POST CONCUSSION MANAGEMENT: EXERTION THERAPY, CARA TROUTMAN- ENSEKI, PT, DPT, OCS 1

Transcription

1 ENSEKI, PT, DPT, OCS 1 So what do I hope that you gain out of this lecture? The 2 objectives for this lecture I hope that by the end of it you ll be able to understand our model, our 5 stages of exertion, and in turn use those 5 stages to create an exercise program for your individual patients. So why do exertion therapy, why not just have your athletes go work out on their own, work out with their team? The problem with that is we don t know what they re doing. Exertion means something different to every different person. We found that a lot of athletes would come back and say oh I ran up and down the field that s enough, I m fine, no symptoms. Or I worked out with my team, but you don t know if it s just a run through practice for football or if they re actually doing something or if they re just walking through. So we realize the need that we needed to have more standardized approach to kind of make sure each athlete was being stressed appropriately and one athlete wasn t doing more than the other. It also falls into the return to play criteria so part of our return to play criteria states that the athlete must be symptom free with both physical and cognitive exertion. Now one of the hardest things I had a problem with when I started with the concussion program is I went to Pitt, everything was evidence based, evidence based. But when I started doing exertion therapies there s no evidence, I had nothing to go off of. I ve kind of had to use experience as my guide and the little stuff that I had to go off of. In these 2 studies actually show the negative effects of exertion. The first one shows that student athletes that engaged in high levels of physical exertion following a concussion actually had worsened neurocognitive data, increased symptoms and longer recovery times. This suggests to us that we need to have more of a systematic approach to make

2 ENSEKI, PT, DPT, OCS 2 sure that these athletes are carefully monitored and they re not pushed too hard in the beginning but also so they re not pushed too little. And the second study that just came out this past February I believe, showed that in post concussive patients after they exerted and took neurocognitive tests, their scores actually decreased even though they said that they were symptom free. So this also kind of gives us a need for making sure that we re exerting these patients once they re symptom free prior to neurocognitive testing to make sure there isn t a decline in scores. So what is our model for the 5 stages of exertion? We ll talk a little bit about our old model first. Our old model relied completely on heart rate, so we looked at the Karvonen formula, calculated the heart rate max based on the patients age and resting heart rate and progressed them through the stages. So for example stage 1 would be 20-30% of heart rate max progressing all the way to stage 5 which was max exertion. We used this model for the first year or two that we started out with exertion therapy, but the more I worked with patients as everyone said, we see thousands in the clinic a year, I kind of found that it wasn t really a heart rate model. My patients could do max exertion on the stationary bike for 25 minutes but as soon as I would take them off the bike and they would try to do a squat or a lunge they would become completely symptomatic. So talking amongst ourselves with Ann, Mickey we kind of realized that there was more of a vestibular problem as you ve heard multiple talks before me. So we kind of moved away from the heart rate model and kind of focused more on the stages by movement. So each stage progresses the athlete by movement incorporating more dynamic movements into each stage.

3 ENSEKI, PT, DPT, OCS 3 So now I m going to go through our model of the 5 stages of exertion. So stage 1, stage 1 exertion therapy in our clinic consists of light aerobic conditioning, balance activities, exercises that limit head movement, so this is where you can still work them out, you can do stretching, you can do weight machines, you can do squats and lunges with focusing so you can have them perform a squat staring off into the horizon, focusing on an object so they re limiting their head movement, still allowing them to do some activities. And this varied greatly from our old model because our old model in stage 1 they really weren t doing a whole lot of anything and we were cutting them off once they reached that 20-30% heart rate max. Stage 1 through stage 5 I ll always do core exercises so my stage 1 core exercises might consist of planks, side planks, 6 inches. Recommendations in this stage-exercise in a quiet area, this might be the patients that Ann was talking about with the face and motion discomfort. We have 2 gyms in our clinic, we have a smaller gym and a larger gym and these are the patients I would have in the smaller gym to limit the vestibular stimuli so they re not getting too symptomatic early on. No impact activities in this stage because the quick up and down really makes them symptomatic. This is where they ll usually be seeing Ann along with myself, so that the balance in vestibular treatment is by a specialist in this case, so they might be seeing Ann in the morning and come to see me afterwards in the afternoon. In this stage you really want to stress limiting the head and positional change and limit concentration activities in this stage. Moving onto stage 2, stage 2 consists of light to moderate aerobic conditioning, balance activities with head movement. So this is where you can really get sport specific as you see in the photo I have a hockey player single leg stance while stick handling. So we re incorporating a little bit more visual tracking and head movement in these stages. With the strengthening exercises now you

