The Role of Active Rehabilitation -taking a targeted approach

Transcription

1 The Role of Active Rehabilitation -taking a targeted approach Willem (Winne) Meeuwisse, MD, PhD MANAGING CONCUSSIONS IN THE TEAM SETTING ATPC Marrakech, Morroco September, 2018

2 Rehab: from what? Majority recover in 7-10 days Physical and cognitive rest

3 Rest? Absolute? Relative? Active Rest?

4 What is normal recovery time?

5 PERCENTAGE DAYS NHL UNIVERSITY HIGH SCHOOL

6 PERCENTAGE 35 Source: Comper, Hutchison & Richards, The MacIntosh Sports Medicine Clinic University of Toronto, DAYS NHL UNIVERSITY HIGH SCHOOL

7 Makdissi et al. AJSM % AFL dataset n=1015 players 88 concussions 18%

8 Prolonged Recovery 1. Same injury but more severe? 2. Different type(s) of injury?

9 >10 Days Delayed recovery Persistent symptoms Simple vs complex (Prague 2004) Difficult concussion

10 FACTORS Symptoms Signs Sequelae Temporal Threshold Age Co and Premorbidities MODIFIER Number Duration (>10 days) Severity Prolonged LOC (>1min) Amnesia Concussive convulsions Frequency repeated concussion over time Timing injuries close together Recency recent concussion or TBI Repeated concussions occurring with progressively less susceptible impact force or slower recovery after each successive patient concussion Child and adolescent (< 18 years old) Migraine, depression or other mental health disorders, attention deficit hyperactivity disorder (ADHD), learning disabilities (LD), sleep disorders Medication Behaviour Sport Psychoactive drugs Anticoagulants Dangerous style of play High sporting level

11 Who is at Risk? Iverson t. Al., BJSM 2017 The development of subacute problems with headaches or depression is likely a risk factor for persistent symptoms lasting greater than a month. mental health problems Teenage years (girls > boys) Attention deficit hyperactivity disorder (ADHD) or learning disabilities do not appear to be at substantially greater risk.

12 Persistent symptoms following SRC can be defined as clinical recovery that falls outside expected time frames (ie, >10 14 days in adults and >4 weeks in children). It does not reflect a single pathophysiological entity, but describes a constellation of non-specific post- traumatic symptoms that may be linked to coexisting and/or confounding pathologies A detailed multimodal clinical assessment is required to identify specific primary and secondary processes, and treatment should target specific pathologies identified Makdissi M, et al. Br J Sports Med 2017

13 Is it all about the brain?

14 susceptible patient

15 susceptible patient

16 VESTIBULAR NEURO CERVICAL SLEEP & HORMONAL susceptible patient COGNITIVE MOOD AUTONOMIC BEHAVIOUR

17 VESTIBULAR NEURO CERVICAL SLEEP & HORMONAL susceptible patient COGNITIVE MOOD AUTONOMIC BEHAVIOUR SCAT3

18 Neck pain Headache Shoulder pain Cramps Burning pain Stiffness Decreased ROM Radicular symptoms Vertigo Dizziness Balance and spatial orientation Visual focusing/tracking Night blindness Depth perception Light sensitivity Fatigue Weakness LOW Abdo pain Low BP Coldness Dry skin Loss of libido Erectile difficulties Menstrual dysfunction Vaginal dryness CERVICAL VESTIBULAR SLEEP & HORMONAL NEURO susceptible patient AUTONOMIC BEHAVIOUR COGNITIVE MOOD Insomnia EDS Sleep apnea RLS Narcolepsy Circadian rhythm disorders Cardiovascular GI symptoms Fatigue Exercise intolerance Decreased sweating Light sensitivity Urogenital function SCAT5

19 Manual Therapist Physiatrist Neuropsychologist Neurologist VESTIBULAR NEURO CERVICAL SLEEP & HORMONAL susceptible patient COGNITIVE MOOD Physician Cardiologist AUTONOMIC BEHAVIOUR Psychiatrist Psychologist

20 We are too much accustomed to attribute to a single cause that which is the product of several, and the majority of our controversies come from that. Marcus Aurelius, Roman emperor and philosopher AD

21 Migraine Vestibular Cervical Causes of dizziness? Central Nervous System Psychogenic Fife and Kalra, 2015; Ernst et al 2005, Treleaven et al, 2003 Vascular Medication Other?

