April 28, Katie Barnes Wood, PT, DPT Orthotennessee Therapy. Concussion Therapy. How and Why Physical Therapy Can Help Concussions

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1 April 28, 2018 Katie Barnes Wood, PT, DPT Orthotennessee Therapy Concussion Therapy How and Why Physical Therapy Can Help Concussions

2 Background Concussion Rehab at KOC Our Care Team Athletic Trainers MDs Physical Therapy Outside Referrals Cognitive Therapy Speech Therapy Psychological Counseling Vision Care Providers You! My Background Graduate of Farragut High School Bachelor of Arts in Physical Education at Maryville College Doctorate of Physical Therapy at Western Carolina University Focus on Sport-Related Concussions

3 Concussion Review Concussions are a MILD TRAUMATIC BRAIN INJURY (mtbi) Variety of causes DOES NOT REQUIRE LOSS OF CONSCIOUSNESS DOES NOT REQUIRE A HIT FROM ANOTHER PLAYER!

4 4 The Facts CDC estimates ~1.1 million people treated with non-fatal TBI annually in ER 1 Estimated 300,000 are moderate 128 per 100,000 in US yearly At least 75% of all TBIs reported each year are MILD 2 5/10 concussions go unreported or undetected 3

5 What is happening in the brain? A physiological disruption of brain function caused by an external force 5 Damage to tissues of the brain White Matter Grey Matter Neurons/Axons Calcium Potassium Initiates metabolic changes within the brain 6 Can see metabolic changes occurring as far out as 10 days May take 30 days to return to baseline ATP Glucose Lactate Period of decreased cerebral blood flow

6 What does an invisible injury look like? 75-94% Headache 57% Difficulty Concentrating Predictors of Delayed Recovery History of Prior Concussion Headache Dizziness Slow to rise On-field amnesia 52% Fatigue 51% Drowsiness 49% Dizzy 7

7 Look My head is killing me! Listen Appears dazed or stunned (such as glassy eyes) Forgets an instruction or play I can t focus! Blurry Vision Is unsure of score or opponent Moves clumsily or has poor balance Answers questions slowly Loses consciousness (even briefly) My balance is never this bad! Anxiety Nervous Stressed Cannot recall events prior to or after hit or fall I just don t feel normal I forgot where I m supposed to be

8 More Serious Considerations Second Impact Syndrome 1 Only seen in younger populations RARE Second concussion sustained while patient is still symptomatic from first concussion Brain loses ability to control intracranial pressure and blood flow Brainstem herniation Death within 2-5 minutes Chronic Traumatic Encephalopathy 8 Linked to repetitive head trauma Can appear in the late 20s Seen in mood changes, aggression, impulsivity Symptoms worsen with age Parkinsonism, speech changes, memory loss, confusion Exposure <12 y.o. associated with worse outcomes REQUIRES POST-MORTEM EXAM

evaluation by a licensed health care professional, if available, by the coach or by other designated person 9 No youth athlete who has been removed from play

9 So your student has a concussion what next? Any youth athlete who shows signs, symptoms and behavior consistent with a concussion shall immediately be removed from the activity or competition for evaluation by a licensed health care professional, if available, by the coach or by other designated person 9 No youth athlete who has been removed from play due to suspected concussion shall return to practice or competition until the youth athlete is evaluated by a health care provider and receives written clearance from the health care provider for a full or graduated return to play 9 Slow Resolution or Worsening of Symptoms? Get Help!

10 There s physical therapy for concussions? APTA Position Statement 10 Physical therapists are part of the multidisciplinary team of licensed health care providers that provides concussion management, which includes: education and prevention to minimize risk and increase awareness examination and evaluation to establish a diagnosis, treatment through implementation of a plan of care, monitoring of progress, and making return to participation decisions by using best available evidence and standards of care.

