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Exertion: Just Do It!

Annie Doda, DPT

TRIA Orthopedic Center

October 26, 2018

Disclosures

• No disclosures to report

Objectives

1. Define exertion as it relates to concussion.

2. Discuss the value of exercise during acute and protracted

recoveries during concussion treatment/management.

3. Demonstrate understanding of formal exertion therapy,

various tools utilized for exertion assessment, and value of

sport specificity.

What is exertion?

• Exertion Definition

– the act or an instance of exerting; especially : a laborious or

perceptible effort

Exert

• a : to put forth (strength, effort, etc.)

• b : to put (oneself) into action or to tiring effort

(https://www.merriam-webster.com/dictionary/exertion, 2018)

https://corticalchauvinism.com/2013/03/20/key-

players-in-autism-iii-brain-weight/

Which athletes should be exerted?

• All Sports Concussion Athletes

– Often overlooked

• Graduated RTS Strategy

(McCrory et al, 2017)

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Who can assist athletes with exertion/RTP?

Exertion

Patient

Parent Coach AT PT

Multi-disciplinary recommendations: Rehab

• Berlin consensus (McCrory et al, 2017)

– “closely monitored active rehabilitation programme involving

controlled sub-symptom-threshold, submaximal exercise have been

shown to be safe and may be of benefit in facilitating recovery”

– More research needed in this domain

• CDC statement (Lumba-Brown et al, 2018)

– Optimal timing not established

– “inactivity beyond initial 3 days post concussion may worsen their

self-reported symptoms”

Multi-disciplinary Rehab recommendations

(continued)

• University of Pittsburgh-- Targeted Evaluation and Active

Management (TEAM) Approach (Collins et al., 2015)

– Are we behind? Typical course of medicine

– 71% of US adults did not recognize concussion as treatable (Poll,

Harris, 2015)

• Pathophsyiology vs. symptoms and impairments

– Need to find level of activity that is just right for patient- not too

little, not too much

• Avoiding contact remains important

For most cases, would we totally shut down

an orthopedic patient for weeks after

surgery/injury?

Optimal Loading

• Current practice and a

building body of evidence

now encourage “optimal

loading” as opposed to

rest; even for concussions

patients

• Can be applied to non-

sport activities as well-

choir, band, theater, etc.

Timing for activity?

• Great question!

– Research for timing and type of exertion still needed and are multi-

center studies currently recruiting

• What we do know…

– After 24-48 hour acute phase- gradual and progressive light aerobic

activity (McCory et al, 2017)

– Shorter time initiation of aerobic exercise= faster full return to sport

and school/work

– Bed rest 5 days= situational depression (Thomas, Apps, Hoffmann,

NcCrea &Hammeke, 2015)

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Evidence to support active treatment during

the Acute/Sub-acute phase of recovery

• 2 objectives

– Safe to perform Buffalo Concussion Treadmill Test (BCTT) acute

phase?

– Prognostic factors?

• Results:

– No difference in recovery period – NO ADVERSE EFFECTS

– Heart rate strongly predicted recovery prognosis

• Proposed- start day 6 post concussion:

– 8 sessions

– 10 minutes in duration and exercise intensity 50% HRM

– Next session 20 mins, same 50%

– Following sessions at 30 mins, 5% increase in HRM up to 70%

Take away points:

– Everyone completed safely!

– Not formal PT- physician progressed

– Reduction in symptom severity scores

Clinical Take Away

• Using symptom threshold light aerobic activity is safe and

beneficial – even assessments

• Improves patient’s self-report of symptoms on Post-

Concussion Symptom Scale

• More structure- FITT principles need to be applied and

investigated (Lawrence, Richards, Comper & Hutchinson, 2018)

Benefits of Exercise: General

• Favorable effects on brain neuroplasticity

• Improved neuronal functioning

• Aerobic exercise cognitively protective

– Associated with greater levels BDNF

• Promotes conditioning of CV system

• Mood/overall well being

(Leddy et al, 2016) )https://newlyfitlife.wordpress.com/2015/02/13/lol-of-the-week/