22 VESTIBULAR NEURO CERVICAL SLEEP & HORMONAL susceptible patient COGNITIVE MOOD AUTONOMIC BEHAVIOUR

23 Clinical exam Otoneurological testing Functional testing History Exam Imaging Electrophysiology Clinical exam Functional testing Imaging VESTIBULAR NEURO Questionnaires SCAT3/SAC Neuropsychology CERVICAL COGNITIVE Sleep history Sleep scales Sleep study/apps Blood workup SLEEP & HORMONAL AUTONOMIC susceptible patient BEHAVIOUR MOOD History Partner/parent report Questionnaires Imaging RHR/HRV ECG/Echocardiogram BP/Tilt study Exercise test Autonomic assessment History Partner/parent report Questionnaires Imaging

24 Rest Graduated exercise Skill training Clinical exam Otoneurological testing Functional testing History Exam Imaging Electrophysiology Rest Graduated exercise Skill training Clinical exam Functional testing Imaging VESTIBULAR NEURO Questionnaires SCAT3/SAC Neuropsychology CERVICAL COGNITIVE Sleep history Sleep scales Sleep study/apps Blood workup SLEEP & HORMONAL AUTONOMIC susceptible patient BEHAVIOUR MOOD History Partner/parent report Questionnaires Imaging Rest Graduated exercise Skill training RHR/HRV ECG/Echocardiogram BP/Tilt study Exercise test Autonomic assessment History Partner/parent report Questionnaires Imaging Rest Graduated exercise Skill training

25 What does the evidence say? Schneider et. al., BJSM 2017 A brief period (24 48 hours) of cognitive and physical rest is appropriate for most patients. Following this, patients should be encouraged to gradually increase activity. There is support for interventions including cervical and vestibular rehabilitation and multifaceted collaborative care. Closely monitored subsymptom threshold, submaximal exercise may be of benefit.

26 Active Rehabiltation

27 Rest Graduated exercise Skill training Clinical exam Otoneurological testing Functional testing History Exam Imaging Electrophysiology Rest Graduated exercise Skill training Clinical exam Functional testing Imaging VESTIBULAR NEURO Questionnaires SCAT3/SAC Neuropsychology CERVICAL COGNITIVE Sleep history Sleep scales Sleep study/apps Blood workup SLEEP & HORMONAL AUTONOMIC susceptible patient BEHAVIOUR MOOD History Partner/parent report Questionnaires Imaging Rest Graduated exercise Skill training RHR/HRV ECG/Echocardiogram BP/Tilt study Exercise test Autonomic assessment History Partner/parent report Questionnaires Imaging Rest Graduated exercise Skill training

28 Rest Graduated exercise Skill training Vestibular rehabilitation Manual therapy Acupuncture Medications Clinical exam Otoneurological testing Functional testing History Exam Imaging Electrophysiology Rest Graduated exercise Skill training CBT/psychotherapy Acupuncture Medications Brain training TMS Clinical exam Functional testing Imaging VESTIBULAR NEURO Questionnaires SCAT3/SAC Neuropsychology CERVICAL COGNITIVE Sleep history Sleep scales Sleep study/apps Blood workup SLEEP & HORMONAL AUTONOMIC susceptible patient BEHAVIOUR MOOD History Partner/parent report Questionnaires Imaging Rest Graduated exercise Skill training Sleep hygiene Resistance training Medications RHR/HRV ECG/Echocardiogram BP/Tilt study Exercise test Autonomic assessment History Partner/parent report Questionnaires Imaging Rest Graduated exercise Skill training CBT/psychotherapy Medications Apps

29 Rest Graduated exercise Skill training Vestibular rehabilitation Manual therapy Medications Clinical exam Otoneurological testing Functional testing History Exam Imaging Electrophysiology Rest Graduated exercise Skill training CBT/psychotherapy Medications Brain training TMS Clinical exam Functional testing Imaging VESTIBULAR NEURO Questionnaires SCAT3/SAC Neuropsychology CERVICAL COGNITIVE Sleep history Sleep scales Sleep study/apps Blood workup SLEEP & HORMONAL AUTONOMIC susceptible patient BEHAVIOUR MOOD History Partner/parent report Questionnaires Imaging Rest Sleep hygiene Graduated exercise Skill training Resistance training Medications RHR/HRV ECG/Echocardiogram BP/Tilt study Exercise test Autonomic assessment History Partner/parent report Questionnaires Imaging Rest Graduated exercise CBT/psychotherapy Medications Apps