4 ENSEKI, PT, DPT, OCS 4 might add head turns so some examples of that are side stepping with a band, with a head turn. They might do a side lunge with a head turn. Low intensity sport specific activities, so you saw the balance you can do that. Up in the corner we have the slide board for hockey players so starting that movement that s going to get them back into their activity. Core exercises now will incorporate head movement so side planks with a upper arm head rotation so they are turning, looking as they are performing their core exercise or Russian twist which is a lot of head movement, you might have to start off slowly and have them slowly track a ball as they are doing their twist, but then you are going to kind of progress the speed as they get better. Recommendations in this stage: this is where I would move them into our larger gym, kind of challenge them a little bit, expose the system, make sure that they are not getting symptomatic as they go into busier environments. Use various equipment, so now we are getting away from just the weight machine, we are trying to get a little bit more dynamic so we ll use dumbbells, kettle bells, medicine balls, whatever you have in your clinic and allow for positional changes in head movement. This stage is where you might start some low concentration activities such as counting repetitions because you want to challenge both the cognitive and exertional systems at the same time. Moving on to stage 3, so this is moderately aggressive aerobic exercises. This is where you might have them do intervals, stair climbing, pyramids, all forms of strength exercises. Stage 3 is where I ll incorporate dynamic warmups, so carioca, side sashays, (inaudible), whatever you guys do for dynamic warmup. So this is the stage where I ll incorporate that. Stage 3 is where I also incorporate

5 ENSEKI, PT, DPT, OCS 5 impact activities, so running, plyometrics and agility drills. You ll also really challenge the positional changes in the stage. Some great exercises I personally found are burpees or up-down where they do a quick jump, come down, push up, jump, it s great for positional change and mountain climbers. You ll have a lot of people that won t be symptomatic so you ll try these two exercises and they ll suddenly get symptomatic so you know that they are not 100% yet. And then moving on to more aggressive sports specific exercises in this stage. Recommendations, any environment is okay, so indoor and outdoor. Integrate strength, conditioning and balance/proprioceptive exercise and now you are going to incorporate concentration challenges. At our clinic we have MRS equipment which is just a leg press with a video screen so they can do games so they are concentrating on the game as they are doing a leg press. But you don t need fancy equipment to do any of this stuff. One of my aids actually thought of a clock lunge which is an awesome idea. So you have the patient imagine the face of a clock and then you call out a number from 1 to 12 and they have to turn, jump, lunge into that position so they are thinking about stuff as they are doing movement exertion exercises. Stage 4, so stage 4 is max exertion, all activity is just avoiding contact. This is where I ll have the patient attend a noncontact practice, so they might be hockey, football, cheerleading, whatever they do they are going to attend a noncontact practice in this stage to make sure that they are okay. And then moving on to stage 5, stage 5 is exactly the same as 4 except now you are going to initiate contact. So that s the only thing that separates 4 and 5 in our model is the aspect of contact.

6 ENSEKI, PT, DPT, OCS 6 So when do you initiate exertion therapy? This is the million dollar question and as everyone has kind of alluded to there is no cookie cutter answer to this question. You don t say in 2 weeks we are going to start exertion therapy. Every patient is different, so you have to go based on their individual presentation. So we initiate exertion therapy in many different situations, the first one being initiated in athletes with minimal to no symptoms. This might be the kid that gets a concussion at a football game Friday night, Sunday and Monday he has no symptoms, we might exert them there. Or this might be the patient that symptoms cleared up over a week or two, then we are going to initiate it. But it s also initiated in athletes that are still symptomatic but have crossed over to that chronic stage of concussion management. These are the ones we want to get going, they ve been sitting around doing nothing, symptoms really haven t changed. They ve tried medication, they ve done vestibular and everything is kind of stale so we might kind of push them a little bit to keep them going, get them moving in the right direction. It s also as Kelly and Ann talked about, we initiate it earlier on an anxious and depressed patient, when someone is sitting around in a room doing nothing it increases their anxiety and depression so these are the patients we want to catch early on and get them going, get them towards their goal, so kind of relieve some of those psychological symptoms to kind of get them symptom free. It s also initiated earlier in the migraine suffering patients as we know research shows that migraine suffering patients do well with exercise. This helps decrease the symptoms, so we want to kind of start these people off earlier to kind of diminish some of the headaches and dizziness.