Active treatment with prolonged recovery

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Aerobic Activity and Protracted Recovery (>3-4

weeks) – For consideration…

• Important to identify concurrent ocular, vestibular, and cervical

symptom contributions

• Previous recommendations: rest until asymptomatic

– Rat vs. Human Models- Humans can identify symptom= SUB-

SYMPTOM THRESHOLD

– Use BCTT to identify physiologic response

(Leddy, Baker, Haider, Hinds & Wiler, 2017)

• Not always long intervention- 4 week program improved

symptoms in adolescents with mean 7 weeks of persistent

symptoms

(Gagnon, Galli, Friedman, Grilli & Iverson, 2009)

Formal Exertion Therapy

Formal Exertion Therapy: Who?

• normal progression of Return to Sport Strategy

– previous history of concussion or other co-morbidities- want formal

evaluation

• progression from basic vestibular interventions to higher level

vestibular with exertion emphasis

• Deconditioning

• Increased fear/anxiety

• Address physiologic intolerance to exercise due to concussion

sequelae- autonomic dysregulation

Autonomic Dysregulation Theory

• Initial decreased Cerebral Blood Flow

• Altered ANS connections to cardiac system

• Increased cerebral blood flow during exercise= symptoms

• Assessed: Buffalo Concussion Treadmill Test

(Leddy, Hinds, Sirica, Willer, 2016)

Formal Exertion Therapy: When to initiate?

• Major vestibular, ocular or cervical identified

• Exertion/Sport specificity can be concurrent

• Clinical Pearl: Low symptom profile, Timeline varies

Formal Exertion Therapy: Exertion tools utilized

• Buffalo Concussion Treadmill Test

• TRIA Active Assessment

• TRIA Clearance Test

• Sport specificity

• Graduated RTP strategy

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Formal Exertion Therapy: Buffalo Concussion

Treadmill Test

• Validated and

reliable (Leddy,

Willer, 2013)

• Safe with

pediatric

population

(Cordingly et al,

2016)

• Exercise induced

vs. concussive

related (Leddy &

Willer, 2013)

Formal Exertion Therapy: Sport Specific

Circuits/Activities

Demands of each sport/activities can vary, but also have

commonalities (swimmer vs gymnast vs football vs lacrosse)

• Common: reaction time, turns, aerobic demands

• Sport Specific:

– Swimmer: horizontal, vestibular rich environment

– Gymnast: space/body awareness, inverted movements

– Football: contact, designed plays, position dependent

– Lacrosse: contact, position dependent, use of stick

*Typically most motivating to pts

Formal Exertion Therapy: PT sessions

• All PTs capable of performing all aspects of concussion

management

– Vestibular

– Cervical

– Exertion

• Clinic Athletic Trainers lead progression/sport specificity

Formal Exertion Therapy

• Breakdown to the various treatment aims

– Typically a combination

– Targeted limitations to be addressed:

• High Level Vestibular sensitivity with exertion emphasis

• Autonomic Dysregulation

• Deconditioning

• Anxiety/Fear

Treatment: High Level Vestibular sensitivity

with exertion emphasisTreatment: Autonomic Dysregulation

• (+) BCTT

Identify sub-maximal threshold

20 minutes subthreshold intensity (80% of HR achieved on BCTT)

5-6 days/week

Increased 5-10 bpm every 2 weeks

Physiologic resolution – voluntary exhaustion 85-90% HR for 20

mins w/o symptoms

(Leddy & Willer, 2013)

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Treatment: Deconditioning

General Strength and

conditioning Exercises

Treatment: Anxiety/Fear

• 0-100% where are you at?

– What is that remaining 10%

• Often times contact/game intensity

Summary

• All concussed athletes need to pass RTS

– Includes exertion components!

• PT can help with RTS, further assessment of prolonged symptoms

– High level vestibular sensitivity

– Autonomic Dysregulation

– Deconditioning

– Anxiety/Fear

• Formal assessments tease sensitivities

– BCTT

– TRIA Active Assessment

• Sport specificity is key

• More research needed

Thank you!

References

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