findings unrelated to trauma (cysts, Chiari malformations, etc) Do I wake him/her up every couple hours?

ZZZZZ SLEEP HYGIENE Want to normalize sleep patterns as soon as possible Common complaints Difficulty falling asleep What is the typical recovery time?

11 ZZZZZ SLEEP HYGIENE Want to normalize sleep patterns as soon as possible Common complaints Difficulty falling asleep What is the typical recovery time? Difficulty staying asleep Sleeping all day After first 48 hours, try to establish sleep routine EDUCATED GUESS IT DEPENDS Children and teenagers: 4wks average recovery time Adults: 2-4 weeks Recovery depends on severity, concussion history, preexisting medical conditions, activity modifications, etc Can I go to school? Need to educate parents that 7-10 days recovery time is not the norm LEARNING IS FUN AS TOLERATED CONSIDERATIONS Try to get back in school as soon as possible minimizing symptom provocation NCHSAA recommendations available online Use clinical findings to assess cognitive and vestibular/ocular deficits that might delay return to school Send paperwork for guidance to school counselors Importance of 'return-to-learn' in pediatric and adolescent concussion. Pediatr Ann Sep;41(9):1-6. doi: /

Play RETURN TO PLAY KNOW YOUR ROLE RTP PROGRESSION Should be supervised by ATC or first responder Must get final sign-off

12 MODIFY When can I play again? FOR THE SAFETY OF NC ATHLETES GFELLER-WALLER Education Emergency Action and Post-concussion Protocol Clearance/Return to Play RETURN TO PLAY KNOW YOUR ROLE RTP PROGRESSION Should be supervised by ATC or first responder Must get final sign-off by managing physician or designated LAT, NP, or PA 24 hours between each phase May progress if no recurrence of symptoms from previous phase

13 LET S MOVE! NO MORE COCOON! New recommendations to start low impact nonprovocative activity as soon as able For example: Easy walk Can I drive? Stretching, modified yoga Caution to not overdo it BEHIND THE WHEEL DRIVING RECOMMENDATIONS Recommendations based on safety Can't move head quickly due to dizziness or pain Slowed cognitive fxn or reaction time What medications can I take? Decreased visual acuity or awareness FYI MEDICATIONS IT TAKES A VILLAGE CONCUSSION CARE TEAM No naproxen (advil, motrin, aleve) for first 24 hours Acetaminophen ok if necessary Prefer to not be on meds that may mask symptoms May take daily meds as usual (BP, ADD/ADHD, etc) Consider migraine meds for persistent HA (Amitryptyline, Imitrex, Topamax) Meclizine for dizziness Zofran for nausea Melatonin, Benadryl, Ambien to help with sleep MEDICAL Physician ATC PT Neuropsych Vision Speech OT Psych SCHOOL Counselor Teachers Coaches ADs SOCIAL Parents Siblings Friends

PUTTING IT ALL TOGETHER Comprehensive history and evaluation to guide interventions Address most provocative symptoms first, generally cervical and vestibular Education for activity modifications to

ATTENTION Mucha, Anne, et al. "A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions: preliminary findings." The American journal of sports medicine 42.

14 PUTTING IT ALL TOGETHER Comprehensive history and evaluation to guide interventions Address most provocative symptoms first, generally cervical and vestibular Education for activity modifications to minimize symptom provocation Guidance for early and appropriate physical activity Identify need for additional referrals as appropriate RECOMMENDED READING FOR ADDITIONAL INFORMATION THANKS FOR YOUR ATTENTION Mucha, Anne, et al. "A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions: preliminary findings." The American journal of sports medicine (2014): Questions? Matuszak, Jason M., et al. "A Practical Concussion physical examination toolbox: evidence-based physical examination for concussion." Sports health 8.3 (2016): Ellis, Michael J., John J. Leddy, and Barry Willer. "Physiological, vestibulo-ocular and cervicogenic postconcussion disorders: an evidence-based classification system with directions for treatment." Brain injury 29.2 (2015): Schneider, Kathryn J., et al. "Rest and treatment/rehabilitation following sport-related concussion: a systematic review." Br J Sports Med (2017): bjsports McCrory, Paul, et al. "Consensus statement on concussion in sport the 5th international conference on concussion in sport held in Berlin, October 2016." Br J Sports Med (2017): bjsports Lundblad, Mark. "A conceptual model for physical therapists treating athletes with protracted recovery following a concussion." International journal of sports physical therapy 12.2 (2017): 286.

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