7 ENSEKI, PT, DPT, OCS 7 And as everyone has mentioned numerous times, the timing of everything is it s really a group effort. We all talk amongst ourselves, so Ann and Kelly and Mickey will all talk and say hey this kid needs to get moving, let s go send him down to Cara. So then it s really a group effort so that s why we really don t use a cookie cutter approach to everything. Now our evaluation for exertion, I m going to just highlight the key topics, this is another lecture in itself. It took me 3 hours to do it for our residents so I m just going to go over a little bit of what we do for our actual evaluation. So the exertion evaluation is performed at the onset of symptoms. If the patient is not symptom free they must perform the exertion evaluation again before I say that they are cleared from exertion therapy. The hardest part about exertion is everything is subjective. So we don t have a lot of objective measures, it s not like a knee or a hip where I can measure range of motion, test strength, so we are really going off of subjective kind of measurements with these athletes. So I ll have them write their symptoms pre and post exertion and the scale that we use is based on of ImPACT. So that s where the 0 to 6, everything I ve ever done in my life is 0 to 10 but once I came into concussion it s 0 to 6. So 0 means no symptoms and 6 is the worst it can be, meaning I have to go to the hospital, with 3 as our midline. So they ll go through and rate headaches, nausea, lightheadedness, dizziness, mental fatigue and mental fogginess. They ll rate is pre and post exertion, so we know if there s a change, sometimes it might be an increase but other times there might be a decrease in symptoms.

8 ENSEKI, PT, DPT, OCS 8 We also screen for potential involvement of outside symptoms. As everyone in this room knows there is many different causes of dizziness, many different causes of headaches so we really want to cover all our boundaries and make sure that we check all these symptoms so we are not missing anything. The first thing we ll look for is orthostatic hypotension, that can cause dizziness, lightheadedness, so can a concussion so we want to make sure that that s not some of causing some of their symptoms. A huge topic is cervical involvement. All my patients when they come to me they get screened for cervical involvement even though they probably already have been screened by Kelly, Dr. Collins, but I want to make sure myself just to make sure I m not missing anything so I ll look at active range of motion, I ll measure it to make sure it s within normal limits, I ll do C2 kick test and Sharp-Purser test to make sure there is no instability in the cervical spine, and then I ll also palpate the cervical spine and test mobility in the supine position. If there is some involvement I ll treat it. I m an orthopedic therapist so I will go ahead and treat those impairments. We also screen for vestibular. It sounds like overkill but many times a patient might be fine when they go through Dr. Collins and I just want to make sure that we are not missing anything with the vestibular system. I also like to make sure that I know what s going on with the vestibular system too because that helps me create my exercise programs. And for the exertion evaluation we also look at the BESS test as Ann talked about, and I do the BESS test pre and post exertion.

9 ENSEKI, PT, DPT, OCS 9 After all of that has been cleared, after we ve checked everything, got their symptoms we move on to the actual meat and potatoes of the evaluation. The first part is cardiovascular assessment, so they ll perform 25 minutes of cardiovascular activity. Now I determine the cardiovascular activity based on what they come in presenting with. If they have an abnormal vestibular exam and reporting high symptoms they are going to start on the bike. I m not going to start them on the treadmill or the elliptical because that s just going to exacerbate their symptoms. Now on the flip side of it if they are coming in reporting minimal symptoms, have a normal vestibular screen I might start them on the elliptical or the treadmill because I know that they can handle it. After the cardiovascular portion of the exam we go through the dynamic and functional testing. Now this consists of many different movements in both static and dynamic positions to kind of challenge the vestibular system. When we made this evaluation we talked amongst ourselves about all the key exercises that included all the key components of the vestibular system. We wanted to make sure we didn t miss anything so that if an athlete came in and didn t have vestibular therapy and just went through my evaluation we would pick-up on anything that could potentially be wrong. Now if they pass this whole evaluation we ll move into sports specific activities. Now this is where it varies based on the individual. So a hockey player you are going to focus more on hockey stuff or a gymnast you might have them do stunting, tumbling, whatever they are going back to and this kind of gives you free rein as a physical therapist to kind of decide what the pieces that you feel are important for this athlete.