30 How do you do it? 1. Detection 2. Treatment

31 Balance Testing in Concussion Balance Error Scoring System (BESS) Stances = double, single, tandem Surfaces = firm, unstable Footwear = barefoot, socks, shoes, sport specific Rhomburg test Tandem Gait 3 m tape, heel toe walk Timed?

32 Vestibular/Ocular Motor Screening (VOMS) (Mucha et al, AJSM 2014) 1. Smooth pursuits 2. Horizontal + Vertical Saccades 3. Near Point of Convergence (NPC) 4. Horizontal VOR 5. Vertical VOR 6. Visual Motion Sensitivity (VMS) Rate change in symptoms 0-10

33 Occulo-vestibular Vestibulo-occular reflex (VOR) Dynamic Visual Acuity Head Thrust Dix-Hallpike

34 Vestibulo-ocular Reflex (VOR) Responsible for maintaining stable vision during head motion Eye velocity Head velocity Image projected on fovea of retina

35 VOR

36 Dynamic Visual Acuity

37 Dynamic Visual Acuity

38 Head Thrust Test Quick Clinical test Head flexed 30 degrees Eyes focused on target Head rotated unpredictably 5-15 degrees High acceleration, small amplitude Normal: Eyes stay on target Positive test: Corrective saccade Schubert, 2004

39 Head Thrust Test

40 Benign Paroxysmal Positional Vertigo (BPPV) Most common cause of vertigo in adults Seconds of vertigo following changes of head position ± Unsteadiness Characteristic Nystagmus Herdman, 2007

41 Dix-Hallpike test Patient long sitting Head rotated 45 Examiner assists to bring head and trunk into supine position with head hanging 30 Characteristic Nystagmus Positive test for BPPV Reproduction of symptoms

42 Dix-Hallpike Test

43 Complex Tasks Divided Attention Timed walk-while-talk test Recite alphabet Recite alternate letters of alphabet Pertubation For assessment AND treatment

44 Pertubation

45 Complex Tasks

46 What is Vestibular Rehabilitation? Canalith repositioning maneouvers Habituation exercises Substitution Gaze stability retraining Static and dynamic balance retraining

47 Headache Dizziness Neck Pain

48 Multimodal physiotherapy in the treatment of individuals with persistent symptoms following a sport related concussion: A Randomized Controlled Trial Kathryn J Schneider PT, PhD Willem H Meeuwisse MD, PhD Alberto Nettel-Aguirre PhD, PStat Lara Boyd PT, PhD Karen Barlow MB, ChB, MRCPCH Carolyn A Emery PT, PhD BJSM 2014

49 Subjects Dizziness, neck pain and/or headaches years Screened by study Sport Medicine Physician Physiotherapist assessment Randomized: Control (n=16) Intervention (n=15) Primary outcome: Number of days to medical clearance to RTS

50 Both Groups: Weekly sessions with PT and Protocol of rest followed by graded exertion Treatment Group Education General range of motion/stretching/strength Orthopaedic physiotherapy Vestibular rehabilitation Control Group Education General range of motion/stretching/strength Primary outcome: Number of days to medical clearance to RTS

51 Results

52 Cross Over -Results 35% improved (half as effective) More severe group? Timing of treatment?

53 Exercise? Graded return to activity protocol decrease in symptoms in athletes (Leddy et al, 2010; Baker et al 2012) Exercise as medicine (Leddy et al 2018) Exercise intolerance believed to be secondary to ANS dysfunction Normalizes cerebrovascular dysfunction

54 Take Home Message! Normal : hours initial rest then symptom limited activity for most Then graded return to activity Difficult, delayed, prolonged : Look for alternate or comorbid cause(s) Target therapy to affected system

55 The Role of Active Rehabilitation -taking a targeted approach Willem (Winne) Meeuwisse, MD, PhD MANAGING CONCUSSIONS IN THE TEAM SETTING ATPC Marrakech, Morroco September, 2018