11 Concussion Rehabilitation Vestibular Ocular Cervical All the other stuff

12 Who have we been seeing? (April 2017-April 2018) Males vs Females 25 Ages % 46% Male: Female: to to >26

13 Examining and Evaluating Concussions Subjective is KEY Cervical Spine Vertebral Artery Test Ligament Testing Transverse Ligament Alar Ligament Movement Testing Does this make you dizzy? Strength Testing

14 Convergence - The Ability of the Eyes to Work Together

15 Saccades how accurately can you shift gaze? One of the fastest movements in the body Creates a 3D, more accurate perception of our world Imagine implications for activities like Walking down the hallway at school Driving Reading Looking between the board and notes in class Playing a sport

16 Smooth Pursuit the ability to follow a moving target

17 Vestibulo-ocular Reflex and Visual Motion Sensitivity Vestibulo-ocular Reflex Stabilizes images on the retina Keeps the world stable Helps to interpret environment while mobile The world is bouncing Visual Motion Sensitivity Maintaining focus on a target while the head and body are moving Actually inhibits VOR Imagine implications for the athlete

18 Balance Testing Vision + Proprioception + Vestibular = Balance Increased sway Less reactionary response Slowed processing with dual tasks Avoidance of movements that cause increased symptoms

19 Initial Testing Varies Based on the Patient Evaluation is largely dictated by the patient s response to testing Not uncommon for testing to take place over several visits

20 Once all the testing is done what s next? This part gets a little more fun The examination helps determine what needs to be fixed Many times, it s more than one thing! Vestibular Retraining Exertion Therapy Motion Sensitivity Exposure Balance Training Focus may shift during treatment sessions Ocular Retraining Feeling Better! Cognitive Tasking

21 What kind of exercises are we talking about? Ocular Vestibular Concussion Therapy Cervical Exertion

23 Is it safe to exercise? Voluntary, gentle exercise = good! Neuroprotective properties following brain injury Positive Effects on Mental Health combats depression in athletes Having said that Vigorous activity too early actually takes LONGER to return to play Important to avoid any activities that could result in additional injury Research indicates that patients who start guided exercise and vestibular rehabilitation before 6 weeks post-injury return to play FASTER!

24 Does it work? The Good News Vestibular and Ocular Rehab is supported in literature Limited studies Exertion Protocols can guide safe return to activity We see improvements in the clinic every day The sooner we address needs, the faster they get better! The Other News Concussions will continue to happen We need more information! Complex nature of concussions make treatment protocols difficult to develop NECESSITATES community approach to put the pieces together

25 Management of the Concussed Cognitive/Behavioral Therapy Light/Noise Sensitivity Create a Good Environment Blue setting on electronics when necessary Academic modifications Homebound/Partial Days Extra time for assignments Audiotaped lectures Sleep Allow them to sleep at night! Sleep schedule Avoiding naps, caffeine Medication Amitryptiline Amantadine SSRIs Supplements Magnesium Melatonin

26 Management of the Concussed Must Identify ON FIELD On-field amnesia Headache Dizziness Red Flags Graded Return to Play Collaboration between coaches, Ats Must challenge performance BEFORE full return to sport Create approachable environment to report symptoms Keep them engaged with team! Parent Education Support with Home Exercise Program

27 Questions & Discussion Thank you!

28 References 1. Bey T, Ostick, B. Second Impact Syndrome. West J Emerg Med Feb; 10(10): National Center for Injury Prevention and Control. Report to Congress on Mild Traumatic Brain Injury in the United States: Steps to prevent a Serious Health Problem. Atlanta, GA: CDC; UPMC Sports Medicine. Concussion Facts and Statistics. Accessed 4/18/ NCAA. Concussion and College Sports. Accessed 4/18/ O Neil ME, Carlson K, Storzbach D, et al. Complications of Mild Traumatic Brain Injury in Veterans and Military Personnel: A Systematic Review. Department of Veterans Affairs (US): 2013 Jan Giza C, Hovda D. The Neurometabolic Cascade of Concussion. J Athl Train Jul-Sep; 36(3): Kontos AP, Elbin RJ, Covassin T, Henry L, Pardini J, Collins MW. A Revised Factor Structure For the Post-Concussion Symptom Scale: baseline and post-concussion factors. Am J Sports Med. Oct; 40(10): Concussion Legacy Foundation. What is CTE? Accessed 4/20/ Knox County Parks & Recreation. Youth Sports Concussion Policy: Adapted from the Tennessee Secondary School Athletic Association Concussion Policy. Accessed 4/16/ American Physical Therapy Association. The Physical Therapist s Role in Management of the Person with Concussion. House of Delegates. June 12, Vote 10.

Physiotherapy management of concussion

Physiotherapy management of concussion Ms. Mairead Daly, Senior Physiotherapist, Bon Secours Health System Saturday November 17 th Silver Springs Hotel Cork Concussion Physiotherapy Assessment and Management