10 ENSEKI, PT, DPT, OCS 10 So how do you determine the stage of exertion? So after you ve completed the entire evaluation you kind of determine their stage based on how they did. If they made it through the cardio but then the more dynamic movements kind of flared them up, they weren t feeling too good you had to cut off the evaluation before they got to the functional testing you ll put them in an earlier stage. So this might be your stage 1, stage 2 patients. Now if they made it through the entire evaluation feeling pretty good, just minimal symptoms this is where they d get a higher stage, stage 3, stage 4. It s all based on how they presented in that evaluation. The most important part of the evaluation is that second visit. This is where you are going to gain all your information. You are going to ask them how did you feel after you left? A lot of times someone might be okay when they are done with you but an hour after they left they had an intense headache, they felt nauseous, they felt dizzy, it lasted into the next day; this is the key to myself that I have to back them down a little bit and not push them so hard. But on the flip side of it you might have an athlete that came in that said I felt great, there is no problems so then you know to yourself hey I can push them a little bit harder. You also want to inquire to them about their recovery time, this is extremely important with exertion therapy. So a patient might go home, might have symptoms for an hour, they might have a headache but you need to educate them that s okay, you are going to get symptoms, you want to look at how long it takes for those symptoms to go away. We don t want to see the symptoms going and lasting into the next day, but if they are an hour or two after they leave I m okay with that. And what you want to set your goals at is the more you see them, see their recovery time decrease. So that s a positive experience. That s working towards

11 ENSEKI, PT, DPT, OCS 11 your goal as that recovery time decreases we are looking at that and that s a key to us that they are actually improving, they are getting better. And each individual s program is tailored to the individual, so you might have two hockey players, they are not going to have the same program. Each of those hockey players is going to come in and present with different impairments. Someone might have problems with vertical movements where the other one might have space and motion discomfort. So even though it s hockey you are going to tailor that program to what that individual presents with. And the last thing I m going to go over today is I m going to take you through a sport specific example; but I would like to say that this is just a general example. I chose to do cheerleading because we talked endlessly about football yesterday and I wanted to represent the female population a little bit too. So I did choose cheerleading just to change the tone a little bit. But just as I said about the hockey players you can have two different cheerleaders but you want to focus more on what that individual is presenting with. So this is a general example, take it with a grain of salt, but I wanted to be comprehensive in my example. Okay, so exertion therapy following the 5 stages that we use for a cheerleader. So in stage 1 this is where the patient might be instructed to perform the program 2 to 3 days a week in a quiet environment so this is where they are symptomatic, this is where you are going to want to limit the visual stimuli, you are going to want to limit setting them off but you want to slowly and safely expose them to some exercise. Cardio in this stage might consist of the bike or treadmill walking,

12 ENSEKI, PT, DPT, OCS 12 core exercises limiting the head movement, so planks, side planks, flutter kicks. Balance in this stage you might have them do single leg stance and tandem stance on the foam, eyes open, eyes closed; stretches, so you can still get sports specific in your stretches. So cheerleading has a lot of stunting, tumbling, they have a lot of wrist injuries so this is a great stretch for cheerleading specific, so wrist flexor extensor stretches. So you can see in the corner splits, they love this. They are in stage 1, they are symptomatic but they can do a split and they are so happy because they are working towards their goal or working towards what they are going to, we are not just doing random exercises, we are working towards what do I have to get back to so just allowing a cheerleader to do a split you ll see the biggest smile because they ll get so excited that they are actually doing something they are going back to. I won t go into detail but I wanted to be comprehensive so these are other stretches specific for cheerleading. And I should say I did a lot of research on this. I was a cheerleader so this one was easy, but I do do every sport so I had to do a lot of research into each sport of what s appropriate for each sport. Strengthening in stage 1, so minimizing head movements in stage 1. So these are some examples of strengthening exercises that you might see in stage 1, so wall sits, Bosu weight shifts, Bosu squats, lunges, biceps curls, simple but still allowing them to do movements. Triceps dips, wall sits with biceps curls, just still in strengthening, still stage 1, very different than our old stage 1 based on the heart rate model, they wouldn t be able to do any of this stuff after cardio because they d be shut down.

13 ENSEKI, PT, DPT, OCS 13 Moving on to stage 2, so stage 2 we are incorporating movement. This is the stage where we are allowing them to be exposed a little bit more to movement. Now we are adding on a workout day, so they may be instructed to perform the exercises 3 to 4 days a week in a gym so we want to stress the vestibular system, we are putting them in a gym now, they are not in a quiet environment. Cardio might consist of 20 to 25 minutes of stationary bike level 5-6 resistance. Now with the core exercises we are adding movements. This might be where we might incorporate the Russian twist. We might do planks with leg extensions, hollow hold. Now we are getting even more sports specific so their single leg stance now has become doing what they have to go back to so scale on foam, liberty on foam, heel stretch on foam and really making it sports specific, really different than the picture I showed before of the hockey player doing stick handling. So that just shows you how you can individualize these programs based on sport. With the strengthening you are adding more dynamic movements, so backward lunges, hamstring curls on Physioball, sidestepping with a band, once they can do, fine, that you ll add sidestepping with a band with a head turn. So now you are adding the head turn movement. Pushups, pushups are a great exercise. The last student I had actually thought of a great one for convergence problems, pushups looking up and down, alternating, so you are getting that real quick near to far. So that s another good exercise to kind of challenge that. The type of exercise is great for a base in cheerleading because they are getting that real quick up and down movement with the medicine ball which adds the weight component of what they have to go back to, they have to go back to lifting their partners, so you are working on that in the clinic.

14 ENSEKI, PT, DPT, OCS 14 Moving on to stage 3, so now the patient is instructed to perform the program 4 to 5 days a week in any environment. Cardio might be 25 to 30 minutes of the stationary bike or elliptical, now this is the stage where we talked about we will add that dynamic warmup. For a cheerleader you might do walking with arm circles, toe touches, jumping jacks, knee hugs, carioca, side sashays, whatever they need to do. Your core exercises become more complicated so V-ups, planks with oblique twists, knees to chest on Physioball. Now we add the height component to the balance, so it wouldn t do cheerleading justice if you were just going to have a flyer go back after practicing single leg stance, so now you are going to add the height component. I ll have them perform the scales, liberties, heel stretches on a platform now to make sure that they don t get symptomatic once that height component is added. Strengthening even more dynamic so walking with lunges, so now you are walking with the lunges, you can add a head turn side to side, squats on disc with weights, medicine ball overhead throws in a basing stance and as I talked about earlier this is where you would add the plyometrics, the mountain climbers, 2 hurdle quick step for agility, bounding squat jumps. Trampoline, trampoline is a great exercise to challenge the vestibular system so trampoline exercises, jumps, high knees, turns, you ve got that real quick up and down movement so that s a great tool to make sure that they don t get symptomatic. I will not clear a cheerleader without doing two important things, one is jumping and then you ll see in stage 4 the other is tumbling. So jumping, they must perform all these jumps and we don t just

15 ENSEKI, PT, DPT, OCS 15 perform one of each, we do them in unison so they will do multiple repetitions of these jumps. So I ll make them do everything that they have to go back to, tucks, toe touch, hurkey, hurdler. Moving on to stage 4, so now they are instructed to perform the program 5 days a week in any environment. They are instructed to perform their dance routines and cheers at cheerleading practice, so this is where you incorporate that noncontact practice. Cardio might be 30 minutes of spin intervals, elliptical or treadmill jogging, core exercises might be V-ups with medicine ball, flutter kicks with medicine ball toss and side planks with rows. This is a tumbling series, so if they have accomplished these feats prior to obtaining a concussion they must do them before I clear them. So if they have their back hand spring they are doing it before they are cleared; before I tell Mickey that they are okay to go. So we will go over, we are lucky in our clinic we have a Plyometric floor so we ll use that floor and we ll go over cartwheels, round offs, back handsprings, front handsprings and back tucks. Jumps in series now, so they might do split lunge jumps, they might do knee to chest with medicine ball. Box jumps and depth jumps, we ll do all these in the stage 4 to make sure that they are not symptomatic. Agility drills in this stage we do have a stairwell in our clinic but we also have it across the field, we are allowed to use the Steelers indoor practice field so I might have them do running stairs. So stair workouts, they might do for example forward 2 feet, side stepping with right and left leg leading, every 2 steps, single leg bounds and they might do jumping rope. Some of the examples of some of the jump rope work routines are high knees, skipping, 2 feet hops and single leg hops.

16 ENSEKI, PT, DPT, OCS 16 And then the last stage moving on to stage 5, so now the cheerleader is instructed to perform the program 5 days a week in any environment. Once they are cleared by neuropsychology they can return to contact, they ll go back to tumbling and stunting with their teammates and you want to really make sure that their dry land drills are high intensity interval drills to challenge the patient s anaerobic exercise threshold and the cardio in stage 5 might consist of 25 to 30 minutes of jogging, sprinting intervals and running stair circuits. And before I conclude one of the questions that I was asked last night was why cheerleading? I just want to say that I ve had just as many cheerleaders as football players this year so that it is an injury that s highly prevalent in cheerleaders as well. Thank you.